LAKESHORE POST ACUTE AND REHABILITATION CENTER

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story wood framed structure, Type V (000) construction slab on grade without a basement. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1975 and is licensed for 106 beds. This re-certification survey conducted on November 20, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) chapter 19, Existing Health Care Occupancies. The deficiencies cited were discussed with the Maintenance Director, Social Services Manager and Facility Administrator during the exit conference conducted at the end on-site survey.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed egress door Hallway E needs to have frog eyes installed | All delayed egress doors should have emergency lighting on the egress sideNFPA 101 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:(1)The door leaves shall unlock in the direction of egress upon actuation of one of the following:(a)Approved, supervised automatic sprinkler system in accordance with Section 9.7(b)Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6(c)Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6(2)The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a)The force shall not be required to exceed 15 lbf (67 N).(b)The force shall not be required to be continuously applied for more than 3 seconds.(c)The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d)Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.(4)* A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDS(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011. Emergency lighting no annual 90 minute inspection report available for review 2. Exit Lights no annual 90 minute inspection report available for reviewNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. Semi Annual Hood Inspection | Only 09/01/2023 report available for review | no previous report available 2. Semi Annual Hood Cleaning | Only 01/13/2023 report available for review | most recent cleaning report not available NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations SemiannuallyThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the kitchen of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Annual Fire Alarm Report | 3 Pull Stations Failed | Heat Detector state "visual inspection only" | No repair report available | Heat Detector should be tested NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not have Fire Alarm out of service guidance in accordance with NFPA 101. 1. Fire Alarm Out of Service Guidance: Need to update with local contacts and add DFPC WebsiteNFPA 101 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Annual Sprinkler Report | Need to review antifreeze replacement report2. F.reezer Sprinkler head dirty 3. Sprinkler head rehab escutcheon dropped from ceiling NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not have Sprinkler System out of service guidance in accordance with NFPA 101 and NFPA 251. Sprinkler Out of Service: Need to update with local contacts and add DFPC WebsiteNFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:(1) The extent and expected duration of the impairment have been determined.(2) The areas or buildings involved have been inspected and the increased risks determined.(3) Recommendations have been submitted to management or the property owner or designated representative.(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:(a) Evacuation of the building or portion of the building affected by the system out of service(b) *An approved fire watch(c)*Establishment of a temporary water supply(d)* Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire(5) The fire department has been notified.(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.(7) The supervisors in the areas to be affected have been notified.(8) A tag impairment system has been implemented. (See Section 15.3.)(9) All necessary tools and materials have been assembled on the impairment site. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Ceiling needs repair in Hallway D | does not resist the passage of smokeNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1. Polarity/Retention - No annual report available for reviewNFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. Generator Weekly | Facility needs to start recording weekly inspections 2. Generator Battery Conductance | 12 months of reports not available to surveyor need to record monthly 3. Generator Monthly Inspection | 12 months of reports not available to surveyor 4. Generator Transfer Switch | 12 months of reports not available to surveyor 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with complaint #CO32703, #CO32353, CO33987 and Incident #32077 was completed on 10/23/23 to 10/26/23. Fourteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/23/23 to 10/26/23. Nine deficiencies were cited.

Based on record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency plan. Specifically, the facility failed to have a policy and procedure to address alternate sources of energy to maintain temperatures to protect residents' health and safety and sanitary storage of provisions. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and the maintenance supervisors (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have at minimum a policy and procedure to address alternate sources of energy to maintain temperatures to protect residents health and safety included in the EPP. II. Staff interview The EPP was reviewed with the NHA and MS on 10/26/23 at 9:30 a.m. The NHA said the facility did not have a policy and procedure to address alternate sources of energy to maintain temperatures to protect residents' health and safety in the EPP. The regional environmental facility consultant (REFC) was interviewed on 10/26/23 at 11:57 a.m. The REFC said it was important to update the EPP annually and as needed to keep up with the requirements for the safety of the residents.

Based on record review and interview, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to have a system to track the location of on-duty staff and sheltered residents in the facility's care during an emergency. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and the maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility failed to have a system to track the location of on-duty staff and sheltered residents in the facility's care during an emergency included in the EPP. II. Staff interview The EPP was reviewed with the NHA and the MS on 10/26/23 at 9:30 a.m. The NHA said the facility did not have a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency in the EPP. The regional environmental facility consultant (REFC) was interviewed on 10/26/23 at 11:57 a.m. The REFC said it was important to have a system to track the locations of on-duty staff and sheltered patients in the facility in the EPP to keep up with the requirements.

Based on record review and staff interviews, the facility failed to develop and maintain an emergency preparedness plan (EPP) which addressed the following criteria in the event of an emergency. Specifically, the facility failed to develop policies and procedures, for a system of medical documentation that preserved resident information, protected confidentiality of resident information and secured and maintained availability of records, during an emergency situation. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have a system of medical documentation that preserved residents' information, protected confidentiality of resident information, and secured and maintained availability of records in the EPP in the event of an emergency evacuation. II. Staff interviews The EPP was reviewed with the NHA and MS on 10/26/23 at 9:30 a.m. The NHA said the facility did not have a system of medical documentation that preserved resident information, protected confidentiality of resident information, and secured and maintained availability of records in the EPP. The regional environmental facility consultant (REFC) was interviewed on 10/26/23 at 11:57 a.m. The REFC said it was important to develop a program that preserves resident information and protects confidentiality.

Based on record review and interview, the facility failed to have a complete emergency preparedness and emergency communication plan to include a policy and procedure outlining the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. Specifically, the facility failed to develop policies and procedures outlining the facility's role and responsibility for providing service at alternate care sites under an 1135 waiver. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have a policy and procedure describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver in the EPP. II. Staff interviews The EPP was reviewed with the NHA on 10/26/23 at 9:30 a.m. The NHA said he was not familiar with the 1135 waiver. The NHA said the facility did not have a policy and procedure describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver in the EPP. The regional environmental facility consultant (REFC) was interviewed on 10/26/23 at 11:57 a.m. The REFC said it was important that the facility was aware of their role in providing care and treatment at alternative care sites.

Based on record review and interview, the facility failed to develop a communication plan that complies with Federal, State and local laws and must be reviewed and updated annually. Specifically, the facility failed to have a communication plan that complies with Federal, State and local laws included in their emergency preparedness plan. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have a communication plan, which had been reviewed and updated. II. Staff interview The EPP was reviewed with the NHA and MS on 10/26/23 at 9:30 a.m. The NHA said the facility had not developed a communication plan. She said it would be important to identify a means for communication with community resources and facility staff to follow in case of an emergency situation.

Based on record review and interview, the facility failed to develop and implement an effective communication plan in the emergency plan. Specifically, the facility failed to have contact information for Federal, State, tribal, regional and local emergency preparedness staff. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have all contact information for Federal, State, tribal, regional and local emergency preparedness staff in the EPP. II. Staff interview The EPP was reviewed with the NHA and MS on 10/26/23 at 9:30 a.m. The NHA said it was important to have contact information for Federal, State, tribal, regional and local emergency preparedness staff. The MS said it was important to update the EPP annually and as needed to keep up with the requirements.

Based on record review and interviews, the facility failed to have a written emergency communication plan that complies with Federal, State and local laws. Specifically, the facility failed to ensure there was a written plan for sharing information and medical documentation for residents, under the facility's care, with other health providers to maintain continuity of care. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have a method for sharing information with other health providers included in the EPP. II. Staff interview The EPP was reviewed with the NHA and MS on 10/26/23 at 9:30 a.m. The NHA said the facility did not have a plan that included a method for sharing information to other health providers. The MS said it was important to update the EPP annually and as needed to keep up with the requirements.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program. Specifically, the facility failed to have an emergency preparedness training and testing program for current and new staff. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and the maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility did not have an emergency preparedness training and testing program for current and new staff. II. Staff interview The EPP was reviewed with the NHA and MS on 10/26/23 at 9:30 a.m. The NHA said the facility did not have a current training or testing program for staff and new hires included in the EPP. She said it was important to have an EPP training and testing program to ensure the staff were up to date on the most current information available to provide the best care possible to the residents who resided in the facility.

Based on record review and interview, the facility failed to complete an additional testing exercise of choice in addition to activating its emergency plan. Specifically, the facility failed to conduct an additional full-scale exercise, individual facility based functional exercise, mock disaster drill, table top exercise or workshop in the last year. Findings include: I. Testing The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and the maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. Review of the EPP revealed the facility had not conducted an additional full-scale exercise, individual facility based functional exercise, mock disaster drill, table top exercise or workshop in the last year. II. Staff interview The EPP was reviewed with the NHA and the MS on 10/26/23 at 9:30 a.m. The NHA said the facility had not participated in an exercise in the past year. The MS said it was important to train and test the EPP annually to keep up with the requirements and ensure the EPP was effective.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity. Findings include:I. Facility policy and procedureThe Resident Council policy, revised February 2021, was provided by the corporate nurse consultant (CN) on 10/25/23. It read in pertinent part, "The purpose of the resident council is to provide a forum for discussion of concerns and suggestions for improvement. "A resident council response form will be utilized to track issues and their resolutions. The facility department related to any issues will be responsible to address the item(s) of concern."II. Resident interviewThe resident council president, Resident #23, was interviewed on 10/26/23 at 10:19 a.m. She stated she did not know who was supposed to handle the grievances brought up in the council meeting. The council did not receive a resolution for grievances brought up in prior council meetings. III. Record reviewA review of the resident council meeting minutes dated 9/20/23 revealed group grievances concerning clothes not being returned timely and an insufficient amount of towels and washcloths. A review of the resident council meeting minutes dated 10/11/23 revealed group grievances concerning not being able to receive money timely, rooms not being mopped, unsatisfactory water pressure, noise levels due to residents who scream and staff not providing assistance with meals. A review of a resident council response form dated 9/20/23 revealed there had been training with the laundry staff concerning no washcloths, towels and linens. The resolution was dated 9/28/23. The nursing home administrator (NHA) signed off on the concern form 10/2/23. -No manager was listed as conducting the training and no training was attached. -There was no mention of discussing the resolutions with the resident council. A review of a resident council response form dated 10/11/23 revealed medications were not being given on time. The NHA signed off on the concern form 10/17/23. -No manager was listed as responding to the concerns, no resolution was documented and there was no mention of discussing resolutions with the resident council. A review of a resident council response form dated 10/11/23 revealed medications were being left on food trays and being taken to the kitchen. The NHA signed off on the concern form 10/17/23. -No manager was listed as responding to the concerns, no resolution was documented and there was no mention of discussing resolutions with the resident council. An in-service training form was included pertaining to medication administration being given on time and not being left at the bedside dated 10/12/23. Five nurses attended out of the twelve nurses employed. A review of a resident council response form dated 10/11/23 revealed there had been training with the housekeeping staff concerning mopping rooms properly. The resolution was dated 10/12/23. The NHA signed off on the concern form 10/16/23. -It was not documented that the resolution was discussed with the resident council. IV. Staff interviewsThe social services director (SSD) was interviewed on 10/25/23 at 2:27 p.m. She said she handled individual grievances and not the resident council grievances. The activities department ran the resident council meeting and wrote up the grievances. The grievances were given to the NHA who was the grievance official. The SSD did not know where the grievance forms went after it was resolved or who was responsible for following up with the residents. The activities assistant (ACT) was interviewed on 10/26/23 at 10:10 a.m. She said the activities director was currently out of the facility. The activity assistants helped the activities director with documentation during the resident council meetings. If a concern was brought up in the meeting and was isolated to one resident, the concern form was written as an individual grievance. If the concern brought up pertained to more than one resident, it would be written as a group concern. Group concern forms were given to the department responsible for the concern. The ACT did not know what happened to the concern forms after being given to the department manager. The NHA was interviewed on 10/26/23 at 11:36 a.m. The NHA stated not until October 2023, the facility had not been writing group grievances generated by resident council. The NHA had started a log to track the group grievances and responses. She was still evaluating the process and considering adjustments to ensure all grievances were being included in a group grievance form and followed up on with the council.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 60 resident rooms in six hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment were conducted on 10/24/23 at 1:24 p.m. revealed:Room #C-21: The resident's sink had a one inch ring of rust around the drain. The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. The vent on the ceiling had peeling and chipped sheetrock approximately two inches around the whole vent. The wood railing outside of C hall had chipped and splintering corners approximately three inches long and a half inch wide. The sheet rock was chipped and peeling with metal corners exposed. The nursing station had swinging doors that were removed. The area where the door hinges were located had chipped and damaged sheet rock approximately five inches long by four inch wide. The corner had chipped and peeling sheetrock. The wood railing outside of B hall had chipped and splintering wood approximately six feet long by one inch wide. Room #B-10: The telephone jack box had been removed next to the resident's bed with the outline visible. Room #B-1: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room #B-9: The toilet does not always flush. The floor around the toilet had water damage and black stained caulking around the whole base of the toilet. The laminate above the sink had an area approximately 14 inches long by one wide which was lifting and peeling. The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room #B-7: The restroom had no call light. The wall next to the door had several dime sized holes where the television bracket had been removed. The restroom had two dime sized holes on the wall above the toilet paper. The wall in the bathroom behind the toilet had an area approximately five feet long by two feet wide which had rough and unfinished plaster. Room #B-5: The baseboard cove next to the restroom had a section approximately 10 inches long peeling away from the wall. There were four dime sized holes in the restroom where a soap dispenser had been removed. The wall in the bathroom behind the toilet had an area approximately five feet long by four feet wide which had rough and unfinished plaster. Room #A-2: The baseboard cove next to the sink had a section approximately five inches long by four inches high missing. Room #A-3: The wiring conduit behind the resident's bed had an area approximately six feet long which was damaged from the bed being lifted and lowered. Room #A-4: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room #A-7: the wall underneath the resident's window had water damaged approximately 10 feet long by two feet wide. The laminate next to the sink had an area approximately five feet long by two inches wide with damaged and peeling laminate. Room #A-6: The baseboard cove in the restroom had an area approximately 15 feet in length which was peeling away from the wall. The wood railing on hall A next to room A-9 was loose and could be physically moved when grabbed. Room #D-5: the entrance door had peeling and rusted paint chips approximately 14 inches high. Room #D-4: the baseboard cove had an area approximately 12 inches long by four inches wide which was peeling away from the wall. The wood rails next to the social workers office on D hall were loose and could be moved when they were grabbed. The baseboard cove by the secured unit entrance door had an area approximately six feet long which was lying on the ground. The baseboard past the entrance door to the secured unit had a section approximately seven feet long peeling away from the wall. Room #F-4: the wall next to the resident's bed had three large four inch screws sticking out of the wall and had seven dime sized holes. The baseboard cove next to the restroom had an area approximately four feet long peeling away from the wall. Two of the dresser drawers were broken and hanging off the dresser. II. Environmental tour and staff interviewThe environmental tour was conducted with the maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said the facility utilized work orders as well as a computer system to identify environmental issues. The MS said he did not have work orders for the damage identified during the environmental tour. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on interviews and record review, the facility failed to ensure two (#31 and #55) out of four residents reviewed for abuse were kept free from abuse out of 32 sample residents. Specifically, the facility failed to:-Prevent a resident-to-resident altercations between Resident #58 and #55; and. -Prevent a resident-to-resident altercation between Resident #58 and #31. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the director of nursing (DON) on 10/23/23 at 4:28 p.m., included in part, "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being."Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm."II. Resident #58A. Resident statusResident #58, age 82, was admitted on 5/9/22. According to the October 2023 computerized physicians orders (CPO), diagnoses included dementia, cognitive deficit and muscle weakness. The 7/28/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. No behaviors were identified on the assessment. B. Record reviewThe care plan, dated 7/31/23 and revised on 8/21/23, identified aggressive behaviors that appear to be unprovoked. Interventions included:-Monitor for signs and symptoms of aggression.-One-to-one for safety.-The care plan did not include interventions for Resident #58 when she would become aggressive (cross-reference F744 for dementia care). A progress note from Resident #31's record dated 7/17/23 at 5:00 p.m. included, "The aide informed this writer at 4:50 p.m. that Resident #58 smacked Resident #31 on their head. Aide stated that she was assisting another resident with dinner when she heard Resident #31 yell, 'Leave me alone.' When aide went to see what was wrong, Resident #58 was standing near Resident #31 who was sitting in her wheelchair next to the dining room door in the hall. Resident #31 was holding her head. Another resident's family member who was sitting with her mom at a table next to the dining room door told the aide that Resident #58 was attempting to push Resident #31 in her wheelchair and when Resident #31 did not allow her to do so, Resident #58 smacked Resident #31 in the head."A progress note dated 7/31/23 at 2:30 p.m. included, "Resident #55 was getting up from (the) sofa and Resident #58 was coming into the common area/television area. Resident #58 slapped Resident #55 in the face, and hit her again in the head. The CNA (certified nurse aide) got between the two residents so Resident #58 would not hit again, Resident #55 was redirected to her room. The aide told Resident #58 to sit down on the couch." III. Resident #55A. Resident statusResident #55, age 83, was admitted on 10/27/22. According to the October 2023 CPO, diagnoses included Alzheimer's disease and dementia. The 10/5/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The assessment identified verbal behaviors towards others and other behavioral symptoms toward others. IV. Resident #31A. Resident statusResident #31, age over 65, was admitted on 11/18/21 and readmitted 6/3/22. According to the October 2023 CPO, diagnoses included neurocognitive disorder and psychosis. The 10/4/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. No behaviors were identified on the assessment. V. Altercation on 7/17/23A. InvestigationResident #58 was attempting to push Resident #31 down the hallway in her wheelchair. Resident #31 was telling Resident #58 to stop and Resident #58 slapped Resident #31 in the head. The residents were immediately separated and Resident #58 was placed on a one-to-one monitoring until she went to bed. The altercation was witnessed by a visitor. Resident #31 did not have noted injuries. The facility substantiated the assault. VI. Altercation on 7/31/23A. InvestigationResident #55 had just gotten up from the couch when Resident #58 walked into the television room, passing each other when Resident #58 started hitting Resident #55 in the face and right arm. Resident #55 did not have noted injuries. The facility substantiated the assault. VII. InterviewThe nursing home administrator (NHA) was interviewed on 10/26/23 at 12:00 p.m. She said she was the abuse coordinator. She said the facility was every resident's home and they have the right to live and not be afraid and not be harmed by anyone. She said the facility had implemented the one-to-one staff supervision originally on 7/17/23 and discontinued it on 7/31/23 and within 15 minutes the second altercation had happened. She said the facility had implemented one-to-one staff supervision again after the second altercation which had been effective since the 7/31/23 altercation. She said since then there have not been any altercations since the one-to-one staff supervision.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and the least restrictive alternatives were used for two (#52 and #11) of three residents reviewed for restraints out of 32 sample residents. Specifically, the facility failed to:-Obtain a physician's order for a lap buddy for Resident #52 and #11;-Obtain consent before the use of a lap buddy for Resident #52 and #11; and,-Evaluate the ongoing use of a lap buddy for Resident #52 and #11. Findings include: I. Facility policy and procedureThe Restraint Free Environment policy, implemented 12/1/22, was provided by the director of nursing (DON) on 10/25/23 at 3:10 p.m. included: "Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints."Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints."Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising."A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint."Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine:-How the use of restraints would treat the medical symptom.-The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released.-The type of direct monitoring and supervision that will be provided during use of the restraint.-How the resident will request staff assistance and how his/her needs will be met while the restraint is in place.-How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being."II. Resident #52A. Resident status Resident #52, age over 65, was admitted on 9/27/19. According to the October 2023 computerized physicians orders (CPO), diagnoses included degeneration of the brain, dementia and abnormalities of gait. The 8/6/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired and unable to complete a brief interview for mental status (BIMS). The assessment identified the resident had two or more falls during the look back period. No restraints were identified in the assessment. B. ObservationsA lap buddy can be used as a positioning device when the resident is unable to maintain upright position in the chair and is used to provide trunk and upper arm/body support for wheelchair mobility or self-feeding. It can be used as a restraint to prevent a resident from rising from the wheelchair. Resident #52 was in the television room on 10/23/23 at 3:00 p.m. with a lap buddy on. Resident #52 was in the dining room on 10/24/23 at 10:40 a.m. with a lap buddy on. Resident #52 was in the television room on 10/25/23 at 11:00 a.m. with a lap buddy on. C. Record reviewThe care plan, initiated on 4/28/2020 and revised 8/1/23, included a history of falls. Interventions included, lap buddy to wheelchair, check function and placement every shift. Resident able to remove independently.-The October 2023 CPO did not include an order for the lap buddy.-There was evidence of the facility checking function and placement of the lap buddy every shift.-The resident did not have a signed consent to review the risks of the lap buddy. The 7/24/23 quarterly device evaluation identified Resident #52 had a lap buddy positioning device for the medical reasons of cognitive impairment, behavior and mobility impairment. The evaluation documented there had not been a risk versus benefits reviewed with the resident or the responsible party. -The evaluation did not review whether the resident could remove it or not. The lap buddy was not reviewed with resident/responsible party to review the risks of it restricting the resident's movement. D. Staff interviewsCertified nurse aide (CNA) #7 was interviewed 10/25/23 at 12:40 p.m. She said Resident #52 needed a lap buddy because Resident #52 had a history of falling. She said she did not know if Resident #52 could remove the lap buddy on her own. Registered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She said she could not locate a physician's order for the lap buddy in the October 2023 CPO. She said Resident #52 was a fall risk and the lap buddy was in place to help prevent falls. She said she did not know if Resident #52 could remove the lap buddy or not. The social services director (SSD) was interviewed on 10/25/23 at 2:30 p.m. She said a restraint was a mechanism that restricted movement. She said Resident #52 had a lap buddy, however, she could not locate a consent or a current order for the lap buddy. She said a lap buddy restricted the movement of Resident #52. The DON was interviewed on 10/25/23 at 4:35 p.m. She said Resident #52 had a history of falling and the lap buddy was in place to help prevent the falls. She said she thought Resident #52 could remove the lap buddy on her own. E. Facility follow-upThe facility provided a restraining evaluation dated 10/26/23. The evaluation identified the resident had impaired cognition, was mobility impaired with the use of a wheelchair and had muscle weakness. The evaluation identified the resident would benefit from the use of a restraint or assistive device for positioning in the wheelchair.-The evaluation did not review whether or not the resident could remove the device. It did not document the benefit was reviewed with the responsible party. III. Resident #11 A. Resident status Resident #11, age 66, was admitted on 4/26/23. According to the October 2023 computerized physician orders (CPO), diagnoses included bipolar, schizoaffective, catatonic disorder and chronic obstructive pulmonary disease. According to the 10/5/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had verbal behaviors directed toward others. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The restraint assessment did not document use of a lap buddy. B. Observation Resident #11 was sitting in the common area on 10/24/23 at 8:50 a.m. Resident #11 was leaning forward with her arms extended to the floor and her upper torso was lying on the lap buddy. The resident's feet were behind the double footrest on her wheelchair. Resident #11 was sitting in her wheelchair in the common area on 10/25/23 at 12:40 p.m. Resident #11 was trying to lift her left leg back over the double footrest. Resident #11 was having difficulty moving her foot back in front of the double foot support on her wheelchair. C. Record review The care plan, initiated 4/26/23 and revised 10/5/23, identified the resident had a history of falls related to poor balance, poor safety awareness. She often removes lap buddy and attempts to self-ambulate. She will often scoot on her bottom in her room. She has a soft helmet for safety that she wears intermittently. She will often lower herself to the floor related to the history of sitting on the floor per her culture norms. Interventions include a fall mat placed next to bed. Check cushion and lap buddy for proper placement. Floor of the room was padded with foam squares for safety while moving about when not in a wheelchair. Hipsters at all times to reduce risk for major injuries as resident tolerates. Mattress on floor for safety.-The resident did not have a physician's order for the lap buddy. -An evaluation/assessment, interdisciplinary notes and risk-benefit statement were requested during the survey. They were not provided at time of exit on 10/26/23.-In addition, there was no evaluation/assessment of the footrest that could inhibited her movement (see observations above). D. Staff interviews CNA #2 was interviewed on 10/24/23 at 12:55 p.m. CNA #2 said the resident had a lap buddy as the resident would lean forward in her wheelchair because of lack of core support. Licensed practical nurse (LPN) #2 was interviewed on 10/25/23 at 11:31 a.m. She said the resident had a history of falls. She said the lap buddy was to keep the resident in her wheelchair and from falling forward. She said she did not know if the resident could take the lap buddy off on her own. IV. Administrative interview The DON was interviewed on 10/25/23 at 4:35 p.m. She said a restraint was a device that confined a resident or did not allow them to move freely. She said all restraints needed to have a consent and an order. The resident should have an assessment, should be updated and reviewed by the interdisciplinary team.

