Every finding on record at Arbor Valley of Cascadia

Based on observation, interview, policy review, and review of the FDA Food Code, the facility failed to ensure food items were not past the use-by-date, food preparation supplies were in good condition, drinks were covered during transport, and hand hygiene was performed when assisting residents with meals. These deficient practices placed all 132 residents who received meals prepared by the kitchen at risk for food-borne illness and potential for cross-contamination. Findings include:The FDA Food Code Section 4-501.12 Cutting Surfaces - documented cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.The facility's Meal Service policy, dated 9/12/25, documented Dining Environment and Service Protocols 3.b. For in-room delivery: Ensure food is covered during transport and uncovered at bedside.The facility's Hand Hygiene policy dated 9/15/25, documented all healthcare workers should perform hand hygiene at critical moments during resident care, according to CDC guidelines. These moments include but are not limited to before and after assisting a resident with meals. On 8/17/26 at 10:18 AM, observed in the dry food storage pantry with the Culinary Manager present: - An opened box containing multiple packages of single serve seasoned croutons with a manufacturer printed expiration date of June 2026. On 8/17/26 at 10:21 AM, the Culinary Manager stated the crouton packages should have been discarded and had not been. On 8/17/26 at 10:26 AM, observed two large plastic-type food cutting boards with multiple deep penetrations and discoloration to the center portion of the boards on each side. On 8/17/26 at 10:31 AM, the Culinary Manager stated the cutting boards should have been removed from the kitchen and had not been. On 8/17/26 at 11:40 AM, observed during the 600 Hallway meal service delivery, the Activities Assistant and other staff transporting cups of coffee or juice down the hall without a cover or a lid to residents' rooms. On 8/17/26 at 11:52 AM, the Activities Assistant stated she was not aware the drink cups needed to be covered when transporting them to the residents' rooms. On 8/17/26 at 5:06 PM, the DCS stated the drink cups should have been covered when transporting them to the residents' rooms and had not been. On 8/17/26 at 12:17 PM, observed CNA #1 deliver food trays to various rooms on 200 Hall without performing hand hygiene before or after delivering each tray. On 8/17/26 at 12:32 PM, CNA #1 stated she normally washed her hands in the resident rooms but had not during this lunch meal tray delivery. On 8/19/26 at 1:45 PM, the 200 Hall Unit Manager #1 stated the CNAs should be washing their hands before delivering each tray into a resident's room.

Based on record review, staff interview, and policy review, it was determined the facility failed to ensure a Bed Hold Notice and Transfer/Discharge forms were provided to residents or their representatives at the time of the resident's transfer to the hospital. This was true for 5 of 7 residents (Resident #7, #16, #34, #61, and #77) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed or room at the facility within a specified time. Findings include:The facility's Resident Rights policy dated 9/12/25, documented the resident has the right to receive advance notice of transfers or discharges of the resident as required by law.The facility's Discharge or Transfer policy, revision date 8/30/25, documented Notice of Transfer or Discharge 3. A copy of the notice shall be maintained in the resident's clinical record. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, respiratory diseases, and acute kidney failure. Resident #7's medical record documented resident had been transferred on 7/5/26, to a local emergency department after having a fall at the facility. On 8/19/26 at 9:03 AM, review of Resident #7's medical record included a Bed Hold Agreement dated 7/5/26, which documented that the facility received a verbal bed hold request from the resident and on the signature line included two facility staff signatures. Resident #7's medical record had no documentation showing that the facility provided the written Bed Hold Agreement to the resident or resident's representative. On 8/19/26 at 10:46 AM, the DCS stated when staff receive a verbal bed hold request from the resident two staff members sign the document. The DCS further stated there is no documentation in Resident #7's medical record that the resident or resident's representative received a written copy of the Bed Hold Agreement. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure, depression, and diabetes. Resident #16's medical record documented resident had been transferred on 5/7/26, to a local emergency department. On 8/19/26 at 9:07 AM, review of Resident #16's medical record included a Bed Hold Agreement dated 5/7/26, which documented that the facility received a verbal bed hold request from the resident and on the signature line included two facility staff signatures. Resident #16's medical record had no documentation showing that the facility provided the written Bed Hold Agreement to the resident or resident's representative. On 8/19/26 at 10:48 AM, the DCS stated when staff receive a verbal bed hold request from the resident two staff members sign the document. The DCS further stated there is no documentation in Resident # 16's medical record that the resident or resident's representative received a written copy of the Bed Hold Agreement. Resident #77 was admitted to the facility on [DATE], with multiple diagnoses including drug induced secondary Parkinsonism (chronic degenerative disease of the central nervous system that produces progressive movement disorders and changes in cognition and mood), obstructive sleep apnea, and anxiety. Resident #77's medical record documented resident had been transferred on 7/29/26, to a local emergency department after having a fall at the facility. On 8/19/26 at 9:13 AM, review of Resident #77's medical record included a Bed Hold Agreement dated 7/29/26, which documented that the facility received a verbal bed hold request from the resident and on the signature line included two facility staff signatures. Resident #77's medical record had no documentation showing that the facility provided the written Bed Hold Agreement to the resident or resident's representative. On 8/19/26 at 10:49 AM, the DCS stated when staff receive a verbal bed hold request from the resident two staff members sign the document. The DCS further stated there is no documentation in Resident # 77's medical record that the resident or resident's representative received a written copy of the Bed Hold Agreement. Resident #61 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia. On 8/17/26 at 4:22 PM, Resident #61's medical record had no documentation that a written bed-hold and transfer/discharge form for hospitalization on 3/18/26 to 3/25/26 had been provided to the resident or resident's representative. On 8/19/26 at 3:25 PM, the DCS stated she was not aware a written copy of the bed-hold and transfer/discharge forms had to be provided to the resident or resident's representative. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and end stage renal disease. Resident #34's progress note dated 4/18/26, documented, Received a call from Fresenius Dialysis stating that they were transporting resident to ED r/t fistula not working and they were unable to dialyze resident. Call placed to on call MD and resident's wife. Review of Resident #34's medical record revealed a Bed Hold Agreement dated 4/18/26, which documented that the facility received a verbal bed hold request from the resident's legal representative. The record lacked documentation showing that the facility provided the written Bed Hold Agreement to the resident or their legal representative. On 8/19/26 at 10:44 AM, the DCS stated the family had not received a written copy of the bed hold. On 8/19/26 at 10:59 AM, the CEO stated there was no documentation that the bed hold was given to family for any of the discharged residents.

Based on record review, staff interview, and policy review, it was determined the facility failed to ensure a resident and/or their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 4 of 9 residents (Resident #7, #50, #59, and #77) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. Findings include:The facility's Advance Directives and Advance Care Planning policy dated 8/28/25, documented, Procedure 1. Residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care.and the formation of advance directives on admission. 4. If the resident has an advance directive, the facility associate will request a copy of the directive so that it may become part of the medical record and are incorporated into the resident's care plan. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, respiratory diseases, and acute kidney failure. On 8/18/26 at 11:33 AM, Resident #7's medical record did not include an advance directive for healthcare or documentation she was provided with information on her right to formulate an advance directive. On 8/18/26 at 11:42 AM, the Licensed Certified Social Worker (LCSW) stated the Advance Directive education check marked on Resident #7's Care Conference document was the LCSW verbally letting the resident know she could assist in completing an advance directive and that she did not have an actual informational document that could be provided to residents. On 8/18/26 at 5:32 PM, the DCS stated there was no advance directive in Resident #7's medical record or that information had been provided to the resident or resident's representative. Resident #77 was admitted to the facility on [DATE], with multiple diagnoses including drug induced secondary Parkinsonism (chronic degenerative disease of the central nervous system that produces progressive movement disorders and changes in cognition and mood), obstructive sleep apnea, and anxiety. On 8/18/26 at 11:37 AM, Resident #77's medical record did not include an advance directive for healthcare or documentation she was provided with information on her right to formulate an advance directive. On 8/18/26 at 11:44 AM, the Licensed Certified Social Worker (LCSW) stated the Advance Directive education check marked on Resident #77's Care Conference document was the LCSW verbally letting the resident know she could assist in completing an advance directive and that she did not have an actual informational document that could be provided to residents. On 8/18/26 at 5:34 PM, the DCS stated there was no advance directive in Resident #77's medical record or that information had been provided to the resident or resident's representative. Resident #50 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute and chronic respiratory failure, diabetes, and COPD (chronic obstructive pulmonary disease- long term lung disease that blocks airflow and makes it hard to breathe). On 8/18/26 at 2:00 PM, Resident #50's medical record documented a POST form dated 6/25/26. On 8/18/26 at 2:04 PM, Resident #50's medical record had not contained a copy of Advance Directives. On 8/18/26 at 11:44 AM, the Licensed Certified Social Worker (LCSW) stated the Advance Directive education check marked on Resident #50's Care Conference document was the LCSW verbally letting the resident know she could assist in completing an advance directive and that she did not have an actual informational document that could be provided to residents. No further documentation of education was provided. Resident #59 was initially admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including diabetes and acquired absence of the left leg below the knee. A SS: Care Conference Review evaluation dated 6/29/26, documented under section C. Code Status/Advanced Directive 3a. If yes, specify: Durable Power of Attorney for Healthcare (Healthcare Proxy) was checked. On 8/19/26 at 2:48 PM, record review of Resident 59's medical record revealed no documentation of an advanced directive. Further review of his medical record failed to reveal any documentation demonstrating that Resident #59 or his resident representative were provided with written information regarding advanced directives, or that they were offered assistance to formulate an advanced directive. During an interview on 8/18/26 at 5:37 PM, the DCS confirmed that there was no documentation in Resident #59's medical record to show that written information regarding advance directives was provided, or that assistance was offered to the resident or his resident representative.

Based on record review, policy review, and interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 4 of 6 Residents (#16, #89, #104 and #146) reviewed for baseline care plan. This failure created the potential for harm when the base line care plan failed to provide directions for care. Findings include:The facility's Baseline Care Plans policy dated 9/3/25, documented the facility will initiate a baseline care plan for each resident within 48 hours of admission. This plan will outline essential care instructions to support safe, person-centered services that reflect the resident's immediate needs. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure, depression, and diabetes. On 8/19/26 at 8:32 AM, Resident #16's medical record documented the baseline 48-hour care plan was initiated on 6/27/25 but not completed until 6/30/25. On 8/20/26 at 9:46 AM, the DCS stated the baseline care plan should have been completed within 48 hours and had not been. Resident #141 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy (brain dysfunction marked by varying degrees of impairment of speech, cognition, orientation, and arousal), heart failure, and muscle wasting and atrophy (loss of skeletal muscle mass). On 8/19/26 at 9:17 AM, Resident #141's medical record documented the baseline 48-hour care plan was initiated on 2/25/26 but not completed until 3/2/26. On 8/20/26 at 9:48 AM, the DCS stated the baseline care plan should have been completed within 48 hours and had not been. Resident #89 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and kidney failure. On 8/18/26 at 10:17 AM, Resident #89's medical record documented the baseline 48 hour care plan was initiated on 12/12/26 but not locked and completed until 12/15/26 four days after he was admitted . Resident #146 was admitted to the facility on [DATE], with multiple diagnoses including intestinal adhesions bands (scar tissue bands are causing a bowel blockage) and pneumonia. On 8/18/26 at 10:36 AM, Resident #146's medical record documented the baseline 48 hours care plan was initiated on 8/9/26 but not locked and completed until 8/10/26 three days after she was admitted . On 8/19/26 at 12:00 PM, the DCS stated facility staff have been told to complete and lock baseline care plans within 48 hours otherwise they are considered late.

