**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#68 and #70) of five residents reviewed for falls out of 33 sample residents. Specifically, for Resident #68 and #70, the facility failed to: -Identify the root cause of falls and implement timely and effective interventions to prevent further falls; and, -Update and revise the residents' care plans with new interventions after each fall. Findings include: I. Facility policy. The Fall Clinical Protocol policy, revised March 208, was provided by the director of nursing (DON) on 5/16/24 at 1:44 p.m. It read in pertinent part, Staff will begin to try to identify possible causes within 24 hours of the fall. The staff will continue to collect and evaluate information until either the cause of the fall is identified or it is determined that the cause cannot be found or is not correctable. If underlying causes cannot be readily identified, staff will try various relevant interventions based on assessment until fall reduces or stops or until a reason is identified for its continuation. II. Resident #68 A. Resident status Resident #68, age [AGE] years old, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia with agitation, abdominal pain, vascular (blood vessels) disorder of the intestine and cystic disease (condition that causes fluid filled sacs) of the liver. The 2/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident required partial assistance with oral hygiene and dress. He required substantial assistance with showering and personal hygiene. He required supervision with toileting. B. Record review Resident #68's fall care plan, revised 1/4/24, revealed the resident was at risk for falls related to confusion and poor safety awareness. Interventions included ensuring the resident wore non-skid shoes when ambulating and anticipating the resident's needs. The vision care plan, revised 8/16/23, revealed the resident had impaired visual functions in both eyes. Interventions included reminding the resident to wear glasses and ensuring glasses were clean and free from scratches. A 4/13/24 fall nurse note revealed Resident #68 had an injury to the left side of his eye, brow and bridge of his nose. -A 4/14/24 nurse note revealed there was bruising noted over the bridge of his nose, left eye upper and lower eyelids and lateral aspect of the left eye. There was black and blue bruising of his bilateral hands. -An incident report was requested for the 4/13/24 fall but not provided. A 4/25/24 interdisciplinary team (IDT) progress note revealed a fall meeting was held. The fall from 4/13/24 was reviewed. The new intervention was for physical therapy to do an evaluation. -The intervention was not implemented until 12 days after the resident's 4/13/24 fall. -The interdisciplinary team (IDT) did not identify the root cause of the fall. -The new intervention for a physical therapy evaluation was not added to the Resident #68's fall care plan. A 5/16/24 fall incident report was reviewed. The resident was found on the floor in the secure unit dining room. The report documented the resident tried to maneuver around another resident's wheelchair and his foot was caught in the other resident's wheelchair's back wheel. He tried to hold onto the wheelchair's handles but lost his balance and fell on his right side. -The incident report did not identify any new fall interventions that were implemented at the time of the fall. A 5/17/24 nurse note revealed the resident continued to walk around the unit. He looked down at the floor while walking instead of looking ahead. A 5/19/24 nurse note revealed the resident walked around the unit with his head down at the floor or bent over to pick up items from the floor. Staff monitored the resident to give safety prompts as needed. -There was no IDT note documented to indicate the fall had been reviewed by the IDT and new interventions were implemented. -The fall care plan did not identify new interventions after the fall. -The IDT did not identify the root cause of the fall. The 5/22/24 fall risk assessment revealed that the resident fell before, did not use an assistive device, such as a wheelchair or walker to ambulate, had a weak gait and overestimated or forgot his limits. He scored a 65 which indicated he was a high risk to fall. D. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 5/23/24 at 11:32 a.m. CNA #6 said she knew a resident was at a high fall risk if the resident used oxygen, if they were woozy or if the resident tried to stand without assistance when the resident required assistance. She said she kept an eye on residents to prevent a fall. She said she was familiar with Resident #68. She said he was a high fall risk. She said she kept an eye on the resident, encouraged the resident to sit down and kept food and water close to him to prevent him from falling. Registered nurse (RN) #2 was interviewed on 5/23/24 at 11:40 a.m. RN #2 said she knew a resident was at a high fall risk based on their gait, diagnoses and observation of the resident. She said she made sure the area was clear of spills to prevent a fall. She said she was familiar with Resident #68. She said he was a high fall risk. She said she asked him to sit and walked with him to prevent him from falling. The DON was interviewed on 5/23/24 at 10:13 a.m. The DON said staff knew a resident was a high fall risk based on a fall star placed on the door of residents who were a high fall risk. She said a nurse knew a resident was a fall risk based on the fall assessment. She said the nurses communicated to the staff verbally when a resident was a fall risk. She said if a resident fell, a RN completed an assessment and started a fall protocol that included neurological checks. The DON said the nurse should look at what happened to cause the fall and add a fall intervention to prevent further falls. She said the IDT met weekly and added further interventions if appropriate. She said she was familiar with Resident #68. She said he was a high fall risk. The DON said there was not a root cause analysis done for Resident #68's falls on 4/13/24 and 5/16/24. She said she was not aware Resident #68's eyesight was decreasing and his head was down frequently. She said if she knew she would include therapy and maintenance to develop interventions to prevent accidents and falls. The DON said interventions were not reviewed and a new intervention was not added for Resident #68's fall on 5/16/24. She said the nurse who completed the nurse assessment should identify the initial root cause of the fall and an intervention. V. Facility follow up On 5/28/24 at 7:23 a.m. the minimum data set coordinator (MDSC) sent a performance improvement plan which indicated the facility had created an action plan to review falls and interventions in a timely manner and to decrease the number of falls. It revealed the steps included reviewing falls, reviewing interventions, staff considerations, staff education and staff awareness of high fall risk residents. -The follow-up plan did not include dates when the action steps were completed. III. Resident #70 A. Resident status Resident #70, age [AGE], was admitted on [DATE]. According to the May 2024 CPO, diagnoses included malignant melanoma of skin, malignant neoplasm of prostate, malignant neoplasm of brain, nontraumatic intracerebral hemorrhage, and history of falling. The 2/29/24 MDS assessment revealed the resident's cognition was severely impaired with a BIMS score of six out of 15. He had no behaviors. He required partial moderate assistance with toileting, dressing, personal hygiene and transfers. B. Resident representative interview Resident's #70's representative was interviewed on 5/20/24 at 3:45 p.m. The representative said the resident was falling frequently at home and in the facility. She said the resident still thought he was strong and tried to do things he used to, such as getting up and walking. She said he was not able to use the call light to call for assistance with transfers. C. Record review The fall care plan, initiated 3/7/24, revealed the resident had a history of falls due to poor balance, poor communication/comprehension and unsteady gait. Interventions included placing a fall mat by the resident's bed while he was in bed (initiated 4/1/24), placing a wedge cushion in the resident's wheelchair (initiated 4/8/24), placing a silent bed sensor (bed alarm) on the resident's bed (initiated 4/23/24), staff to provide frequent checks on the resident (initiated 4/23/23) and providing a lipped mattress on the bed (initiated 5/16/24). -Despite the resident's history of frequent falls (see resident's diagnoses and resident representative interview above), the facility failed to initiate a fall care plan with interventions to prevent falls until 3/7/24, after Resident #70 sustained a fall on 3/6/24 (see below). -The care plan failed to specify how often frequent checks should be conducted for Resident #70. On 2/17/24, a nursing note revealed Resident #70 was admitted to the facility under hospice care. The note documented the resident was admitted to the facility following falls at home. The resident required extensive assistance of one staff member for transfers. 1. Fall on 3/6/24 On 3/6/24 at 5:45 a.m. a nurse documented Resident #70 sustained an unwitnessed fall. The resident was noted to be on the floor at the side of his bed, face down. The resident had been displaying increased restlessness and/or confusion during the night. The resident's call light had been in reach, but the resident did not always use it to call for assistance from staff. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. 2. Fall on 3/26/24 On 3/26/24, a nurse documented Resident #70 was sitting in one of the regular chairs, watching TV (television) in the lounge area. The resident's wheelchair was locked/parked close to the chair. The nurse heard a noise and found the resident lying on his back on the floor in front of the chair he had been sitting in and the resident's wheelchair had been unlocked. The resident was placed in bed with the bed in low position and the call light in reach. The door to the resident's room was left open so he could be monitored by the staff. The nurse encouraged the resident to call for assistance when needing to transfer. The resident continued to display his usual episodes of forgetfulness/confusion and made some comments to the nurse that he could stand on his own. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. -The resident's fall care plan was not updated until 4/1/24 (six days after the fall) when a floor mat was added as an intervention (see care plan above). 3. Fall on 4/4/24 On 4/4/24 at 10:30 p.m. a nurse documented Resident #70 was found sitting on the floor in front of his wheelchair in the hallway. Two staff members used a gait belt to stand the resident and get him in his wheelchair. The resident had been watching TV late in the TV room. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. -The resident's fall care plan was not updated until 4/8/24 (four days after the fall) when a wedge cushion was added to the resident's wheelchair as an intervention (see care plan above). 4. Fall on 4/14/24 On 4/14/24 at1:14 a.m. a nurse documented Resident #70 was found sitting on the floor with his feet towards the wall, holding on to the bed halo (bed rail). The resident was unable to state what occurred but mentioned his wife and trying to meet with someone. The resident was reoriented to time. He required a two) person assistance back to bed. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. -The resident's fall care plan was not updated until 4/23/24 (when the resident sustained another fall which was nine days after the 4/14/24 fall) when a bed alarm and frequent checks on the resident were added as interventions (see care plan above). 5. Fall on 4/23/24 On 4/23/24 at 7:11 a.m. a nurse documentedResident #70 had been in his wheelchair in the lounge area watching TV. The nurse was searching for him and found him on the floor beside his bed in his room. The resident had closed the door to his room. The floor mat was beside the bed and the resident had landed on the floor mat. The resident's call light was in reach, but the resident did not use it to call for staff assistance. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. 