Based on interviews and record review, the facility failed to report alleged violations of potential abuse administration in accordance with State law involving one resident (#54) of four residents reviewed for abuse out of 32 sample residents. Specifically, a certified nurse aide failed to report verbal abuse immediately that she witnessed to facility administration by a nurse towards Resident #54. She documented it on a concern form and failed to take further action. Findings include: I. Facility investigationReview of the incident report on 4/30/23 revealed a certified nurse aide (CNA) #10 reported on a concern form that a nurse was verbally abusive toward a resident. 4/29/23 Concern form:(CNA) reported to the RN that the resident did not want to take a shower and (the CNA) asked for help. "(The RN) threw the blankets off of him and told him you are getting in the shower." She continued to tell him that he needed to lose weight because he looked pregnant, making fun of him for the way his pants and underwear looked stating that he looked like he was wearing maternity pants. Alleged assailant summary of interview dated 4/30/23 at 10:10 a.m. documented in part:The registered nurse (RN) stated she was told by CNA that the resident wanted a shower and then did not want one. RN reported that she went into the resident's room and asked him to take a shower and he agreed to do so. RN reported that she did not throw his blankets back or throw them on the floor. She did not tell the resident that he looked pregnant or that his pants looked like maternity pants. She stated she did ask the CNA, "What was up with his pants, are they small?" CNA stated she did not know. Witness interview summary dated 4/30/23 at 10:40 a.m. documented in part:The witness associate (CNA) reported on a concern form that RN was verbally abusive towards a resident on 4/29/23. The associate put a concern form in the nursing home administrator (NHA) mailbox on 4/30/23 and did not report to anyone. Alleged victim interview summary dated 4/30/23 at 10:40 a.m. documented in part:The resident stated everyone treated him well and did not recall someone throwing his blanket down. Witness (CNA) follow-up interview on 4/30/23 revealed she was questioned about the above statement; she reported that she felt like the RN was verbally abusive. She did not know when asked if the resident heard what the RN said. She reported the resident was getting his stuff ready so, "I don't know." When asked if she reported this incident to anyone on 4/29/23 she said "No, I was busy."The alleged allegation of verbal abuse was unsubstantiated. The resident denied anyone being rude to him or throwing his blankets off or on the floor. No resident or staff had any concerns with any nurse mistreating any resident. Describe interventions that were put into place to prevent reoccurrence documented in part:Review of abuse training with staff, education was provided to the witness (CNA) that reporting was to be done immediately. She voiced understanding. II. Resident interviewResident #54 was interviewed on 10/25/23 at 12:27 p.m. Resident #54 said he had been yelled at by a nurse but when asked to clarify what happened he said, "I don't want to get anyone in trouble." III. Staff Interviews CNA #10 was interviewed on 10/25/23 at 1:04 p.m. CNA #10 said she had requested help from the RN to help get the resident to take a shower. She said that was when the RN became verbally abusive with the resident making fun of the way he was dressed. She said Resident #54 wore his pants up to his waist and that was what the comments were about. She said the RN had since left the facility as she received a new job. The nursing home administrator was interviewed on 10/26/23 at 12:00 p.m. She said she was the abuse coordinator. The NHA said the CNA alleged the RN had made some inappropriate comments towards the resident and the facility investigated but no staff heard the RN verbally abuse Resident #54. She said the nurse was suspended pending the investigation. She said staff and other residents in other halls had not heard the nurse speak to the resident in an aggressive manner so the verbal abuse was unsubstantiated. She said the CNA reported it but stated she was not aware if the resident heard the comments.

Based on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#71) out of 32 sample residents. Specifically, the facility failed to ensure Residents #71 was assessed by a registered nurse (RN) following a fall. Findings include: I. Resident status Resident #71, age 76, was admitted on 7/7/23. According to the October 2023 computerized physician orders (CPO), diagnoses included atrioventricular block, atrial fibrillation, chronic obstructive pulmonary disease (COPD), urinary tract infection and kidney failure. According to the 7/31/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had no falls since admission. II. Record review The care plan, initiated 5/4/23 and revised 10/19/23, identified the resident was at risk for falls due to impaired mobility and comorbidities. The resident had actual falls. The resident was impulsive and often chooses not to use call light. When he did use the call light, he was unwilling to wait for staff assistance. Interventions include bariatric bed as resident utilized queen bed at home. Be sure the call light was within reach and encourage the resident to use it for assistance as needed. He needs prompt response to all requests for assistance. Offered to move the room closer to the nurse's station. The 9/3/23 nursing progress notes documented at 11:46 p.m. certified nurse aide (CNA) notified that resident was found on the floor. When this nurse arrived at the incident area, the resident was seen seated on his buttocks. His legs stretched and back leaning to the wall behind the door in a room. Resident verbalized sliding down, refusing to hit his head. The resident verbalizes mild pain to left hip. Resident checked head to toe, no new injuries noted. Vital signs were within baseline, existing bruise to left hip from previous fall. Resident was assisted to bed with a two person assist. The resident was cleaned, dried and situated in bed with the bed at its lowest comfortable position. As needed, medication administered. Resident was responsible to self, director of nursing (DON), physician on call notified. Neurological checks and vital signs checks initiated and ongoing. The nursing progress note was documented by a licensed practical nurse (LPN). A review of the resident's medical record on 10/25/23 did not reveal documentation the resident was assessed by an RN following the fall the resident sustained on 9/3/23. Nursing progress note effective date 9/3/23 at 10:35 p.m. Nursing note created on 10/26/23 at 12:26 p.m. (during the survey) documented in part, this nurse assessed resident after being notified by CNA that resident was found on the floor. Resident noted sitting on the floor in the room. Alert and oriented by three, speech clear. Resident denies injury. The resident was able to move all extremities within normal limits. Vital signs were stable. Neurological checks initiated per facility protocol. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 10/25/23 at 11:31 a.m. She said after a resident fall she would ensure the resident was okay and call out for help. She said after ensuring the resident was okay she would help them stand up, get them to bed, start vitals and start neurological checks in the event they hit their head. The director of nursing (DON) was interviewed on 10/25/23 at 11:26 a.m. The DON said the staff should get the nurse immediately and should not move the resident off the ground without the registered nurse completing a full assessment. She said an LPN was not able to conduct an assessment because it was outside of an LPN's scope of practice. She said the RN must complete theassessment to determine if the resident sustained an injury. She said the RN assessment should be documented in the resident's medical record.

Based on observations, record review and interviews the facility failed to provide hearing assistive devices to residents for one (#22) of three residents reviewed for hearing devices out of 32 sample residents. Specifically, the facility failed to ensure the availability and education with staff on the use of hearing aides as ordered for Resident #22. Findings include: I. Resident #22A. Resident statusResident #22, age over 65, was admitted on 11/29/21 and readmitted 12/28/21. According to the October 2023 computerized physicians orders (CPO), diagnoses included Alzheimer's disease, vertigo and bilateral (both ears) hearing loss. The 8/22/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. She had the identified behaviors of wandering during the assessment period. The assessment identified the use of hearing aides. B. ObservationsThe resident was observed on 10/23/23 at 11:10 a.m. without hearing aids. The resident was observed on 10/24/23 at 1:51 p.m. without hearing aids. The resident was observed on 10/25/23 at 10:57 a.m. without hearing aids. C. Record reviewThe care plan, initiated 12/14/23 and revised on 10/9/23, identified a communication deficit related to bilateral hearing loss. She had hearing aids but often chose not to wear them and had a history of throwing them in the trash. Interventions included:-Ensure hearing aids are in place and turned on to both ears as tolerated. The October 2023 CPO included:-Assist resident with inserting her hearing aids. Store case in cart. Ordered 2/2/22.-Remove hearing aids and store in case in medication cart. Ordered 2/2/22.-The progress noted did not identify the resident had missing hearing aids or refused to wear the aids. II. InterviewsCertified nurse aide (CNA) #7 was interviewed on 10/25/23 at 12:40 p.m. She said the resident did not have or wear hearing aids. Registered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She said the resident had an order for hearing aids, however, she could not locate the aides in the medication cart. RN #1 verified the resident did not have the hearing aids in and said she was hard of hearing. She said the resident should be wearing her hearing aides, but did not know where they were. The social services director (SSD) was interviewed on 10/25/23 at 2:30 p.m. She said she did not believe Resident #22 had hearing aids available. She said Resident #22 had hearing aids, but she would refuse to wear them and had a history of throwing them away. She said she did not know where they were. She said she needed to reach out to the family to see if the family took the hearing aids home or if the hearing aids were missing. She said there was some difficulty getting the aids replaced. She said there should be a progress note and an addendum to the care plan that identified the hearing aids were unavailable at that time. The director of nursing (DON) was interviewed on 10/25/23 at 4:35 p.m. She said Resident #22 did have an order for hearing aids. She said she was not sure if the family had the aids. She said if there was an order, she should have them or at least the facility should educate the staff that they were missing, updated the care plan and write a note in the chart.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (#58) of three residents reviewed for accidents/hazards out of 32 sample residents. Specifically, the facility failed to ensure Resident #58 identified as a fall risk wore non-skid footwear while ambulating as identified in the care plan. Findings include: I. Resident #58 A. Resident status Resident #58, age 82, was admitted on 5/9/22. According to the October 2023 computerized physicians orders (CPO), diagnoses included dementia, cognitive deficit and muscle weakness. The 7/28/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident needed the assistance of one person for dressing. No falls were identified on the assessment. B. Observation and interview The resident was in the dining room on 10/23/23 at 1:52 p.m. She was wearing regular socks and was ambulating around the dining room and the hallways. The resident was in the dining room and the television area on 10/25/23 at 8:59 a.m. wearing regular socks. C. Record review The care plan, initiated on 5/19/22 and revised on 6/15/23, identified the resident was a fall risk. Interventions included to ensure Resident #58 was wearing appropriate, non-skid footwear when ambulating. II. InterviewsCertified nurse aide (CNA) #7 was interviewed on 10/25/23 at 12:40 p.m. She said Resident #58 had fallen. She said Resident #58 had special shoes, but she did not like wearing them. She said she should have non-skid footwear while ambulating to help prevent falls. Registered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She said Resident #58 was a fall risk and should be wearing non-skid footwear. RN #1 verified Resident #58 did not have non-skid footwear on. She said she would make sure going forward she would have non-skid footwear on. The director of nursing (DON) was interviewed on 10/25/23 at 4:35 p.m. She said Resident #58 was a fall risk. She said Resident #58 should have non-skid footwear while ambulating to help prevent falls.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#183) of three residents reviewed for supplemental oxygen use out of 32 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #183. Findings include: I. Facility policy The Oxygen Administration Policy, revised 4/14/23, was provided on 10/25/23 at 1:55 p.m. by the nursing home administrator (NHA). It read in pertinent part, "Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person centered care plans, and the resident's goal and preferences." II. Resident #183 A. Resident status Resident #183, age 73, was admitted on 9/22/23. According to the October 2023 computerized physician orders (CPO), diagnoses included chronic respiratory failure, venous insufficiency and psychophysiology insomnia. According to the 9/28/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. The resident had verbal and physical behaviors directed towards others. He required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Observation On 10/23/23 at 2:16 p.m. Resident #183 was lying in bed sleeping with her oxygen cannula on the right side of her bed, The resident's oxygen concentrator was set on two liters per minute (LPM).-However, there was an order for 3 LPM continuously (see below). On 10/24/23 at 1:31 p.m. Resident #183 returned from her smoking break and she did not have her oxygen cannula on. An unidentified male certifed nurse aide (CNA) did not encourage or tell the resident to put her nasal cannula on. -At 3:34 p.m. Resident #183 was observed sitting in her wheel chair in her room. Resident #183 was not wearing her oxygen. Her oxygen cannula was on her bed. The restorative nurse aide (RNA) observed Resident #183 sitting in her wheelchair without her oxygen on. The RNA had a pulse oximeter and placed it on the resident's finger. The RNA read the pulse oximeter which was 75. The RNA had the resident take several deep breaths and the resident was able to get it to 78 and the resident continued to take deep breaths and was able to get her oxygen up to 91. C. Record review The care plan, initiated 9/22/23 and revised 10/4/23, identified the resident was on oxygen therapy related to emphysema and chronic respiratory failure with hypoxia (low oxygen levels). The resident prefers to hold the nasal cannula for oxygen therapy at her mouth. Education and encouragement provided to use nares during eating, the resident declines. Interventions include giving medications as ordered by the physician. Monitor/document side effects and effectiveness. Monitor for signs and symptoms of respiratory distress and report to medical provider as needed, respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Oxygen setting via nasal cannula at 3 LPM continuous. The October 2023 CPO included an order dated 10/3/23 for oxygen at 3 liters per minute (LPM) continuously via nasal cannula every shift due to diagnosis of hypoxia. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 10/24/23 at 3:51 p.m. She said she was familiar with Resident #183. She said Resident #183 liked to wear her cannula in her mouth as she did not like it in her nostrils. She said if staff saw she was not wearing they should encourage the resident to put her oxygen on. She said oxygen was a medication and should be administered per physician's order. The director of nursing (DON) was interviewed on 10/25/23 at 4:35 p.m. The DON said oxygen was a medication. She was told of the observation above. She said staff should be encouraging the resident to wear her oxygen and report the refusal to wear her oxygen and when it was low. The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls and hypoxic events and could have put the residents in respiratory distress.

Based on record review and interviews, the facility failed to ensure residents who were diagnosed with Alzheimer's/dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for one (#58) out of four residents reviewed for mood and behavior out of 32 sample residents. Specifically, the facility failed to:-Develop a person centered individualized care plan with effective interventions for Resident #58; and,-Train staff on individualized person centered interventions for aggressive behaviors for Resident #58. Findings include: I. Resident #58A. Resident statusResident #58, age 82, was admitted on 5/9/22. According to the October 2023 computerized physicians orders (CPO), diagnoses included dementia, cognitive deficit and muscle weakness. The 7/28/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. No behaviors were identified on the assessment. B. Record reviewThe care plan, dated 7/31/23 and revised on 8/21/23, identified aggressive behaviors that appear to be unprovoked. Interventions included:-Monitor for signs and symptoms of aggression.-One-to-one for safety.-The care plan did not include interventions for Resident #58 when she would become aggressive as indicated by staff (see below). C. AltercationsResident #58 was involved in two resident-to resident altercations on 7/17/23 and 7/31/23. She was the aggressor in both altercations (cross-reference F600 for abuse). II. InterviewsCertified nurse aide (CNA) #7 was interviewed on 10/25/23 at 12:40 p.m. She said Resident #58 had a one-to-one to prevent altercations with other residents. She said usually it would be another resident who would start an argument, Resident #58 would just finish it. She said when Resident #58 became upset, the staff encouraged her to go to her room where it was quiet and away from people always helped her calm down. Registered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She said Resident #58 had behaviors of striking out and yelling at others. She said taking her to her room where she was by herself when she was upset was the most effective intervention. RN #1 said the one-to-one helped prevent altercations as well. The social services director was interviewed on 10/25/23 at 2:30 p.m. She said Resident #58 had a history of hitting others. She said when Resident #58 would display aggression, staff were to redirect her, ask her if she needed the restroom, see if she needed food or drink, distract her or take her to an activity. She said she had not provided training for the staff to include the interventions for Resident #58's aggressive behaviors. She said she was not aware the direct staff had different interventions for Resident #58. The DON was interviewed on 10/25/23 at 4:35 p.m. She said when Resident #58 displayed aggressive behaviors, staff should redirect her off the unit and offer snacks. She said Resident #58 liked old movies at one point also. She said she was not aware the direct staff identified different approaches with Resident #58. She said she was not aware of any training for staff on Resident #58's aggressive behaviors and interventions to implement.