Based on record review, policy review, AARC Clinical Practice Guidelines, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for 4 of 6 residents (Resident #8, #10, #89, and #102) reviewed for quality of care. This failed practice had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice. Findings include: The facility's Non-Pressure Wound Treatment policy revision date 10/8/24, documented the facility shall ensure that residents with non-pressure wounds - including venous, arterial, diabetic, surgical, and other etiologies - receive care consistent with professional standards of practice. The facility's Resident Bowel Management policy, dated 5/8/26, documented Interventions 2. Medication Management a. Bowel-related medications are administered as ordered by the provider. The AARC Clinical Practice Guidelines for Oxygen Therapy in the Home or Alternate Site Health Care Facility dated 2027, documented some patients may not demonstrate a need for oxygen therapy at rest (normoxic) but will be hypoxemic during ambulation, sleep, or exercise. Oxygen therapy is indicated during these specific activities when the SaO2 is demonstrated to fall to less than or equal to 88%. Resident #8 was initially admitted to the facility on the10/3/24, and readmitted [DATE], with multiple diagnoses including cellulitis (bacterial skin infection) of the left lower limb and diabetes. Resident #8's physician's order dated 7/25/26, documented skin treatment Left LE stump surgical site - Cleanse with wound cleaner or Vashe (wound cleanser), apply Ioplex pad (wound dressing), cover with superabsorbent dressing secured with rolled gauze. Change dressing every other day and prn every day shift every other day for Skin treatment. Review of Resident #8's Treatment Administration Record did not document that her wound care was provided on 8/4/26 and 8/6/26. Review of Resident #8's progress notes did not have documentation that the wound care provider had completed wound care on 8/4/26 or 8/6/26. On 8/21/26 at 9:50 AM, the DCS stated there was no documentation showing that Resident #8's wound care was provided but it should have been done. Resident #10 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnosis including chronic venous hypertension with ulcer of right lower extremity (a long-term leg sore caused by poor blood flow) and heart failure. Resident #10's physician order dated 8/10/26, documented: Lt lower leg venous stasis ulcers clean with wound cleaner or Vashe, Apply Iodosorb, cover with ABD dressing and secure with rolled gauze. Change 3x/wk and PRN every day shift every other day for Skin treatment. A review of Resident #10's August 2026 Treatment Administration Record (TAR) revealed that nursing facility staff failed to document or execute the ordered wound treatment to his left lower leg on Friday, 8/14/26. The TAR space corresponding to the day shift on 08/14/26 was left blank, and there was no alternative documentation within the nursing progress notes indicating the treatment was performed or why it was omitted. Resident #10's physician's order dated 6/29/26, documented: Rt lower leg venous stasis ulcers clean with wound cleaner or Vashe, Apply Iodosorb, cover with ABD dressing and secure with rolled gauze. Change 3x/wk and PRN every day shift every Mon, Wed, Fri for skin treatment. A review of Resident #10's August 2026 Treatment Administration Record (TAR) revealed that nursing facility staff failed to document or execute the ordered wound treatment to his right lower leg on Friday, 08/14/26. The TAR space corresponding to the day shift on 08/14/26 was left blank, and there was no alternative documentation within the nursing progress notes indicating the treatment was performed or why it was omitted. Resident #10's physician order dated 7/27/27 documented: Skin Treatment: Right Gluteal fold MASD- Cleanse with soap and water, pat dry, apply Anasept gel layered with collagen flakes/powder, cover with superabsorbent dressing and change qshift and prn every shift for Skin treatment. A review of Resident #10's August 2026 Treatment Administration Record (TAR) revealed that nursing facility staff failed to document or execute the ordered wound treatment to his gluteal fold on Monday, 8/3/26 and Wednesday 8/19/26. The TAR space corresponding to the day shift on 8/3/26 and 8/19/26 was left blank, and there was no alternative documentation within the nursing progress notes indicating the treatment was performed or why it was omitted. On 8/21/26 at 10:01 AM, the DCS stated Resident #10's medical record did not document wound care was proved on 8/3/26, and he was out shopping on 8/19/26, so wound care was not done that day and but was done the next day. Resident #102 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes, and muscle weakness. On 08/18/26 at 9:17 AM, Resident #102's medical record documented he had no recorded bowel movement from 7/30/26 to 8/5/26. On 8/18/26 at 9:22 AM, review of Resident #102's July and August MAR documented no bowel management medication had been administered from 7/30/26 to 8/4/26. On 8/18/26 at 9:23 AM, Resident #102's medical record documented physician order dated 7/30/26 for: - MiraLax Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth as needed for Step 1: Bowel Care Give after 72 hours if no BM. Mix with at least 4 oz. fluid of choice-Start Date 07/30/2026 1145 PRN - Dulcolax Oral Tablet Delayed Release 5 MG (Bisacodyl) Give 2 tablet by mouth every 24 hours as needed for bowel care-Start Date 07/30/2026 1145 PRN - Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally as needed for Step 2: Bowel Care Give on Day 4 if No Results from Miralax. If no results in 24 hours see Fleets Enema order.-Start Date 07/30/2026 1145 - Fleet Enema Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for Step 3: Bowel Care Give On Day 5 if no results from Miralax and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results.-Start Date 07/30/2026 1145 PRN On 8/18/26 at 9:31 AM, Resident #102's medical record documented a physician order, dated 8/4/26, for MiraLax Oral Powder 17 Gm/scoop (Polyethylene Glycol 3350) – Give STAT for constipation. On 8/21/26 at 8:55 AM, the DCS stated Resident #102 had not received his bowel management medications as ordered by the physician and should have. Resident #89 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and kidney failure. On 8/18/26 at 8:03 AM, Resident #89's medical record documented his SpO2 saturations were low (85% on room air) on 6/2/26. Nursing progress notes had no documentation the provider had been notified related to low SpO2. On 8/18/26 at 10:21 AM, Resident #89's medical record documented he had no recorded BM from 7/29/26 to 8/1/26. Review of Resident #89's July and August MAR documented no nursing interventions for BM care for July or August of these dates. Resident #89's care plan documented resident is at risk for constipation. Resident #89's physician orders related to BM medications were as follows: - MiraLAX Powder 17 GM/SCOOP (Polyethylene Glycol 3350), give 17 gram by mouth as needed for Constipation Give after 72 hours if no BM. Mix with at least 4 oz. fluid of choice - Docusate Sodium Oral Capsule 100 MG (Docusate Sodium), Give 1 capsule by mouth every 12 hours as needed for Bowel care- - Polyethylene Glycol Powder (Polyethylene Glycol 1450), Give 17 gram by mouth one time a day for bowel care - Dulcolax Suppository 10 MG (Bisacodyl), Insert 1 suppository rectally as needed for Constipation. Give on Day 4 if No Results from Miralax. - Fleet Enema Enema 7-19 GM/118ML (Sodium Phosphates), Insert 1 unit rectally as needed for Constipation. Give On Day 5 if no results from Miralax and subsequent Dulcolax suppository. notify MD if no results. On 8/20/26 at 2:15 PM, the DCS stated nursing staff should have been documenting bowel care interventions and monitoring and addressing low SpO2 levels and had not.

Based on policy review, review of call light logs, and resident council meeting notes, it was determined the facility failed to ensure enough staff were available to answer call lights in a timely manner during the 2026 second quarter. This was true for residents that reside on the 500, 600, 700, and 800 Halls reviewed for call light response time. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay in care. Findings include:The facility's Homelike Environment policy dated 9/17/25, documented call light systems (will be) adapted to meet individual resident needs and promote independence.The facility's Quality of Life policy dated 6/4/25, documented the facility provides the appropriate treatment and services to maintain or improve his/her overall health and level of ability to carry out the activities of daily living (ADL) and their abilities/health do not diminish.A review of the 2026 2nd quarter weekend call light logs greater than 30 minutes for Hall 500, 600, 700, and 800 were documented as follows:Date range April4th/5th 24 calls ranging from 30 minutes to 1 hour 10 minutes11th/12th 23 calls ranging from 30 minutes to 1 hour 10 minutes18th/19th 18 calls ranging from 30 minutes to 1 hour 8 minutes25th/26th 27 calls ranging from 30 minutes to 1 hour 38 minutesMAY2nd/3rd 18 calls ranging from 30 minutes to 1 hour4 minutes9th/10th 19 calls ranging from 30 minutes to 1 hour20 minutes16th/17th 28 calls ranging from 30 minutes to 2 hours 2 minutes23rd/24th 24 calls ranging from 30 minutes to 1 hour 30 minutes30th/31st 20 calls ranging from 30 minutes to 1 hour30 minutesJune6th/7th 23 calls ranging from 30 minutes to 1 hour 16 minutes13th/14th 25 calls ranging from 30 minutes to 1 hour 49 minutes20th/21st 18 calls ranging from 30 minutes to 1 hour 57 minutes27th/28th 18 calls ranging from 30 minutes to 1 hour 8 minutesOn 4/13/26, Resident #153 from room [ROOM NUMBER] filed a complaint that CNAs take 30 minutes to 1 hour to respond to her room when she pushed the call light button.According to the call light log for 4/26/26 at 3:57 AM, it took 1 hour 38 minutes for nursing staff to answer the call light for room [ROOM NUMBER].The facility daily staffing assignment log documented there are no CNA staff assigned to the 600 Hall and the RN for 600 Hall was only assigned to work 6 PM to 10 PM. The LPN from 700 Hall was assigned to cover the 600 Hall from 10 PM to 6 AM along with their previously assigned 700 Hall.On 8/20/26 at 4:30 PM, the DCS stated the call lights should be answered within about 10 minutes.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure daily nurse staffing information was accurate when posted for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 8/18/26 at 2:11 PM, the daily staffing sheets from January 2026 to August 2026 were missing the actual hours worked.On 8/18/26 at 2:50 PM, the DCS stated the daily staffing sheets should document the actual hours worked and had not.

Based on record review and staff interview, the facility failed to ensure that medications were administered as prescribed by the physician for 1 of 2 residents (Resident #59), resulting in the resident receiving an unnecessary amount of insulin. This failure placed Resident #59 at risk for, and had the potential to experience, an adverse reaction due to receiving an unnecessary amount of insulin, specifically severe hypoglycemia (low blood sugar), which can lead to dizziness, confusion, seizures, or loss of consciousness. Findings include: The facility's Medication Administration policy revision date 9/10/25, documented all staff authorized to administer medications must follow the 10 Rights of Medication Administration to ensure resident safety, reduce medication errors, and maintain compliance with federal and state regulationsResident #59 was initially admitted to the facility on [DATE], with multiple diagnoses including diabetes and acquired absence of left leg below the knee.Resident #59's physician's order dated 5/5/26, documented Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 95 unit subcutaneously at bedtime for DM type 2 Hold for BG <130.Review of the medication administration recorded for Resident #59 documented 95 units of insulin glargine was administered on the following dates when his blood sugar was less than 130:July 2026:7/10 - 1277/11 - 1187/14 - 1207/17 - 987/18 - 1117/19-1237/21-1207/27-1197/28-1117/29-1247/31-96August 2026:8/2-1118/3-1108/4-1128/6-1158/7-1298/10-1038/11-1238/13-1218/16-115On 8/20/26 at 9:33 AM, the DCS stated there was an issue with the amount of insulin Resident #59 was given, the order had not been followed.