6. Fall on 5/16/24 On 5/16/24 at 6:30 a.m. a nurse documented Resident #70 attempted to transfer himself out of bed and was found by CNA lying on the fall mat beside his bed. The 5/16/24 IDT fall review note documented the hospice services provider was to provide a lipped mattress. No further interventions were documented. D. Staff interviews CNA #7 was interviewed on 5/22/24 at 10:45 a.m. CNA #7 said Resident #70 was falling frequently during evening or nighttime looking for his wife or trying to get out of bed. She said the resident's room was across the nurses' desk and the staff was keeping an eye on him through the open door. RN #3 was interviewed on 5/22/24 at 10:55 a.m. RN #3 said most of Resident #70's falls happened at night. She said the resident was not able to understand or remember to use his call light. She said he did not have any of his falls on her shifts (during the day). CNA #8 was interviewed on 5/23/24 at 1:18 p.m. CNA #8 said she checked on Resident #70 frequently and took him to the toilet. She said the resident did not fall on her shifts. RN #4 was interviewed on 5/23/24 at 1:23 p.m. RN #4 said the resident had been falling usually in the late afternoon and at night. She said he had a short attention span. She said the resident would not participate in activities for longer than a couple of minutes before he started looking for his wife. RN #4 said when he was in the living room watching TV he would try to stand up and look for his wife. She said he did the same thing when he was in bed. She said as soon as he opened his eyes he would try to stand up and ask the staff about his wife. She said the best approach to prevent falls for the resident would be to have someone with the resident at all times. RN #4 said his wife lived very close to the facility and visited most of the weekdays in the afternoon. The DON was interviewed on 5/23/24 at 3:00 p.m. The DON said falls were reviewed in the facility during morning stand-up meetings and approaches to prevent falls were discussed. She said the IDT was meeting to review falls weekly and there was a new fall intervention added after each fall for Resident #70. -However, Resident #70's progress notes and care plan did not reflect that a new intervention was added timely after each of the resident's falls (see record review above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VIII. Resident #18 A. Resident status Resident #18, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and dementia. The 1/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 13 out of 15. She required partial/moderate assistance with transfers and toileting, set up assistance with personal hygiene and was independent with eating and bed mobility. -The assessment indicated that restraints and bed rails were not used. B. Observations On 5/23/24 at 8:00 a.m. Resident #18 was observed with a bed rail on her bed. C. Record review The activities of daily living (ADL) care plan, initiated on 2/21/22 and revised 9/1/22, revealed Resident #18 used a halo assistive device (bed rail) on the door side of the bed to maximize independence with turning and repositioning in bed. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation, physician's order or consent done prior to the initiation of the bed rail as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. IX. Resident #25 A. Resident status Resident #25, age less than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included encephalopathy and protein malnutrition. The 2/22/24 MDS assessment revealed severe cognitive impairment with a BIMS score of zero out of 15. He was dependent with toileting and personal hygiene, required substantial/maximal assistance with bed mobility and transfers and required supervision with eating. -The assessment indicated that restraints and bed rails were not used. B. Observation On 5/23/24 at 8:02 a.m. Resident #25 was observed with bed rails on his bed. C. Record review The ADL care plan, initiated on 6/10/23 and revised on 2/27/24 revealed Resident #25 had a bed rail on his bed for assistance with positioning. The May 2024 CPO revealed a physician's order for bilateral bed rails to be used for positioning, ordered 2/22/23. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation prior to the initiation of the bed rails. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. X. Resident #41 A. Resident status Resident #41, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included CKD, chronic respiratory failure and vascular dementia. The 2/1/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. She required substantial/maximal assistance with transfers, partial/moderate assistance with personal hygiene, bed mobility, toileting and was independent with eating. -The assessment indicated that restraints and bed rails were not used. B. Observations On 5/23/24 at 8:04 a.m. Resident #41 was observed with a bed rail on her bed. C. Record review The ADL care plan, initiated on 8/11/23 and revised on 3/6/24, revealed Resident #41 required partial/moderate assistance of one staff member for bed mobility. -The care plan failed to indicate the use of bed rails as an intervention as a positioning enabler. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation, physician's order or consent done prior to the initiation of the bed cane/halo as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. XI. Resident #53 A. Resident status Resident #53, age [AGE], was admitted on [DATE]. According to the May 2024 CPO, diagnoses included atrial fibrillation, pancreatic insufficiency and cognitive communication deficit. The 4/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. She required partial/moderate assistance for toileting, supervision with bed mobility, transfers and was independent with eating, personal hygiene. -The assessment indicated that restraints and bed rails were not used. B. Observations On 5/23/24 at 8:06 a.m. Resident #53 was observed with a bed rail on her bed. C. Record review The ADL care plan, initiated on 5/12/23 and revised on 1/31/24, revealed Resident #53 was able to roll side to side in bed and go from sitting to lying and lying to sitting with the partial/moderate assistance of one staff member. -The care plan failed to indicate the use of bed rails as an intervention as a positioning enabler. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation, physician's order or consent done prior to the initiation of the bed cane/halo as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. XII. Staff interviews CNA #2 was interviewed on 5/23/24 at 8:30 a.m. CNA #2 said Residents #18. #25. #41 and #53 all used bed rails as bed mobility positioning or bed transferring devices. Licensed practical nurse (LPN) #2 was interviewed on 5/23/24 at 8:34 a.m. LPN #2 said residents with bed rails should all have an assessment by occupational or physical therapy for their use of the bed rails. She said the resident or the resident's representative should give consent for the bed rails prior to their use. She said an order should be placed before the bed rails were used. She said bed rails should have a regular assessment by maintenance to maintain the safety and functionality of their use. She said she was new to the facility and was unfamiliar with the facility's policies and procedures. Based on observations, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for eight (#1, #33, #36, #44, #18, #25, #41, and #53) of seventeen residents reviewed for bed rails out of 33 sample residents. Specifically, for Resident #1, #33, #36, #44, #18, #25, #41 and #53, the facility failed to: -Assess the resident for risk of entrapment prior to installing the bed rails; -Obtain consent, which included the risks versus benefits of bed rails, from the resident and/or the resident's representative prior to bed rail installation; -Obtain physician's orders for bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate the continued need and safety of the bed rails. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Recommendations for Health Care Providers Using Adult Portable Bed Rails (2/27/23), was retrieved on 5/28/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health- care-providers-using-adult-portable-bed-rails. It read in pertinent part, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Bed Safety and Bed Rails policy and procedure, revised August 2022, was provided by the nursing home administration (NHA) on 5/22/24 at 2:00 p.m. It read in pertinent part, Residents' beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails are prohibited unless the criteria for use have been met. Consideration is given to the residents' safety, medical conditions, comfort and freedom of movement, as well as input from residents and resident families regarding previous sleeping habits and bed environment. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator and reports results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action. III. Resident #1 A. Resident status Resident #1, under age [AGE], was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis, dementia, contracture of muscle and chronic respiratory failure. The 2/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff assistance with transfers, toileting personal hygiene and mobility. -The assessment documented Resident #1 did not use bed rails. B. Observations On 5/20/24 at 9:40 a.m., Resident #1 was observed lying in bed with two metal half rails attached to the resident's bed. On 5/21/24 at 2:35 p.m. Resident #1 was observed to be lying in bed with the two metal half rails up on the bed. C. Resident interview Resident #1 was interviewed on 5/22/24 at 10:57 a.m. Resident #1 said the bed rails were used to help him roll left and right side when the staff changed his briefs. He said the bed rails had been in place for a long time. D. Record review The May 2024 CPO revealed Resident #1 had a physician's order for a set of half side rails on each side of the bed to help aid with mobility, ordered on 3/9/18. The comprehensive care plan, initiated on 3/7/18 and revised on 1/9/19, revealed Resident #1 used half side rails to his bed related to multiple sclerosis. Interventions included Resident #1 holding on to the bed rails to assist with turning and repositioning. -A comprehensive review of the resident's electronic medical record (EMR) failed to reveal a bed rail evaluation and consent prior to the initiation of the bed rails as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the half bed rails. -The maintenance department had no routine inspections for the resident's half bed rails. IV. Resident #33 A. Resident status Resident #33, over the age [AGE], was admitted on [DATE]. According to the May 2024 CPO, diagnoses included multiple sclerosis, dementia, major depressive disorder, lower back pain and chronic obstructive pulmonary disease (COPD). The 3/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required set up assistance with toileting, showering, dressing, personal hygiene and mobility. -The assessment documented Resident #33 did not use bed rails. B. Observation On 5/20/24 at 10:36 a.m. and on 5/21/24 at 3:02 p.m., a bed rail was observed on the left side of Resident #33's bed. C. Resident interview Resident #33 was interviewed on 5/22/24 at 11:05 a.m. Resident #33 said the bed rail had been on her bed for a very long time. The resident said she does not know the reason the bed rail was attached to her bed because she does not use it. D. Record review The care plan, initiated on 4/19/24 and revised on 10/10/23, revealed Resident #33 was at risk for falls related to multiple sclerosis and abnormality of gait. Interventions included the use of a bedside rail for mobility. -Review of Resident #33's May 2024 CPO revealed there was no physician's order for the resident's bed rail. -The resident's EMR revealed Resident #33 was not evaluated for the use of a bed rail, there was no consent for bed rails and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. V. Resident #36 A. Resident status Resident #36, over the age [AGE], was admitted on [DATE]. According to the May 2024 CPO, diagnoses included cerebral infarction (a condition that occurs when brain tissue is damaged), type 2 diabetes and depressive disorder. The 2/22/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. She