Based on record review and interviews, the facility failed to ensure five (#13, #38, #3, #23 and #52) of eight residents were free from unnecessary psychotropic medications out of 32 sample residents. Specifically, the facility failed to:-Monitor targeted behaviors and individualized non-pharmacological approaches for psychotropic medications for Residents #13, #38 and #3; -Follow pharmacist recommendations for gradual dose reductions of psychoactive medications for Resident #3 and #23;-Ensure risks were reviewed for an antipsychotic medication prior to administration for Resident #3; and,-Ensure as-needed (PRN) orders for psychotropic/antipsychotic medication did not extend 14 days without documented clinical rationale from the physician or a physician evaluation of the resident for Residents #52 and #23. Findings include: I. Facility policyThe Behavior Monitoring policy dated 3/10/23, was provided by the corporate nurse consultant (CN) on 10/25/23 at 3:36 p.m. It read in pertinent part:"The purpose of behavior monitoring is to establish an accurate pattern of resident target behaviors determined by the resident's history, evaluation, assessment."If a psychoactive medication is needed, use the lowest possible dose and document the outcome. Initiate behavior tracking for the specific psychoactive medication-list the target behaviors identified." II. Resident #13A. Resident statusResident #13, age under 65, was admitted on 10/22/21. According to the October 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type and unspecified intellectual disabilities. The 9/5/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. No behaviors were indicated. B. Record reviewThe comprehensive care plan, revised 9/5/23, revealed the resident had poor boundaries with staff, primarily male staff members. She made sexually inappropriate comments and had delusional beliefs she was in romantic relationships with male staff. Interventions included to monitor, report and document sexually inappropriate behaviors. The resident had a history of sexual trauma and when feeling triggered, she would display sleep disturbances, increased irritation, and make false allegations. Staff were to provide the resident care with another staff member present. The resident had a history of physical aggression such as throwing items or self harm. Triggers included others' public display of affection and being called by her legal name not her preferred name. Interventions included being aware of triggers, monitoring for signs and symptoms of depression, anxiety, difficulty sleeping, irritability, anger and sadness. The October 2023 CPO revealed the following physician orders:Sertraline 100 milligram (MG)- give one time a day for depression-ordered on 8/30/23. Observe for general behaviors related to schizoaffective disorder: itching, picking at the skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care- ordered on 8/30/23.-A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 8/1/23 to 10/24/23 failed to reveal any behavior tracking. III. Resident #38A. Resident statusResident #38, age under 65, was admitted on 7/28/23. According to the October 2023 CPO, diagnoses included bipolar disorder. The 8/31/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Record reviewThe comprehensive care plan, indicated on 7/28/23, revealed the resident received antidepressant, antianxiety, and antipsychotic medications related to bipolar disorder. Symptoms included insomnia, auditory hallucinations, perseveration of stressful events and expressions of sadness. Interventions included monitoring for behaviors of sadness, loss of pleasure or interest in activities, feelings of worthlessness and mania or hypomania. The October 2023 CPO revealed the following physician orders:Aripiprazole (antipsychotic) 5 MG- give one time a day for bipolar disorder-ordered on 7/28/23,Clonazepam (anticonvulsant) 2 MG- give one time a day for bipolar disorder-ordered on 7/28/23; and,Mirtazapine (antidepressant) 15 MG- give one time a day for insomnia-ordered on 9/7/23. -A review of the resident's MAR and TAR from 8/1/23 to 10/24/23 failed to reveal any behavior or hours of sleep tracking. IV. Resident #3A. Resident statusResident #3, age under 65, was admitted on 328/17. According to the October 2023 CPO, diagnoses included borderline personality disorder and major depressive disorder. The 9/25/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Record reviewThe comprehensive care plan, revised 6/22/23, revealed the resident had a history of trauma and difficulty trusting male staff members. When feeling triggered, she would become resistant to personal care, have difficulty managing her anger, engage in self-harm, or punch walls. Non-pharmacological interventions such as audio books, arts/crafts, taking her to smoke and socializing with other residents were to be encouraged. Staff were to monitor for signs and symptoms of depression, anxiety and substance abuse issues. The resident had a history of becoming verbally aggressive with other residents, teasing other residents and making false allegations towards staff. Interventions include to assess the residents' understanding of the situation and document observed behaviors, potential causes and interventions tried. The resident had a history of cutting (self-mutilation) and expressions of suicidal ideations. Staff were to observe and monitor for indicators such as verbal expressions of suicidal ideations, stock pilling pills, saying goodbye to family, refusing to eat or refusing medications or therapies. Interventions include offering games to play on a tablet, coloring, talking when she had calmed down, providing a physically based pillow for anger moments and praising the resident for improvement in behaviors. The October 2023 CPO revealed the following physician orders:Paroxetine (antidepressant) 30 MG-give two tablets a day for major depressive disorder-ordered on 9/17/22; and, Lamotrigine (anticonvulsant) 200 MG-two times a day for major depressive disorder-ordered on 5/16/22. Observe behaviors related to antipsychotic medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered or other-ordered on 1/18/23. Abilify (antipsychotic) 5 MG-give one time a day for major depressive disorder-ordered on 5/22/23. Observe behaviors of sad affect and labile mood related to antidepressant medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered, or other-ordered on 6/7/23;Observe behaviors of anger and thoughts of self-harm related to antidepressant medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered, or other- ordered on 7/28/22; and,Observe behaviors of increased aggression related to antidepressant medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered, or other- ordered on 7/28/22; Latuda (antipsychotic) 20 MG-give one time a day for major depressive disorder-ordered on 8/3/23. The 8/4/23 medication regimen review from the pharmacist documented a recommendation to review the Lamotrigine 200 MG two times a day and the Paroxetine 30 MG two tablets a day for a gradual dose reduction. -As of time of survey on10/23/23, the gradual dose reduction had not been reviewed. -A review of the resident's medical record failed to reveal consent that reviewed the risks associated with the medication had been obtained for the administration of the Abilify. -Behavior tracking was initiated in the orders however, the non-pharmacological interventions were not individualized. Behavior tracking for the antipsychotics had no target behaviors listed. V. Resident #23A. Resident statusResident #23, age 80, was admitted on 12/6/12. According to the October 2023 CPO, diagnoses included bipolar disorder and post traumatic stress disorder. The 8/7/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. No behaviors were indicated. B. Record reviewThe comprehensive care plan, revised 3/16/22, revealed the resident had a diagnosis of gastroesophageal reflux disease (GERD) and experienced nausea. The resident took PRN Prochlorperazine for her nausea. Interventions include to observe and document side effects and effectiveness. The October 2023 CPO revealed the following physician orders:Prochlorperazine (antipsychotic) 10 MG-give one tablet every six hours as needed for nausea- ordered on 6/19/23; and, Alprazolam (antianxiety) 0.5 MG- give one tablet every six hours PRN for anxiety-ordered on 10/12/23. The October MAR reviewed from 10/1/23 to 10/26/23 revealed:Prochlorperazine 10 MG was administered 20 days out of the month. Alprazolam 0.5 MG was administered 11 days out of the month. The 8/4/23 medication regimen review from the pharmacist dated 8/4/23 documented "regulations limit the PRN use of any psychoactive medications to 14 days. Antipsychotic medications must have a 14 day stop date. There is no exception for psychotropic medications being used for nausea. Please add a 14 day stop date to the order for prochlorperazine." -As of 10/25/23, the time of the survey, the medication remained as a PRN administration. VI. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 10/25/23 at 11:10 a.m. She stated Resident #13 had no behaviors other than becoming upset when she did not get her way. There were no concerns with male caregivers taking care of her and CNA #3 was unaware of any incidents with male caregivers. The resident had no history of harming herself or others. She knew the resident required care in pairs, meaning more than one caregiver present during care, but she did not know why. She was not aware of specific behaviors to monitor or individualized interventions for the resident. CNA #3 stated Resident #38 had no behaviors towards staff or other residents. She had no behaviors of self-harm or harming others. She was not aware of specific behaviors to monitor or individualized interventions for the resident. Resident #3 had no behaviors toward staff or other residents. She had no behaviors of self-harm or harming others. CNA #3 was not aware of specific behaviors to monitor or individualized interventions for the resident. If a new behavior was noticed, the CNA would report the behavior to the nurse. She was not sure where the nurse documented behaviors. CNAs documented in a different system than the nurses and the behaviors and interventions for each resident were the same. Behaviors and interventions were not personalized. She did not have access to look at resident care plans. Licensed practical nurse (LPN) #1 was interviewed on 10/25/23 at 11:28 a.m. She stated Resident #13 was manipulative towards the staff, pitting staff against each other. If the resident could get one-on-one attention from the staff for 10 minutes, her behaviors improved. The resident had no history of harming herself or others. LPN #1 knew the resident required care in pairs, and said it was because of the resident's physical condition. She was unaware of any inappropriate behaviors or behaviors directed towards male staff. She was not aware of specific behaviors to monitor or individualized interventions for the resident. LPN #1 said Resident #38 did not have behaviors. There were no specific interventions for her. Staff would offer her food or drinks or take her to activities. There were no hours of sleep tracked because the resident was on an antidepressant for insomnia not a sleep aid. She stated Resident #3 suffered from depression and had a history of making suicidal statements. The interventions were to provide her with one-on-one attention and take her out for a cigarette break. She was not aware of any other specific behaviors to monitor or individualized interventions for the resident. LPN #1 said the nurses have to track the resident's behaviors, interventions and outcome on the TAR. If a resident had specific interventions other than the generic ones listed on the TAR, it would be communicated verbally to the nurses by management. She was not sure what was done if a staff member who provided care for a resident was not present when management discussed new interventions. LPN #4 was interviewed on 10/25/23 at 12:37 p.m. She stated Resident #13 had behaviors of making false allegations toward staff but did not know specifically what the allegations had been. She was not aware of inappropriate behaviors toward males or why the resident required care in pairs. She was not aware of any other specific behaviors to monitor or individualized interventions for the resident. LPN #4 stated Resident #3 had behaviors of making suicidal comments. There were no other behaviors she was aware of or specific interventions to use with the resident. The social services director (SSD) was interviewed on 10/25/23 at 2:27 p.m. She stated behavior tracking showed up on the nurse's TAR for documentation. The nurse entered the order and triggered it to show up on the TAR. Behaviors documented were used in the facility's drug committee meeting to determine if medications were effective or not. Resident specific target behaviors and interventions came from the resident's admission information, evaluations from the state mental health agency, the resident or the family. The behaviors listed on the trackers were personalized but the interventions were generic for each resident. A behavior tracker was put into effect when a psychoactive medication was started and should be initiated for all psychoactive medications. Tracking behaviors were important to ensure a resident's needs are met and the care provided is effective. The CNAs had only recently started documenting resident behaviors in the CNA tasks and had not received any education on monitoring or documenting behaviors. The behaviors and interventions on the tasks were not personalized for each resident. Resident #13 had behaviors of being sexually inappropriate with male staff. The nurses and CNAs should be looking in the resident's care plan for specific behaviors and interventions. The SSD was not aware the staff were not looking in the care plans. Resident #13 displayed behaviors of throwing items at staff and residents. Resident #3 had behaviors of expression of suicidal ideations, manipulation of staff and providers and verbal aggression. She said the behavior tracking for the antipsychotic medication was missed. Resident #38 experienced auditory hallucinations and would perseverate on stressful life events. She said the behavior tracking for the antipsychotic and anticonvulsant medications were missed. Anticonvulsant medications used to treat mental illness needed to have behavior tracking in order to monitor effectiveness. The resident was taking an antidepressant for insomnia and hours of sleep should be tracked. She said she was not aware hours of sleep were not being tracked. She said PRN antipsychotic medications must have a 14-day stop date included in the order when started. She was not aware Resident #23 had been on a PRN antipsychotic since June 2023 without a stop date and that a stop date was requested in a pharmacy review in August 2023. The director of nursing (DON) was interviewed on 10/25/23 at 4:39 p.m. The facility's policy on PRN antipsychotic medications was a 14-day stop date to be included in the initial order. When a resident was admitted on psychoactive medications, the admission nurse would obtain consent from the resident or responsible party. When a resident was started on a psychoactive medication, consent was needed before the medication could be started. She was not aware Resident #3 did not have a consent in place for Abilify. A consent should have been obtained before the medication was ordered to ensure the resident or responsible party were in agreement. She said to track behaviors, CNAs utilize the kardex (CNA tasks system) for behavior interventions. The kardex were linked to the resident's care plan. Behaviors observed and interventions tried generated in the CNA documentation system but the behaviors and interventions were not personalized. The facility provided training to nurses on how to document behaviors but no specific training for the CNAs. Generic interventions that were not person centered were not helpful for the staff when managing behaviors because each resident was different. The DON was not aware the trackers non-pharmacological interventions for suicidal ideations were the same as the interventions for aggression. During the survey, the DON identified the pharmacy recommendations were not being sent to the residents attending physicians and the system was broken. She would be working on developing a new system for pharmacy recommendations to ensure better communication with the physicians. VII. Facility follow-up On 10/26/23 at 10:39 a.m. the DON provided consent for Resident #3's Abilify. The consent was obtained on 10/26/23 at 10:15 a.m. On 10/27/23 at 1:28 p.m an email was received from the DON. It revealed education had been provided to the hospice provider for Resident #23 and #52 regarding including a 14-day stop date on all PRN orders. Documentation included in the email was a stop date order for Resident #52 Lorazepam dated 10/27/23 and Resident #23 Alprazolam dated 10/27/23. -However, there was no stop date on Resident #23's Prochlorperazine, which was an antipsychotic medication that could not be renewed past 14 days unless the attending physician evaluated the resident for the appropriateness of the medication. VIII. Resident #52A. Resident statusResident #52, age over 65, was admitted on 9/27/19. According to the October 2023 computerized physicians orders (CPO), diagnoses included degeneration of the brain, dementia and abnormalities of gait. The 8/6/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired and unable to complete a brief interview for mental status (BIMS). The assessment did not identify the resident had any behaviors during the assessment period. The assessment identified the resident was taking an anti-anxiety medication. B. Record reviewThe care plan, initiated on 6/29/23 and revised on 10/9/23, identified the resident had physical aggression related to dementia and poor impulse control. Interventions included:-Administer medications as ordered. Monitor/document for side effects and effectiveness.-Monitor/Document observed behaviors and attempted interventions in behavior log every shift. The care plan, initiated on 10/16/2020 and revised on 10/6/23, identified the use of antianxiety medication for a diagnosis of dementia with behavioral disturbance. Interventions included:-Administer anxiolytic (antianxiety) medications as ordered by the physician. Observe for side effects and effectiveness.-Observe/document/report as needed medications show any adverse reactions to anxiolytic therapy. The October 2023 CPO included Lorazepam 0.5 milligrams (mg), Give one tablet by mouth three times a day and every six hours as needed (PRN) for agitation. The order was written on 9/18/23. She received one PRN dose on 10/11/23. The medication regimen review dated 7/5/23 identified the medication Lorazepam 0.5 mg as needed. The review included, "Can you please indicate an anticipated duration of use and document continued use and rationale for the medication." C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She reviewed the order for Lorazepam in the resident's electronic chart. She identified the standing order for three times a day was written with the as needed order. She said the orders should have been written separately. The DON was interviewed on 10/25/23 at 4:35 p.m. She said she was not aware how the order was written. She said the order should have been written separately and the as needed order should have been reviewed if used after 14 days by the physician for indication and duration.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure:-Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process;-Cutting boards were free from deep scratches and stains; and,-Beard restraints were worn in kitchen areas while serving food. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 "Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds." B. Observations and staff interview On 10/25/23 at 9:55 a.m. the cook (CK) had prepared the pork that was from the oven and placed it in a large metal container. The CK poured a large bottle of barbeque into the pan of pork and started mixing in the barbeque sauce and pork. The CK did not take the temperature of the pork prior to mixing in the barbeque sauce. The CK placed 11 scoops of the barbequed pork into the food processor and proceeded to puree the pork. The CK poured hot water into the barbequed pork until the puree reached the right consistency. The CK placed the pureed barbequed pork into a metal pan and proceeded to wrap it with aluminum foil. The CK was asked what the temperature of the pureed pork and the CK stated the temperature of the pureed chicken was 111 degrees F. He then wrapped the metal container and placed it into the warming oven. The CK pureed the green beans in the same process. With the temperature of the green beans being 121 degrees F after being prompted to take the temperature. He then wrapped the metal container and placed it into the warming oven. The CK proceeded to complete the same process for the minced meat mechanical soft barbequed pork. He then placed 11 scoops of the barbequed pork into the blender and proceeded to finish the minced meat mechanical soft pork. After getting it to the correct consistency he grabbed another metal pan and poured the barbequed pork into the pan. He placed it on the counter and took the temperature after being prompted, which was 111 degrees F. He wrapped it with aluminum foil and placed it into the oven. -At 10:13 a.m., the CK was asked if he checked the temperature of the minced moist foods and pureed food after pureeing them. The CK said, "No, I do not, but I would take the temperatures before serving them and they should be at 160 degrees F." -At 11:04 a.m. the dietary manager (DM) again took the temperature of all items listed above. The barbequed pork minced meat mechanical soft was at 163 degrees F, the pureed barbequed pork was at 162 degrees F and the pureed green beans was at 163 degrees F. The regular barbequed pork was at 113 degrees F which was on the hold line. C. Additional interview The DM was interviewed on 10/26/23 at 8:41 a.m. She said she was aware the temperatures of the modified food dropped at times. She said the food was okay as long as it reached 165 degrees F before serving. She said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and "Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized." B. Observation The initial kitchen tour conducted on 10/23/23 at 8:45 a.m. revealed four large cutting boards. There were green, blue, red and brown cutting boards. All cutting boards were heavily scored and stained. On 10/25/23 at 9:47 a.m., the CK was cutting the pork on a red cutting board. C. Staff Interview The DM was interviewed on 10/26/23 at 8:44 a.m. The DM was told of the observations of the cutting boards in the kitchen. She said the cutting boards were visibly stained and scored. She said he would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Beard restraints A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19) pg. 51, "food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles." B. Observations and interviews On 10/25/23 at 8:32 a.m. the CK was observed in the kitchen area without wearing a beard restraint. The CK's beard was approximately two inches long. The CK was preparing meals and was standing over the oven stirring various foods. -At 9:49 a.m. the CK was observed in the kitchen area not wearing a beard restraint. The CK was observed preparing lunch meals. The DM was interviewed on 10/26/23 at 8:44 a.m. She stated all kitchen staff were required to wear hair restraints and should have all hair covered. The DM said staff who had facial hair should be wearing a mask or a beard guard while preparing or serving meals. She said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas to ensure hair did not fall into any food.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for three of six unitsSpecifically, the facility failed to ensure: -Staff performed hand hygiene between glove use;-Staff wore personal protective equipment (PPE) when entering COVID positive rooms;-Staff doffed (removed) gowns prior to exiting a COVID positive room; and,-A COVID positive resident did not occupy areas frequented by COVID negative residents. Findings include: I Professional referenceAccording to the Centers for Disease Control (CDC) guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 11/2/23 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf. It read in pertinent part,"-PPE must be donned correctly before entering the patient area.-PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted.-Both your mouth and nose should be protected."II. Facility policyThe COVID-19 Prevention, Response, and Testing policy, dated 6/26/23, was provided by the corporate nurse consultant (CN) on 10/24/23 at 1:39 p.m. It read in pertinent part: "Procedure when COVID-19 is suspected or confirmed:"Place the resident in isolation with droplet transmission-based precautions with the door closed. Wear gloves, gowns, goggles/face shields, and N95 masks upon entering the room and when caring for the resident. Evaluate the need for hospitalization. "Restrict the resident to his/her room. Ask the resident to cover their nose/mouth prior to entering the room. Place facemask on resident if leaving the room for medically necessary activities."III. Failures with PPESignage on the COVID-19 rooms on isolation read:"Enhanced droplet precautions, perform hand hygiene, N95 mask, eye protection, gown when entering room, gloves when entering the room." Observations on 10/24/23The nurse practitioner (NP) was observed at 10:09 a.m. donning (putting on) personal protective equipment (PPE) prior to entering Resident #53's room, who was COVID-19 positive. The NP wore the same N95 mask he came into the hallway wearing. He did not perform hand hygiene prior to putting on gloves or put on eye protection before entering Resident #53's room. The NP exited Resident #53's room at 10:14 a.m. He doffed all of his PPE outside of the residents room. He rolled up his gloves in the gown, entered Resident #53's room again and discarded the PPE inside the room. He did perform hand hygiene after doffing his PPE. The NP proceed with same process as he had done with Resident #53's room when entering Resident #19 and Resident #66's rooms at 10:20 a.m. who were COVID-19 positive. He did not change his N95, he did not perform hand hygiene before or after entering the residents' rooms. He doffed his PPE outside of the resident's room and then reentered the room to dispose of the PPE. The NP entered the room of a resident who was not COVID positive on a different unit at 10:25 a.m.. He did perform hand hygiene prior to entering or exiting the room. An unidentified resident aide (RA) and RA #1 were observed going into Resident #19's room at 10:53 a.m to change the resident's linen. During this process neither of the RAs were wearing PPE when changing the residents linens. RA #1 was then asked to assist with another resident who was not COVID positive. RA #1 entered the resident's room to assist. IV. COVID-19 positive residentResident #35 was observed on 10/24/23 at 2:45 p.m. exiting a quarantined unit. The resident was COVID-19 positive and not wearing a mask. An unidentified certified nurse aide (CNA) offered him a mask but he ignored her. He left the unit and went into the main lobby coughing several times. There were no other residents in the lobby. An unidentified nurse passing by was able to encourage the resident to put a mask on at 2:46 p.m. Resident #35 was observed again in the front lobby at 3:35 p.m. He had left through the smoking area, came around the building and entered. He was sitting in the front lobby without a mask. He then returned to his quarantined unit at 3:39 p.m. No residents had been in the lobby with him. V. Staff interviewsCNA #11 was interviewed on 10/24/23 at 10:05 a.m. CNA #11 said she was informed that morning Resident #53, Resident #19 and Resident #66 were all positive for COVID-19. She said the residents had been feeling bad for some time and were tested that morning. The results showed all three residents were COVID-19 positive. The NP declined to be interviewed on 10/24/23 at 10:30 a.m. Registered nurse (RN) #4 was interviewed on 10/24/23 at 2:50 p.m. RN #4 worked in the quarantined unit. She stated residents were to keep the room doors closed and wear a mask if they left the rooms. The staff encouraged the residents to stay on the unit but if the residents wanted to leave the unit, staff were to encourage the resident to wear a N95 mask or at least a surgical mask. The infection preventionist (IP) was interviewed on 10/24/23 at 4:20 p.m. She stated Resident #35 often refused care and redirection. If the staff persisted to attempt to redirect a behavior, he would become angry and agitated. The staff would have to walk away and return. The staff tried to encourage him to wear a mask when he left his room and if he left the quarantined unit. The staff tried to keep other residents away from him when he sat in the front lobby. The director of nursing (DON) was interviewed on 10/24/23 at 5:07 p.m. The facility had assigned a designated sitter to accompany Resident #35 when he left his unit. This was to ensure if he refused to wear a mask, he could be redirected from other residents and areas he occupied would be disinfected. The staff would utilize some of the resident's favorite snacks to provide incentive for him to wear a mask. VI. Facility COVID-19 status The IP was interviewed on 10/24/23 at 4:20 p.m. She said the facility had 11 COVID-19 positive residents.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management for six of six CNAs reviewed. Specifically, the facility failed to ensure CNAs #3, #4, #5 #6, #1 and #2 received annual dementia management training. I. Training review Six nurse aides were reviewed for the annual required dementia management training. Training records revealed six of the six did not have the required annual training:CNA #3 was hired on 7/7/22. She had not had annual dementia management training. CNA #4 was hired on 1/21/21. She had not had annual dementia management training. CNA #5 was hired on 10/27/22. She had not had annual dementia management training. CNA #6 was hired on 8/31/21. She had not had annual dementia management training. CNA #1 was hired on 8/23/22. She had not had annual dementia management training. CNA #2 was hired on 1/12/22. She had not had annual dementia management training. II. InterviewThe director of nursing (DON) was interviewed 10/25/23 at 4:35 p.m. She said the facility had not provided dementia management training to any CNAs in the past 12 months. She said all aides providing care should be trained on dementia management due to the population the facility serves.