Based on observation, staff interview, record review, policy review, facility water management program, CDC's water management guidelines, and Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens regulations, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment and to ensure its water management program included an assessment of the facility's swamp cooler and decorative water towers to identify where Legionella and other opportunistic waterborne pathogens could grow and spread and failed to establish measures to prevent the growth of opportunistic waterborne pathogens and how those measures would be monitored. This was true for 4 of 4 residents (Resident #14, #35, #41, and #95) and the facility observed for infection control. These deficient practices had the potential to place residents at risk for cross contamination, infection, and to expose residents with opportunistic waterborne pathogens, including Legionella, from a water-containing system that was not identified, assessed, or addressed in the facility's water management program. Findings include: The facility's Oxygen Administration, Safety, Storage & Maintenance policy, revision date 10/10/25, documented Infection Control 3. Store oxygen and respiratory supplies in a plastic bag when not in use. The facility's Oral Suctioning policy dated 9/12/25, documented the facility will ensure equipment is stored to keep clean. The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens regulations 1910.1030, updated 10/19/21, states, Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure and Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.The facility's Water Management Plan dated 10/10/25, documented a multidisciplinary team.shall create a flow diagram of the facility's water systems, identifying all water sources, distribution points, and areas of aerosol generation. The team shall assess each component of the water system for potential Legionella growth and transmission risk. Control strategies shall be implemented, including temperature regulation, disinfection, and routine flushing of stagnant water. The facility shall establish procedures for monitoring water quality parameters and document results.CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings A Practical Guide to Implementing Industry Standards, dated 9/30/25, at https://www.cdc.gov/control-legionella/media/pdfs/toolkit.pdf, documented that water management programs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens. Hospitals and long-term care facilities are among the settings where the entire building needs a water management program. CDC's Steps to Develop a Water Management Program documented that an effective Legionella water management program includes describing the building water systems; identifying areas where Legionella could grow and spread; determining where to apply and how to monitor control measures; establishing interventions when control limits are not met; ensuring the program operates as designed and is effective; and documenting and communicating program activities. On 8/17/26 at 4:04 PM, observed in Resident #14's room: - Yankauer suction catheter was lying in his dresser drawer not covered. - IV pole with enteral feeding solution hanging from it observed to have a large amount of dry, light brown, substance on the base. - Next to Resident #14's IV pole observed a large amount of dry, light brown substance with a tissue on top of it. - two 60 cc syringes on bedside table. One syringe dated 8/15/26 and the other dated 8/17/26. On 8/17/26 at 4:09 PM, RN #3 stated Resident #14's feeding pole should have been cleaned weekly, the old syringe should have been thrown away, and he was not sure what was dried on the floor, but it should have been cleaned up. On 8/20/26 at 11:33 AM, the DCS stated the feeding pole should have been cleaned when soiled and as needed and the suction Yankauer should have been stored in a bag when not in use. On 8/18/26 at 4:45 PM, during a medication administration observation RN #2 placed two prefilled heparin syringes and two prefilled normal saline syringes on Resident #95's bed prior to flushing her PICC line, violating standard aseptic technique. On 8/18/26 5:10 PM, RN #2 stated he should not have laid the syringes on the bed without a barrier, he normally puts them on the bedside table. On 8/19/26 at 7:30 AM, observed a Purple Monster drink on the 100- hall medication cart. On 8/19/26 at 7:33 AM, LPN #1 stated she should not have had her personal drink on the cart. On 8/19/26 at 8:10 AM, observed a half full water bottle on the 400-hall medication cart. On 8/19/26 at 8:13 AM, LPN #2 stated the water bottle must have been the night nurses and it should not have been on the cart. On 8/19/26 at 4:48 PM, observation with the Maintenance Director, a swamp cooler located outside of the kitchen/dining room area. The swamp cooler was a ducted evaporative cooler. On 8/19/26 at 5:07 PM, observed with the Maintenance Director, a sensory LED 4 feet tall bubble tube in the 200 Hall activities room. The tube was in the direct sunlight next to a window and had an opening at the top to allow for air circulation. The tube is situated so residents can sit next to and observe the bubbles in the water. Review of the facility's Water Management Program undated revealed the program identified ice machine, water filters, showerheads, less frequently used areas, hot water storage tanks, and eyewash stations as areas that had a potential risk for spread of Legionella through aerosols. The program did not identify or include the swamp cooler or decorative water features in the description/assessment of the facility's water systems. The program did not contain an assessment of the swamp cooler for locations or conditions where Legionella or other opportunistic waterborne pathogens could grow and spread, control measures to prevent such growth, or monitoring of control measures. On 8/20/26 at 8:35 AM, the Maintenance Director stated the swamp cooler was not included in the facility's Water Management Program. The Maintenance Director stated he was responsible for cleaning and maintaining the swamp cooler but was not sure who cleaned or maintained the sensory water tube. The Maintenance Director stated he had worked at the facility for more than four years and had not assessed the swamp cooler for Legionella risk and had no established Legionella control measures for the cooler. On 8/20/26 at 2:20 PM, the CEO stated he was not aware the swamp cooler and sensory water tube had not been included in the facility's water management program and should have been. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease, diabetes, and chronic obstructive pulmonary disease (group of debilitating, progressive, and potentially fatal lung diseases having an increased resistance to air movement). A physician order, dated 4/30/25, documented Resident #35 was to receive CPAP @ 6-20cmH20 with humidification. Continuous positive air pressure (CPAP) scheduled start at HS. Discontinue in AM, every shift. On 8/17/26 at 11:16 AM, observed Resident #35's CPAP equipment hanging on the wall at the head of Resident #35's bed uncovered and not stored in a plastic bag. On 8/18/26 at 10:43 AM, the DCS stated the CPAP equipment was not appropriately bagged after use to prevent contamination of the equipment and should have been. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, bilateral below knee amputations, and obstructive sleep apnea (temporary cessation of breathing during sleep). A physician order, dated 7/15/25, documented Resident #41 was to receive bilevel positive airway pressure (BiPAP) @ 12cmH20 inspiration; 10 cmH20 expiration on room air with humidification and 5L oxygen bleed in. Bipap scheduled start at HS. Discontinue in AM, to meet goal of 6-8 hours each night. Every day and evening shift. On 8/17/26 at 1:16 PM, observed Resident #41's BiPAP mask and tubing lying on his bedside nightstand uncovered and not stored in a plastic bag. On 8/18/26 at 10:47 AM, the DCS stated the BiPAP equipment was not appropriately bagged after use to prevent contamination of the equipment and should have been.

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure residents' privacy was maintained for 1 of 1 resident (Resident #34) reviewed for privacy. This deficient practice placed residents at risk of embarrassment and loss of control over their personal information. The facility also failed to ensure residents' rights were respected regarding communication. Specifically, the facility failed to ensure that incoming mail was delivered to residents on Saturdays, resulting in a complete failure to distribute personal mail to the resident population. This deficient practice had the potential to affect all residents residing in the facility by disrupting their contact with family and the community. Findings include: Resident #34 was initially admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including diabetes and end stage renal disease. On 8/17/26 at 2:11 PM, observation revealed a white, dome shaped video camera on the roommate's side of the room shared by Resident #34. The roommate stated his sister brought it in. Interviews on 8/17/26, completed with two CNAs, one LPN, the CEO and DCS confirmed that none of them were aware that the video camera was in the room. The DCS stated the video camera should not have been in the room. On 8/20/26 at 10:32 AM, Resident #34 stated he was unaware that his roommate had a video camera on his side of the room. He also stated he would have liked to have known it was there, but he has not been affected by him (his roommate) having the camera. On 8/19/26 at 12:30 PM, during a confidential resident group meeting attended by 10 facility-identified cognitively intact residents and a family member,residents were asked whether anyone had received mail on a Saturday during the previous six months. All 10 residents responded that they had not received mail on a Saturday. On 8/20/26 at 2:40 PM, during an interview the Activities Director identified the weekend Activity staff responsible for handling resident mail on Saturdays. The Activities Director stated there had been schedule changes that have affected Saturday mail delivery and she knew residents needed to receive their mail within 24 hours of it arriving at the facility. The Activities Director further stated packages delivered by commercial carriers addressed to residents are brought to the back of the building and remain there until residents retrieve them independently. She stated packages that are not retrieved independently are delivered on Monday. On 8/20/26 at 2:48 PM, during an interview the Administrative Assistant stated she did not work on Saturdays and Activity staff were responsible for delivering resident mail on Saturdays. The Administrative Assistant stated residents needed to have their mail delivered every day. She further stated that more than once a month, when she returned to work on Monday morning, she found resident mail remaining on her desk or behind the front lobby office area that had not been distributed to residents from the weekend. She stated she then distributed the mail to the residents. On 8/21/26 at 10:05 AM, during an interview the CEO stated mail was delivered to the facility six days a week by the United States Postal Service (USPS) and was to be delivered promptly to residents. The CEO defined promptly as within 24 hours of the mail or packages being delivered to the facility. The CEO confirmed the distribution of mail on weekends was the responsibility of Activity staff.