required set up assistance for oral and personal hygiene, substantial to maximum assistance with showers, dressing, and was dependent on staff with toileting. -The assessment documented Resident #36 did not use bed rails. B. Observation On 5/20/24 at 9:14 a.m. and on 5/21/24 at 2:15 p.m. Resident #36 was lying in her bed. Bed rails were observed on both sides of the resident's bed. C. Resident interview Resident #36 was interviewed on 5/22/24 at 1:04 p.m. Resident #36 said the bed rails were for her to hold on to to assist her with turning herself during incontinent care. D. Record review The resident care plan, revised on 5/24/21, revealed Resident #36 had a mobility deficit related to stroke and cognitive impairment as evidenced by difficulty with bed mobility requiring the use of bed rails. -Review of Resident #36's May 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #36 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VI. Resident #44 A. Resident status Resident #44, age greater than 65, was admitted on [DATE]. According to the May 2024 computerized CPO, diagnoses included Alzheimer's disease, myxedema coma (severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs), insomnia and muscle weakness. The 4/30/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required partial assistance with showering and supervision with toileting and personal hygiene. -The assessment documented Resident #44 did not use bed rails. B. Observation On 5/20/24 at 3:30 p.m., 5/21/24 at 8:57 a.m. and 5/22/24 at 10:30 a.m. bed rails were observed on both sides of Resident #44's bed. C. Record review The care plan, revised on 4/12/24, revealed Resident #44 had an activity of daily living (ADL) self care performance deficit related to Alzheimer's disease. -Bed rails were not included in the resident's care plan interventions. -Review of Resident #44's May 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #44 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VII. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 5/22/24 at 9:14 a.m. CNA #5 said the bed rails were handles added to the sides of the bed. She said bed rails helped a resident, if used appropriately, for bed mobility and when the resident got in and out of bed. CNA #5 said the resident held on to the bed rails during incontinence care. Licensed practical nurse (LPN) #4 was interviewed on 5/22/24 at 9:32 a.m. LPN #4 said the bed rails were used when residents were alert and oriented and could help themselves instead of waiting for a staff member to help them. She said a resident should be evaluated for safety before using the side rail. She said the evaluation was based on the residents' level of care based on their everyday needs. LPN #4 said consent should be obtained from the resident or resident's representative prior to use of the bed rails. The director of nursing (DON) was interviewed on 5/22/24 at 2:15 p.m. The DON said, before side rails could be used, a bed rail evaluation and consent needed to be completed. However, she said the facility did not consider the bed rails as a form of restraint, therefore the facility did not perform evaluations and did not obtain consent from the residents. The DON said the facility did not have a formal document to show maintenance staff routine inspections of all bed rails for a potential entrapment risk. The DON said the facility would immediately ensure consent and evaluations were completed.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards on two of four units. Specifically, the facility failed to: -Ensure Tuberculin purified protein derivative (PPD) was dated after opening; and, -Ensure refrigerated medications were stored in a sanitary manner, separately from refrigerated food items. Findings include: I. Professional reference According to the Sanofi Pasteur (2020) package insert for Tuberculin Purified Protein Derivative (Mantoux): Tubersol Food and Drug Administration (FDA), retrieved on 5/31/24 from https://www.fda.gov/media/74866/download, A vial of Tubersol (tuberculin purified protein derivative) which has been entered and in use for 30 days should be discarded. Do not use it after the expiration date. II. Facility policy and procedure The Storage of Medications policy and procedure, reviewed 2/17/23, was provided by the director of nursing (DON) on 5/23/24 at 10:00 a.m. It read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Refrigerated medications are stored separately from food and are labeled accordingly. III. Observations On 5/22/24 at 2:11 p.m. unit medication refrigerator #1 was observed with registered nurse (RN) #1. The following items were found: -A vial of Tubersol PPD was opened and undated. -A vial of Tubersol was dated as opened on 4/12/24. The vial should have been discarded on 5/12/24. -Several unopened nutritional supplement drinks and unopened soda drinks were in the medication refrigerator. On 5/22/24 at 2:15 p.m. unit medication refrigerator #2 was observed. The following items were found: -Multiple unopened yogurt and pudding cups. -One opened med pass shake was lying on its side at the bottom of the refrigerator. -Bisacodyl suppositories, eye drops and probiotic containers were stored on the top shelf of the refrigerator. IV. Staff interviews RN #1 was interviewed on 5/22/24 at 2:14 p.m. RN #1 said nutritional supplements, as long as they were not opened, could be stored in the same refrigerator with the medications. She said she was not sure if soda could be stored in the refrigerator with nutritional supplements. RN #1 said it was not good practice to store food items and beverages with medications. She said tuberculin should be dated after opening and was only good for 30 days after opening, per the manufacturer's directions. The assistant director of nursing (ADON) was interviewed on 5/22/25 at 2:18 p.m. The ADON said food items should not be stored with medications and tuberculin should be dated so it could be identified when it needed to be discarded. She said the manufacturer's recommendation was to discard it after 30 days. She said storing medications and food and beverage items together was not a sanitary practice. The nursing home administrator (NHA) was interviewed on 5/22/24 at 2:18 p.m. The NHA said storing medications and beverages and food items in the same refrigerator was not a sanitary practice and the facility would order additional refrigerators to keep medications and food items separate.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure temperatures were taken of refrigerators in the main kitchen; and, -Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher. Findings included: I. Professional reference According to the Food and Drug Administration Food Code (2022), retrieved on 5/28/24 from https://www.fda.gov/media/164194/download?attachment, Water temperature is critical to sanitization in ware washing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual ware washing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the ware washing machine meet or exceed the required 160 degrees F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical ware washers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160 degrees). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160 degrees F. II. Facility policy and procedure The Refrigerator, Freezer and Dishwashing policy, revised in 2009, was provided by the nursing home administrator (NHA) on 5/22/24 at 11:00 a.m. It read in pertinent part, The facility will ensure safe refrigerators and freezers maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Acceptable temperatures should be 35 degrees to 40 degrees Fahrenheit (F) for refrigerators and below zero degrees F for freezers. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Monthly tracking sheets will include time, temperature, initials, and action taken. The Food Service Supervisor or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. The dishwasher operator will check temperatures using the dishwasher gauge with each washing cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. III. Observations and interviews On 5/20/24 at 8:43 a.m. dietary aide (DA) #2 put a load of dishes through the dishwasher. He said the dishwasher was high temperature and indicated that the external temperature gauge displayed 180 degrees F. He said there was not a temperature log to record the dishwasher temperatures (see record review below). DA #2 said he did not know how to check the internal temperature of the dishwasher to ensure the temperature on the outside display was correct. He said the facility did not keep a log of the temperature of the dishwasher. IV. Record review A request was made for the dishwasher temperature log on 5/20/24. DA #2 said the facility did not utilize temperature logs (see interview above). A review of the temperature log that was hung outside the main kitchen's walk-in refrigerator and freezer on 5/22/24 revealed the log was missing 21 of 46 opportunities to monitor the walk-in refrigerator and freezer temperatures on the May 2024 (from 5/1/24 to 5/22/24) walk-in refrigerator and walk-in freezer temperature log. V. Staff interviews DA #1 was interviewed on 5/22/24 at 1:16 p.m. DA #1 said the kitchen had recently gotten a new dishwashing machine. DA #1 said the former dietary manager (DM) explained to her verbally how to operate the dishwasher. DA #1 said she did not remember the appropriate recommendations for a high-temperature dishwasher. She said the facility used to have a log for the dishwasher but she said she did not know why they did not have it now. She said she had not seen the temperature log for the dishwasher for a while. The DM was interviewed on 5/22/24 at 1:35 p.m. The DM said the dining staff members needed to monitor the temperature of the dishwasher on a regular basis and put it on a log to ensure the dishwasher was functioning properly. The DM said it was necessary to monitor the temperature to ensure proper sanitation of the dishes to prevent bacterial growth. She said the temperature logs for the main kitchen walk-in refrigerator and the walk-in freezer were missing temperatures. She said the temperature of the refrigerator and freezer needed to be monitored on a regular basis to ensure they were maintaining the correct temperature. The DM said she would immediately initiate training for all of the kitchen staff on obtaining and documenting daily temperatures of the walk-in refrigerator and freezer. She said she would also provide education on how to monitor and log the temperatures of the dishwasher.