A revisit survey was completed on 5/8/23 for all previous deficiencies cited on 3/9/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 5/8/23 for all previous deficiencies cited on 3/9/23. The facility is in compliance with all regulations surveyed.

Abbreviated survey prompted by complaint #CO31406. Two deficiencies were written.

Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#1and #2) of four out of 10 residents. Specifically, -Resident #1 was at high risk for pressure injury when she entered the facility. The facility failed to encourage the resident to reposition, As a result the resident developed an unstageable pressure injury to her right heel. The facility failed to ensure treatments were provided as ordered by the physician and develop a person-centered care plan for the resident's pressure injury to the right heel. Additionally the facility failed to ensure:-Resident #2 was not repositioned timely and physician orders were not followed. Findings include:I. Professional referenceThe National Pressure Ulcer Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 3/8/23 read in pertinent part:"Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel orischemic limb should not be softened or removed."The National Pressure Ulcer Advisory Panel (NPUAP), "Prevention and Treatment of Pressure Ulcers" reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure ulcer should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented.-The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications.-Signs of deterioration in the wound should be addressed immediately.-The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedureThe Skin Management policy, revised 10/21/2021, was provided by the director of nursing (DON) on 3/9/23. It read in pertinent part: "Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Residents admitted with skin impairments will have: Interventions implemented to promote healing;A physician's order for treatment; Wound location and characteristics documented. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to the following: Hydration; Nutrition;Preventive device;physical activity; Pain management; Positioning requirements; Proper body alignment; and Psychosocial adjustment to skin impairment."III. Resident #1A. Resident statusResident #1 age 86, was admitted on 11/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included, vascular dementia, chronic pain syndrome, type II diabetes mellitus and cognitive communication deficit. A 1/23/23 assessment, revealed the resident had severe cognitive impairment. No behaviors or refusals of care were noted. The resident required total assistance with activities of daily living. The resident was incontinent of bladder and frequently incontinent of bowel. The assessment revealed the resident was at risk for pressure ulcers and indicated the resident had a pressure injury. B. ObservationsOn 3/7/23 Resident #1 was observed continuously from 8:59 a.m. until 1:07 p.m.-At 8:59 a.m., Resident #1 was in the dining area in her wheelchair. The resident had socks on her feet. -At 9:00 a.m., the resident propelled herself to the common area. -At 9:10 a.m., the resident was assisted to her room by certified nursing aide (CNA) #8.-At 9:14 a.m., the resident was assisted by CNA #8 to lay in bed, heel pressure relief boots were not offered. Foot elevation not offered. The resident's bilateral heels were directly on the mattress. -At 9:30 a.m., the resident continued to lay in bed on her right side. Her heels continued to not be offloaded. -At 9:44 a.m., the resident continued laying in bed, registered nurse (RN) #3 took resident ' s vitals. Heel pressure relief boots not offered. Foot elevation not offered. -At 9:48 a.m., the resident was offered water by CNA #8 but declined and remained on her right side in bed. Heel pressure relief boots not offered. Foot elevation not offered.-At 9:59 a.m., the resident remained asleep on her right side.-At 10:58 a.m., the resident remained on her right side in bed.-At 12:30 p.m., the resident remained in bed.-At 12:31 p.m., the resident was assisted out of bed by CNA #8.-At 12:37 p.m., the resident was assisted back to lay down in bed by CNA #8. The resident was not offered or provided the heel pressure relief boots. Foot elevation not offered.-At 1:07 p.m., the resident was still in bed laying on her right side. On 3/8/23 the resident was observed continuously from 8:33 a.m. until 12:03 p.m. -At 8:33 a.m. the resident was in bed, on her back, foot not elevated, pressure relief boots not observed.-At 8:55 a.m., the resident remained at the same position.-At 9:21 a.m. CNA #8 entered the resident ' s room, replaced water in cup beside the bed. CNA #8 did not wake, reposition or encourage hydration. Resident was not offered pressure relief boots or foot elevation. -At 10:13 a.m., the resident was observed in the room asleep on her back. The resident was observed without pressure relief boots and without her foot elevated.-At 10:21 a.m., the resident observed on the floor, she had experienced a fall. CNA #8 and CNA #9 entered the room to assist the resident. -At 10:30 a.m., the resident was assisted into wheelchair. CNA#9 failed to offer the pressure relief boots. -At 10:56 a.m., CNA #9 assisted the resident back into bed. Pressure relief boots and or foot elevation were not offered.-At 11:03 a.m., RN #3 attempted to administer her medications. Pressure relief boots were not offered. -At 11:41 a.m., RN #3 and DON completed wound dressing change. After the dressing change, the resident was not offered the pressure relief boots. Dressing changeThe March 2023 CPO showed a physician order for the pressure injury: wound care; right heel eschar (dead tissue that falls off (sheds) from healthy skin.), cleanse with NS (normal saline), apply layer of Santyl, cover with xeroform, abdominal pad (ABD, an abdominal pad is an extra thick primary or secondary dressing designed to care for moderate to heavily draining wounds), and wrap with kerlix. Notify the medical doctor (MD) with concerns. Do not use wound cleanser. Additionally, a treatment order for the pressure injury: Skin: green heel protector boots to both feet when in bed. On 3/8/23 at 11:34 a.m. a dressing change performed by the director of nursing (DON) was observed. The resident was lying in bed and did not have green heel protector boots on as ordered when the resident was in bed. The soiled dressing was removed and consisted of xeroform and kerlix, an abd pad was not used although it was ordered. The wound was located on the right posterior heel. There was pink tissue with white exudate, the wound was oozing serous fluid and no odor was noted. The DON rubbed the wound bed in an upward and downward motion using the same 2x2 gauze saturated in normal saline, although debridement was not part of the dressing change order. Next, a layer of Santyl was applied followed by xeroform, an abd pad, and wrapped with kerlix. Visibly dirty socks were placed back on the residents feet and the resident was assisted into her wheelchair. C. Record review The 11/15/22 initial skin documented the resident had no pressure injuries. The progress note dated 12/13/22 documented, the resident was found to have a blister on the right heel during shower skin assessment by CNA and was reported to the nurse. The nurse contacted wound nurse to assess. The progress note documented open blistered area, and the resident ' s name was added to the wound care list for the provider to see on next visit. The note documented heel protector boots were initiated and encouraged, however the resident often kicks them off. Treatment orders were in place. The wound measurements were 4 cm length x 3 cm width with no measurable depth, with an area of 12 sq cm. The wound care physician ' s assistant (WCPA) note dated 12/12/22 documented, the blister was a pressure injury, unstageable, stable eschar, will continue to be followed by the wound team. Encourage turn and repositioning, footrests only to be on during transporting. Wound care physician assistant (WCPA) assessed the resident on 12/19/22. Heel eschar stable. Right heel was an unstageable pressure injury, obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Wound encounter measurements are 4 cm length x 3 cm width with no measurable depth, with an area of 12 sq cm. There was no drainage. Wound bed has 100% eschar. The wound was stable. The Kardex for skin integrity and skin protection identified the resident: have an air mattress in place to promote skin integrity. Monitor pain level during wound care, encourage use of pain medication before/during/after wound care as indicated; cease wound care performance if indicated by my verbalization. Need pressure relieving /reducing cushion to protect the skin while up in chair. Need pressure relieving /reducing mattress and position pillows to protect the skin while in bed. Monitor right second finger skin tear. The Kardex failed to address the physician's order for the pressure relieving boots. The Braden scale completed on 2/27/23 showed the resident was at high risk for pressure ulcers with a score of 17. The care plan last revised on 12/29/22 identified the resident was at high risk for potential and or actual impairment to skin integrity related to fragile skin. Pertinent interventions included: pressure relieving/reducing mattress and positioning pillows to protect the skin while in bed. The care plan did not identify the pressure areas, and also failed to include the interventions to provide the pressure relieving boots. D. Interviews RN #3 was interviewed on 3/9/23 at 9:47 a.m. The RN said the resident developed the pressure ulcer from not being mobile and from being in bed all the time and will only get up to use the toilet. In order to treat the pressure injury residents should be repositioned, offered pressure relief boots or elevation and wound care. Any staff member can offer the resident the pressure relief boots and they should be offered every time she was in bed. Wound care team assessed the resident on Monday. The dressing change was ordered for every other day. RN #3 confirmed the resident was not offered the pressure relief boots by her or the staff present on 3/9/23 during continuous observation. The director of nursing (DON) was interviewed on 3/9/23 at 10:57 a.m. The DON said the resident was at high risk for pressure ulcers due to limited mobility, high fall risk, and she enjoyed to be in bed a lot, sometimes she liked to sleep in bed all day. Initially the ulcer started on 12/7/22 as a blister, which is when the resident was we referred the resident to the wound care doctor. Interventions put in place were: elevating heels and pressure relief boots anytime she is in bed, which should be offered every time she is in bed. The pressure ulcer that developed on her right heel was avoidable. DON confirmed she did receive training by the physician'ss assistant on how to do the dressing change. DON confirmed the antibiotic pad was not in place per the March 2023 CPO. DON said the WCPA applied lidocaine prior to debridement of the wound bed and then continued with the dressing change. The wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said the dressing change was always demonstrated because he expects staff to perform the dressing changes exactly how he demonstrated. The WCPA also said when he gave an order it was a verbal order and he also writes the order in his wound care visit note, his note is then uploaded into the residents chart. He also notifies the primary doctor at the facility if the order was complex. Then he logs into the residents chart and signs the order to confirm it was entered correctly. The WCPA also said turning and repositioning is very important and an air mattress is not a substitute. The WCPA said Resident #1 pressure injury on her heel was avoidable. III. Failure to follow physician orders 1. Resident #2A. Resident statusResident #2, age less than 65, was admitted on 10/5/22. According to the October 2022 computerized physician orders (CPO), diagnoses included, osteomyelitis, unspecified, pressure ulcer of other site, stage 3, pressure ulcer of other site, stage 1, pressure ulcer of sacral region, stage 2, pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, stage 4, pressure ulcer of sacral region, unstageable, pressure ulcer of unspecified part of back, stage 3, and pressure ulcer of left heel, unstageable. A assessment dated 1/9/23, showed the resident had no cognitive impairments. The resident required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, and toilet use. The assessment that the resident had two stage 3 pressure injuries, three stage 4 pressure injuries, and two unstageable deep tissue injury. The assessment identified the resident as at risk for pressure injuries and had unhealed pressure injuries. B. Resident interviewResident #2 interviewed on 3/6/23 at 5:30 p.m. Resident #2 said she had two pressure injuries on her buttock area. C. Physician ' s orders for the pressure injury treatmentThe March 2023 CPO documented the following:-Use two green wedges for side to side positioning due to stage IV left and right ischial tuberosity wounds. They are to be used at every shift related to pressure ulcers with a start date of 10/27/22.-Wound care for left ischial tuberosity: Cleanse wound bed, apply collagen, cover with ABD pad, cover with Hydralock super absorbent dressing, do not use tape. Start date/revision date 1/3/23.-Wound care for right sacrum: cleanse wound bed, apply collagen, cover with ABD pad, cover with HudraLock super absorbent dressing, do not use tape. Start date/revision date 1/3/23.-Wound care for right ischial tuberosity: cleanse wound bed, pack 12 o ' clock tunnel with ¼ inch iodoform packing with Mupirocin 2% ointment, apply collagen, cover with ABD pad, cover with HydraLock super absorbent dressing, do not use tape. Start date/revision date 1/3/23. C. ObservationsDuring the dressing change which was performed by the DON on 3/8/23 at 1:06 p.m., the physician was not followed. The physician order was for a HydraLock dressing, however were not present on the soiled dressing and not available for the new dressing. The resident ' s leg was also wrapped in Kerlix which the DON failed to adhere to the physician ' s order. On 3/8/23 at 1:06 p.m. a dressing change was observed for resident #2 performed by the director of nursing (DON). Staff turned the resident on her side from lying on her back and the DON removed the soiled dressing from the residents sacral, left ischial tuberosity and right ischial tuberosity regions. The soiled dressings consisted of three pieces of collagen from each wound, one ABD pad across the sacrum (the ordered HydraLock dressing was not present), one ABD pad from the left ischial tuberosity (the ordered HydraLock dressing was not present), one HydraLock pad from the right ischial tuberosity and one small piece of packing from the tunneling present in the right ischial tuberosity. The wound on the right ischial tuberosity had both red and pink tissue, significant tunneling, serous/serosanguinous fluid, and no odor was present. The wound on the left ischial tuberosity had bright red tissue with a small amount of white exudate, serous fluid, and no odor was present. The wound on the sacral area was a circular area with depth, serous fluid, and no odor present. The DON sprayed each area with wound cleanser, packed the tunneling in the right ischial tuberosity with ¼ inch iodoform with 2% mupirocin, covered each of the three wounds with collagen, and placed an ABD pad over each wound. The ordered HydraLock dressing was not used on any of the wounds. The resident was then placed on her back in the same position as she was prior to the dressing change. A soiled dressing from a fourth wound on the residents right posterior calf consisted of xeroform, ABD pad, and kerlix. The wound had red and pink tissue with white exudate, serous fluid, and no odor present. The DON sprayed wound cleanser on the wound, applied xeroform, covered with an ABD pad and wrapped with kerlix. The orders stated not to wrap this wound. The dressing change was complete at 1:31 p.m. and the resident remained on her back without green wedges or pillows for offloading. Record ReviewThe 10/5/22 admission assessment documented the resident was admitted to the facility with a stage 4 pressure injury to the left and right ischial tuberosities, stage 2 pressure injury to sacral region stage 2, pressure injury unspecified part of back stage 3, pressure injury left heel unstageable, and pressure injury to sacral region unstageable. The 10/5/22 admission Braden scale for predicting pressure injuries revealed the resident was at a high risk for developing pressure sores. The assessment revealed the resident had slightly limited sensory perception, her skin was rarely moist, she was bedfast, very limited mobility, had adequate nutrition, and had a problem for friction or shear which indicated she required moderate to maximum assistance in moving. The care plan, last updated on 1/9/23, revealed the resident had actual skin breakdown. Interventions included:-elevate head of bed (HOB) no more than 30 degrees; -implement turning schedule if resident is unable to turn and reposition self;-observe and assess weekly (sensory, activity, and, mobility risk); and -use pressure redistribution surface to bed and wheelchair if indicated. Wound care note dated 2/27/23 by wound care physician assistant (WCPA) noted that "Wounds worse on today ' s visit. Although unable to probe to bone, recommending XR (x-ray) of right calf, pelvis, and lumbar spine to evaluate for osteomyelitis as the larger wounds are stagnant or worsening. Right 2nd toe wound has resolved and the left 2nd toe wound showing significant improvement. Pending XR results, will also consider VAC (vacuum-assisted closure) therapy on sacral wound as this wound has been stagnant for several weeks."Wound assessment(s) dated 2/27/23: Wound #1 left ischial tuberosity, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 8.5cm length x 7.5cm width x 0.6cm depth, with an area of 63.75 sq cm and a volume of 38.25 cubic cm. Wound #2 right calf, stage 3 pressure injury pressure ulcer, subsequent wound encounter measurements are 9cm length x 2cm width with no measurable depth, with an area of 18 sq cm. Wound #4 right sacrum, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 2.5cm length x 2.5cm width x 2cm depth, with an area of 6.25 sq cm and a volume of 12.5 cubic cm. Wound #5 right ischial tuberosity, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 6.5cm length x 6cm width x 1cm depth, with an area of 39 sq cm and a volume of 39 cubic cm. InterviewsThe director of nurses (DON) was interviewed on 3/7/23 at 4:19 p.m. The DON stated that Resident #2 often refused to be turned side to side, however, the resident needed to be educated and offered with each care. The DON was interviewed a second time on 3/8/23 at 1:56 p.m. The DON said staff were to follow the physician orders which included both the dressing changes and the positioning devices. She said the order not to wrap Resident #2 lower extremity wound was a new order placed last week and had not been updated in the EMR. She also said the facility was out of the HydraLock dressing and she needed to order more. She said orders are typically entered into the EMR as soon as they are received but the wound care nurse is new and still learning. The registered dietician (RD) was interviewed on 3/9/23 at 10:04 a.m. The dietician reviewed the record and said he was familiar with the resident. The RD said the resident had multiple pressure injuries and was prescribed two health shakes a day for added nutrition and in addition was to receive double protein at all meals and a multivitamin. The wound care physicians assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said the dressing change is always demonstrated because he expects staff to do exactly what he demonstrated exactly how he demonstrated. The WCPA also said when he gives an order it is a verbal order and he also writes the order in his wound care visit note, his note is then uploaded into the residents chart. He also notifies the primary doctor at the facility if the order is complex. Then he logs into the residents chart and signs the order to confirm it was entered correctly. The WPCA also said turning and repositioning is very important and an air mattress was not a substitute. Additional interviewsThe wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said pressure injuries were avoidable unless there were outstanding circumstances or comorbidities like diabetic ulcers. He went on to say turning and repositioning were very important and an air mattress did not substitute a turning and repositioning schedule.