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure residents were provided with a safe and clean, homelike environment that did not pose any safety or infection risks. This was true for 1 of 7 shower rooms and the facility that were observed. This deficient practice created the potential for diminished quality of life and psychosocial distress for the 22 residents that use the 200 Hall shower room where a portion of the floor tile was missing and electrical wires were exposed. Findings include:The facility's Homelike Environment policy dated 9/17/25, documented environmental services will be maintained in a sanitary, orderly, and comfortable interior. Interior and exterior surfaces necessary for the health, safety, and comfort of the resident shall be kept at the highest practicable level, clean, and in good repair. Mechanical, electrical, and care equipment is maintained in safe condition.The facility's Electrical Systems and Safety policy dated 10/8/25, documented electrical equipment shall be inspected regularly for wear, corrosion, or damage. Unsafe or deteriorated equipment shall be removed from service until repaired or replaced. On 8/19/26 at 3:33 PM, observed the following in the 200 Hall shower room: - A 12-inch by 10-inch section of floor linoleum was missing at the doorway going from the toilet area to the shower area. There was a piece of linoleum protruding into the missing section that was loose and lifted easily as a potential fall hazard. - The wall heater was missing a cover that allowed electrical wires to hang out next to the toilet. On 8/19/26 at 3:40 PM, the DCS stated the missing linoleum flooring, and exposed electrical wires need to be corrected and had not been. On 8/20/26 at 9:45 AM, observed with the Maintenance Manager and CEO present, the missing linoleum flooring and exposed electrical wires. When the Maintenance Manager examined the damaged flooring, he found water damage under the linoleum that allowed a very large portion of the linoleum to lift increasing the fall potential hazard. The Maintenance Manager stated he should have been told about this sooner and will get it fixed. On 8/20/26 at 9:58 AM, the CEO stated the damaged linoleum needed to be fixed. During an environmental tour on 8/19/26 at 12:10 PM, the following cleanliness and maintenance concerns were observed on the 600-hall: -The ventilation vent located at the end of the 600-hall corridor was covered in a heavy accumulation of a black substance. -The wall area located at the end of the 600-hall corridor contained an accumulation of cobwebs and a black, fuzzy substance. -Multiple overhead ceiling light fixtures spaced throughout the 600-hall contained an accumulation of an unidentified dark spotting inside the lenses. During an interview on 8/20/26 at 1:00 PM, the Maintenance Director stated he did not have a cleaning schedule for the light fixtures but the vents should be cleaned monthly. He also stated he was aware of 808's windowsill needing to be repaired. During an interview on 8/20/26 at 1:04 PM, the Housekeeping Supervisor stated the house keepers have a cleaning schedule for the resident rooms but not for the common areas. The housekeepers do not clean the vents in the halls or the walls or ceilings.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current physician orders. This was true for 3 of 11 residents (Resident #9, #13, and #50) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services ordered by the physician had not been provided. Findings include: Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE], with multiple diagnoses including cerebral palsy (a group of permanent movement disorders that appear in early childhood, affecting body movement, muscle coordination and posture), chronic kidney disease and deaf/nonspeaking.On 8/17/26 at 10:15 AM, Resident #9's physician's orders documented prevlon boots and cpap.On 8/17/26 at 11:45 AM, observed Resident #9 lying in his bed wearing prevlon boots with his cpap machine on his bedside table.On 8/19/26 at 12:00 PM, Resident #9's mother stated he uses the cpap every night.On 8/19/26 at 12:45 PM, Resident #9's care plan was reviewed and did not contain documentation or directives for prevlon boots or cpap.On 8/19/26 at 1:15 PM, the DCS (Director of Clinical Services) stated Resident #9's care plan did not include the prevlon boots or cpap and it should have. Resident #13 was initially admitted to the facility on [DATE], with multiple diagnoses including paraplegia (immobility syndrome) and pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs) and re-admitted on [DATE], with multiple diagnoses including encounter for palliative care (specialized care for people living with a serious illness). Resident #13 had elected to receive hospice services while receiving care at the facility beginning 6/2/26.Resident #13's care plan initiated on 7/13/20, and revised on 7/20/26, documented- 6/2/26, potential for impairment to skin integrity. Rt buttock now stage 4 PU. Multiple interventions in place including - Change catheter when leaking. (date initiated 4/9/26) and tx (treatment) as ordered (initiated 2/12/24). The care plan had not been revised/ updated after initiation of Hospice to determine which discipline (facility or hospice provider) would be responsible for performing the tasks or the frequency.Resident #13's care plan for Foley catheter (date initiated 1/8/24 and revised on 3/5/25, included interventions including - change drainage bag per policy (date initiated 1/8/24 and flush catheter per provider orders (date initiated 4/3/24). The care plan had not been revised/updated after initiation of Hospice to determine which discipline (facility or hospice provider) would be responsible for performing the tasks or the frequency.Resident #13's care plan for ADL's (initiated on 8/1/20 and revised on 2/11/25) documented intervention for bathing - . prefers to have bed bath offered twice weekly. Encourage shower as (resident #13) allows (initiated 8/1/20 and revised on 11/26/25). The care plan had not been revised/ updated after initiation of Hospice to determine which discipline (facility or hospice provider) would be responsible for performing the tasks or the frequency.On 8/19/26 at 1:30 PM, the Hospice care plan, dated 6/2/26 did not indicate frequency of LN or CNA visits and did not indicate which discipline (facility or hospice) would be responsible for completing resident care tasks.On 8/20/26 at 10:15 AM, the DCS stated the care plan had not been revised/updated after the initiation of Hospice and it should have.Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure, diabetes, and COPD (chronic obstructive pulmonary disease- long term lung disease that blocks airflow and makes it hard to breathe).On 8/19/26 at 1:30 PM, the facility's incident investigation dated 2/27/26, for the injury of Resident #50 documented she was injured during a slide board transfer when she received a skin tear to her leg requiring her to go to the ED for sutures. There was no documentation in the care plan of interventions to instruct staff how to care for the injury or prevent further incidents of the same nature from recurring.On 8/19/26 at 1:35 PM, the facility's incident investigation dated 3/19/26, for Resident #50's injury documented she sustained a skin tear, source unknown, to her left forearm. There was no documentation in the care plan to instruct staff how to care for the injury or prevent further incidents from recurring.On 8/20/26 at 10:17 AM, the DCS stated the care plans had not been updated after the incidents and they should have.

Based on observation, record review, policy review, and staff interview it was determined the facility failed to ensure residents were provided with assistance to meet their needs. This was true for 1 of 1 resident (Resident #135) who was reviewed for activities of daily living.This failed practice created the potential for embarrassment and psychosocial harm when Resident #135 was not provided with personal care. Findings includeThe facility's Activities of Daily Living policy, dated 9/8/25, documented Residents receive assistance with activities of daily living (ADLs) based on their individual needs, preferences, and care plan goals. Procedure 2. Staff help with the following ADLs as needed and in accordance with the Resident's care plan: I. Hygiene: Bathing, dressing, grooming, oral care II. Mobility: Transfers, ambulation, wheelchair use III. Elimination: Toileting, incontinence care, use of bedpans or urinals .Resident #135 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia/hemiparesis following cerebral infarct affecting non-dominant left side (paralysis of the left side after a stroke), encephalopathy (disorder or disease that affects the function or structure of the brain causing altered mental status) and left ankle contracture.On 8/20/26 at 0930 AM, observed CNA #2 and CNA #3 providing AM care for resident #135. The two CNA's provided dependent peri-care and CNA #2 exited the room. CNA #3 then assisted her to upright position in bed where she was fed two bites of oatmeal and stated she was full. CNA #3 removed her tray and left the room. On 8/20/26 at 9:40 AM, Resident #135 stated the CNA's did not ask her if she wanted to change into clean clothes, perform oral care, wash her face or comb her hair. Resident #135 stated, they never do. On 8/20/26 at 10:00 AM, review of Resident #135's care plan documented dependent on staff for ADL's including personal hygiene and dressing upper and lower body. On 8/20/26 at 10:20 AM, the DCS stated the CNA's should have provided AM cares as directed in the care plan and had not.

Based on review of staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a nurse aide successfully complete a State approved training and competency evaluation program within 4 months of being hired. This was true for 1 of 1 nurse aide (NA #1) whose personnel file was reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility. Findings include:Nurse Aide #1 was hired by the facility on 1/1/26.On 8/19/26, nurse aide #1's personnel file documented he had not completed a CNA State approved training and competency evaluation program within 4 months of being hired. On 8/19/26 at 3:58 PM, the CEO stated nurse aide #1 had started a CNA training program then stopped attending the classes and never finished the program and should have.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 2 of 4 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication, to receive expired medications with decreased efficacy, and residents to receive the wrong medication due to the medication label being illegible. Findings include: The facility's Medication Storage & Labeling policy dated 10/13/25, documented the facility will ensure that medications are stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles to ensure safety, efficacy, and compliance.On 8/19/26 at 11:49 AM, during a medication storage audit with LPN#1 present, observed a bottle of Nystop powder (antifungal) with an expiration date of 5/31/26 on the 100-hall med cart. On 8/19/26 at 11:51 AM, LPN #1 stated the bottle of Nystop should not have been on the cart, she had just checked the cart and so had the pharmacist. During a medication storage audit of the 500-hall medication cart on 8/19/26 at 12:09 PM, with RN #1 present, the following five medications were observed sitting loose, unsecured, on the bottom of the top drawer of the medication cart: - one Eliquis 5mg- one Dicyclomine HCl 20mg- one fiber tab- one Amlodipine Besylate 5 mg- one Metoclopramide HCL 5 mg On 8/19/26 at 12 :03 PM, RN #1 stated it was only her second day so she didn't know why the pills were on the cart or who should have cleaned the cart.

Based on observation, policy review and interviews, it was determined the facility failed to ensure all call lights were easily accessible to residents in shower rooms. This was true for 1 of 2 shower rooms observed for call light device locations. This failure had the potential for harm if residents were not able to summon staff for assistance. Findings include:The facility's Call Light System policy dated 11/3/25, documented call lights are positioned to be within reach at resident bedsides, and in toileting and bathing areas.Resident #94 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cellulitis and diabetes. Resident #94's annual MDS dated [DATE], documented she was cognitively intact. On 8/18/26 at 4:40 PM, Resident #94 reported the 700-hall shower room emergency call light cord did not reach over to shower stall and she was unable to get assistance if needed when showering. Resident #94 also stated she was able to be left alone in the shower room to bathe independently. During an environmental tour on 8/19/26 at 9:10 AM, an observation of the shared 700-hall shower room revealed that the emergency call light cord was short, reaching only halfway down toward the floor/shower stall. The cord was completely inaccessible to any resident who might fall to the floor or experience an emergency while inside the shower stall.During an interview on 8/20/26 at 10:36 AM, the CEO confirmed the observation. The CEO stated the emergency call light cord was not long enough to reach the shower and should be.

Based on policy review, facility grievances, review of call light logs, and resident interviews, it was determined the facility failed to ensure enough staff were available to answer call lights in a timely manner. This was true for 7 of 27 residents (#12, #24, #50, #64, #76, #97, and #116) reviewed for staffing concerns. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay in care. Findings include: The facility's Quality of Life policy revision date 10/15/22, documented the call light response is provided by nursing and non-nursing staff within their skill set. Resident needs are addressed in a timely and courteous manner. 1. Facility grievance/concerns for 6 months were requested. Two of the grievances dated 3/4/25 and 4/8/25, documented complaints with call light response time. A concern form dated 3/4/25, documented Resident #97 reported when she turned on her call light she had to wait an hour. It had only happened when one nurse was on duty, LPN #3. When Resident #97 told LPN #3 she had her call light on for a long period of time, LPN #3 told Resident #97 they must have had problems with the light because her call light just came on. Attached to the concern form was a Past Calls report dated 3/1/25 - 3/4/25, for all shifts. This form documented the To Room Elapsed Time for 3/2/25 at 3:51 PM, was 16:32 minutes. In the section for Action Taken, it documented the CNO was to educate night shift to increase monitoring of call lights. Attached to the concern form was follow-up documentation that the CNO spoke with LPN #3 regarding complaints about nighttime call lights, and LPN #3 stated she could not always see that the call lights had come on and now she goes down to check the computer regularly. Resident #97 was notified of the plan of correction and was satisfied with action to be taken. A concern form dated 4/8/25, documented Resident #50 reported on 4/5/25 and 4/7/25, her call light had been ignored and she had to wait too long to use the bathroom. Attached to the concern form was a Past Calls report dated 4/5/25, for all shifts. This form documented multiple call light response times with the longest To Room Elapsed Time was 23:36 minutes at 10:11 PM. In the section for Action Taken documented the call light report showed appropriate response times, very minimal wait. Resident #50's response to action taken documented she appreciated the help looking into this issue. 2. Call light logs for all shifts dated 2/13/25 to 5/11/25, were requested. During those 3 months, there were 1,770 call lights with elapsed times greater than 30 minutes and 167 call light elapse time longer than an hour. 3. Residents were interviewed regarding call light response time. Examples include: - On 5/12/25 at 11:42 AM, Resident #64 stated the call light response time has been 15 minutes up to 1 hour and sometimes the staff come in and turn off the call light and say they will be right back and do not return. - On 5/12/25 at 1:34 PM, Resident #97 stated the call light sometimes had been left on for hours. One time she turned her call light on at midnight and no one came in to answer it until 5 am. - On 5/12/25 at 1:36 PM, Resident #50 stated she has had to wait longer than 30 minutes for her call light to be answered. - On 5/12/25 at 1:57 PM, Resident #116 stated her roommate had to waited up to 2 hours to have her light answered on the day shift. - On 5/13/25 at 8:46 AM, Resident #76 stated there is not enough staff. It had taken up to an hour to get someone to answer her call light and sometimes you must call the phone at the front desk to get help. - On 5/13/25 at 11:48 AM, Resident #12 stated it takes a long time for staff to answer the call light in her bathroom to assist her with getting off the commode. She reported that she had to wait so long that her legs go numb, making it hard for her to stand up. - On 5/13/25 at 1:27 PM, Resident #24 reported she had waited over 45 minutes to 2 hours for her light to be answered. On 5/16/25 at 12:03 PM, the CEO stated resident call lights should be answered within 10 minutes. On 5/16/25 at 12:09 PM, the Staff Development Coordinator stated resident call lights should have been answered within 15 minutes.