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in four of four units. Specifically, the facility failed to -Ensure clean technique was followed during wound care for Resident #56; and, -Ensure the facility had an active Legionella water management plan in place to prevent or reduce Legionella in the facility. Findings include: I. Clean technique during wound care A. Facility policy and procedure The Wound Care policy and procedure, revised October 2010, was provided by the director of nursing (DON) on 5/23/24 at 8:30 a.m. It read in pertinent part, Use disposable cloth to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Put on exam gloves. Loosen tape and remove dressing. Pull gloves over the dressing and discard it into the appropriate receptacle. Wash and dry hands thoroughly. Be certain all clean items are on a clean field. B. Observations Licensed practical nurse (LPN) #1 was observed providing wound care, with the assistance of DON, to Resident #56's right foot wound on 5/22/24 at 10:00 a.m. LPN #1 placed a trash bag onto Resident #56's bed with the clean supplies on top of it. -LPN #1 did not establish a clean field separate from Resident #56's bed and placed clean supplies on a trash bag directly on the bed. LPN #1 removed the dressing and placed the old dressing onto the trash bag on the bed next to the clean supplies. -LPN #1 placed a dirty dressing next to clean dressing supplies on a non clean field. LPN #1 picked up the wound cleanser bottle, opened a gauze dressing lying on the trash bag and sprayed wound cleanser onto the wound and wiped it with a gauze dressing. -LPN #1 did not change gloves or perform hand hygiene after removing the old dressing and before touching clean supplies and cleaning the wound. LPN #1 opened up a betadine swab and swabbed around edges of the wound and disposed of the betadine swab onto the trash bag that was lying on the bed with the wound supplies on top of it. -LPN #1 opened the clean betadine swab that was lying on the trash bag next to the soiled dressings and disposed of the used swab back onto the trash bag that contained the soiled dressing and clean supplies. LPN #1 did not change gloves and perform hand hygiene before handling the betadine swab. LPN #1 picked up a skin prep package and opened it and swabbed around the edges of the wound. -LPN #1 did not change her gloves and perform hand hygiene before handling the clean skin prep pad. LPN #1 picked up a gauze dressing package from the trash bag and opened the package. She placed the open gauze package back on the trash bag. She then changed her gloves and performed hand hygiene -LPN #1 did not change her gloves or perform hand hygiene before touching the clean gauze dressing and placed the opened gauze package down onto the non clean field. LPN #1 picked up the open gauze package and placed the gauze onto the wound. -Throughout the wound observation, LPN #1 did not maintain a designated clean field that kept clean wound supplies separate from dirty dressings and supplies. She did not perform hand hygiene or change gloves after touching dirty dressings or supplies. C. Staff interviews The DON was interviewed on 5/22/24 at 10:15 a.m. The DON said when performing a clean technique, a clean field for clean supplies should be maintained and kept separate from dirty dressings and supplies. She said after a nurse removed a soiled dressing or touched soiled supplies, the nurse should change their gloves and perform hand hygiene. The DON said during Resident #56's wound care, LPN #1 should have set-up and maintained a clean field. She said the clean supplies should have been kept separate from the soiled dressings and supplies. She said the nurse should perform hand hygiene and put on clean gloves after touching a dirty dressing or wound supply item and before cleaning or applying a new dressing to a wound. The DON said changing gloves and performing hand hygiene frequently helped prevent cross contamination of organisms from soiled to clean. She said she would review clean technique with LPN #1. LPN #1 was interviewed on 5/22/24 at 10:20 a.m. LPN #1 said she did not set-up a clean field correctly for Resident #56's wound care. She said she should have had a separate clean field established. She said clean wound supplies should be kept on the clean field and dirty items should not be mixed with clean wound items. She said after removing a dirty dressing, touching soiled supplies or after cleaning a wound hand hygiene should be performed and gloves changed. II. Legionella water management A. Professional reference The Centers for Disease Control (CDC). (6/24/21). Developing a Water Management Program to Reduce Legionella Grown and Spread in Buildings. U.S. Department of Health and Human Services was provided by the minimum data set coordinator (MDSC) on 5/23/24 at 10:00 a.m. It read in pertinent part, Legionnaires disease is a serious type of pneumonia caused by bacteria, called Legionella, that lives in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. B. Facility policy and procedure The Legionella Water Management Program policy and procedure, revised September 2022, was provided by the minimum data set coordinator (MDSC) on 5/23/24 at 10:00 a.m. It read in pertinent part, As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The water management team consists of at least the following personnel: infection preventionist, administrator, medical director (or designee), director of maintenance and director of environmental services. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires disease. C. Record review A request was made for the water management monitoring and testing on 5/23/24. -The facility was unable to provide documentation of water management monitoring or testing for the facility. D. Staff interviews The infection preventionist (IP) was interviewed on 5/23/24 at 8:45 a.m. The IP said she was not involved in the water management program for Legionella and she did not know if a water management program was in place. She said the environmental services director (ESD) would have the records of the water management program and testing. The ESD was interviewed on 5/23/24 at 9:30 a.m. The ESD said he was new to his role and was not aware of a water management program for Legionella for the facility. He said he received a report from the city regarding water quality outside of the facility but did not have documentation of water monitoring or testing for Legionella for the facility. He said he was not aware that a water management program needed to be in place to help reduce or prevent Legionella within the facility. The nursing home administrator (NHA) was interviewed on 5/23/24 at 9:40 a.m. The NHA said she had recently started working at the facility. She said it had been identified by the medical director at a recent quality assurance and performance improvement (QAPI) meeting that a Legionella water management program needed to be in place at the facility. She said the facility did not have an active water management program in place yet. She said they were using the CDC guidelines in implementing the Legionella water program. She said this program was necessary to help prevent Legionella in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (#27) of 30 sample residents. Specifically the facility failed to ensure the physician orders related to diabetic management were followed. I. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the March 2020 computerized physician orders (CPO), diagnoses included diabetes mellitus, Alzheimer's disease, dyspnea, and chronic respiratory failure with hypoxia. The 1/6/2020 minimum data set (MDS) assessment, revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required limited assistance of one person for transfers, dressing, and toilet use, supervision/oversight with one person assistance for bed mobility and personal hygiene, and supervision/oversight with setup help only for eating. II. Record review Review of the March 2020 CPO revealed the following order; diabetic protocol for BG (blood glucose) less than or equal to 80 mg/dL, give orange juice, house supplement or snack if condition permits. BG less than or equal to 60 mg/dL, check gag reflex: if present give glucogel by mouth (PO) if no gag reflex give glucagon 1mg intramuscular (IM) and notify triage. BG greater than 400 mg/dL give 2 units of regular insulin or follow residents sliding scale (SS) if resident is asymptomatic recheck BG at next scheduled time and notify the notification line. The February 2020 medication administration record (MAR) documented that on the following dates the resident had BG results below or equal to 80mg/dL; -2/2/2020 at 7:30 a.m. 74 mg/dL -2/6/2020 at 7:30 a.m. 69 mg/dL -2/8/2020 at 7:30 a.m. 64 mg/dL -2/10/2020 at 7:30 a.m. 71 mg/dL -2/12/2020 at 7:30 a.m. 72 mg/dL; at 4:00 p. m. 74 mg/dL, and at 9:00 p.m. 71 mg/dL -2/13/2020 at 7:30 a.m. 74 mg/dL -2/14/2020 at 7:30 a.m. 74 mg/dL -2/17/2020 at 7:30 a.m. 68mg/dL -2/18/2020 at 7:30 a.m. 77mg/dL -2/20/2020 at 4:00 p.m. 67 mg/dL -2/22/2020 at 7:30 a.m. 79 mg/dL The February 2020 medication administration record (MAR) documented that on the following dates the resident had BG results below or equal to 60mg/dL; -2/16/2020 at 7:30 a.m. 60 mg/dL -2/19/2020 at 7:30 a.m. 57 mg/dL Review of the February 2020 MAR and nursing progress notes revealed the diabetic protocol was not implemented for any of the abnormal BG results. The March 2020 MAR documented the resident had BG results below or equal to 80mg/dL on the following dates; -3/1/2020 at 7:30 a.m. 76 mg/dL -3/2/2020 at 7:30 a.m. 76mg/dL and at 9:00 p.m. 66 mg/dL -3/3/2020 at 7:30 a.m. 62 mg/dL -3/4/2020 at 7:30 a.m. 63 mg/dL -3/5/2020 at 7:30 a.m. 62 mg/dL below or equal to 60mg/dL; -3/6/2020 at 7:30 a.m. 52 mg/dL -3/8/2020 at 7:30 a.m. 57 mg/dL Review of the March MAR revealed that the diabetic protocol for below or equal to 80 mg/dL was only implemented on 3/5/2020 at 7:57 a.m. related to the BG of 62. Further review of nursing progress notes revealed: - on 3/5/2020 at 2:18 p.m., a nurse documented the resident's BG level was 62 mg/dL this morning. Administered two glasses of orange juice. Her BG increased to 83 mg/dL. Received a new order from the doctor to decrease Toujeo Solostar 80 units subcutaneous (sq) in the morning to 60 units sq in the morning. He requested that staff call him if blood glucose is less than 100 or over 400. -on 3/6/2020 at 8:53 a.m. a nurse documented that two glasses of orange juice and one tube of glucose gel were given. There was no note addressing the BG results of 57 mg/dL on 3/8/2020. III. Interviews Registered nurse (RN) #5 was interviewed on 3/5/2020 at 11:46 a.m. She said the resident's BG was 62 mg/dL this morning and went up to 82 mg/dL after two glasses of orange juice. She said that the resident had been symptomatic for hypoglycemia and had increased confusion and difficulty completing tasks. She said she worked with the resident regularly and was familiar with her baseline abilities. She said the resident became symptomatic when her BG was below 80mg/dL and that was why she had gotten the order for a snack at bedtime. She said Resident #27's BG is often low in the morning. She said she needed to make a note to the physician to see if he wanted to adjust her insulin dose. The director of nursing was interviewed on 3/10/2020 at 10:06 a.m. She said it is her expectation that the nurse follow the providers orders. She said the nurses should have provided interventions related to the low BG results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, the facility failed to ensure portable oxygen tanks were checked and filled for 11 (#58, #60, #32, #49, #40, #42, #46, #41, #18, #13 and #27 ) of 30 sample residents and out of 32 residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically the facility failed to ensure the residents received continuously oxygen therapy as ordered by the physician. Findings include: I. Facility policy and procedure The Oxygen administration policy, revised October 2010, was provided by the director of nursing (DON) on 3/10/20 at 1:20 p.m. The policy documented the physicians' orders should be checked, reviewed and followed. II. Residents' status A. Resident #58 Resident #58, age [AGE], was admitted on [DATE]. According to the March 2020 computerized physician orders (CPO), the resident's diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease. The 2/13/20 minimum data set (MDS) assessment, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS indicated the resident was utilizing oxygen. 1. Resident observation and interview On 3/04/2020 at 2:23 p.m. Resident #58 was sitting in the living room in her wheelchair with a portable oxygen tank attached to the back of the wheelchair. The oxygen tubing was plugged into the portable oxygen tank. Resident #58 was wearing her nasal cannula. Resident #58 stated she was without oxygen and needed help. Resident #58 said she had been without oxygen for ten to fifteen minutes. Certified nurse aide (CNA) #8 was approached to check the oxygen tank and confirmed the resident's oxygen tank was empty. CNA #8 said she would fill up the tank. Resident #58 stated this situation happened frequently. Resident #58 said she was scared and needed her oxygen right away. Resident #58 said she could not breathe without it and when she ran out it scared her. CNA #8 returned seven minutes later and hooked up the oxygen. Resident #58 said she was thankful for her oxygen. CNA #8 did not ask Resident #58 if she was feeling better. On 3/5/2020 at 11:56 a.m. Resident #58 was sitting at the dining room table in her wheelchair with a portable oxygen tank attached to the back of the wheelchair. The oxygen tubing was plugged into the portable tank. Resident #58 was wearing her nasal cannula. Resident #58 became alarmed and said help me, I have no oxygen. Resident #58 said she was scared and needed her oxygen. CNA #6 verified Resident #58's oxygen tank was without oxygen and registered empty. CNA #6 said he was going to get the tank filled. CNA #6 alerted the registered nurse (RN) #4 that he needed keys to the oxygen storage room to fill Resident #58's tank. RN#4 checked the resident's oxygen level and the pulse oximeter registered a 70. RN #4 stated Resident #58 should be titrating at a 90. RN #4 said the tanks were new and they did not hold as much oxygen as the old tanks. RN #4 stated they were having trouble keeping them filled and oxygen was running out frequently. RN #4 who stood with Resident #58 as CNA #8 went to get the canister refilled, did not reassure or talk to the Resident #58. On 3/5/2020 at 12:00p.m. Resident #58 said she was having a really hard time breathing and she was scared. Resident #58 said that she ran out of oxygen too often and became scared whenever she ran out. Resident #58 seemed concerned that her reading was at a 70 as it should be a 90. Resident #58 stated that she was scared and afraid she was going to run out of oxygen again soon. CNA #4 returned at that time and reattached the oxygen tank. Resident #58 said it was going to be awhile before she felt better as she had been without oxygen for a while. 