Based on observations, record review and interviews, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for four (#1, #3, #5 and #9) of four out of ten residents. Specifically, the facility failed to:-Ensure Resident #1 was offered hydration on a consistent basis or encouraged to accept hydration per assessed daily minimum recommendation (see nutrition assessment below). Although Resident #1 ' s risk for dehydration was identified upon admission, the facility failed to implement measures to ensure the resident received sufficient fluids to maintain hydration needs. As a result, of the resident poor fluid intake Resident #1 had a change of condition prompted by lack of hydration. The resident was diagnosed with dehydration and was ordered intravenous (IV) fluid therapy. The facility's failure to provide Resident #1 with adequate hydration led to the resident needing IV therapy. Upon the completion of the prescribed IV therapy, the facility failed to ensure the resident consumed sufficient amounts of fluids; failed to monitor the resident ' s fluid intakes to ensure fluid intake meet the resident ' s identified hydration needs; and failed to update the care plan with a care focus that identified the resident was at risk for dehydration; and failed to identify and implement appropriate interventions to prevent repeated episodes of dehydration. The facility's failure left Resident #1 at a high risk for repeated occurrences of dehydration. In addition the facility failed to:-Ensure Residents (#5, #3 and #9) were offered and encouraged hydration per daily minimum recommendations based on the facilities nutrition evaluation. Findings include:I. Professional referenceAccording to Beck AM, Seemer J, Knudsen AW, Munk T. Narrative Review of Low-Intake Dehydration in Older Adults. Nutrients. 2021 Sep 9; retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8470893/ accessed on 3/15/23. "Low-intake dehydration is a common and often chronic condition in older adults. Adverse health outcomes associated with low-intake dehydration in older adults are multifaceted, ranging from poorer cognitive performance, reduced quality of life, delirium, falls, fractures, worsened course of illness and recovery to heart disease, heat stress, kidney failure, unplanned hospital admissions, and increased mortality."II. Facility policy and procedureThe Hydration policy, revised 10/1/2021, was provided by the director of nursing (DON) on 3/9/23. It read in pertinent part: "The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Care plan implementation: The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: Offer the resident a variety of fluids during and between meals; provide assistance with drinking; ensure beverages are available and within reach; evaluate resident's medications that may place the resident at risk for dehydration; offer alternative fluids such as broths, popsicles, gelatin, and ice cream; address underlying causes of dehydration or fluid imbalance; provide thickened liquids after underlying causes of symptoms are addressed; real food and beverages will be offered first before adding supplements or assisted hydration (unless clinically indicated); tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. "III. Failure to ensure Resident #1 was offered and encouraged adequate hydration per daily minimum recommendation based on the facilities nutrition evaluation. 1. Resident #1A. Resident statusResident #1, age 86, was admitted on 11/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included, vascular dementia, chronic pain syndrome, type II diabetes and cognitive communication deficit. A 1/23/22 assessment showed the resident had severe cognitive impairment. The resident required total assistance with activities of daily living (ADLs) and staff supervision with encouragement and cuing (throughout the meal) while eating. The resident was incontinent of bladder and frequently incontinent of bowel. The assessment documented the resident was at risk for pressure ulcers and had developed a pressure injury that has not healed since 12/12/23. The assessment documented the resident was not having any behaviors or refusal of care. B. ObservationsThe resident was observed continuously on 3/6/23 from 3:54 p.m. until 6:00 p.m.-At 3:54 p.m. the resident was observed sleeping, with a full bottle of water on the bedside table, but the water bottle was not within reach of the resident. -At 4:14 p.m., the resident was observed sleeping, staff had not entered the resident ' s room.-At 4:22 p.m., the resident was assisted out of her bed to the wheelchair in preparation for dinner time. The resident was not offered hydration.-At 4:26 p.m., the resident was observed out in the hallway and encouraged to dine in the dining room on the unit. -At 4:27 p.m., the resident was served dinner with 240 cubic centimeters (cc) of water, 240 cc of milk, 240 cc of juice, and 240 cc of hot chocolate. -At 4:33 p.m., the resident was observed not eating and or drinking. Certified nurse aide (CNA) #9 encouraged the resident to eat by saying "eat your food." The resident did not eat or drink any of the food or drinks offered.-At 4:45 p.m., the resident was not eating the served meal; staff approached and offered the resident an alternative meal. -At 4:47 p.m., the resident had not consumed any of the meal and pushed away from the table. When the resident pushed the meal away from the table, none of the staff present encouraged the resident to return to the table to eat or drink any of her fluids. -At 4:55 p.m., the resident was transported and transferred to bed by CNA #9. No hydration was offered and or encouraged during this care.-At 5:20 p.m., the resident remained in bed. The water bottle beside the bed was untouched and remained full.-At 6:00 p.m., the resident remained in bed. The water bottle was untouched and remained full. No staff provided encouragement, or physical assistance for the resident to accept any amount of hydration during this observation. The resident was observed continuously on 3/7/23 from 8:45 a.m. until 1:07 p.m.-At 8:45 a.m., Resident #1 was observed in the unit ' s dining room, food and drinks were untouched.-At 8:59 a.m., the resident remained in the dining area in her wheelchair, food and drinks untouched. Staff were observed providing assistance to other residents but not with Resident #1.-At 9:00 a.m., the resident propelled herself to the common area. -At 9:10 a.m., the resident was assisted to her room by CNA #8. The CNA proceeded to assist the resident to lay down. No hydration was offered or encouraged. Resident #1 ' s water bottle was observed to be full and not within reach of the resident.-At 9:30 a.m., the resident continued to lay in bed on her right side. Staff had not entered the room since 9:10 a.m. A full water bottle was available by bedside, however, it was not within the resident ' s..-At 9:44 a.m., the resident continued laying in bed. RN #3 took the resident's vital signs. The RNa did not offer or encourage the resident to accept hydration. The water bottle at the resident ' s bedside remained full and out of reach. -At 9:48 a.m., the resident was offered water by CNA #8 stating " Do you want something to drink?" The resident did not respond and remained on her right side asleep. The CNA did not make any other attempt to wake the resident or encourage the resident to drink. -At 9:59 a.m., the resident remained asleep on her right side. Water bottle was untouched and remained full by the bedside.-At 10:58 a.m., the resident remained on her right side in bed. The water bottle at the bedside remained full and untouched.-At 12:00 p.m., the resident was assisted to the dining room. The resident was served lunch, however, she was not served anything to drink. -At approximately 12:15 p.m., RN #3 provided the resident a glass with approximately 90 cc of water. RN #3 placed the water on the table; however, RN #3 did not encourage the resident to drink. The resident did not drink on her own.-At 12:20 p.m., the resident was assisted to bed. No fluids offered/ encouraged. -At 12:30 p.m., the resident was assisted by CNA #8 to sit up in bed. CNA #8 asked the resident "Would you like some food?" The water bottle at bedside remained full and out of reach. -At 12:34 p.m., the resident was assisted by CNA #8 to the unit ' s dining room. The resident was offered 240 cc of juice, a grilled cheese and meal assistance. The resident did not respond to meal assistance and propelled herself away from the table. Food and drink untouched. CNA #8 asked the resident "Do you want to lay down?"-At 12:35 p.m., the resident was assisted to her room by CNA #8. The resident was not offered hydration.-At 12:37 p.m., the resident was assisted to sit up in bed by CNA #8. The resident was prompted to eat a snack by CNA #8 " Do you want a snack?", no hydration offered. The CNA #8 exited the room.-At 1:07 p.m., the resident was still in bed laying on her right side. The water bottle remained full and untouched. The resident was observed continously on 3/8/23 from 8:33 a.m. to 12:17 p.m.-At 8:33 a.m., the resident was in bed, on her back. The resident ' s water bottle was full by the bedside but not within reach of the resident.-At 8:55 a.m., the resident remained at the same position. The water bottle remained untouched.-At 9:21 a.m., CNA #8 entered the residents room, and provided fresh water but did not wake or encourage hydration.-At 10:13 a.m., the resident was observed in the room asleep on her back. The water bottle remained full.-At 10:21 a.m., the resident was observed on the floor mat beside the resident ' s bed, calling out "help me", it was unclear if the resident climbed or rolled out of her low bed, as the angle of view did not allow for full view of the resident ' s bed; but of the resident ' s and the bedside table. CNA #8 and CNA #9 entered the room to assist the resident. The unit RN entered to assess the resident for injury.-At 10:30 a.m., the resident was assisted into a wheelchair, and transported to the common area. CNA #9 poured water in a 90 cc cup and offered it to the resident. The resident refused.-At 10:36 a.m., nursing staff offered the resident 30 cc of Ensure (protein supplement), but did not get the resident to drink any of the supplement. The 90 cc of water remained in front of the resident. -At 10:39 a.m., the resident took a sip of water. CNA #8 entered the secure unit ' s dining room and sat beside the resident to document the resident ' s meal choice. CNA #8 did not encourage the resident to drink. -At 10:50 a.m., the resident ' s water and Ensure remained untouched. -At 10:57 a.m., the resident ' s water and Ensure remained untouched. CNA #9 assisted the resident to her room; the resident was not offered hydration. -At 11:05 a.m., the resident was in bed, still the resident was not assisted or encouraged to accept hydration. -At 11:41 a.m., the director of nursing (DON) offered the resident a snack and drinks. DON stated " Do you want some Sprite, a Twinkie or 7 up? " The resident did not respond to the DON. The DON did not attempt to re-engage the resident and did not provide the resident with a snack or drink. C. Record review 1. Nutritional and fluid needs. The comprehensive care plan, last revised on 12/18/22, identified the resident required supervision with eating and drinking. The resident was to use a two handled cup with lid and built-up utensils at all meals. Pertinent interventions included:-Staff to sit with the resident and share a meal to attempt to increase meal intake; -Staff to observe document/report any signs and symptoms of diminished appetite and intake;-Offer preferred foods, meal alternates, as needed. Offer snack, as needed;-Encourage fluids with and between meals; and-Health shake everyday at lunch and observe intake and record after every meal. 2. Change of conditionNursing progress note dated 1/22/23, revealed in pertinent part: the resident was not acting like herself so CNA took vital signs. All vital signs were within normal limits except for the resident ' s blood pressure which was 97/61. The resident ' s physician was notified and an order for intravenous fluid (IVF) of normal saline (NS) at 100 cc per hour was provided. The physician also ordered lab orders for blood work. The resident's legal representative was notified that the resident had a change of condition, due to not eating or drinking much and dehydration was suspected. The legal representative suggested giving the resident 7up. According to the January 2023 computerized physician orders (CPO) the resident was ordered Normal Saline 0.9 percent via IV every shift for hydration on 1/22/23 and 1/23/23. The nutrition evaluation dated 3/6/23, revealed Resident #1 had been experiencing weight loss since admission. Resident ' s body weight prior to admission was approximately 150 pounds (lbs) and as of the assessment weighted 122 lbs, related to poor intake. The resident ' s nutrition needs indicate the resident ' s minimum recommended fluid intake should be 1,375 cc per day. -Resident #1 required feeding supervision and encouragement for intake to meet assessed nutrition needs. The resident was at risk for malnutrition due to dementia and diabetes. Nursing and CNA reports the resident had increased refusal of meals and supplements. -Recommendation by registered dietician (RD): included to continue with snacks twice a day, protein liquid twice a day, and continue with house shake once per day. Review of the redients ' s fluid intake tracing document revealed facility staff failed to document the resident ' s daily fluid intake to demonstrate whether the resident was meeting the daily minimum fluid intake recommendation. The facility DON was unable to provide any additional documents that tracked the resident ' s daily fluid intake/.The comprehensive care plan last updated 12/18/22 indicated the resident should be offered 7 up as that is her preferred choice of hydration, furthermore the care plan was not updated after the resident documented change of condition with a care focus to adder the resident ' s actual and risk of repeated episodes of dehydration. D. Interviews CNA #8 was interviewed on 3/9/23 at 9:10 a.m. The CNA said Resident #1 was able to feed herself, but required encouragement to eat and drink. The resident did refuse care, however staff were expected to re-approached at a later time when she refused care assistance. CNA #8 said that the amount of the food and fluids the resident consumed were supposed to be documented in the resident record. Registered nurse (RN) #3 was interviewed on 3/9/23 at 9:17 a.m. RN #3 said the resident feeds herself but required encouragement which included reminding the resident to eat, and offering the resident different things to eat and drink. The resident was always very picky when it came to eating and drinking; therefore staff should offer the resident multiple food and drink options based on the resident ' s choice. The resident ' s daughter also brought snacks and drinks the resident enjoys to eat. Staff should also provide positive reinforcement. RN #3 said Resident #1 received intravenous (IV) hydration by infusion into the resident ' s vein (refers to a way of giving a drug or other substance through a needleor tube inserted into a vein.) this past December 2022 because the resident was severely dehydrated and needed to be hydrated with fluid. RN #3 said she only tracked fluids if it was ordered by the physician. Otherwise the CNA ' s were to document the fluids consumed by the resident during meals and snack time. The RD was interviewed on 3/9/23 at 10:04 a.m. The RD was in the facility weekly to assess residents who were on the high risk list for pressure ulcer, dialysis, enteral nutrition (nutrition by gastric tube into the gastric intestinal tract) or hospice care. Otherwise residents were reviewed every three months. The RD said he did evaluate residents for hydration needs. Residents in general at meal times should receive 237 cc to 356 cc of fluids. Additionally, residents should also be offered hydration at medication pass times and additionally provided the facility house shakes if at risk for dehydration. The RD reviewed resident #1 ' s medical record. The RD said Resident #1 had experienced a change of condition due to dehydration and required an IV for fluid hydration. The resident had been assessed to require as minimum daily fluid intake need to be between 1350 cc to1650 cc and that recommendation should be followed. The RD said 1375 cc daily at minimum would be his recommendations. The RD confirmed the care plan did not include a hydration focus or care after the resident December 2022 change of condition. The RD ' s expectation was to offer the resident drinks that the resident preferred such as 7up. The director of nurses (DON) and the regional nurse consultant (RNC) were interviewed on 3/9/23 at 10:57 a.m. The DON said residents should be offered something to drink at meals; in between meals;, when they wake up from sleeping; and at just before going to bed. The minimum hydration recommendation identified by the RD should be followed. The DON said the resident fluid intake at meals were tracked, but facility staff missed documenting the additional fluids provided to the residents. The RNC confirmed that they were unable to find the fluid intake tracker for Resident #1. The DON said the Resident #1 should have a specific care plan for hydration which included the residents's hydration needs with an intervention that included a need to track the resident ' s fluid intake. The RNC said the resident's fluid consumption needed to be watched more closely. IV. Other failures to maintain resident hydration 1. Resident #5A. Resident statusResident #5, age older than 80, was admitted on 7/12/17 and re-admitted on 9/8/22. According to the March 2023 CP) diagnoses included dementia, overactive bladder, mild cognitive impairment, and abnormalities of gait and mobility. A 3/17/22 assessment, documented the resident had severe cognitive impairments. The resident required extensive assistance with activities of daily living, including supervision for eating. The resident was frequently incontinent of bladder and bowel. The assessment documented as an individual that sustained 5% -10% weight loss in the last 6 months. The assessment documented the resident as not having any behaviors or refusal of care. B. ObservationsThe resident was observed continuously on 3/6/23 from 3:54 p.m. to 6:03 p.m.-At 4:01 p.m., Resident #5 was in the secure unit's dining area in her wheelchair.-At 4:23 p.m., kitchen staff provided meals to the secure unit. -At 4:47 p.m.,the resident started to eat her dinner.-At 5:49 p.m., the resident finished her meal. The resident drank: 100 % of a 240cc cup of water and 50% of a 240cc cup of hot chocolate (120cc). The resident was observed continuously on 3/7/23 from 8:59 a.m. to 1:03 p.m. Throughout the observations, the resident was not offered anything to drink until the meal time. Observations were as follows-At 8:59 a.m., Resident #5 was in the dining area in her wheelchair.-At 9:08 a.m.,the resident was propelled to the common area by CNA #8. -At 9:20 a.m., the resident was asleep in her wheelchair in the common area.-At 9:59 a.m., the resident remained asleep in her wheelchair in the common area.-At 10:58 a.m., the resident remained asleep in her wheelchair in the common area.-At 11:08 a.m., CNA #8 escorted the resident to the dining area.-At 11:23 a.m., the resident received her meal. She received 240 cc of milk, 240 cc of coffee.-At 11:25 a.m., the resident began to eat. The resident drank: approximately 180 cc of milk, and 120 cc of coffee but not all of the hydration provided.-At 12:27 p.m., the resident was no longer eating her meal and was not being prompted to eat or drink. Staff approached and the resident was taken back to the secure unit by CNA #8 to sit in the common area. C. Record review The nutrition evaluation was completed on 3/6/23. The evaluation showed the resident ' s minimum recommended fluid intake should be 1590 cc per day. The evaluation documented the resident required supervision and encouragement with eating and drinking. Resident #5 was at risk for malnutrition due to dementia. The comprehensive care plan, last revised on 11/10/22, identified the resident required supervision with eating and drinking. Pertinent interventions included:-Encourage juice and milk with meals for added calories. -Observe intake and record every meal. -Encourage good nutrition and hydration in order to promote healthier skin. The nutrition-amount eaten task records (records daily fluid intake), dated 2/21/23 through 3/8/23, that were completed by the CNA staff were reviewed. The documentation revealed the Resident #5 averaged a fluid intake of approximately 777 cc of fluid per day in contrast with the RD recommended minimum of 1590 cc based on the nutrition evaluation. D. InterviewsThe RD was interviewed on 3/9/23 at 10:04 a.m. The RD said Resident #5 ' s recommended minimum daily fluid intake for the resident to consume 1500 cc of fluid per day. The RD reviewed resident #5 ' s record and confirmed the care plan did not include hydration care focus. The RD ' s expectation would be for the resident to have a care focus for hydration, based on the documentation showing an inadequate fluid intake where the resident averaged a fluid intake of 583cc per day in comparison with the daily recommended minimum fluid intake of 1500cc. CNA #8 was interviewed on 3/9/23 at 9:10 a.m. The CNA said Resident #5 was able to feed herself, but required to be reminded to eat and drink. The resident had refused care, especially being fed, as she is very independent and attempts to maintain her independence. CNA #8 said that the amount of the food and fluids the resident consumed were supposed to be documented in the resident record. Registered nurse (RN) #3 was interviewed on 3/9/23 at 9:17 a.m. RN #3 said the resident feeds herself but required encouragement which included reminding the resident to eat, and offering the resident different things to eat and drink. RN #3 said she only tracked fluids if it was ordered by the physician. Otherwise the CNA ' s were to document the fluids consumed by the resident during meals and snack time. 2. Resident #9A. Resident statusResident #9 was admitted on 7/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included nontraumatic intracranial hemorrhage, cerebral infarction, and anxiety. According to a 1/18/23 assessment, the resident had had severe cognitive impairments. The resident required total assistance with activities of daily living. The resident was incontinent of both bowel and bladder. The assessment documented the resident did not having any behaviors or refusal of care. B. ObservationsObservations revealed the resident did not receive the minimum amount of fluid as assessed. Observations were as follows:On 3/7/22 at 8:38 a.m. continuous observation began. Resident #9 was observed in the main dining room eating breakfast. The resident was served 240 cc of red drink. -9:07 a.m. Resident #9 finished 240 cc of a red drink.-9:35 a.m. Resident #9 was laying in bed. The 240 cc of protein drink was on the table in front of her but no one offered any encouragement for her to consume it.-10:37 a.m. Resident #9 was provided incontinence care and placed in her wheelchair. The meal replacement drink was in the same location and the volume had not changed.-10:38 a.m. Resident #9 was assisted into the dining room for lunch and a 240 cc regular cup of water was placed in front of her.-10:48 a.m. Resident #9 took two small sips of water.-11:07 a.m. Resident #9 was served lunch which included 240 cc of a red drink.-12:48 p.m. Resident #9 returned to her room after drinking approximately 120 cc of a red drink, 120 cc of a meal replacement drink, and 4 small sips of water.-2:01 p.m. CNA #3 went into Resident #9's room and said goodbye. There was a container of water in front of the resident within her reach but the CNA did not offer or encourage the resident to drink it. -2:29 p.m. CNA #5 entered Resident #9 room and asked about dinner choices, however a drink was not offered.-2:53 p.m. Resident #9 remained in the same position in her wheelchair in her room.-3:08 p.m. LPN #1 and CNA #5 entered Resident #9 ' s room for incontinence care and did not offer any drinks.-4:10 p.m. Resident #9 was assisted to the dining room for dinner.-5:53 p.m. Resident #9 was assisted back to her room after she finished eating dinner and approximately 120 ml of the red drink. Observations ended and the total amount of fluid consumed was 600 cc. C. Record ReviewThe 3/1/23 physician diet order read, "HSG (name of kitchen contract) regular diet, HSG dysphagia advanced texture, regular/thin consistency, two-handed cup, scoop plate, built-up handle utensils, and red lap tray for all meals."The nutritional assessment dated 2/16/23 documented the resident required 1022 cc to 1200 cc fluid per day. The care plan also directed staff to offer water in conjunction with turning/care schedules. The Nutrition tracking chart for 3/7/23 for Resident #9 documented Resident #9 consumed 270 cc at 1:38 p.m., 270 cc at 1:39 p.m. and 800 cc at 9:48 p.m. for a total of 1340 cc. Continuous observations directly contradicted that amount. 3. Resident #3A. Resident statusResident #3, age 66, was admitted on 10/13/22 and discharged on 10/24/22. According to the October 2022 computerized physician orders, diagnoses included, pressure ulcer of left hip, stage 3, and chronic respiratory failure with hypoxia. According to the minimum data set (MDS) dated 10/17/22, the resident had no cognitive impairment as she scored a 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #3 did not have any complaints of difficulty or pain when swallowing and loss of liquids/solids from mouth when eating or drinking. Record ReviewThe 10/18/22 nutrition evaluation showed Resident #3 ' s estimated amount of fluid intake was 1500-1900 cc a day. The evaluation stated that resident #3 required limited assistance during meals. The hydration tracking task flow sheet record showed Resident #3 ' s average amount of fluid intake ranged between 480 cc to 1200 cc of fluid intake daily. The nursing daily skilled charting dated 10/20/22 showed, the resident required extensive assist for self-feeding and had weakness in right and left hand. InterviewsThe registered dietician (RD) was interviewed by phone on 3/9/23 at 10:04 a.m. The RD reviewed the medical record and said the resident ' s hydration needs were estimated at 1500cc to 1900cc's a day. The RD did not know how much Resident #3 was drinking per day. The RD reported that he was involved in Resident #3's care upon admit and after that he reported that he did not see her again. Additional interviewsThe director of nurses (DON) and the regional nurse consultant were interviewed on 3/9/23 at 10:54 a.m. The DON said that residents should begetting fluids between meals, when they were awake and throughout the day. The DON said that they follow the recommendations of the dietician regarding how much fluid each resident should consume. The DON said that they track fluid amounts on tasks which only tracked fluid intake during meals. The DON said that an additional fluid task has been asked to be put in, so that it showed residents were not just getting fluids at meal times but at other times during the day.