Based on observation, record review, policy review, and interviews, it was determined the facility failed to ensure residents received prior written rationale regarding room changes. This was true for 2 of 27 residents (#38 and #97) whose records were reviewed. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Findings include: The facility's Room to Room Transfer policy dated 11/28/17, documented under procedures: - Facility discusses transfer with resident, family and/or responsible party in advance to explain rationale and rights. - Residents are offered an opportunity to tour the room prior to a room move. - Residents are introduced to the new roommate prior to a room move. a. Resident #38 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and acquired absence of left leg below knee. On 5/12/25 at 3:30 PM, Resident #38 stated when he was outside in his wheelchair smoking on 3/7/25, the CEO came outside and told him they were packing up his property and moving him from room [ROOM NUMBER] to room [ROOM NUMBER]. Resident #38's medical record Room Transfer Notification document dated 3/7/25, had no reason or rationale documented for the room transfer. On 5/12/25 at 2:37 PM, during Resident Council meeting Resident #38 stated he was not told why he had to move to another room when the room transfer occurred on 3/7/25. On 5/12/25 at 3:10 PM, Resident #38 stated this room transfer upset him because he did not meet the new roommate prior to the move and he could not find his prosthetic leg after the move. Resident #38's prosthetic leg was later found on top of the closet shelf, which he could not see or retrieve without help. On 5/14/25 at 1:20 PM, the CRN stated the facility had used an older room transfer document that did not require a rationale for transfer, so they did not have any documentation explaining the rationale for Resident #38's transfer to a different room. b. Resident #97 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cutaneous abscess of abdominal wall and bipolar disorder. On 5/12/25 at 1:31 PM, Resident #97 stated she had been transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 6/13/24, and had not been provided a rationale when it happened. Resident #97's medical record Room Transfer Notification document dated 6/13/24, had no rationale documented for the room transfer. On 5/14/25 at 1:20 PM, the CRN stated the facility had used an older room transfer document that did not require a rationale for transfer, so they did not have any documentation explaining the rationale for Resident #97's transfer to a different room.

Based on observation, policy review, and interviews it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 10 residents (Resident #21) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Findings include: The facility's Quality of Life policy dated 10/15/22, documented staff were to refrain from practices demeaning to residents such as keeping urinary catheter bags uncovered. Resident #21 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Myotonic Muscular Dystrophy (a genetic disorder that causes progressive muscle weakness, stiffness, and other symptoms) and functional quadriplegia (a complete inability to move all four limbs due to severe physical disability or frailty, but without actual physical injury or damage to the brain or spinal cord). On 5/12/25 at 2:20 PM, observed a Hoyer lift transfer from bed to bath chair so Resident #21 could be taken to the shower room. After the transfer, CNA #1 and CNA #2, covered Resident #21 with blankets. On 5/12/25 at 2:21 PM, CNA #2 placed Resident #21's visible uncovered urinary bag at his feet. On 5/12/25 at 2:21 PM, CNA #2 stated Resident #21's urinary catheter bag was normally covered when he was in his wheelchair, but they were transporting him from his room on hall 800 to the shower room on 500 hall so it did not need to be covered. On 5/15/25 at 11:07 AM, the CNO stated the facility catheter bags have covers so she is not sure why the catheter bag did not have a cover over it but it should have.

Based on observation, policy review, record review, and interviews, it was determined the facility failed to assess residents for safe smoking practices. This was true for 1 of 3 residents (Resident #97) whose medical records were reviewed. This deficient practice placed residents at risk for harm when proper smoking assessment or supervision was not provided. Findings include: The facility's Smoking Campus policy dated 10/5/22, documented the interdisciplinary team evaluates residents desiring to smoke for their ability to smoke independently or dependently upon admission, quarterly, with a significant change or as deemed necessary. Resident #97 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cutaneous abscess of abdominal wall and bipolar disorder. Resident #97's Quarterly MDS dated [DATE], documented a BIMS score of 15 (meaning she was cognitively intact). On 5/12/25 at 4:29 PM, Resident #97 stated she is an independent smoker. Resident #97's medical record had no smoking assessment documented. Resident #97's care plan had not documented she smoked. On 5/14/25 at 11:40 AM, the CNO stated they did not know Resident #97 was a smoker and her smoking assessment had not been completed and should have been.

Based on record review, policy review, and staff interview, it was determined the facility failed to professional standards of practice were followed to prevent the development of prevent pressure ulcers for 1 of 12 residents (Resident #164) reviewed for quality of care. This failure resulted in harm when Resident #164 developed a deep tissue injury on her heel. Findings include: The facility's policy entitled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An avoidable injury occurred when the resident developed a pressure ulcer or injury due to the facility's failure to evaluate the resident's clinical condition and risk factors and implement interventions consistent with resident needs, goals, and professional standards of practice. The policy listed appropriate interventions for the prevention of pressure ulcers, including repositioning and protecting and/or offloading heels. The Lippincott Manual of Nursing Practice, 10th edition, pages 183-184, directed nurses to reposition residents every 2 hours to relieve pressure. Risk factors for pressure ulcers included malnourishment and immobility. The policy and recommendations were not followed. Resident #164 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #164's admission evaluation, dated 11/2/20, stated she required physical assistance of 2 persons to turn and reposition. The admission evaluation did not identify a wound to Resident #164's left heel. Resident #164's evaluation summary, dated 11/2/20, documented she was at moderate risk for developing pressure ulcers. Resident #164's physical therapy progress report, dated 11/3/20, stated she was totally dependent with her bed mobility and required maximum assistance. Resident #164's repositioning with staff assistance was documented on the following days and times: - 11/2/20, repositioned at 5:58 PM and 10:31 PM. - 11/3/20, repositioned at 9:52 AM. - 11/4/20, repositioned at 5:59 PM and 12:24 AM. - 11/5/20, repositioned at 1:31 PM and 5:59 AM. - 11/6/20, repositioned at 4:13 PM and 3:13 AM. - 11/7/20, repositioned at 3:44 PM, 5:59 AM, and 11:15 PM. - 11/8/20, repositioned at 3:35 PM and 9:34 PM. - 11/9/20, repositioned at 11:55 AM and 10:27 PM. - 11/10/20, repositioned at 1:32 PM. - 11/11/20, repositioned at 5:59 PM and 5:59 AM. On 11/11/20, a health status note documented a CNA notified nursing staff about a black wound on Resident #164's heel. The NP was notified and initiated wound orders. On 11/12/20, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Prevalon boots are assistive devices placed on the foot to reduce pressure due to mobility issues. Resident #164's weekly pressure ulcer report, dated 12/2/20, documented a pressure wound to her left heel first observed on 11/11/20. The wound was documented as a suspected deep tissue injury. The National Pressure Ulcer Advisory Panel - 2016 Definitions, states a deep tissue injury may include intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. The definition notes this type of injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface (connection). On 8/18/21 at 3:39 PM, LPN #4 was asked how often residents with mobility impairment should be repositioned or turned to reduce the risk of acquiring pressure ulcers. LPN #4 stated, it depends on the resident, but as often as every hour, but no more than every two hours. On 8/19/21 at 10:51 AM, RN #1 stated residents with mobility impairment should be repositioned or turned to reduce the risk of acquiring pressure ulcers. She stated, it was resident dependent, but repositioning every 2 hours isn't uncommon. On 8/18/21, beginning at 4:16 PM, the Clinical Resource Nurse stated the facility did not have a policy on resident turning or repositioning to include frequency of repositioning. On 8/19/21 at 1:40 PM, the Clinical Resource Nurse confirmed Resident #164's Prevalon boots were not ordered prior to her pressure ulcer being identified. When asked how often a resident with identified bed mobility impairment issues should be repositioned or turned in order to reduce the risk of acquiring pressure ulcers, the Clinical Resource Nurse stated, at least 3 times in an 8-hour shift. She confirmed Resident #164's documented repositioning or turning in bed was not adequate.