2. Record review The December 2019 physician orders revealed the following: -Titrate oxygen (O2) to 88-92% with a liter flow rate of three liters per minute continuously to relieve signs of hypoxia. B. Resident #60 Resident #60, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included cardiovascular disease and hypertension. The 2/13/2020 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. The resident was utilizing oxygen. 1. Resident observation and interview Resident #60 was observed on 3/5/2020 at 1:15 p.m. sitting in the living room with other residents watching television. Resident #60 had her nasal cannula in with the oxygen tubing connected to a portable oxygen tank. Resident #60 said she had always been on two liters of oxygen and it would run out of oxygen from time to time. When CNA #14 checked the oxygen tank it registered empty. CNA #14 took the canister and went to fill it. CNA #14 returned and attached the tubing to the canister and left. CNA #14 did not ask Resident #60 how she felt or if she needed anything. 2. Record review The June 2018 physician orders revealed the following: -Titrate oxygen (O2) via nasal cannula at two liters per minute to prevent signs and symptoms of hypoxia. C. Resident #32 Resident #32, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The 2/13/2020 MDS assessment revealed the resident's cognition was mildly impaired with a brief interview for mental status score of 12 out of 15. The resident utilized supplemental oxygen. 1. Observation On 3/5/2020 at 1:15 p.m. Resident # 32 was sitting in the living room with a portable oxygen tank attached to her wheelchair while oxygen tubing was being worn via a nasal cannula. CNA #14 checked the oxygen and said it was empty and told Resident #14 she would fill it and be right back. 2. Resident interview Resident #32 was interviewed on 3/5/2020 at 1:17 p.m. She stated her oxygen runs out frequently and she would often remind staff to refill the canister. 3. Record review The March 2020 physician orders revealed the following: -Titrate oxygen (O2) via nasal prongs at three litters continuously to greater than 89% every shift. D. Resident #49 Resident #49, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included chronic pulmonary disease and hypertension. The 2/4/2020 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The assessment indicated the resident was utilizing oxygen. 1. Resident observation On 3/5/2020 at 1:15 p.m. Resident #49 was observed in the living room. She was sitting in a chair with a portable oxygen tank present on the ground in front of her. The oxygen tubing was connected to the tank and to the resident via nasal cannula. CNA #14 checked the oxygen tank and stated the tank was empty. CNA #14 went and refilled the oxygen. 2. Record review The March 2020 physician orders revealed the following: -Titrate oxygen (O2) at two liters per nose cannula continually at 90%. E. Resident #40 Resident #40, age [AGE], was admitted on [DATE] according to the March 2020 CPO, the resident's diagnoses included acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The 1/29/2020 MDS assessment revealed the resident was mildly impaired with a brief interview for mental status score of 11 out of 15. The resident utilized supplemental oxygen. 1. Observation On 3/5/2020 1:15 p.m. Resident # 40 was sitting in the living room with a portable oxygen tank attached to her wheelchair while oxygen tubing was being worn via a nasal cannula. CNA #8 checked the oxygen tank and stated it was empty. CNA #8 told Resident #32 that she would fill it and be right back. 2. Resident interview Resident #32 was interviewed on 3/5/2020 at 1:15 p.m. She said her oxygen runs out frequently and she needed to remind staff at times. 3. Record review The March 2020 physician orders revealed the following: -Titrate oxygen (O2) via nasal prongs at three liters continuously to greater than 89% every shift. F. Resident #42 Resident #42, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The 1/29/2020 MDS assessment revealed the resident's cognition was intact with a brief interview for mental status score of 13 out of 15. The resident utilized supplemental oxygen. 1. Observation On 3/5/2020 at 1:15 p.m. Resident #42 was sitting in the living room with a portable oxygen tank on the floor at her side. The oxygen tubing was being worn via a nasal cannula. CNA #14 checked the oxygen canister and stated it was empty. CNA #14 told Resident #42 she would fill it and be right back. 2. Record review The March 2020 physician orders revealed the following order: -Titrate oxygen (O2) via nasal cannula at two liters per min continuously to relieve signs of hypoxia related to chronic obstructive pulmonary disease (COPD). G. Resident #46 Resident #46, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included atelectasis, hypoxemia and dysphagia. The 1/30/2020 MDS assessment, the resident was severely impaired with a brief interview for mental status score of 6 out of 15. It indicated the resident utilized supplemental oxygen. 1. Observation On 3/5/2020 at 1:15 p.m. Resident #46 was sitting in the living room with a portable oxygen tank attached to her wheelchair while oxygen tubing was being worn via a nasal cannula. CNA #14 checked the oxygen canister and stated it was empty. CNA #14 told Resident #14 she would fill it and be right back. 2. Record review The March 2020 physician orders revealed the following order: -Titrate oxygen (O2) at three liters per nasal cannula continuously. H. Resident #41 Resident #41, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease. According to the 1/29/2020 MDS assessment, the resident was severely impaired with a brief interview for mental status score of 6 out of 15. It indicated the resident utilized supplemental oxygen. 1. Observation On 3/5/2020 at 1:15 p.m. Resident #41was sitting in the living room with a portable oxygen tank located on the ground next to her. Oxygen tubing was being worn via a nasal cannula. CNA #14 checked the oxygen canister and stated it was empty. CNA #14 told Resident #32 she would fill it and be right back. 2. Record review The March 2020 physician orders revealed the following order: -Titrate oxygen (O2) via two liters of oxygen via the nose cannula continuously. I. Resident #18 Resident #18, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included emphysema and hypoxia. According to the 12/11/2020 MDS assessment, the resident was intact cognitively with a brief interview for mental status score of 15 out of 15. It indicated the resident utilized supplemental oxygen. 1. Observation On 3/9/2020 at 12:28 p.m. Resident #18 was sitting in the dining room with a portable oxygen tank, the oxygen tubing was being worn via a nasal cannula. CNA #14 checked the oxygen canister and stated it was empty and needed to be changed. CNA #14 asked RN #4 to stand with the resident as she refilled Resident #18's portable oxygen tanks. RN#4 told Resident #18 that CNA #14 would be right back. 2. Record review The March 2020 physician orders revealed the following: -Titrate oxygen (O2) via nasal cannula at two litters continuously at greater than 89%. J. Resident #13 Resident #13, age [AGE], was admitted on [DATE]. According to the March 2020 CPO, the resident's diagnoses included chronic systolic congestive heart failure. According to the 12/3/19 MDS assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. It indicated the resident utilized supplemental oxygen. 1. Observation On 3/5/2020 at 1:15 p.m. Resident #13 was sitting in the living room with a portable oxygen tank attached to her wheelchair, the oxygen tubing was worn via nasal cannula. CNA #14 checked the oxygen tank and stated it was empty. CNA #14 told Resident #13 she would fill it and will be right back. 2. Record review The March 2020 physician orders revealed the following order: -Titrate oxygen (O2) via nasal cannula at two liters continuously to relieve signs and symptoms of hypoxia. III. Staff interviews Registered nurse (RN) #4 was interviewed on 3/5/2020 at 1:38 p.m. She stated the staff should be checking the oxygen portable tank levels consistently. RN #4 said the portable oxygen tanks did not last long and that there were times when the oxygen would run out in less than two hours. The tanks were new to the facility and they have been using them for two months. RN #4 said staff had been trained on them when the facility made the change over to the new tanks. RN #4 said it takes a long time to refill the tanks and the canister would leak. RN #4 said the residents will let the staff know if they did not have oxygen and staff would also look for signs of distress. CNA #6 was interviewed on 3/5/2020 at 12:00 p.m. CNA #6 stated he was not trained on when to check the portable oxygen tank levels. He stated he would check the level if a resident asked him to refill it. CNA #6 stated that when he filled the portable oxygen tanks he verified the setting with the nurse on duty. CNA #6 said the oxygen tanks would often run out at the same time. CNA #8 was interviewed on 3/5/2020 at 1:38p.m. CNA #8 stated she was trained to check the oxygen levels at the beginning and end of her shifts. CNA #8 said the new tanks run out faster and she did not know how long they typically lasted. CNA #8 said the staff follow physician orders when they set the portable oxygen tank setting, CNA #8 said the staff will notify the nurse if they saw signs of distress. Director of nursing (DON) was interviewed on 3/10/2020 at 9:13 a.m. DON said her expectations were for the residents oxygen to be filled on a regular basis and for the staff to anticipate when the residents oxygen canisters would need to be refilled. DON said any resident who received oxygen therapy should have a physician's order and the facility should follow it. DON said the CNA or the nurse should monitor a resident after they have been without oxygen for signs of distress and to ensure their oxygen returned to prescribed levels. DON said the facility had started reeducating staff on 3/5/2020. The staff reviewed the policy and professional standards. The plan put into place was for staff to begin checking residents' oxygen every hour and a half. The staff were to make sure the residents were on the concentrator while staff filled the oxygen tanks. On 3/7/2020 the facility held an in-service for checking and refilling portable oxygen tanks. The in-service included checking portable oxygen tanks prior to assisting residents from their room. Checking the portable oxygen tanks prior to the resident going out of the facility. The facility also made a plan for each resident to be checked every hour and a half. K. Resident #27 Resident #27, age [AGE], was admitted on [DATE]. According to the March 2020 computerized physician orders (CPO), diagnoses included diabetes mellitus, Alzheimer's disease, dyspnea and chronic respiratory failure with hypoxia. The 1/6/2020 minimum data set (MDS) assessment, revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required limited assistance of one person for transfers, dressing, and toilet use, supervision/oversight with one person assistance for bed mobility and personal hygiene, and supervision/oversight with setup help only for eating. She required oxygen therapy. 