A complaint survey, prompted by #CO31029 and Incident #CO31112 was conducted on 3/2/23 through 3/9/23. Four deficiencies were cited.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for two (#9 and #5) of four sample residents for incontinence care out of 10 sampled residents. Specifically, the facility failed to ensure:-Resident #9 was provided incontinent care and positioning timely-Resident #5 offered incontinence care and positioning timelyFindings include:I. Professional referenceNational Pressure Injury Advisory Panel (2016), Pressure Injury Prevention Points, retrieved from https://npiap.com/page/PreventionPoints (retrieved on 3/16/23)It read in pertinent part, the process for turning and repositioning residents included the following steps:-Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments.-Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual ' s preferences.-Consider lengthening the turning schedule during the night to allow for uninterrupted sleep.-Turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed.-Avoid positioning the individual on body areas with pressure injury.-Ensure that the heels are free from the bed.-Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface.-Continue to reposition an individual when placed on any support surface.-Use a breathable incontinence pad when using microclimate management surfaces.-Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs.-Reposition weak or immobile individuals in chairs hourly. II. Facility policy and procedureThe Routine Resident Care policy, revised September 2011, was provided by the Nursing Home Administrator on 3/9/23. It read in pertinent part: "Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure resident safety at all times. Residents who are capable of performing their own personal care are encouraged to do so. Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed. Bed linens are changed at this time. Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands, combing their hair each morning, and brushing their teeth and/or providing denture care. Residents are encouraged or assisted to dress in appropriate clothing and footwear daily (appropriate to season and weather, clean and in good repair). Residents are encouraged or assisted with bedtime care that includes washing their faces and hands and putting on sleepwear. Residents are encouraged or assisted to perform mouth care morning and night. Residents are offered assistance to the restroom or with the bedpan, urinal, or bedside commode as needed. Incontinence care is provided timely according to each resident's needs. Resident call lights are answered timely and resident requests are addressed, if permitted. Call lights should always be placed within easy reach of the resident. "III. Failure to provide timely incontinent care 1. Resident #9A. Resident statusResident #9, age 81, was admitted on 7/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included nontraumatic intracranial hemorrhage, cerebral infarction, and anxiety. According to the 1/18/23 minimum data set (MDS) assessment, showed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of 5 out of 15. The resident required total assistance with activities of daily living. The resident was incontinent of both bowel and bladder. The MDS coded the resident was at risk for pressure ulcers. The MDS coded the resident as not having any behaviors or refusal of care. B. Record reviewThe weekly head to toe skin check completed on 2/26/23 showed the resident had redness to the right and left buttocks. The following week on 3/5/23 the head to toe skin check identified rashes on the left and right buttocks. The care plan last revised on 1/18/23 identified the resident was at high risk for pressure injuries. Pertinent interventions included; implement turning schedule, extensive total assistance of one to two staff to turn and reposition in bed, offer water in conjunction with turning/care schedule, air mattress to bed at all times, pressure relieving/reducing cushion in geri-chair, and keep skin clean and dry. The March 2023 Kardex indicated the resident needs weekly skin inspections, staff use of a draw sheet or lifting device to move resident, and an air mattress to the bed at all times. C. ObservationsOn 3/7/22 at 8:38 a.m. continuous observation began. Resident #9 was observed in the main dining room eating breakfast.-9:12 a.m. Resident #9 was assisted to her room by CNA #3.-9:27 a.m. Resident #9 was in her wheelchair at the sink brushing her teeth.-9:35 a.m. Resident #9 was in bed laying on back with eyes closed.-10:37 a.m. Resident #9 was provided incontinence care and assisted her into her wheelchair.-10:38 a.m. Resident #9 was assisted into the dining room for lunch.-12:48 p.m. Resident #9 returned to her room.-2:01 p.m. CNA #3 went into Resident #9 room and said goodbye. No repositioning or incontinence care was provided.-2:12 p.m. CNA #3 gave CNA #5 report and stated Resident #9 had been changed.-2:29 p.m. CNA #5 entered Resident #9 room and asked about dinner choices, however there was not any repositioning offered or incontinence care provided.-2:53 p.m. Resident #9 remained in the same position in her wheelchair in her room.-3:08 p.m. LPN #1 and CNA #5 entered Resident #9 room for incontinence care after being notified by surveyor the resident had not been changed or repositioned in over 4 hours.-3:18 p.m. Resident #9 was assisted to the bed for incontinence care to begin.-3:18 p.m. Resident #9 was incontinent of urine and bowel. The bowel was dry around the edges and staff used a liquid spray and scrubbed to remove the bowel that was stuck to the skin. Resident #9 had a small 2-inch X 2 inch padded bandage on her sacrum that was soiled from the bowel; however that bandage was not removed or replaced at the time. The resident was provided a fresh incontinence brief and transferred back into her wheelchair. The bandage continued to not be changed and remained soiled. -4:10 p.m. Resident #9 was assisted to the dining room for dinner.-5:53 p.m. Resident #9 was assisted back to her room after she finished eating dinner.-6:02 p.m. Resident #9 was transferred into bed for the dressing change. The director of nursing (DON) removed the soiled bandage, cleaned the area and applied a clean dressing. The DON said the bandage was a preventative measure and the resident did not have an active open wound. D. InterviewsThe licensed practical nurse (LPN) #1 was interviewed on 3/7/23 at 3:04 p.m. LPN #1 said Resident #9 should be checked for incontinence and changed every two hours. The DON was interviewed on 3/7/23 at 4:23 p.m. The DON said the resident should be checked for incontinence and changed every two hours. The DON said she had reviewed the resident's record and it showed the resident was changed at 1:38 p.m.., (however, observations revealed the resident was in the same position and had not been checked, changed or repositioned). CNA #6 was interviewed on 3/9/23 at 9:20 a.m. CNA #6 said information is in the computer for incontinence care but they also get report from staff and hear word of mouth from other coworkers. She said not everyone does a shift handoff. Additional interviewsThe wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said pressure injuries were avoidable unless there were outstanding circumstances or comorbidities like diabetic ulcers. He went on to say turning and repositioning were very important and an air mattress did not substitute a turning and repositioning schedule. III. Failure to ensure Resident #5 offered incontinence care and positioning timely to prevent potential pressure injuries from forming. 1. Resident #5A. Resident statusResident #5, age over 80, was admitted on 7/12/17 and readmitted on 9/8/22. According to the March 2023 computerized physician orders (CPO) diagnoses included, dementia, overactive bladder, mild cognitive impairment, abnormalities of gait and mobility, hypothyroidism and hyperlipidemia. According to the 3/17/22 minimum data set (MDS) assessment, the resident brief interview for mental status (BIMS) score was a four out of 15 which indicated the resident was severely cognitively impaired. The resident required extensive assistance with activities of daily living. The resident was frequently incontinent of bladder and bowel. The MDS coded the resident as not having any behaviors or refusal of care. B. Observations3/7/23The resident was observed continuously from 8:59 a.m. to 1:03 p.m.-At 8:59 a.m., Resident #5 was in the dining area in her wheelchair.-At 9:08 a.m.,the resident was propelled to the common area by certified nurse aide (CNA) #8. Repositioning and or offloading was not provided, incontinence check not completed.-At 9:20 a.m., the resident was asleep in her wheelchair in the common area.-At 9:59 a.m., the resident remained asleep in her wheelchair in the common area, no repositioning and or offloading provided.-At 10:58 a.m., the resident remained asleep in her wheelchair in the common area, no repositioning and or offloading provided, incontinence check not completed.-At 11:08 a.m., CNA #8 escorted the resident to the dining area by propelling the resident ' s wheelchair. Repositioning and or offloading was not provided.-At 12:27 p.m., the resident finished her meal and was assisted back to the secure unit and was propelled by CNA #8 to the common area. Repositioning and or offloading was not provided, incontinence check not completed since 9:00 a.m.- At 12:53 p.m., CNA #10 assisted the resident into her room to provide incontinence care and to assist the resident to bed, offloading performed by staff assistance.-At 1:01 p.m., CNA #10 walked out of the room with a trash bag with a lightly soiled urine brief. C. Record review The care plan last revised on 11/10/22 identified the resident required to be offered water in conjunction with turning and care schedules (due to moisture risk). Use absorbent incontinent briefs that hold moisture away from skin. The resident required extensive assistance by one to two staff to turn and reposition in bed, extensive assistance by one staff for toileting, extensive assistance by one staff to move between surfaces, encourage to change positions frequently, not sit in one position for a long period of time, change disposable briefs as needed, clean peri-area with each incontinence episode, establish voiding patterns, check frequently and assist with toileting as needed, observe pattern of incontinence and initiate toileting schedule if indicated, toilet at same time each day due to routine bowel movement after meals, and observe/document/report as needed any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles. The CNA documented on the- ADL (activities of daily living) for 3/7/23 at 09:45 a.m. The record revealed the resident was provided with total ADL dependence. The documentation is in contrast with observations made as the resident was asleep in the secure unit common area at the time, with no ADL performed. The CNA documented on the- turning and repositioning document (record of daily turn and reposition task by staff) for 3/7/23 at 9:45 a.m. The record revealed the resident was turned and repositioned. The documentation was in contrast with observations made as the resident was asleep in the secure unit ' s common area at the time, staff did not reposition and or turn the resident during continuous observations. D. InterviewsCNA #10 was interviewed on 3/7/23 at 1:37 p.m. CNA #10 said resident #5 should be changed and repositioned every two to three hours and confirmed the resident was not repositioned or changed within two to three hours on 3/7/23. CNA #10 confirmed the resident was changed and repositioned after approximately 4 hours had elapsed. Registered Nurse (RN) #3 was interviewed on 3/7/23 at 1:45 p.m. The RN said the resident should be checked and repositioned every two hours. The resident was currently at risk for developing pressure injuries. RN said to ensure resident ' s changed and repositioned within two hours she would put something in the medication administration record (MAR), however, currently there was no schedule in the MAR to prompt the RN for the resident. RN expects staff to ask and prompt for reposition and incontinence as the resident is cognitively impaired. The DON was interviewed on 3/7/23 at 4:17 p.m. The DON said residents should be repositioned and checked for incontinence at least every two hours.

Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#1and #2) of four out of 10 residents. Specifically, -Resident #1 was at high risk for pressure injury when she entered the facility. The facility failed to encourage the resident to reposition, As a result the resident developed an unstageable pressure injury to her right heel. The facility failed to ensure treatments were provided as ordered by the physician and develop a person-centered care plan for the resident's pressure injury to the right heel. Additionally the facility failed to ensure:-Resident #2 was not repositioned timely and physician orders were not followed. Findings include:I. Professional referenceThe National Pressure Ulcer Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 3/8/23 read in pertinent part:"Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel orischemic limb should not be softened or removed."The National Pressure Ulcer Advisory Panel (NPUAP), "Prevention and Treatment of Pressure Ulcers" reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure ulcer should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented.-The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications.-Signs of deterioration in the wound should be addressed immediately.-The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedureThe Skin Management policy, revised 10/21/2021, was provided by the director of nursing (DON) on 3/9/23. It read in pertinent part: "Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Residents admitted with skin impairments will have: Interventions implemented to promote healing;A physician's order for treatment; Wound location and characteristics documented. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to the following: Hydration; Nutrition;Preventive device;physical activity; Pain management; Positioning requirements; Proper body alignment; and Psychosocial adjustment to skin impairment."III. Resident #1A. Resident statusResident #1 age 86, was admitted on 11/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included, vascular dementia, chronic pain syndrome, type II diabetes mellitus and cognitive communication deficit. The 1/23/23 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). No behaviors or refusals of care were noted. The resident required total assistance with activities of daily living. The resident was incontinent of bladder and frequently incontinent of bowel. The MDS revealed the resident was at risk for pressure ulcers and indicated the resident had a pressure injury. B. ObservationsOn 3/7/23 Resident #1 was observed continuously from 8:59 a.m. until 1:07 p.m.-At 8:59 a.m., Resident #1 was in the dining area in her wheelchair. The resident had socks on her feet. -At 9:00 a.m., the resident propelled herself to the common area. -At 9:10 a.m., the resident was assisted to her room by certified nursing aide (CNA) #8.-At 9:14 a.m., the resident was assisted by CNA #8 to lay in bed, heel pressure relief boots were not offered. Foot elevation not offered. The resident's bilateral heels were directly on the mattress. -At 9:30 a.m., the resident continued to lay in bed on her right side. Her heels continued to not be offloaded. -At 9:44 a.m., the resident continued laying in bed, registered nurse (RN) #3 took resident ' s vitals. Heel pressure relief boots not offered. Foot elevation not offered. -At 9:48 a.m., the resident was offered water by CNA #8 but declined and remained on her right side in bed. Heel pressure relief boots not offered. Foot elevation not offered.-At 9:59 a.m., the resident remained asleep on her right side.-At 10:58 a.m., the resident remained on her right side in bed.-At 12:30 p.m., the resident remained in bed.-At 12:31 p.m., the resident was assisted out of bed by CNA #8.-At 12:37 p.m., the resident was assisted back to lay down in bed by CNA #8. The resident was not offered or provided the heel pressure relief boots. Foot elevation not offered.-At 1:07 p.m., the resident was still in bed laying on her right side. On 3/8/23 the resident was observed continuously from 8:33 a.m. until 12:03 p.m. -At 8:33 a.m. the resident was in bed, on her back, foot not elevated, pressure relief boots not observed.-At 8:55 a.m., the resident remained at the same position.-At 9:21 a.m. CNA #8 entered the resident ' s room, replaced water in cup beside the bed. CNA #8 did not wake, reposition or encourage hydration. Resident was not offered pressure relief boots or foot elevation. -At 10:13 a.m., the resident was observed in the room asleep on her back. The resident was observed without pressure relief boots and without her foot elevated.-At 10:21 a.m., the resident observed on the floor, she had experienced a fall. CNA #8 and CNA #9 entered the room to assist the resident. -At 10:30 a.m., the resident was assisted into wheelchair. CNA#9 failed to offer the pressure relief boots. -At 10:56 a.m., CNA #9 assisted the resident back into bed. Pressure relief boots and or foot elevation were not offered.-At 11:03 a.m., RN #3 attempted to administer her medications. Pressure relief boots were not offered. -At 11:41 a.m., RN #3 and DON completed wound dressing change. After the dressing change, the resident was not offered the pressure relief boots. Dressing changeThe March 2023 CPO showed a physician order for the pressure injury: wound care; right heel eschar (dead tissue that falls off (sheds) from healthy skin.), cleanse with NS (normal saline), apply layer of Santyl, cover with xeroform, abdominal pad (ABD, an abdominal pad is an extra thick primary or secondary dressing designed to care for moderate to heavily draining wounds), and wrap with kerlix. Notify the medical doctor (MD) with concerns. Do not use wound cleanser. Additionally, a treatment order for the pressure injury: Skin: green heel protector boots to both feet when in bed. On 3/8/23 at 11:34 a.m. a dressing change performed by the director of nursing (DON) was observed. The resident was lying in bed and did not have green heel protector boots on as ordered when the resident was in bed. The soiled dressing was removed and consisted of xeroform and kerlix, an abd pad was not used although it was ordered. The wound was located on the right posterior heel. There was pink tissue with white exudate, the wound was oozing serous fluid and no odor was noted. The DON rubbed the wound bed in an upward and downward motion using the same 2x2 gauze saturated in normal saline, although debridement was not part of the dressing change order. Next, a layer of Santyl was applied followed by xeroform, an abd pad, and wrapped with kerlix. Visibly dirty socks were placed back on the residents feet and the resident was assisted into her wheelchair. C. Record review The 11/15/22 initial skin documented the resident had no pressure injuries. The progress note dated 12/13/22 documented, the resident was found to have a blister on the right heel during shower skin assessment by CNA and was reported to the nurse. The nurse contacted wound nurse to assess. The progress note documented open blistered area, and the resident ' s name was added to the wound care list for the provider to see on next visit. The note documented heel protector boots were initiated and encouraged, however the resident often kicks them off. Treatment orders were in place. The wound measurements were 4 cm length x 3 cm width with no measurable depth, with an area of 12 sq cm. The wound care physician ' s assistant (WCPA) note dated 12/12/22 documented, the blister was a pressure injury, unstageable, stable eschar, will continue to be followed by the wound team. Encourage turn and repositioning, footrests only to be on during transporting. Wound care physician assistant (WCPA) assessed the resident on 12/19/22. Heel eschar stable. Right heel was an unstageable pressure injury, obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Wound encounter measurements are 4 cm length x 3 cm width with no measurable depth, with an area of 12 sq cm. There was no drainage. Wound bed has 100% eschar. The wound was stable. The Kardex for skin integrity and skin protection identified the resident: have an air mattress in place to promote skin integrity. Monitor pain level during wound care, encourage use of pain medication before/during/after wound care as indicated; cease wound care performance if indicated by my verbalization. Need pressure relieving /reducing cushion to protect the skin while up in chair. Need pressure relieving /reducing mattress and position pillows to protect the skin while in bed. Monitor right second finger skin tear. The Kardex failed to address the physician's order for the pressure relieving boots. The Braden scale completed on 2/27/23 showed the resident was at high risk for pressure ulcers with a score of 17. The care plan last revised on 12/29/22 identified the resident was at high risk for potential and or actual impairment to skin integrity related to fragile skin. Pertinent interventions included: pressure relieving/reducing mattress and positioning pillows to protect the skin while in bed. The care plan did not identify the pressure areas, and also failed to include the interventions to provide the pressure relieving boots. D. Interviews RN #3 was interviewed on 3/9/23 at 9:47 a.m. The RN said the resident developed the pressure ulcer from not being mobile and from being in bed all the time and will only get up to use the toilet. In order to treat the pressure injury residents should be repositioned, offered pressure relief boots or elevation and wound care. Any staff member can offer the resident the pressure relief boots and they should be offered every time she was in bed. Wound care team assessed the resident on Monday. The dressing change was ordered for every other day. RN #3 confirmed the resident was not offered the pressure relief boots by her or the staff present on 3/9/23 during continuous observation. The director of nursing (DON) was interviewed on 3/9/23 at 10:57 a.m. The DON said the resident was at high risk for pressure ulcers due to limited mobility, high fall risk, and she enjoyed to be in bed a lot, sometimes she liked to sleep in bed all day. Initially the ulcer started on 12/7/22 as a blister, which is when the resident was we referred the resident to the wound care doctor. Interventions put in place were: elevating heels and pressure relief boots anytime she is in bed, which should be offered every time she is in bed. The pressure ulcer that developed on her right heel was avoidable. DON confirmed she did receive training by the physician'ss assistant on how to do the dressing change. DON confirmed the antibiotic pad was not in place per the March 2023 CPO. DON said the WCPA applied lidocaine prior to debridement of the wound bed and then continued with the dressing change. The wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said the dressing change was always demonstrated because he expects staff to perform the dressing changes exactly how he demonstrated. The WCPA also said when he gave an order it was a verbal order and he also writes the order in his wound care visit note, his note is then uploaded into the residents chart. He also notifies the primary doctor at the facility if the order was complex. Then he logs into the residents chart and signs the order to confirm it was entered correctly. The WCPA also said turning and repositioning is very important and an air mattress is not a substitute. The WCPA said Resident #1 pressure injury on her heel was avoidable. III. Failure to follow physician orders 2. Resident #2A. Resident statusResident #2, age less than 65, was admitted on 10/5/22. According to the October 2022 computerized physician orders (CPO), diagnoses included, osteomyelitis, unspecified, pressure ulcer of other site, stage 3, pressure ulcer of other site, stage 1, pressure ulcer of sacral region, stage 2, pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, stage 4, pressure ulcer of sacral region, unstageable, pressure ulcer of unspecified part of back, stage 3, and pressure ulcer of left heel, unstageable. The minimum data set (MDS) dated 1/9/23, showed the resident had no cognitive impairment with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, and toilet use. The MDS coded that the resident had two stage 3 pressure injuries, three stage 4 pressure injuries, and two unstageable deep tissue injury. The MDS coded the resident as at risk for pressure injuries and had unhealed pressure injuries. B. Resident interviewResident #2 interviewed on 3/6/23 at 5:30 p.m. Resident #2 said she had two pressure injuries on her buttock area. C. Physician ' s orders for the pressure injury treatmentThe March 2023 CPO documented the following:-Use two green wedges for side to side positioning due to stage IV left and right ischial tuberosity wounds. They are to be used at every shift related to pressure ulcers with a start date of 10/27/22.-Wound care for left ischial tuberosity: Cleanse wound bed, apply collagen, cover with ABD pad, cover with Hydralock super absorbent dressing, do not use tape. Start date/revision date 1/3/23.-Wound care for right sacrum: cleanse wound bed, apply collagen, cover with ABD pad, cover with HudraLock super absorbent dressing, do not use tape. Start date/revision date 1/3/23.-Wound care for right ischial tuberosity: cleanse wound bed, pack 12 o ' clock tunnel with ¼ inch iodoform packing with Mupirocin 2% ointment, apply collagen, cover with ABD pad, cover with HydraLock super absorbent dressing, do not use tape. Start date/revision date 1/3/23. C. ObservationsDuring the dressing change which was performed by the DON on 3/8/23 at 1:06 p.m., the physician was not followed. The physician order was for a HydraLock dressing, however were not present on the soiled dressing and not available for the new dressing. The resident ' s leg was also wrapped in Kerlix which the DON failed to adhere to the physician ' s order. On 3/8/23 at 1:06 p.m. a dressing change was observed for resident #2 performed by the director of nursing (DON). Staff turned the resident on her side from lying on her back and the DON removed the soiled dressing from the residents sacral, left ischial tuberosity and right ischial tuberosity regions. The soiled dressings consisted of three pieces of collagen from each wound, one ABD pad across the sacrum (the ordered HydraLock dressing was not present), one ABD pad from the left ischial tuberosity (the ordered HydraLock dressing was not present), one HydraLock pad from the right ischial tuberosity and one small piece of packing from the tunneling present in the right ischial tuberosity. The wound on the right ischial tuberosity had both red and pink tissue, significant tunneling, serous/serosanguinous fluid, and no odor was present. The wound on the left ischial tuberosity had bright red tissue with a small amount of white exudate, serous fluid, and no odor was present. The wound on the sacral area was a circular area with depth, serous fluid, and no odor present. The DON sprayed each area with wound cleanser, packed the tunneling in the right ischial tuberosity with ¼ inch iodoform with 2% mupirocin, covered each of the three wounds with collagen, and placed an ABD pad over each wound. The ordered HydraLock dressing was not used on any of the wounds. The resident was then placed on her back in the same position as she was prior to the dressing change. A soiled dressing from a fourth wound on the residents right posterior calf consisted of xeroform, ABD pad, and kerlix. The wound had red and pink tissue with white exudate, serous fluid, and no odor present. The DON sprayed wound cleanser on the wound, applied xeroform, covered with an ABD pad and wrapped with kerlix. The orders stated not to wrap this wound. The dressing change was complete at 1:31 p.m. and the resident remained on her back without green wedges or pillows for offloading. Record ReviewThe 10/5/22 admission assessment documented the resident was admitted to the facility with a stage 4 pressure injury to the left and right ischial tuberosities, stage 2 pressure injury to sacral region stage 2, pressure injury unspecified part of back stage 3, pressure injury left heel unstageable, and pressure injury to sacral region unstageable. The 10/5/22 admission Braden scale for predicting pressure injuries revealed the resident was at a high risk for developing pressure sores. The assessment revealed the resident had slightly limited sensory perception, her skin was rarely moist, she was bedfast, very limited mobility, had adequate nutrition, and had a problem for friction or shear which indicated she required moderate to maximum assistance in moving. The care plan, last updated on 1/9/23, revealed the resident had actual skin breakdown. Interventions included:-elevate head of bed (HOB) no more than 30 degrees; -implement turning schedule if resident is unable to turn and reposition self;-observe and assess weekly (sensory, activity, and, mobility risk); and -use pressure redistribution surface to bed and wheelchair if indicated. Wound care note dated 2/27/23 by wound care physician assistant (WCPA) noted that "Wounds worse on today ' s visit. Although unable to probe to bone, recommending XR (x-ray) of right calf, pelvis, and lumbar spine to evaluate for osteomyelitis as the larger wounds are stagnant or worsening. Right 2nd toe wound has resolved and the left 2nd toe wound showing significant improvement. Pending XR results, will also consider VAC (vacuum-assisted closure) therapy on sacral wound as this wound has been stagnant for several weeks."Wound assessment(s) dated 2/27/23: Wound #1 left ischial tuberosity, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 8.5cm length x 7.5cm width x 0.6cm depth, with an area of 63.75 sq cm and a volume of 38.25 cubic cm. Wound #2 right calf, stage 3 pressure injury pressure ulcer, subsequent wound encounter measurements are 9cm length x 2cm width with no measurable depth, with an area of 18 sq cm. Wound #4 right sacrum, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 2.5cm length x 2.5cm width x 2cm depth, with an area of 6.25 sq cm and a volume of 12.5 cubic cm. Wound #5 right ischial tuberosity, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 6.5cm length x 6cm width x 1cm depth, with an area of 39 sq cm and a volume of 39 cubic cm. InterviewsThe director of nurses (DON) was interviewed on 3/7/23 at 4:19 p.m. The DON stated that Resident #2 often refused to be turned side to side, however, the resident needed to be educated and offered with each care. The DON was interviewed a second time on 3/8/23 at 1:56 p.m. The DON said staff were to follow the physician orders which included both the dressing changes and the positioning devices. She said the order not to wrap Resident #2 lower extremity wound was a new order placed last week and had not been updated in the EMR. She also said the facility was out of the HydraLock dressing and she needed to order more. She said orders are typically entered into the EMR as soon as they are received but the wound care nurse is new and still learning. The registered dietician (RD) was interviewed on 3/9/23 at 10:04 a.m. The dietician reviewed the record and said he was familiar with the resident. The RD said the resident had multiple pressure injuries and was prescribed two health shakes a day for added nutrition and in addition was to receive double protein at all meals and a multivitamin. The wound care physicians assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said the dressing change is always demonstrated because he expects staff to do exactly what he demonstrated exactly how he demonstrated. The WCPA also said when he gives an order it is a verbal order and he also writes the order in his wound care visit note, his note is then uploaded into the residents chart. He also notifies the primary doctor at the facility if the order is complex. Then he logs into the residents chart and signs the order to confirm it was entered correctly. The WPCA also said turning and repositioning is very important and an air mattress was not a substitute. Additional interviewsThe wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said pressure injuries were avoidable unless there were outstanding circumstances or comorbidities like diabetic ulcers. He went on to say turning and repositioning were very important and an air mattress did not substitute a turning and repositioning schedule.

Based on record review, observations and interviews, the facility failed to keep residents safe from avoidable skin impairment related to proper repositioning for four (#9, #10, #4, and #6) of four out 10 total sample. Specifically, the facility failed to properly reposition residents while seated in their wheelchairs using a gait belt to prevent skin injury. I. Professional referencesThe Wound Pressure Injury Management article (2022) , retrieved on 3/18/23 from https://www.ncbi.nlm.nih.gov/books/NBK532897/ revealed the following pertinent information: "It is very important to avoid friction and shear force injuries. These injuries may occur when the patient is sliding...""Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. Pressure, friction, and shear forces should be avoided during positioning. "II. Facility policy and procedureThe routine resident care policy, revised 9/2011, was received from the director of nursing (DON) on 3/9/23 at 11:46 a.m. The policy documented in pertinent part, "All direct care personnel use gait belts during ambulation and transfers for residents requiring contact guard, contact assist, or greater care in accordance with the resident's Plan of Care."III. Failure to reposition properly 1. Resident #9A. Resident statusResident #9, age 81, was admitted on 7/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included nontraumatic intracranial hemorrhage, cerebral infarction, and anxiety. According to the 1/18/23 minimum data set (MDS) assessment, the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of 5 out of 15. The resident required extensive assistance with activities of daily living, transfers, and bed mobility. The resident was incontinent of both bowel and bladder. The MDS coded the resident was at risk for impaired skin integrity. The MDS coded the resident as not having any behaviors or refusal of care. B. Record reviewThe care plan last updated on 1/18/23 identified the resident as being at risk for skin breakdown with additional risk for friction and shear injury. Pertinent interventions were head of bed no more than 30 degrees, and to provide extensive assistance in repositioning. C. ObservationsOn 3/7/23 at 3:18 p.m., the resident was sitting in her high back wheelchair preparing to be transferred to her bed for incontinence care. Certified nurse aide (CNA) #5 held onto the resident's pants at the waistline during transfer to bed and did not use the available gait belt. 2. Resident #10A. Resident statusResident #10, age less than 65, was admitted on 8/18/22.. According to the March 2023 CPO diagnoses included anoxic brain damage. According to the 3/7/23 minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS) and was coded as severely impaired. The resident required total assistance with activities of daily living, transfers, and bed mobility. The MDS coded the resident was at risk for impaired skin integrity. The MDS coded the resident as not having any behaviors or refusal of care. B. Record reviewThe care plan last updated on 1/31/23 identified the resident as being at risk for skin breakdown. Pertinent interventions were to perform weekly skin inspections. C. ObservationsOn 3/7/23 at 8:55 a.m., the resident was sitting in her wheelchair when registered nurse (RN) #1 went behind the resident, reached down between the wheelchair and the resident's back, grabbed onto the resident ' s pants and pulled her up and back in the chair. A gait belt was not used. On 3/7/23 at 9:49 a.m. CNA #4 went behind the resident while sitting in her wheelchair, reached down between the wheelchair and the resident ' s back, held on to the residents pants and pulled her up and back in her chair. A gait belt was not used. On 3/8/23 at 11:53 a.m. the resident was in the dining room in her wheelchair for lunch when CNA #1 reached down between the wheelchair and the resident ' s back, held on to the residents pants and pulled her up and back in her chair. A gait belt was not used. 3. Resident #4A. Resident statusResident #4, age 64, was admitted on 2/20/22. According to the March 2023 CPO diagnoses included epileptic seizures, Parkinson's disease, type 2 diabetes, and morbid obesity. According to the 2/23/23 minimum data set (MDS) assessment, the resident required extensive assistance with activities of daily living, transfers, and bed mobility. The resident was incontinent of both bowel and bladder. The MDS coded the resident was at risk for impaired skin integrity. The MDS coded the resident as not having any behaviors or refusal of care. B. Record reviewThe care plan last updated on 2/21/23 identified the resident as a potential/actual skin issue related to impaired mobility, morbid obesity, comorbidities, and incontinence. Pertinent interventions were to keep skin clean and dry, use of air mattress at all times when in bed, use of a draw sheet or lifting device to move the resident, and to provide frequent and extensive assistance in repositioning. C. ObservationsOn 3/6/23 at 1:06 p.m., the resident was sitting in her high back wheelchair after being provided with incontinence care. CNA #1 and CNA #2 held onto the residents pants at the waistline from each side and pulled the resident back in her wheelchair. A gait belt was not used. 4. Resident #6A. Resident statusResident #6, age 71, was admitted on 3/14/17. According to the computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and vascular dementia, mild, with mood disturbance. B. Record reviewThe minimum data set (MDS) dated 1/25/23 mobility, Resident #6 required substantial/maximal assistance with rolling left and right, sitting to lying, and lying to sitting on side of bed. Resident #6 required dependent assistance for sit to stand, chair/bed-to-chair transfer, and picking up objects. Resident #6 ' s functional limitation in range of motion: upper extremity (shoulder, elbow, wrist, and hand) documented impairment on one side, lower extremity (hip, knee, ankle, and foot) documented impairment on one side. Resident #6 was cognitively intact indicated by the brief interview for mental status (BIMS) score of 14 out of 15. C. ObservationsOn 3/6/23 at 3:58 p.m., the resident was sitting in her wheelchair. CNA #2 held onto the resident's pants at the waistline and pulled the resident back in her wheelchair. A gait belt was not used. D. InterviewsThe physical therapist (PT) was interviewed on 3/8/23 at 2:45 p.m. The PT said when residents were repositioned in their wheelchair there should be two people, one on each side with an arm under the residents arm and the other arm under the residents leg and shift up. She said if the resident was a smaller person one person can go behind under both arms and lift up. PT said adjustments should not be made using the resident ' s pants under any circumstances because that was not proper technique. PT also said proper adjustment training was done by the restorative training employee upon new hire. The restorative CNA (RCNA) trainer was interviewed on 3/8/23 at 2:57 p.m. The RCNA the restorative trainer was interviewed and said residents should always be repositioned using a gait belt unless one was not available in which case staff can place their arms under the residents arms and legs. RCNA said pulling up by the pants could cause skin shearing. RCNA also confirmed the training was completed for new hires. The nursing home administrator (NHA) was interviewed on 3/8/23 at approximately 4:00 p.m. The NHA said training was being completed with all nursing staff to ensure a gait belt was used.