Based on staff interview, observation, and review of a bed manufacturer's manual, facility policy, and resident records, it was determined the facility failed to ensure: * Residents were provided the level of supervision necessary to prevent falls. * Care plan interventions to prevent falls were updated as needed and consistently implemented. * Equipment used by residents was assessed for safety prior to use. * Beds were assesed to ensure the bed, bed frame and mattress dimensions were appropriate for the resident's size and weight. This was true for 3 of 10 residents (#2, #13, and #14) reviewed for accident prevention. Resident #13 was harmed when she passed away following a fall. Resident #2 was at risk of harm when he experienced 19 falls in the facility from 8/28/17 through 3/26/18, and Resident #14 was at risk of harm when equipment to improve her comfort and bed mobility were not assessed for safety. Findings include: 1. Resident #13 was admitted to the facility in (YEAR) and readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #13's fall risk assessment, dated 12/27/17, documented a score of 10 which indicated a high risk for falls. Resident #13's Nutritional care plan, dated 1/24/18, documented Resident #13 preferred not to be weighed. Resident #13's most recent weight obtained by facility staff on 12/21/17, was 310 lbs. a. Resident #13's potential risk for skin breakdown care plan related to limited mobility, diabetes, incontinence, [MEDICAL CONDITION], lower extremity [MEDICAL CONDITIONS], and chronic pain, directed staff to assist her to reposition every 2 hours as she allowed with cares and provide a low air loss mattress. The care plan stated Resident #13 utilized bilateral 1/4 side rails and a trapeze to enable bed mobility and liked her bed in the high position. The facility provided the User-Service manual for the Joerns support surface DermaFloat low air loss bed model Resident #13 utilized. The safety information included: * To minimize the risk of falls or injury the resident surface should always be in the lowest practical position when the resident is unattended. * Specialty bed products are designed to reduce/redistribute pressure and the shearing/friction forces on the resident's skin. The risk of gradual movement and/or sinking into hazardous positions of entrapment and/or inadvertent bed exit may be increased due to the nature of these products. An undated Event Summary Report documented Resident #13 had an unwitnessed fall from bed on 3/8/18 at 4:15 AM. Resident #13 was found face down with her head under the bed. The Report documented it was unclear if she had pulled herself up that way while on her knees. The Report further stated staff remained with Resident #13 under the bed providing support. Licensed Nurses remained in the resident's room, attempted to find C-collar (cervical) to stabilize her neck, and attempted to provide oxygen support. The Report noted Resident #13's body taken by the County coroner and the exact cause of death was being investigated. The Report documented the facility presumed through investigation and witness statements that Resident #13 slid off the bed. A phone interview documented by the facility as part of its investigation into the fall, dated 3/9/18 at 2:00 PM, documented LPN # 7 stated she was called to the resident's room at 4:25 AM. Resident #13's bed was in the high position and her face was on the bed frame and trapeze (frame.) On 4/3/18 at 4:20 PM, the DON stated there was not a safety assessment addressing Resident #13's use of the bed in the high position, as Resident #13 preferred. The DON stated, We talked to her about it. b. Resident #13's most recent MDS assessment, dated 2/19/18, documented Resident #13 was cognitively intact and required extensive assistance of 2 people for bed mobility and toileting (incontinence care.) The assessment documented Resident #13 had impaired range of motion to bilateral lower extremities (legs). Resident #13's care plan, dated 1/24/18, documented Resident #13 required assistance from, or was dependent on, staff for activities of daily living. The care plan directed staff to provide 2 person assist for bed mobility and toileting. A Fall Interview/Witness Questionnaire, dated 3/8/18, documented CNA #3 provided personal care to Resident #13 at 4:15 AM. CNA #3 left the room and at approximately 4:25 AM, CNA #3 returned to Resident #13's room and found Resident #13 on the floor, between the bed and the wall. The report documented CNA #3 did not have assistance while providing the care because Resident #13 helps and holds on to the rails when she is turned. The report further documented Resident #13 always helped CNA #3 and he could complete cares for Resident #13 by himself. On 4/3/18 at 3:00 PM, CNA #3 stated that technically Resident #13 was a two person assist, however; she did not like a lot of people in her room. CNA #3 stated he always provided cares for Resident #13 by himself. A Fall Interview/Witness Questionnaire, dated 3/8/18, documented CNA #3 provided personal care to Resident #13 at 4:15 AM when 2 skin impairments were observed to Resident #13's buttocks. CNA #3 positioned Resident #13 on her back, covered her with her gown, and clipped the call light and bed control to the gown. The questionnaire documented CNA #3 left the room and notified the licensed nurse of the skin impairment at approximately 4:23 AM. At approximately 4:25 AM, CNA #3 returned to Resident #13's room and found Resident #13 on the floor, between the bed and the wall. On 3/14/18, the facility documented the measurements of Resident #13's actual bed, a Joerns low air loss mattress, as 34.5 inches (2 feet 10.5 inches) by 78 inches. The manufacturer's system specifications documented mattress dimensions of 36 inches (3 feet) by 80 inches or 42 inches by 80 inches. The Joerns Bed Frames User - Service Manual recommended the use of a mattress with minimum dimensions of 36 inches by 72 inches. The low air loss mattress provided integrated CairRails risk management side air bolsters, two-inch side bolsters that inflate on both sides of the resident along the mattress edge to provide additional support and to provide a gentle reminder to the resident that they are near the edge of the mattress. On 4/3/18 at 3:00 PM, CNA #3 stated that when he turned Resident #13, she would hold on to the side rail. CNA #3 stated that Resident #13 was on a regular size mattress and she took up most of the bed. CNA #3 stated that when he turned Resident #13, her belly hung over the side of the bed. CNA #3 stated the base on the trapeze was wider than the bed. A facility Fall Investigative Report dated 3/8/18, documented CNA #3 provided incontinence care to Resident #13 at approximately 4:15 AM. The report documented CNA #3 did not have assistance while providing the care because Resident #13 helps and holds on to the rails when she is turned. The report further documented Resident #13 always helped CNA #3 and he could complete cares for Resident #13 by himself. On 4/3/18 at 3:00 PM, CNA #3 stated that technically Resident #13 was a two person assist, however; she did not like a lot of people in her room. CNA #3 stated he always provided cares for Resident #13 by himself. On 4/3/18 at 4:45 PM, CNA #8 stated Resident #13 required extensive assist from two staff for bed mobility and incontinence care. CNA #8 stated Resident #13 did not turn or reposition herself. CNA #8 stated the resident preferred to turn to her right side because it was easiest for her. CNA #8 stated Resident #13 needed someone on each side of the bed because her feet would start to slide toward the edge of the bed. On 4/4/18 at 5:00 PM, CNA #7 stated Resident #13 required extensive assist of two staff for bed mobility and incontinence care. CNA #7 stated Resident #13 was difficult to turn because of her pain and did not turn independently. CNA #7 stated Resident #13 did not fit her bed, she was on an air bed, and it did not have bolsters. She said without the second person there, Resident #13 could fall out of the bed. On 4/5/18, the DON stated she had no idea how someone that was on the correct size of bed, never moved independently, and was left positioned on her back, fell out of bed. The DON stated they were waiting for the coroner's report to see if Resident #13 had a [MEDICAL CONDITION] or a [MEDICAL CONDITION]. The DON stated, We don't know what happened. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including a history of falls and [DIAGNOSES REDACTED]. The facility's Falls Management policy, dated 3/15/16, directed staff to update the care plan to reflect new interventions. Resident #2's Events Summary Reports (incident reports) documented the resident had 19 falls in the facility from 8/28/17 through 3/26/18 without major injury. On 9/2/17 and 11/29/17, the resident fell and received minor skin tears to his left elbow and to the back of his left upper arm, respectively. Resident #2's 8/29/17 admission MDS assessment documented the resident was moderately cognitively impaired, required extensive two-person assistance for transfers, and had two falls without injury since admission. a. Resident #2's Events Summary Reports documented the resident had 6 falls from 8/31/17 to 10/3/17. Resident #2's falls care plan, dated 9/22/17, directed staff to not leave the resident unsupervised in areas such as TV room and dining room. Resident #2's physician's orders [REDACTED]. This order remained in place on the physician's orders [REDACTED]. Resident #2's Event Summary Report, dated 10/4/17, documented the resident was found on the floor in the hallway between the dining and the TV rooms and had no injuries. The root cause of the fall was the resident attempted to transfer or ambulate unassisted in the hallway. New interventions included escorting the resident to and from each meal. This intervention was not initiated on the care plan until 12/18/17. b. Resident #2's Events Summary Reports documented the resident had 2 falls from 10/17/17 to 11/14/17. Resident #2's Event Summary Report, dated 11/15/17, documented the resident was found on the fall mat in his room and had no injuries. A new intervention directed staff to check the resident every half hour between 7:00 PM and 7:00 AM. This intervention was not documented on Resident #2's care plan. c. Resident #2's falls care plan, dated 9/22/17, directed staff to not leave the resident unsupervised in areas such as TV room and dining room. Resident #2's Event Summary Reports, dated 11/24/17 and 11/29/17, documented the resident was left in his room in his wheelchair unattended, and he fell while trying to self-transfer to his bed, and attempting to throw away a tissue. The resident did not sustain an injury on 11/24/17 and sustained a 5 cm by 0.4 cm skin tear to the back of his left upper arm on 11/29/17. d. Resident #2's falls care plan, dated 9/22/17, directed staff to not leave the resident unsupervised in areas such as TV room and dining room. Resident #2's Event Summary Report, dated 12/1/17, documented the resident was left in the dining room in his wheelchair unattended and fell without injury. New interventions included escorting the resident to and from each meal. Resident #2's Event Summary Report, dated 10/4/17 documented the same intervention. This intervention was not added to the care plan until 12/18/17. e. Resident #2's Events Summary Reports documented the resident had 3 falls from 1/15/18 to 3/15/18 without injury. Resident #2's Event Summary Report, dated 3/26/18, documented the resident was in his room and rolled out of bed without injury. No new interventions were implemented and staff was re-educated to enter into the resident's room when making rounds. f. Resident #2's Fall Risk assessment, dated 2/11/18, documented the resident was a high fall risk. Resident #2's 2/27/18 significant change MDS assessment documented the resident was moderately cognitively impaired and required extensive two-person assistance for transfers. Resident #2's (MONTH) (YEAR) Order Summary Report documented a physician's orders [REDACTED]. Resident #2's current Activities of Daily Living and falls care plan documented the following interventions: *8/22/17-Keep the call light within reach while the resident was in bed. *10/1/17-Keep mobile phone within resident's reach. *11/29/17-Keep the trash can beside the bed to dispose of tissues, etc. *1/11/18-Keep dental picks within reach for easy access. Resident #2's (MONTH) and (MONTH) (YEAR) TARs documented staff performed hourly checks, except on 4/3/18 from 4:00 PM to 7:00 PM. The following observations were made in Resident #2's room: *On 4/2/18 at 4:00 PM, Resident #2 was awake in his bed flossing his teeth with a floss pick and his trash can was 7 feet away near the sink. *On 4/2/18 at 4:25 PM, Resident #2 was observed awake in his bed with the call light hanging off the left side of the bed. The call light was below the mattress and not within the reach of the resident. The resident's door was wide-open and the bed and call light could be observed from the hallway. At 4:30 PM, CNA #1 and the Administrator were observed to walk by the resident's room without acknowledging the call light. At 4:32 PM, Resident #2 did not respond when asked about his call light placement. From 4:48 PM to 4:50 PM, two CNAs, a nurse, and another staff member walked by the room without acknowledging the call light. At 5:18 PM, CNA #1 was asked about the call light placement and said the call light was out of reach because it was clipped to the blanket which had gotten tangled up. CNA #1 said the resident was able to use the call light when he wanted to. *On 4/3/18 from 10:25 AM to 10:50 AM, Resident #2 was observed in his bed asleep and no floss picks were near the resident. *On 4/3/18 at 12:50 PM, CNA #1 said the resident usually had the floss pick on his tray table next to his bed and she could not find them there. She then searched the room and found a large bag of floss picks in a dresser drawer 10 feet away from the bed. CNA #1 did not place any of the floss picks on the tray table. *On 4/3/18 at 2:55 PM, Resident #2 was in his bed asleep with no floss picks nearby, and the resident's cell phone was on the counter next to the sink 7 feet away. *On 4/3/18 from 4:30 PM to 5:00 PM, Resident #2 was observed in his bed asleep with no floss picks on the tray table or nearby. *On 4/4/18 at 10:15 AM, Resident #2 was in his bed asleep with no floss picks nearby, his trash can was 7 feet away, next to the sink. On 4/3/18 at 4:15 PM, Resident #2's Interested Party said staff should be checking on the resident more often because the resident had several falls since his admission. The Interested Party said staff did not consistently implement the falls care plan. On 4/4/18 at 10:18 AM, LPN #1 said the order for hourly checks for Resident #2 meant that staff were to make sure he was in a safe place. On 4/4/18 at 10:35 AM, CNA #1 said the resident was checked every hour to make sure fall precaution interventions were in place. She said she was not aware of where the trash can should be located for Resident #2. On 4/4/18 at 1:35 PM, CNA #2 said the resident was checked every hour to make sure fall precaution interventions were in place. On 4/4/18 at 2:20 PM and 4/5/18 at 9:00 AM, the DON said Resident #2 was a high fall risk and said the facility could do a better job making sure the resident remained safe. She said staff did not follow the care plan and left the resident unattended during the 10/4/17, 11/24/17, 11/29/17, and 12/1/17 falls and the new intervention of escorting the resident to and from his meals was not placed on the care plan until 12/18/17. The DON said the intervention to conduct safety checks every 30 minutes from 7:00 PM to 7:00 AM after the 11/15/17 fall was not implemented or placed on the care plan, and that must have been missed by the interdisciplinary team. She said there were no new interventions after the 3/26/18 fall but the staff were re-educated. The DON said she would expect staff to follow the care plan and make sure the resident had his call light, floss picks, cell phone and trash can within reach of the resident. 3. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses, including pneumonia, [MEDICAL CONDITION], and chronic pain. On 4/2/18 at 12:45 PM, Resident #14 was observed sitting on the right side of the bed, a pad was hanging down over the right side of the bed, and a free-standing trapeze bar was above the bed. Resident #14 stated her family brought a memory foam pad from home to place on top of the facility's mattress. On 4/4/18 at 9:30 AM, Resident #14 was observed sitting on the edge of the right side of bed with her left leg up on the bed and her right foot on the floor. Resident #14's mattress memory foam pad was hanging down the right side of the bed. Resident #14 stated she needed the memory foam pad for comfort to help her sleep and she used the free-standing trapeze bar for bed mobility. On 4/4/18 at 10:25 AM, Resident #14 was observed as she ambulated from the bathroom to her bed, sat on the edge of the right side of the bed, and used the trapeze bar to reposition herself on the edge of the bed. She consented to having her mattress and memory foam pad to be measured. The facility's mattress measured 47 inches wide (3 feet 11 inches). The memory foam mattress pad, which was aligned with the left side of the facility's mattress, measured 2 1/2 inches thick and overlapped the facility's mattress by 14 inches and hung down the right side of the bed to 7 inches above the floor. The base of the free-standing trapeze device was positioned in between the wheels of the bed frame. The trapeze device did not have brakes. Resident #14's care plan, dated 3/29/18, documented Resident #14 utilized a trapeze to enable bed mobility. The care plan did not document the memory foam mattress pad. Resident #14's inventory sheet, dated 3/29/18, documented, bed pad with cover. On 4/418 at 1:40 PM, the DNS stated she was unaware Resident #14 had a memory foam mattress pad. The DNS stated the mattress pad and trapeze bar device had not been assessed for safety. The manufacturer's manual for the Free-standing Bariatric Trapeze with base documented, The trapeze, used in conjunction with a bed, can assist an individual weighing up to 650 lbs. The trapeze is designed to provide support, increase stability and assist the user when repositioning in bed. The trapeze is not designed, however, to support the total body weight of an individual. Use it for assistance only. IMPORTANT, Prior to patient use, be sure that all connections are inspected and secure. On 4/4/18 at 5:00 PM, the Regional Nurse stated there was no documentation of inspections for Resident #14's free-standing trapeze device.