1. Record review Review of the March 2020 computerized physician orders (CPO) revealed an order for oxygen at two liters per nasal cannula continuously for hypoxia. 2. Observation On 3/05/2020 at 1:22 p.m. Resident #27 was observed in the memory care unit, sitting by the nurses station, she was groaning. She did not have oxygen on. A staff member standing close by asked the resident if she was okay. She said no, I feel like I am going to fall. CNA #13 had returned to the unit with the resident's portable oxygen tank and placed the resident back on her oxygen at two liters. RN #5 checked her pulse oximetry, she was at 83 percent (%) on two liters. The RN said she must have been without her oxygen for a longer period of time. She turned the portable oxygen flow up to three liters. The resident's oxygen level increased to 90%. The RN said to leave her on three liters until she returned from her appointment.

III. Medication administration A. Observation Registered nurse (RN) #4 was observed on 3/5/2020 at 10:48 a.m. during medication administration to Resident #267. The resident held the cup of medications, took a few of the pills then had a coughing spell and was unable to take all of her medications. RN #4 took the medication cup with remaining pills out of the residents room and put the medication cup in the medication storage room and said she will give it to the resident at a later time. B. Interviews RN #1 was interviewed on 3/10/2020 at 10:09 a.m. She said when the resident did not take all the medications she would discard the rest of them and call the physician. She said the medication that was once dispensed should never be restored in the medication storage room nor in the medication cart. Director of nursing (DON) was interviewed on 3/10/2020 at 10:39 a.m. She said her expectation was to discard medications that were not taken by the resident and to call the physician to let him/her know. The medication was not to be put back into the medication cart or storage room to use at a later time. II. Infection surveillance A. Facility policy The facility Surveillance for Infections policy, dated August 2014, read in pertinent part: The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. The criteria for such infections are based on the current standard definitions of infections. Infections that will be included in routine surveillance include those with: pathogens associated with serious outbreaks (e.g. streptococcus group A, acute viral hepatitis, norovirus, scabies, and influenza). Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible. If transmission-based precautions or other preventive measures are implemented to slow or stop the spread of infection, the infection control nurse will collect data to help determine the effectiveness of such measures. B. Observations 1. Pine unit On 3/4/2020 at 11:49 a.m. five residents were observed in the dining room coughing. On 3/5/2020 at 10:39 a.m. four residents were observed sitting together in the living room, watching television. They were coughing into their hands and touching items around themselves and each other. They were sitting within two feet of each other and sharing a tissue. Registered nurse (RN) #4 asked a resident to sit down on the couch and rest, in-between two of the coughing residents. On 3/5/2020 at 11:30 a.m. the activity director identified a resident as having a new and severe cough. She notified RN #4. The resident continued to sit on the couch and cough while watching television, with three other residents within three feet of each other. The resident was coughing in her hand. She took a cup of water from the nurse, drank it and handed the cup back to the nurse. The nurse took the cup, did not wash her hands or use hand sanitizer after taking the cup. She then touched numerous items and handed items to other residents. On 3/5/2020 between 10:00 a.m. to 12:00 p.m. residents on the unit were observed not assisted to wash their hands or use ABHR. The residents sat together and shared items and space. The residents that had displayed a cough, coughed openly or into their hand. The staff were shaking hands with residents when they passed by them and then touched other residents' hands. The staff did not wash their hands or use an ABHR. On 3/5/2020 at 11:50 a.m. A male resident and his wife were observed at the dining room table eating lunch. The resident's wife came from the community to visit. They both had a cough. On 3/5/2020 at 12:00 p.m. a dietary aide was observed placing residents' silverware into the napkins. She did not wash her hands or use ABHR. She touched trays, cups and plates while rolling the silverware. C. Interviews RN #3 was interviewed on 3/4/2020 at 11:29 a.m. She said a couple of the residents had just been tested for the flu and pneumonia. They were in isolation. She said there seems to be a bug that is going through the building. Certified nurse aide (CNA) #8 was interviewed on 3/5/2020 at 12:48 p.m. She said most of the residents on the unit were ill with cold and flu like symptoms. RN #4 was interviewed on 3/5/2020 at 1:15 p.m. She said there was something going around but nothing concerning, maybe the vents are the problem. She said the ventilation system was just cleaned and might have something to do with all the coughing and there could be a little something in the air. She said she had noticed residents coughing throughout the whole facility. She said that they would not document regarding the coughing or any other symptoms unless it had gone on for more than two shifts. If the nurse was concerned about the symptoms a resident had, she would document it in the electronic medical record, but they would generally communicate verbally with the next nurse coming on the shift. Based on observation and interviews the facility failed to ensure infection prevention and control practices were followed to prevent the spread of infection. Specifically the facility failed to ensure effective infection prevention and control. Finding include: I. Hand hygiene A. Facility policy The facility Handwashing/Hand Hygiene policy, dated August 2015, read in pertinent part: All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personal, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents; and before and after assisting a resident with meals. B. Observations 1. Memory care unit On 3/4/2020 at 10:16 a.m. Licensed practical nurse (LPN) #4 was observed entering a resident's room with an injectable medication. She did not wash her hands. She put on gloves and closed the door behind her. After a few minutes she opened the door and came out of the resident's room with her gloves on. On 3/4/2020 at 11:53 a.m. the lunch meal was observed on the memory care unit. The staff did not assist the residents to wash their hands or use an alcohol based hand rub (ABHR) prior to eating. The dietary aide (DA) that was serving the meal washed her hands and put on gloves. She touched the serving utensils, plates, the dietary cart and the ready to eat foods. She did not change gloves and did not wash or sanitize her hands. Dessert was served, some of the residents licked their fingers while eating and after eating their desserts. On 3/5/2020 at 10:16 a.m., a male resident was observed being assisted by a certified nurse aide (CNA) to the dining room table. The resident was not assisted to wash his hands or use ABHR. He was provided breakfast by the CNA. He ate 100% of his breakfast. He used his hands to eat. On 3/5/2020 at 10:35 a.m. a DA was observed bringing dishes and silverware to the unit on a rolling cart. She did not wash her hands, use ABHR or put gloves on. She unlocked the drawer for the silverware. She placed the silverware in the drawer, handling it by the eating surface. She locked the drawer and then she unlocked the cabinet below the drawer for the dishes. She touched the inside eating surface of the bowls while she was placing them in the cabinet. She locked that cabinet and unlocked the next one. She touched the inside area and the top drinking surface area of the cup. She locked the cabinet and then cleaned up the dirty dishes in the sink. She threw items in the trash, holding the trash can lid with her hands. She then left the memory care unit. She did not wash her hands or use ABHR. On 3/5/2020 at 11:46 a.m. A CNA was observed to cough on the back side of his hand, he did not wash his hands or use ABHR after he coughed or prior to beginning to prepare to help serve the residents their lunch meal. C. Interviews On 3/10/2020 at 9:13 a.m. CNA #12 was interviewed. She said that they should wash their hands every time they enter and exit a room, at meal or snack times and when staff comes in contact with a resident. On 3/10/2020 at 9:45 a.m. registered nurse (RN) #2 was interviewed. She said staff should wash their hands anytime they have contact with a resident, entering and exiting resident rooms, before preparing medications, between routes when administering medications, and before assisting residents with snacks and meals. On 3/102020 at 10:00 a.m. the director of nursing (DON) was interviewed. She said the facility provided education regarding hand washing upon hire, with CNA annual competencies and as needed. She said that the staff should wash their hands anytime they are visibly soiled, when they enter and exit a room, when they assist residents with meals or snacks, and between resident contacts. She said the facility did not have a policy in place to assist the residents to wash their hands before meals but there will be now. She said the infection prevention education to the staff was provided on 3/7/2020.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide services provided by qualified persons for one (#44) of three residents reviewed for falls of 26 sample residents. Specifically, the facility failed to ensure assessments were conducted by a registered nurse (RN) after the residents experienced falls prior to moving the residents. Cross-reference F689 Findings include: A. Professional reference According to Scope of Practice-Registered Nurse (RN) and Licensed Practical Nurse (LPN), Title 12, Professions and Occupations, Article 38, Nurses, Colorado Revised Statutes, Effective July 1, 2013, https://www.colorado.gov/ ./Satellite/ .filename%3D%22ScopePractice (September 2017): -Delegation of nursing function is limited to patients that are stable and where the outcome of the task is predictable. -Assessment function of a LPN includes collecting, reporting and recording objective/subjective data, observing condition or change of condition, and collecting and reporting signs and symptoms of deviation from normal health status. -Assessment function of a RN includes assessing and evaluating the health status of an individual. B. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the March 2019 computerized physician orders (CPOs), diagnoses included lack of coordination, muscle weakness, history of falls, and fracture of head and neck of right femur (newly diagnosed on [DATE] after fall). The 12/7/18 minimum data set (MDS) assessment revealed the resident had a brief interview for mental status score of 15 of 15, which indicated that resident had intact cognitive functions and thought process. C. Record review The medical record showed the resident experienced a fall on 1/11/19 which resulted in a fracture Resident ' s progress notes dated 1/11/19 at 7:11 p.m. documented, certified nurse aide (CNA) reported to licensed practical nurse (LPN #2) Resident #44 was found sitting down on the floor, leaning against the door. According to the progress note, LPN #2 asked the resident if she was hurt ,however, the resident said no and denied hitting her head. LPN #2 wrote in pertinent parts, .Assessment of her extremities showed no deformity . FurthermoreAccording to the progress note revealed, a CNA helped LPN #2to stand the resident up but upon standing, she complained of pain (the medical record failed to show a specific pain rating) in the right hip and could not bear weight. LPN #2 then assisted the resident to her walker chair and pushed her to her bed where they (LPN #2 and CNA) transferred the resident to her bed. LPN #2 wrote that she did not complete an assessment for any injury or bruises on resident ' s skin around the hip area or anywhere. The resident continued to complain of pain so therefore she palpated (a form of assessment by applying pressure) the resident ' s hip at the joint site but Still, no deformity noted to her right leg. The LPN then notified the director of nursing (DON) of the need for an RN assessment. The medical record failed to show a RN completed a full assessment after the resident fell prior to the resident being moved or transferred off of the floor. D. Interviews LPN #2 was interviewed on 3/18/19 at 2:54 p.m. She said she found the resident on the floor squatting with her back against the door. LPN #2 said she asked the resident if she was hurt but the resident said she was not. She began to assess the resident and could not find any deformities to the resident ' s extremities. She said a CNA helped her (LPN #2) to get the resident up and encouraged her to use her walker to walk. She said the resident could not walk nor bear any weight on the right leg since she was in a lot of pain. The LPN #2 confirmed a RN did not assess the resident after the fall and prior to assisting her off of the floor. The DON was interviewed on 3/18/19 at 3:39 p.m. She said, what the LPN #2 did was correct to asses the resident for injuries. She said registered nurses (RNs) and LPNs had the same job description and therefore there was no difference. She said the resident initially expressed no pain so LPN #2 was right to get her up to walk using her walker. She said LPNs were assigned charge nurse positions in her facility and as such, a charge nurse could do any assessment on residents at any time regardless of the circumstances, therefore, the assessment LPN #2 conducted after Resident #44 ' s fall was legitimate and could not have been any different from what an RN in her facility would do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure for two (#16 and #44) of four residents environment remains as free of accident hazards as possible out of 26 sample residents reviewed. Specifically, the facility failed to: -Implement safety precautions when transferring injured Resident (#44) from the floor to her bed after sustaining a fall with a broken femoral head bone; and, -Assess and monitor a bruise of unknown origin for Resident #16. Findings include: I. Failure to implement safety precautions after Resident #44 fell A. Facility policy The Assessing Falls and Their Causes policy revised 10/10 was provided by the director of nursing on 3/12/19 at 6:00 p.m. The policy revealed the purpose of this procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. -After a fall procedure: if a resident has just fallen, or was found on the floor without a witness to the event, nursing staff would record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. -If there was evidence of a significant injury such as a fracture or bleeding, nursing staff would provide appropriate first aid. -Once an assessment ruled out significant injury, nursing staff would help the resident to a comfortable sitting, lying or standing position and then document relevant details. -Nursing staff would notify the resident's attending, physician and family in an appropriate time frame. When a fall resulted in a significant injury or condition change, nursing staff would notify the practitioner immediately by phone. When a fall did not result in significant injury or condition change the nursing staff would notify the practitioner routinely by fax or phone the next day. -If the causes of a fall could not be readily identified and if the fall was accompanied by other signs and symptoms, such as confusion or lethargy, the staff and physician would consider a possible underlying acute medical cause. -When a resident falls, the following information should be recorded in the resdient;s medical record: -The condition in which the resident was found, such as the resident was found lying on the floor between the bed and a chair. -Assessment data, including vital signs and any obvious injuries. -Interventions, first aid or treatment administered. -Notification of the physician and family as indicated. -Completion of a falls risk assessment. -Appropriate interventions taken to prevent future falls, -The signature and title of the person reason recording the data. B. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the March 2019 computerized physician orders (CPOs), diagnoses included lack of coordination, muscle weakness, and fracture of head and neck of right femur (newly diagnosed on [DATE] after a fall). The 12/7/18 minimum data set (MDS) assessment revealed the resident had a brief interview for mental status score of 15 of 15, which indicated that resident had intact cognitive functions and thought process. Resident ambulated with a four wheel walker and had no history of falls prior to her injury. C. Record review The care plan for falls, initiated 10/20/18 and revised 1/18/19, identified the resident had an activities of daily living (ADL) self-care performance deficit related to right hip fracture and used a walker for her ambulating needs. Resident's progress notes dated 1/11/19 at 7:11 p.m. documented, certified nurse aide (CNA) reported to licensed practical nurse (LPN #2) Resident #44 was found sitting down on the floor, leaning against the door. According to the progress note, LPN #2 asked the resident if she was hurt ,however, the resident said no and denied hitting her head. LPN #2 wrote in pertinent parts, .Assessment of her extremities showed no deformity . Furthermore the progress note revealed, a CNA helped LPN #2 to stand the resident up but upon standing, she complained of pain but did not rate the resident's pain level in the right hip. LPN #2 then assisted the resident to her walker chair and pushed her to her bed where they (LPN #2 and CNA) transferred the resident to her bed. LPN #2 wrote that she did not complete an assessment for any injury or bruises on resident's skin around the hip area or anywhere. The resident continued to complain of pain so therefore she palpated (a form of assessment by applying pressure) the resident's hip at the joint site but Still, no deformity noted to her right leg. The LPN then notified the director of nursing (DON) of the need for an RN assessment. Progress notes of 1/11/19 at 8:32 p.m. showed the x-ray result was positive for a right femoral neck fracture and therefore the resident was transferred to the local hospital at 8:25 p.m. via ambulance for surgery. D. Resident interview Resident #44 was interviewed on 3/12/19 at 2:45 p.m. She said she was on her way to dinner when she fell. The resident said she was in excruciating pain and did not want to move but the nurse (LPN #2) asked her to use her walker to go to the dining room. She said they stood her up but she was in pain and could not feel her right leg nor bear any weight on it. The resident said she attempted to walk per the nurse's suggestion but nearly fell. She said the two staff (LPN and CNA) members supported her to take a couple of steps with her walker for her to then sit down. The resident said the nurse and the CNA took her to her room and then transferred her to her bed. E. Staff interviews LPN #2 was interviewed on 3/18/19 at 2:54 p.m. She said she found the resident on the floor squatting with her back against the door. LPN #2 said she asked the resident if she was hurt but the resident said she was not. She began to assess the resident and could not find any deformities to the resident's extremities. (The resident was not assessed by a registered nurse, cross-reference F659). She said a CNA helped her (LPN #2) to get the resident up and encouraged her to use her walker to walk. She said the resident could not walk nor bear any weight on the right leg since she was in a lot of pain. The LPN said she and the CNA assisted the resident to sit on her walker and together, they pushed the resident to her room and laid her down on her bed to rest. She said Resident #44 continued to cry out in pain to the right hip area so she palpated the site for any signs of injury, however, found no injury nor saw any bruises on resident's skin around the hip area. She said the resident continued to cry out in pain. She said she (LPN #2) did not know what to do at that time so she went to notify the director of nurses (DON) about the incident. She said the DON assessed the resident and asked her to order an x-ray for the resident. She said the x-ray confirmed a fractured bone so they sent the resident to the hospital for further treatment. The DON was interviewed on 3/18/19 at 3:39 p.m. She said, what the LPN #2 did was correct to asses the resident for injuries. She said registered nurses (RNs) and LPNs had the same job description and therefore there was no difference. She said the resident initially expressed no pain so LPN #2 was right to get her up to walk using her walker. The DON said although the LPN asked the resident to walk after the fall, her suggestion could not have aggravated the resident's injury and pain; neither did it put the resident at risk for further injuries nor escalated the resident's pain. The DON said the LPN and CNA did the right thing by transferring the resident from the floor position to the walker, and then to bed because the resident was in an uncomfortable position and they wanted to provide some comfort and to relieve her pain. II. Failure to investigate a bruise for Resident #16 A. Facility policy The Accidents and Incidents - Investigating and Reporting policy (AIIR) revised on 7/16 was provided by the DON on 3/18/19 at 3:30 p.m. The policy revealed in pertinent part the nurse supervisor/charge nurse and or the department director or supervisor shall promptly initiate and document the investigation of the accident or incident. The following data, as applicable, should be included on the Report of Incident/Accident form: -The data and time the accident or incident took place. -The nature of the injury/illness (bruise, fall, nausea, ect). -The circumstances surrounding the accident or incident. -The name (s) of the witnesses and their accounts of the accident or incident. -The injured person's account of the accident or incident. -The condition of the injured person, including their vital signs. -The disposition of the injured such as transferred to a hospital, put to bed, sent home, returned to work, ect. -Other pertinent data as necessary or required. B. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the March 2019 computerized physician orders (CPO) diagnoses included repeated falls, dementia with behaviors, symbolic dysfunction, difficulty in walking, and chronic obstructive pulmonary disease. The 12/25/18 minimum data set (MDS) revealed the resident had both short and long-term memory problems. The resident was modified independence in his cognitive skills for daily decision making. The resident required staff supervision for bed mobility, transfers, eating, toileting, and personal hygiene. He required limited staff assistance for dressing. The resident had no impairments in his functional ranges of motion. The resident had sustained one fall since his last assessment. C. Record review The care plan (CP) revised on 10/8/18 for falls noted the resident was a high risk related to confusion, gait/balance problems and unaware of safety needs. The pertinent interventions revealed to provide the resident with a safe environment with even floors free from spills and/or clutter. The CP also revealed to provide the resident with adequate glare free lighting, a working and reachable call light, handrails on the walls and personal items placed within reach. Staff were to ensure the resident was wearing appropriate footwear when ambulating or mobilizing in his wheelchair. Physical therapy was to evaluate and treat as physician ordered or as needed. The CP revised on 10/8/18 for an actual fall noted the resident had a minor injury due to poor balance and unsteady gait. The pertinent interventions revealed vital signs for 72-hours with neurological assessments with an unwitnessed fall or a fall with a head injury. Monitor/document or report as needed for 72-hours to a physician for any signs/symptoms of pain, bruises, change in mental status, and new onset of confusion, sleepiness, inability to maintain posture or agitation. 