Based on observations, record review and interviews, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for four (#1, #3, #5 and #9) of four out of ten residents. Specifically, the facility failed to:-Ensure Resident #1 was offered hydration on a consistent basis or encouraged to accept hydration per assessed daily minimum recommendation (see nutrition assessment below). Although Resident #1'ss risk for dehydration was identified upon admission, the facility failed to implement measures to ensure the resident received sufficient fluids to maintain hydration needs. As a result, of the resident poor fluid intake Resident #1 had a change of condition prompted by lack of hydration. The resident was diagnosed with dehydration and was ordered intravenous (IV) fluid therapy. The facility's failure to provide Resident #1 with adequate hydration led to the resident needing IV therapy. Upon the completion of the prescribed IV therapy, the facility failed to ensure the resident consumed sufficient amounts of fluids; failed to monitor the resident ' s fluid intakes to ensure fluid intake meet the resident ' s identified hydration needs; and failed to update the care plan with a care focus that identified the resident was at risk for dehydration; and failed to identify and implement appropriate interventions to prevent repeated episodes of dehydration. The facility's failure left Resident #1 at a high risk for repeated occurrences of dehydration. In addition the facility failed to:-Ensure Residents (#5, #3 and #9) were offered and encouraged hydration per daily minimum recommendations based on the facilities nutrition evaluation. Findings include:I. Professional referenceAccording to Beck AM, Seemer J, Knudsen AW, Munk T. Narrative Review of Low-Intake Dehydration in Older Adults. Nutrients. 2021 Sep 9; retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8470893/ accessed on 3/15/23. "Low-intake dehydration is a common and often chronic condition in older adults. Adverse health outcomes associated with low-intake dehydration in older adults are multifaceted, ranging from poorer cognitive performance, reduced quality of life, delirium, falls, fractures, worsened course of illness and recovery to heart disease, heat stress, kidney failure, unplanned hospital admissions, and increased mortality."II. Facility policy and procedureThe Hydration policy, revised 10/1/2021, was provided by the director of nursing (DON) on 3/9/23. It read in pertinent part: "The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Care plan implementation: The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: Offer the resident a variety of fluids during and between meals; provide assistance with drinking; ensure beverages are available and within reach; evaluate resident's medications that may place the resident at risk for dehydration; offer alternative fluids such as broths, popsicles, gelatin, and ice cream; address underlying causes of dehydration or fluid imbalance; provide thickened liquids after underlying causes of symptoms are addressed; real food and beverages will be offered first before adding supplements or assisted hydration (unless clinically indicated); tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. "III. Failure to ensure Resident #1 was offered and encouraged adequate hydration per daily minimum recommendation based on the facilities nutrition evaluation. 1. Resident #1A. Resident statusResident #1, age 86, was admitted on 11/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included, vascular dementia, chronic pain syndrome, type II diabetes and cognitive communication deficit. According to the 1/23/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). The resident required total assistance with activities of daily living (ADLs) and staff supervision with encouragement and cuing (throughout the meal) while eating. The resident was incontinent of bladder and frequently incontinent of bowel. The MDS documented the resident was at risk for pressure ulcers and had developed a pressure injury that has not healed since 12/12/23. The MDS documented the resident was not having any behaviors or refusal of care. B. ObservationsThe resident was observed continuously on 3/6/23 from 3:54 p.m. until 6:00 p.m.-At 3:54 p.m. the resident was observed sleeping, with a full bottle of water on the bedside table, but the water bottle was not within reach of the resident. -At 4:14 p.m., the resident was observed sleeping, staff had not entered the resident ' s room.-At 4:22 p.m., the resident was assisted out of her bed to the wheelchair in preparation for dinner time. The resident was not offered hydration.-At 4:26 p.m., the resident was observed out in the hallway and encouraged to dine in the dining room on the unit. -At 4:27 p.m., the resident was served dinner with 240 cubic centimeters (cc) of water, 240 cc of milk, 240 cc of juice, and 240 cc of hot chocolate. -At 4:33 p.m., the resident was observed not eating and or drinking. Certified nurse aide (CNA) #9 encouraged the resident to eat by saying "eat your food." The resident did not eat or drink any of the food or drinks offered.-At 4:45 p.m., the resident was not eating the served meal; staff approached and offered the resident an alternative meal. -At 4:47 p.m., the resident had not consumed any of the meal and pushed away from the table. When the resident pushed the meal away from the table, none of the staff present encouraged the resident to return to the table to eat or drink any of her fluids. -At 4:55 p.m., the resident was transported and transferred to bed by CNA #9. No hydration was offered and or encouraged during this care.-At 5:20 p.m., the resident remained in bed. The water bottle beside the bed was untouched and remained full.-At 6:00 p.m., the resident remained in bed. The water bottle was untouched and remained full. No staff provided encouragement, or physical assistance for the resident to accept any amount of hydration during this observation. The resident was observed continuously on 3/7/23 from 8:45 a.m. until 1:07 p.m.-At 8:45 a.m., Resident #1 was observed in the unit ' s dining room, food and drinks were untouched.-At 8:59 a.m., the resident remained in the dining area in her wheelchair, food and drinks untouched. Staff were observed providing assistance to other residents but not with Resident #1.-At 9:00 a.m., the resident propelled herself to the common area. -At 9:10 a.m., the resident was assisted to her room by CNA #8. The CNA proceeded to assist the resident to lay down. No hydration was offered or encouraged. Resident #1 ' s water bottle was observed to be full and not within reach of the resident.-At 9:30 a.m., the resident continued to lay in bed on her right side. Staff had not entered the room since 9:10 a.m. A full water bottle was available by bedside, however, it was not within the resident ' s..-At 9:44 a.m., the resident continued laying in bed. RN #3 took the resident's vital signs. The RNa did not offer or encourage the resident to accept hydration. The water bottle at the resident ' s bedside remained full and out of reach. -At 9:48 a.m., the resident was offered water by CNA #8 stating " Do you want something to drink?" The resident did not respond and remained on her right side asleep. The CNA did not make any other attempt to wake the resident or encourage the resident to drink. -At 9:59 a.m., the resident remained asleep on her right side. Water bottle was untouched and remained full by the bedside.-At 10:58 a.m., the resident remained on her right side in bed. The water bottle at the bedside remained full and untouched.-At 12:00 p.m., the resident was assisted to the dining room. The resident was served lunch, however, she was not served anything to drink. -At approximately 12:15 p.m., RN #3 provided the resident a glass with approximately 90 cc of water. RN #3 placed the water on the table; however, RN #3 did not encourage the resident to drink. The resident did not drink on her own.-At 12:20 p.m., the resident was assisted to bed. No fluids offered/ encouraged. -At 12:30 p.m., the resident was assisted by CNA #8 to sit up in bed. CNA #8 asked the resident "Would you like some food?" The water bottle at bedside remained full and out of reach. -At 12:34 p.m., the resident was assisted by CNA #8 to the unit ' s dining room. The resident was offered 240 cc of juice, a grilled cheese and meal assistance. The resident did not respond to meal assistance and propelled herself away from the table. Food and drink untouched. CNA #8 asked the resident "Do you want to lay down?"-At 12:35 p.m., the resident was assisted to her room by CNA #8. The resident was not offered hydration.-At 12:37 p.m., the resident was assisted to sit up in bed by CNA #8. The resident was prompted to eat a snack by CNA #8 " Do you want a snack?", no hydration offered. The CNA #8 exited the room.-At 1:07 p.m., the resident was still in bed laying on her right side. The water bottle remained full and untouched. The resident was observed continously on 3/8/23 from 8:33 a.m. to 12:17 p.m.-At 8:33 a.m., the resident was in bed, on her back. The resident's water bottle was full by the bedside but not within reach of the resident.-At 8:55 a.m., the resident remained at the same position. The water bottle remained untouched.-At 9:21 a.m., CNA #8 entered the residents room, and provided fresh water but did not wake or encourage hydration.-At 10:13 a.m., the resident was observed in the room asleep on her back. The water bottle remained full.-At 10:21 a.m., the resident was observed on the floor mat beside the resident's bed, calling out "help me", it was unclear if the resident climbed or rolled out of her low bed, as the angle of view did not allow for full view of the resident's bed; but of the resident ' s and the bedside table. CNA #8 and CNA #9 entered the room to assist the resident. The unit RN entered to assess the resident for injury.-At 10:30 a.m., the resident was assisted into a wheelchair, and transported to the common area. CNA #9 poured water in a 90 cc cup and offered it to the resident. The resident refused.-At 10:36 a.m., nursing staff offered the resident 30 cc of Ensure (protein supplement), but did not get the resident to drink any of the supplement. The 90 cc of water remained in front of the resident. -At 10:39 a.m., the resident took a sip of water. CNA #8 entered the secure unit ' s dining room and sat beside the resident to document the resident ' s meal choice. CNA #8 did not encourage the resident to drink. -At 10:50 a.m., the resident's water and Ensure remained untouched. -At 10:57 a.m., the resident's water and Ensure remained untouched. CNA #9 assisted the resident to her room; the resident was not offered hydration. -At 11:05 a.m., the resident was in bed, still the resident was not assisted or encouraged to accept hydration. -At 11:41 a.m., the director of nursing (DON) offered the resident a snack and drinks. DON stated "Do you want some Sprite, a Twinkie or 7 up? "The resident did not respond to the DON. The DON did not attempt to re-engage the resident and did not provide the resident with a snack or drink. C. Record review 1. Nutritional and fluid needs. The comprehensive care plan, last revised on 12/18/22, identified the resident required supervision with eating and drinking. The resident was to use a two handled cup with lid and built-up utensils at all meals. Pertinent interventions included:-Staff to sit with the resident and share a meal to attempt to increase meal intake; -Staff to observe document/report any signs and symptoms of diminished appetite and intake;-Offer preferred foods, meal alternates, as needed. Offer snack, as needed;-Encourage fluids with and between meals; and-Health shake everyday at lunch and observe intake and record after every meal. 2. Change of conditionNursing progress note dated 1/22/23, revealed in pertinent part: the resident was not acting like herself so CNA took vital signs. All vital signs were within normal limits except for the resident ' s blood pressure which was 97/61. The resident ' s physician was notified and an order for intravenous fluid (IVF) of normal saline (NS) at 100 cc per hour was provided. The physician also ordered lab orders for blood work. The resident's legal representative was notified that the resident had a change of condition, due to not eating or drinking much and dehydration was suspected. The legal representative suggested giving the resident 7up. According to the January 2023 computerized physician orders (CPO) the resident was ordered Normal Saline 0.9 percent via IV every shift for hydration on 1/22/23 and 1/23/23. The nutrition evaluation dated 3/6/23, revealed Resident #1 had been experiencing weight loss since admission. Resident ' s body weight prior to admission was approximately 150 pounds (lbs) and as of the assessment weighted 122 lbs, related to poor intake. The resident's nutrition needs indicate the resident ' s minimum recommended fluid intake should be 1,375 cc per day. -Resident #1 required feeding supervision and encouragement for intake to meet assessed nutrition needs. The resident was at risk for malnutrition due to dementia and diabetes. Nursing and CNA reports the resident had increased refusal of meals and supplements. -Recommendation by registered dietician (RD): included to continue with snacks twice a day, protein liquid twice a day, and continue with house shake once per day. Review of the resident's fluid intake tracing document revealed facility staff failed to document the resident's daily fluid intake to demonstrate whether the resident was meeting the daily minimum fluid intake recommendation. The facility DON was unable to provide any additional documents that tracked the resident's daily fluid intake/.The comprehensive care plan last updated 12/18/22 indicated the resident should be offered 7 up as that is her preferred choice of hydration, furthermore the care plan was not updated after the resident documented change of condition with a care focus to adder the resident's actual and risk of repeated episodes of dehydration. D. Interviews CNA #8 was interviewed on 3/9/23 at 9:10 a.m. The CNA said Resident #1 was able to feed herself, but required encouragement to eat and drink. The resident did refuse care, however staff were expected to re-approached at a later time when she refused care assistance. CNA #8 said that the amount of the food and fluids the resident consumed were supposed to be documented in the resident record. Registered nurse (RN) #3 was interviewed on 3/9/23 at 9:17 a.m. RN #3 said the resident feeds herself but required encouragement which included reminding the resident to eat, and offering the resident different things to eat and drink. The resident was always very picky when it came to eating and drinking; therefore staff should offer the resident multiple food and drink options based on the resident's choice. The resident's daughter also brought snacks and drinks the resident enjoys to eat. Staff should also provide positive reinforcement. RN #3 said Resident #1 received intravenous (IV) hydration by infusion into the resident's vein (refers to a way of giving a drug or other substance through a needle or tube inserted into a vein.) this past December 2022 because the resident was severely dehydrated and needed to be hydrated with fluid. RN #3 said she only tracked fluids if it was ordered by the physician. Otherwise the CNAs were to document the fluids consumed by the resident during meals and snack time. The RD was interviewed on 3/9/23 at 10:04 a.m. The RD was in the facility weekly to assess residents who were on the high risk list for pressure ulcer, dialysis, enteral nutrition (nutrition by gastric tube into the gastric intestinal tract) or hospice care. Otherwise residents were reviewed every three months. The RD said he did evaluate residents for hydration needs. Residents in general at meal times should receive 237 cc to 356 cc of fluids. Additionally, residents should also be offered hydration at medication pass times and additionally provided the facility house shakes if at risk for dehydration. The RD reviewed resident #1's medical record. The RD said Resident #1 had experienced a change of condition due to dehydration and required an IV for fluid hydration. The resident had been assessed to require as minimum daily fluid intake need to be between 1350 cc to1650 cc and that recommendation should be followed. The RD said 1375 cc daily at minimum would be his recommendations. The RD confirmed the care plan did not include a hydration focus or care after the resident December 2022 change of condition. The RD's expectation was to offer the resident drinks that the resident preferred such as 7up. The director of nurses (DON) and the regional nurse consultant (RNC) were interviewed on 3/9/23 at 10:57 a.m. The DON said residents should be offered something to drink at meals; in between meals;, when they wake up from sleeping; and at just before going to bed. The minimum hydration recommendation identified by the RD should be followed. The DON said the resident fluid intake at meals were tracked, but facility staff missed documenting the additional fluids provided to the residents. The RNC confirmed that they were unable to find the fluid intake tracker for Resident #1. The DON said the Resident #1 should have a specific care plan for hydration which included the resident's hydration needs with an intervention that included a need to track the resident's fluid intake. The RNC said the resident's fluid consumption needed to be watched more closely. IV. Other failures to maintain resident hydration 1. Resident #5A. Resident statusResident #5, age older than 80, was admitted on 7/12/17 and re-admitted on 9/8/22. According to the March 2023 CP) diagnoses included dementia, overactive bladder, mild cognitive impairment, and abnormalities of gait and mobility. According to the 3/17/22 MDS assessment, the resident had severely impaired cognition as evidenced by a BIMS score of four out of 15. The resident required extensive assistance with activities of daily living, including supervision for eating. The resident was frequently incontinent of bladder and bowel. The MDS coded the resident as an individual that sustained 5% -10% weight loss in the last 6 months. The MDS coded the resident as not having any behaviors or refusal of care. B. ObservationsThe resident was observed continuously on 3/6/23 from 3:54 p.m. to 6:03 p.m.-At 4:01 p.m., Resident #5 was in the secure unit ' s dining area in her wheelchair.-At 4:23 p.m., kitchen staff provided meals to the secure unit. -At 4:47 p.m.,the resident started to eat her dinner.-At 5:49 p.m., the resident finished her meal. The resident drank: 100 % of a 240cc cup of water and 50% of a 240cc cup of hot chocolate (120cc). The resident was observed continuously on 3/7/23 from 8:59 a.m. to 1:03 p.m. Throughout the observations, the resident was not offered anything to drink until the meal time. Observations were as follows-At 8:59 a.m., Resident #5 was in the dining area in her wheelchair.-At 9:08 a.m.,the resident was propelled to the common area by CNA #8. -At 9:20 a.m., the resident was asleep in her wheelchair in the common area.-At 9:59 a.m., the resident remained asleep in her wheelchair in the common area.-At 10:58 a.m., the resident remained asleep in her wheelchair in the common area.-At 11:08 a.m., CNA #8 escorted the resident to the dining area.-At 11:23 a.m., the resident received her meal. She received 240 cc of milk, 240 cc of coffee.-At 11:25 a.m., the resident began to eat. The resident drank: approximately 180 cc of milk, and 120 cc of coffee but not all of the hydration provided.-At 12:27 p.m., the resident was no longer eating her meal and was not being prompted to eat or drink. Staff approached and the resident was taken back to the secure unit by CNA #8 to sit in the common area. C. Record review The nutrition evaluation was completed on 3/6/23. The evaluation showed the resident's minimum recommended fluid intake should be 1590 cc per day. The evaluation documented the resident required supervision and encouragement with eating and drinking. Resident #5 was at risk for malnutrition due to dementia. The comprehensive care plan, last revised on 11/10/22, identified the resident required supervision with eating and drinking. Pertinent interventions included:-Encourage juice and milk with meals for added calories. -Observe intake and record every meal. -Encourage good nutrition and hydration in order to promote healthier skin. The nutrition-amount eaten task records (records daily fluid intake), dated 2/21/23 through 3/8/23, that were completed by the CNA staff were reviewed. The documentation revealed the Resident #5 averaged a fluid intake of approximately 777 cc of fluid per day in contrast with the RD recommended minimum of 1590 cc based on the nutrition evaluation. D. InterviewsThe RD was interviewed on 3/9/23 at 10:04 a.m. The RD said Resident #5 ' s recommended minimum daily fluid intake for the resident to consume 1500 cc of fluid per day. The RD reviewed resident #5 ' s record and confirmed the care plan did not include hydration care focus. The RD ' s expectation would be for the resident to have a care focus for hydration, based on the documentation showing an inadequate fluid intake where the resident averaged a fluid intake of 583cc per day in comparison with the daily recommended minimum fluid intake of 1500cc. CNA #8 was interviewed on 3/9/23 at 9:10 a.m. The CNA said Resident #5 was able to feed herself, but required to be reminded to eat and drink. The resident had refused care, especially being fed, as she is very independent and attempts to maintain her independence. CNA #8 said that the amount of the food and fluids the resident consumed were supposed to be documented in the resident record. Registered nurse (RN) #3 was interviewed on 3/9/23 at 9:17 a.m. RN #3 said the resident feeds herself but required encouragement which included reminding the resident to eat, and offering the resident different things to eat and drink. RN #3 said she only tracked fluids if it was ordered by the physician. Otherwise the CNA ' s were to document the fluids consumed by the resident during meals and snack time. 2. Resident #9A. Resident statusResident #9 was admitted on 7/15/22. According to the March 2023 computerized physician orders (CPO) diagnoses included nontraumatic intracranial hemorrhage, cerebral infarction, and anxiety. According to the 1/18/23 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 5 out of 15. The resident required total assistance with activities of daily living. The resident was incontinent of both bowel and bladder. The MDS coded the resident as not having any behaviors or refusal of care. B. ObservationsObservations revealed the resident did not receive the minimum amount of fluid as assessed. Observations were as follows:On 3/7/22 at 8:38 a.m. continuous observation began. Resident #9 was observed in the main dining room eatingbreakfast. The resident was served 240 cc of red drink. -9:07 a.m. Resident #9 finished 240 cc of a red drink.-9:35 a.m. Resident #9 was laying in bed. The 240 cc of protein drink was on the table in front of her but no one offered any encouragement for her to consume it.-10:37 a.m. Resident #9 was provided incontinence care and placed in her wheelchair. The meal replacement drink was in the same location and the volume had not changed.-10:38 a.m. Resident #9 was assisted into the dining room for lunch and a 240 cc regular cup of water was placed in front of her.-10:48 a.m. Resident #9 took two small sips of water.-11:07 a.m. Resident #9 was served lunch which included 240 cc of a red drink.-12:48 p.m. Resident #9 returned to her room after drinking approximately 120 cc of a red drink, 120 ml of a meal replacement drink, and 4 small sips of water.-2:01 p.m. CNA #3 went into Resident #9 ' s room and said goodbye. There was a container of water in front of the resident within her reach but the CNA did not offer or encourage the resident to drink it. -2:29 p.m. CNA #5 entered Resident #9 room and asked about dinner choices, however a drink was not offered.-2:53 p.m. Resident #9 remained in the same position in her wheelchair in her room.-3:08 p.m. LPN #1 and CNA #5 entered Resident #9 ' s room for incontinence care and did not offer any drinks.-4:10 p.m. Resident #9 was assisted to the dining room for dinner.-5:53 p.m. Resident #9 was assisted back to her room after she finished eating dinner and approximately 120 ml of the red drink. Observations ended and the total amount of fluid consumed was 600 cc. C. Record ReviewThe 3/1/23 physician diet order read, "HSG (name of kitchen contract) regular diet, HSG dysphagia advanced texture, regular/thin consistency, two-handed cup, scoop plate, built-up handle utensils, and red lap tray for all meals."The nutritional assessment dated 2/16/23 documented the resident required 1022 cc to 1200 cc fluid per day. The care plan also directed staff to offer water in conjunction with turning/care schedules. The Nutrition tracking chart for 3/7/23 for Resident #9 documented Resident #9 consumed 270 cc at 1:38 p.m., 270 cc at 1:39 p.m. and 800 cc at 9:48 p.m. for a total of 1340 cc. Continuous observations directly contradicted that amount. 3. Resident #3A. Resident statusResident #3, age 66, was admitted on 10/13/22 and discharged on 10/24/22. According to the October 2022 computerized physician orders, diagnoses included, pressure ulcer of left hip, stage 3, and chronic respiratory failure with hypoxia. According to the minimum data set (MDS) dated 10/17/22, the resident had no cognitive impairment as she scored a 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #3 did not have any complaints of difficulty or pain when swallowing and loss of liquids/solids from mouth when eating or drinking. Record ReviewThe 10/18/22 nutrition evaluation showed Resident #3's estimated amount of fluid intake was 1500-1900 cc a day. The evaluation stated that resident #3 required limited assistance during meals. The hydration tracking task flow sheet record showed Resident #3's average amount of fluid intake ranged between 480 cc to 1200 cc of fluid intake daily. The nursing daily skilled charting dated 10/20/22 showed, the resident required extensive assist for self-feeding and had weakness in right and left hand. InterviewsThe registered dietician (RD) was interviewed by phone on 3/9/23 at 10:04 a.m. The RD reviewed the medical record and said the resident ' s hydration needs were estimated at 1500cc to 1900cc's a day. The RD did not know how much Resident #3 was drinking per day. The RD reported that he was involved in Resident #3 ' s care upon admit and after that he reported that he did not see her again. Additional interviewsThe director of nurses (DON) and the regional nurse consultant were interviewed on 3/9/23 at 10:54 a.m. The DON said that residents should be getting fluids between meals, when they were awake and throughout the day. The DON said that they follow the recommendations of the dietician regarding how much fluid each resident should consume. The DON said that they track fluid amounts on tasks which only tracked fluid intake during meals. The DON said that an additional fluid task has been asked to be put in, so that it showed residents were not just getting fluids at meal times but at other times during the day.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/20/2023 and 02/26/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.