Based on staff interview and review of facility fall investigations and resident records, it was determined the facility failed to initiate basic life support for 1 of 1 sampled resident (#13) who experienced a life threatening medical emergency. The failure to initiate lifesaving interventions when Resident #13 stopped breathing following a fall may have contributed to her death, and placed all residents who may experience a medical emergency at risk. Finding include: Resident #13 was admitted to the facility in (YEAR) and readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #13's fall risk assessment dated [DATE] documented a score of 10 which indicated a high risk for falls. Resident #13's ADL care plan, dated [DATE], documented Resident #13 required assistance from, or was dependent on, staff for activities of daily living. The care plan directed staff to provide 2 person assist for bed mobility and toileting (incontinence care.). The care plan stated Resident #13 utilized bilateral ,[DATE] side rails to enable bed mobility, liked her bed in the high position, and had a trapeze to the bed to increase her independence with bed mobility. The care plan documented staff were to encourage Resident #13's participation while providing ADL care. The trapeze was attached to a single pole with a ,[DATE] frame to stabilize it on the floor. The bed was positioned within the base of the frame. Resident #13's resuscitation Code Status Care Plan, dated [DATE], documented an established advanced directive was in place, full code with aggressive interventions. The interventions directed staff to activate Resident #13's advanced directives as indicated. A Fall Interview/Witness Questionnaire, dated [DATE], documented CNA #3 provided personal care to Resident #13 at 4:15 AM when 2 skin impairments were observed to Resident #13's buttocks. CNA #3 positioned Resident #13 on her back, covered her with her gown, and clipped the call light and bed control to the gown. The questionnaire documented CNA #3 left the room and notified the licensed nurse of the skin impairment at approximately 4:23 AM. At approximately 4:25 AM, CNA #3 returned to Resident #13's room and found Resident #13 on the floor, between the bed and the wall. A Fall Interview/Witness Questionnaire, dated [DATE], documented LPN #6 entered Resident #13's room and found her face down on the floor between the bed and the window side wall. It stated Resident #13 was angled under the bed from the top of Resident #13's head and right arm and shoulder. Resident #13's head was wedged between the bed frame and the trapeze legs. LPN #6 determined it was not safe or feasible to move the resident and 911 was called at 4:35 AM and EMS responded at 4:40 AM. On a Fall Interview/Witness Questionnaire, dated [DATE], LPN #7 documented that at 4:25 AM, she saw Resident #13 face down by the window and she had blood on her face and right arm. LPN #7 documented staff were not physically able to move the bed without causing further injury to the resident. LPN #7 documented Resident #13 was nonresponsive when she entered the room and Resident #13 was wedged under the bed/trapeze. Resident #13 was on top of bed/trapeze and This LPN was not able to move the bed to safely serve the resident. C-Collar (cervical collar) not found and resident could not be safely moved. 911 called. On a Fall Interview/Witness Questionnaire, dated [DATE], LPN #5 documented she observed LPN #6, CNA #3, and CNA #9 around Resident #13 who was lying face down on the window side of the bed. LPN #5, primary nurse for Resident #13, documented she last saw Resident #13 at 1:00 AM when she provided cough medicine and pain medication to her. On [DATE] at 1:30 PM, LPN #6 documented that she immediately directed staff to call 911 and to not move Resident #13 due to possible neck injury. Placement of oxygen was not successful due to the angle of the resident. LPN #6 left the room to make copies of the paperwork, leaving CNA #3, LPN #5 and CNA #9 in the room. LPN #6 returned to the room after the arrival of the EMS and Resident #13 was on her back with a towel on her face, after EMS had called the incident as death. LPN #6's statement documented EMS initiated CPR as staff could not move resident from under bed and firemen assisted EMS personnel in moving Resident #13. On [DATE] at 10:30 AM, the DON documented an interview with LPN #5. LPN #5 stated 911 was called, per LPN #7's phone, at 4:28 AM. LPN #5 stated she did not remain with Resident #13 the entire time she was on the floor. LPN #5 stated she went to check on getting the paperwork ready for the EMS, and came right back. LPN #5 stated CNA #3 was under the bed with Resident #13. LPN #5 stated Resident #13 was intermittently breathing at 4:25 AM. LPN #5 stated she asked CNA #3 at approximately 4:30 AM, if Resident #13 was still breathing. CNA #3 stated no. LPN #5 asked when Resident #13 stopped breathing and CNA #3 stated, about a minute ago. The DON asked LPN #5 if Resident #13 had a pulse. LPN #5 stated initially she did, but at the point when CNA #3 said Resident #13 was not breathing, LPN #5 was not sure if she had a pulse or not. The DON asked how much longer it took for the EMS to arrive, LPN #5 stated, Up to 5 minutes, it seemed like forever. The DON asked LPN #5 if at any point did she think the risk of moving Resident #13 was greater than the risk of not initiating CPR and LPN #5 stated they could not reach the resident to move her. LPN said Resident #13 was wedged and staff needed additional help from EMS and the Fire Department. The American Heart Association (MONTH) (YEAR), CPR guidelines state: a. Recommend that 'because true spinal immobilization is not possible, the term spinal motion restriction is now being used to describe the practice of attempting to maintain the spine in anatomical alignment and minimize gross movement, with or without the use of specific adjuncts such as collars. b. With a growing body of evidence showing more actual harm and no good evidence showing clear benefit, we recommend against routine application of cervical collars by first aid providers. c. For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (e.g., placing 1 hand on either side of the patient's head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful. d. After activation of the emergency response system, all rescuers should immediately begin CPR for adult victims who are unresponsive with no breathing or no normal breathing (only gasping). e. Occasional gasps do not necessarily result in adequate ventilation. The rescuer should treat the victim who has occasional gasps as if he or she is not breathing On [DATE] at 3:00 PM, RN #4 stated the facility followed the American Heart Association guidelines for CPR. RN #4 stated when breathing stops, CPR should be started for residents that chose full code status. On [DATE] at 4:10 PM, LPN #5 stated they did not attempt CPR because they could not get to Resident #13. LPN #5 stated it took 7 or 8 people to move the bed. On [DATE] at 9:15 AM, LPN #7 stated they did not move Resident #13 because it would have caused more damage to her. LPN #7 stated she was not aware of when Resident #13 stopped breathing. On [DATE] at 10:15 AM, the DON stated there were 7 staff working that shift. An investigative report provided by the facility documented 2 of the CNAs had no interaction with Resident #13 as they were managing call lights during the incident.