1. Fall #1 (3/4/19) A Fall Note (FN) dated 3/4/19 at 8:45 p.m., by a registered nurse (RN) revealed this nurse ran into the resident's room and the resident was standing next to the commode and then he slid to the floor onto his bottom. The resident said he was not injured and had no pain. His vital signs were within normal limits. -This note does not reveal any areas the resident hit when he slid to the floor. A FN dated 3/5/19 at 2:03 p.m., by an RN revealed the resident had a small skin tear on his left elbow and a bruise on his left shoulder. The resident had no complaints of pain. The skin tear was washed and triple antibiotic ointment was applied with a band aid. There were no signs or symptoms of infection. His vitals were within normal limits. -This note did not mention a bruise to the resident's back. -The Morse Fall (MF) scale dated 3/5/19 at 10:30 p.m., revealed a score of 90 or high risk for falling. -The Pain Tool (PT) dated 3/5/19 at 10:30 p.m., noted a score of zero. -The Skin Observation Tool (SOT) dated 3/5/19 at 1:16 p.m., revealed a left elbow skin tear measuring one cm (centimeters) by one cm. It also noted a left scapula bruise measuring three cm by six cm. -The SOT did not mention a bruise to the resident's lower back. -A nursing note dated 3/6/19 at 9:52 a.m., by a licensed practical nurse (LPN) revealed the resident had a fall on 3/5/19. The resident had a band aid over a skin tear on his left elbow but he refused to let this nurse remove the band aide to view the wound or to change the band aide. There was no seepage or drainage of the elbow wound and the residue denied any pain. The resident was at baseline for transfer and ambulation with no acute distress is noted. - This note did not mention a bruise to the resident's left scapula or a bruise to the resident's lower back. -A nursing note dated 3/6/19 at 3:33 p.m., by an LPN revealed the resident refused earlier today to let a nurse look at his skin tear to his left elbow or to change the band aide. The resident allowed treatment at this time. The LPN observed a dark purple bruise around the elbow wound with serous drainage and no signs or symptoms of infection. Triple antibiotic ointment was applied with a new band aid. -This note did not mention a bruise to the resident's left scapula or a bruise to the resident's lower back. -A Witnessed Fall Report (WFR) #243 developed on 3/4/19 at 10:30 p.m., and revised on 3/7/19 at 6:31 a.m., by a RN revealed the resident had a bruise to his left elbow and a bruise to another area (not mentioned). The mental status section of the report revealed the resident had a dark purple bruise to his lower back that appeared consistent with a fall. The resident had a purple bruise to his left elbow at the site of the skin tear. -The report did not mention a bruise to the resident's left scapula and no measurements were taken for this newly discovered deep purple bruise to the resident's lower back. The SOT dated 3/7/19 at 8:58 a.m., revealed the resident had a left elbow bruise and a lower middle back bruise. The resident had a fall on 3/4/19 and these areas were consistent with those occurring during this fall. Both bruises were dark purple. The resident had no complaints of pain at either site and no swelling at either site. -The initial FN did not mention any areas the resident hit when he slid to the floor onto his bottom. This note did not mention a left scapula bruise and did not provide any measurements for a left dark purple elbow bruise and a dark purple bruise to the resident's lower back. -A nursing note dated 3/7/19 at 10:22 a.m., by an LPN revealed the resident remained on fall follow-up related to a fall on 3/4/19 The LPN noted a bruise to the resident's lower back and bruise to his left elbow that was consistent with areas noted to be hit during his fall. The bruises were deep purple in color. There was no swelling or complaint of pain at this time. -The initial FN did not mention any areas the resident hit when he slid to the floor onto his bottom. This note did not mention a dark purple bruise to the resident's left scapula. -The multidisciplinary therapy screen note signed 3/7/19 revealed the resident had a fall on 3/5/19 in his bathroom. The resident lost his balance and fell against the wall. The fall was witnessed by staff. This writer (physical therapist assistant) talked with the resident about therapies and falls. The resident said he did not want therapies because he felt he did not need them. We also discussed the benefits of therapy and he still declined. 2. Fall #2 (3/9/19) A FN dated 3/9/19 at 3:26 a.m by an LPN noted the resident fell in the hallway outside of the entrance to his room. His roller walked was in front of him. There were no observed injuries and range of motion were performed. The resident was assisted back to his bed with two staff members. His vital signs were within normal limits and he had no complaints of pain. An incident report was completed and all parties were notified. -This note did not mention a skin tear with a dark purple left elbow bruise, a dark purple bruise to the left scapula nor a dark purple bruise to the resident's middle lower back. The fall scene investigation report completed by an LPN on 3/9/19 at 2:00 p.m., revealed an unwitnessed fall occurred at 1:00 p.m. in the resident's room. The resident was found on his back with his roller walker in front of him by his entrance room door. The resident was ambulating with his rolling walker and lost his balance. The resident had no complaints of pain and no skin tears. Vital signs were taken. -This note did not mention and the nurse did not document accurately the residents current condition post previous fall of the following: a skin tear with a dark purple left elbow bruise, a dark purple bruise to the left scapula nor a dark purple bruise to the resident's middle lower back. The MF scale dated 3/9/19 at 1:00 a.m., noted a score of 80 out of 150 or a high risk for falling (anything over 51 was a high risk for falls. The FN dated 3/9/19 at 6:37 p.m., by an RN revealed there were no issues to note and no reports of pain. -The nurse failed to accurately document and did not mention a skin tear with a dark purple left elbow bruise, a dark purple bruise to the left scapula nor a dark purple bruise to the resident's middle lower back. The FN dated 3/10/19 at 00:43 a.m., by an LPN revealed this was a post fall note from yesterday. There were no complaints of pain and his vital signs were within normal limits. -This note did not mention the a skin tear with a dark purple left elbow bruise, a dark purple bruise to the left scapula nor a dark purple bruise to the residents middle lower back. The Neurological Assessment (NA) flow sheet started on 3/8/19 at 1:00 p.m., and ended on 3/11/19 at 8:00 a.m., did not reveal and corroborate findings. The SOT dated 3/12/19 at 1:35 p.m., revealed a left elbow skin tear and a scratch to the top of the resident's head. There were no signs or symptoms of infection. -This note did not mention a dark purple left elbow bruise, a dark purple bruise to the left scapula nor a dark purple bruise to the residents middle lower back. D. Staff interviews On 3/18/19 at 3:36 p.m., the director of nursing ( DON) said it was her understanding the bruise to his lower middle back came from his fall on 3/4/19. She said if the resident would have allowed a full skin assessment the nurse's would have looked at his back. She agreed there were no skin assessments revealing he had refused to be assessed. She said nursing staff should expound on injuries in every nurse note. She said any observed skin concerns should be documented and measured on the SOT. The DON reviewed the clinical notes relevant to the falls on 3/4/19 and 3/9/19. The DON acknowledged the following: -FN dated 3/4/19 at 8:45 p.m. did not reveal the resident had any injuries. -FN dated 3/5/19 at 2:03 p.m., revealed the resident had a skin tear to his left elbow and a bruise to his shoulder. -The note did not mention a bruise to the resident's lower middle back. -SOT dated 3/5/19 at 1:16 p.m., revealed a left elbow skin tear and a left scapula bruise. -The SOT did not document a dark purple bruise to his lower middle back. -Nursing note dated 3/6/19 at 9:52 a.m., did not reveal a bruise to the resident's left scapula or a bruise to his lower middle back. -Nursing note dated 3/6/19 at 3:33 p.m., revealed a dark purple bruise around his left elbow wound. This note did not mention a bruise to the resident's scapula or to his lower middle back. -The WFR #243 developed on 3/4/19 at 10:30 p.m., and revised on 3/7/19 at 6:31 a.m., revealed the resident had a purple bruise to his left elbow at the site of the skin tear and a dark purple bruise to his lower back. The report did not note a bruise to the resident's left scapula and did not note any measurements of the bruise to the resident's lower back. -SOT dated 3/7/19 at 8:58 a.m., revealed the resident had a left elbow bruise and a lower middle back bruise. Both bruises were dark purple. This note did not mention a left scapula bruise and there were no measurements for any of the bruises. -Nursing note dated 3/7/19 at 10:22 a.m., revealed a deep purple bruise to his left elbow and to his lower back. The note did not mention a left scapula bruise. -The multidisciplinary therapy screen note signed 3/7/19 did not discuss any injuries such as a skin tear with a dark purple left elbow bruise, a dark bruise to the left scapula nor a dark bruise to the resident's lower middle back. Registered nurse (RN) #3 was interviewed on 3/18/19 at 4:19 p.m., she said she wrote the note dated 3/5/19 at 2:03 p.m. She said the resident recedived a shower and she saw a small bruise on his left shoulder. She said she also saw a small skin tear on his left elbow. She said she did not see a bruise to his lower middle back. She said she also completed the SOT dated 3/5/19 at 1:16 p.m. She said all she saw was the left scapula bruise and a skin tear to his left elbow. She did not see a bruise to his lower middle back. On the reverse side of this form she used the term back in her description. She said this term actually referred to his scapula. She said she had never seen his lower back area. She said yesterday 3/17/19 was the first time she looked at his lower back and there was a slight discoloration to this area. She said she had never observed a dark purple bruise to this lower middle back. She said she did not receive any information in shift change meetings regarding a bruise to his lower middle back. She said at shift change they would discuss any concerns about a resident and any changes in condition such as a skin tear or bruise that deviated from his baseline. She said she would chart and measure any bruise she saw on a resident. LPN#1 was interviewed on 3/18/19 at 4:44 p.m., she said in reference to her nursing note dated 3/6/19 at 10:22 a.m., the resident had his shirt on and she was helping him pull his left elbow out of the shirt when she observed a bruise located between his upper beltline and below his scapula on his left side. She said she did not measure the bruise. She said she assumed this bruise came from his previous fall. She said she was never able to get his shirt off and was not able to see his left scapula nor the actual middle of his lower back. She said in her notes she did not draw where the bruise was located on the resident. She said the brusie she saw was much higher (along his left rib cage) and was not located on his middle lower back area. She said during shift change meetings she never heard a discussion of a dark bruise to his lower middle back. She said when she was told the resident had a fall she was not told he had any injuries at that time. She said she only received information about the skin tear to his left elbow during a shift change meeting. There was no conclusive evidence to support the supposition the bruise to the resident's lower back was the result from his slid to the floor and landing on his bottom from the fall on 3/4/19. The documentation relevant to the second fall on 3/9/19 mentioned the residents left elbow skin tear however there was no mention of any of the other skin issues/bruises on the resident.