Based on observation, staff and resident interview, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 1 of 4 residents (#5) reviewed for pressure ulcers and resulted in harm when Resident #5 developed and/or re-developed skin damage to her left buttocks and her heel. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 3/20/18, documented Resident #5 was cognitively intact and required extensive assistance of 2 staff members for all cares. The MDS documented Resident #5 did not have current skin impairments and was not at risk of developing pressures ulcers. The MDS did not document the resident was on a repositioning schedule. Resident #5's Braden Scale for Predicting Pressure Sore Risk, dated 1/23/18, documented she was at moderate risk for developing pressure ulcers. The (MONTH) (YEAR) Order Review History Report, documented Resident #5's skin impairment prevention orders included: * Z-guard (skin protectant) to groin and buttock every day and night, ordered 11/12/17. * Pressure redistribution cushion to chair, ordered 4/16/17. * Pressure redistribution mattress to bed, ordered 4/16/17. * Skin Checks on Wednesdays, ordered 4/16/17. A Resistive to Cares Care Plan, revised 2/14/18, documented Resident #5 refused showers, incontinence care, and bandage changes. The care plan did not direct staff to monitor Resident #5's resistance to care behaviors. A Potential Skin Impairment Care Plan, revised 2/6/18, documented staff were to observe Resident #5's skin while providing activities of daily living (ADL) care and report abnormalities to the nursing staff. a. A Skin Assessment, dated 12/20/17, documented Resident #5's skin was assessed and no skin damage was found. A Skin Assessment, dated 12/27/17, documented Resident #5 had Moisture Associated Skin Damage (MASD) to her buttocks with the skin intact and blanchable. A Skin Assessment, dated 1/3/18, documented the skin on Resident #5's buttocks was red, blanchable, and intact. A Skin Assessment, dated 1/17/18, documented Resident #5 had small open areas to buttocks due to pressure and prolonged exposure to moisture. A Skin Assessment, dated 2/28/18, documented Resident #5's skin was assessed with [REDACTED]. A Skin Assessment, dated 3/7/18, documented Resident #5 had MASD to her buttocks and peri-area with the skin intact and blanchable. The assessment documented z-guard was applied. A Skin Assessment, dated 3/14/18, documented Resident #5 had MASD to her right groin and peri-area. A Skin Assessment, dated 3/21/18, documented Resident #5 had an open area of MASD to her left buttock. Resident #5's ADL Documentation Survey Report 1/1/18 through 4/4/18, documented Resident #5's bed mobility and toilet use during each shift, showed the following: * Resident #5 refused bed mobility 14 out of 282 opportunities and was not offered bed mobility 77 out 282 opportunities. * Resident #5 refused use of the toilet during the shift 41 out of 282 opportunities and was not offered the use of the toilet during the shift 123 out of 282 opportunities. On 4/2/18 at 11:00 AM, Resident #5 was observed laying on her back in bed with the head of the bed raised 30-35 degrees. The resident said her incontinence brief was not getting changed often enough. She said, It happened 3 days last week and caused a big sore on her right calf and a sore on the left side of her tailbone. An Event Summary Report, dated 4/2/18, documented Resident #5 sustained a skin tear to her right (sic) buttocks. The report documented positioning was a factor in the development of the wounds. The report documented Resident #5 refused cares and pressure and moisture were contributing factors. A Skin Integrity Report, dated 4/2/18, documented Resident #5 sustained an incontinence related skin tear to her right (sic) gluteal measuring 0.5 centimeter (cm) by 0.5 cm. Resident #5's Actual Skin Breakdown Care Plan, revised 4/2/18, documented she had skin breakdown on her buttock related to incontinence, limited mobility, fragile skin, and skin tears. The care plan interventions included: * Staff were to apply barrier cream with each cleansing. * Staff were to monitor Resident #5 for verbal and non-verbal signs of pain related to wound or wound treatment and medicate as ordered. * Resident #5 was to have a pressure redistribution surface to her bed and chair as per protocol. * Staff were to assess Resident #5's skin weekly. * Staff were to provide pericare and incontinence care as needed. The care plan did not document how often staff were to encourage Resident #5 to reposition or if they were to encourage her to reposition. On 4/3/18 at 10:00 AM, Resident #5 was observed lying in bed. Resident #5 stated she had received pain medications earlier in the morning and was waiting for staff to come and assist her with the bathroom. Resident #5 stated she had bed sores on her bottom. Resident #5 stated she had spoken to staff about the bed sores and this was not the first time she had developed sores at the facility. Resident #5 stated she discussed concerns with staff and the issues did not resolve. Resident #5 stated she developed the sores because the facility was not addressing her extreme pain, and due to the pain, she would occasionally refuse cares, such as incontinence care and/or repositioning. Resident #5 stated if the facility provided her better pain management she would be more willing to reposition and allow incontinence care. Resident #5 stated staff would assume she was going to refuse cares and staff would ignore her. On 4/3/18 at 10:46 AM, Resident #5's left buttock was observed with two open areas, the top area was approximately 1 cm by 0.5 cm wide and the lower area was approximately 1.5 cm by 1 cm wide, both were near the sacrum. The open areas were not covered with a bandage or covering. After completion of incontinence care CNA #7 and LPN #4 positioned Resident #5 on her back with the head of the bed raised to about 30 degrees and did not apply a bandage or a covering to the affected area. CNA #7 stated Resident #5's areas on her left buttock were present since she changed from sleeping in her recliner to sleeping in her bed last week. On 4/3/18 at 11:05 AM, CNA #7 and LPN #4 utilized a drawsheet to move Resident #5 up in bed. CNA #7 placed 2 pillows under Resident #5's lower legs, which floated the resident's heels. CNA #7 and LPN #4 did not encourage or offered to reposition Resident #5 off of her back. On 4/3/18 at 11:10 AM, CNA #7 stated she did not offer or encourage Resident #5 to reposition off of her back. The CNA said she knows the resident and the resident always refuses. The CNA stated, It's up to her to let us know when she will turn or wants to turn off of her back. On 4/3/18 at 3:43 PM, CNA #3 stated Resident #5 did not often refuse cares such as repositioning or incontinence care with him. CNA #3 stated Resident #5 complained of pain and if she did refuse it was due to increased pain. On 4/3/18 at 5:00 PM, CNA #4 stated Resident #5 had a history of [REDACTED]. CNA #4 stated she did not have issues with Resident #5 refusing often. On 4/4/18 at 9:41 AM, the DON stated Resident #5 had a history of [REDACTED]. The DON stated she knew there was a problem assessing and monitoring skin issues including pressure ulcers. The DON stated Resident #5's MASD was discovered before the facility completed the Skin Integrity Reports on 4/2/18. On 4/4/18 at 10:38 AM, LPN #3 stated she discovered Resident #5's left buttock skin impairment of 3/7/18. The LPN stated she did not complete an investigation into the cause of the skin impairment because she thought another staff member had completed this task prior. LPN #3 stated since she thought another staff member had completed the investigation, she did not initiate a Skin Integrity Report regarding Resident #5's left buttock. On 4/5/18 at 9:56 AM, the DON stated the wound to Resident #5's buttock was on the left-side and pressure could be a component. The DON stated she needed to assess the area for blood flow before making the determination of the causality of the wound. On 4/6/18 at 8:31 AM, the DON stated the wound to Resident #5's left buttock was one area with an island in between of healing skin. b. Resident #5's heel wound: Resident #5's Actual Skin Breakdown Care Plan, initiated 5/23/17, documented she had skin breakdown related to vascular disease. The care plan documented interventions as: * Staff were to evaluate the wound area daily for drainage and infection. * Staff were to monitor Resident #5 for verbal and non-verbal signs of pain related to wound or wound treatment and medicate as ordered. * Staff were to provide wound treatments as ordered. * Staff were to assess Resident #5's skin weekly. A Physician's Progress Note, dated 10/31/17, documented Resident #5 had venous stasis insufficiency and she had areas on her heels recently healed. On 4/2/18 at 11:00 AM, Resident #5 was wearing non-skid socks on both feet and her heels were in contact with the mattress. On 4/3/18 at 10:00 AM, Resident #5 was wearing non-skid socks on both feet and her heels were in contact with the mattress. On 4/3/18 at 10:38 AM, Resident #5 was observed in bed with her heel in contact with the mattress. CNA #7 removed Resident #5's sock from her left foot and an area of black eschar (dead tissue) was observed on the posterior lateral aspect (back, of her left heel approximately the size of a quarter. On 4/3/18 at 3:04 PM, Resident #5 was observed in bed with her heels in contact with the mattress. Resident #5's ADL Documentation Survey Report 1/1/18 through 4/4/18, documented Resident #5's preventative skin care (protectors heel/elbows) use. The protective skin care was to be documented as applied or not applied once a shift or three times a day. The ADL report documented: * Resident #5 refused the heel protectors 4 out of 282 opportunities; * Resident #5 was not provided the heel protectors 94 out of 282 opportunities; and * Heel protectors were not applied 5 out of 282 opportunities. On 4/5/18 at 10:36 AM, the Regional RN stated there were no other skin impairment investigations completed for Resident #5 other than those previously provided, dated 1/23/18 and 4/2/18. On 4/6/18 at 8:31 AM, the DON stated she had not started a tracking sheet on Resident #5's left heel as of 4/6/18. The DON stated Resident #5's left heel had a 1 cm by 1 cm area that she measured last week. The DON stated she had not completed a skin integrity report or a Event Summary Report. The DON stated she would re-evaluate Resident #5's heel this week.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to provide medicaly social services for 3 of 6 residents (#1, #5, and #6) sampled for mental health related social services. As a result, a) Resident #1 was harmed when the facility failed to ensure psychosocial assessment and interventions were initiated after suicidal ideation requiring transport to a hospital ER, b) Resident #5 was harmed when the facility failed to clarify restrictions related to contact isolation, imposed stricter restrictions than clinically warranted, and failed to assess related psychosocial effects, and c) Resident #6 experienced the potential for harm when the facility failed to monitor behaviors related to psychotropic medication use. Findings include: 1. Resident #1 admitted to the facility 6/24/13, following hospitalization for a suicide attempt. Resident #1 had [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 9/20/16, documented his cognition was intact and he had minimal depressive symptoms. Resident #1's care plan, dated 4/18/16, documented Resident #1 exhibited distressed mood symptoms of tearfulness and negative statements of I just wanna die, along with a history of a suicide attempt requiring hospitalization in June 2013. The care plan documented Resident #1 may exhibit psychosocial distress about his own well-being. Interventions included allowing him time to verbalize anger and frustration, and staff to encourage him to utilize his identified coping skills. The care plan was documented as revised on 10/17/16. It was not clear how the care plan was revised as no suicide ideation, suicide intent, or suicide plan was documented on the care plan after the June 2013 information. There was no new interventions added. Resident #1's care plan, dated 4/18/16, documented he had expressed suicidal thoughts and was at risk for harming himself related to depression. Interventions included assessment of the resident's suicide risk, encouraging him to participate in diversional activities, placing and maintain suicide precautions, which included securing windows, removing items of danger from Resident's room i.e. sharp objects, plastic bags, ropes, ties, belts, etc. Resident #1 was to be provided meals on paper/plastic utensils, and closely supervise during all medication administration. The interventions also documented Resident #1 focused on his fears of his bowel movements and should be redirected to a positive conversation. On 6/20/16, a Nurse Practioner Follow Up note, documented Resident #1 stated that he had regular bowel movements daily but after going, still felt the urge to defecate throughout the day. The NP documented this was discussed with staff, and was identified to be a chronic problem for quite some time. The NP documented Resident #1 was seen and evaluated by a gastroenterologist and had a colonoscopy with no pathology found. An MD visit Progress note, documented on 8/16/16, did not reference Resident #1's suicidal ideation or gastrointestinal concerns. On 8/31/16, a Psychiatry Follow Up note, documented Resident #1 had a history of [REDACTED]. On 9/12/16 at 5:53 pm, a Social Service note documented Resident states that he is suffering and wants to have a bowel movement but cannot. Resident states that if he had a sharp object he would end the suffering and take his life. Sharp objects were removed from patient care area and he is a one to one. Resident did have ball point pens in his pocket which he had utilized in the past in an attempt to end his life. LSW did remove the pens and he immediately went to search for more. Resident is being sent out to the hospital for an evaluation. Resident states he is suffering and wants to no longer suffer. Resident is fixated on his bowel movement. Resident is at risk for harm at this time d/t his plan to harm himself. On 9/12/16 at 6:49 pm, a Nursing Home to Hospital Transfer Form, documented Resident #1 was transferred to the ER for suicidal thoughts. The form documented Resident #1 was stating he will kill himself and wanted to stab himself with a pen or sharp object. The form did not provide communication of Resident #1 verbalizing he was suffering. On 9/12/16 at 9:30 pm, a nurses' note documented Resident #1 returned from the ER and a nursing admission assessment was completed. On 9/16/16 at 3:42 pm, a Social Service note documented Resident #1, had a psychiatric consultation today. Resident with noted life changes and increase in signs and symptoms of depression including two statements of suicidal ideation. Resident #1's antidepressant dose was increased to assist with management of his symptoms. On 9/16/16, a Psychiatry Follow Up note documented Resident #1 had been voicing suicidal ideations and his antidepressant dose was increased. On 9/23/16 at 4:28 pm, a Social Service note from the SOPD, documented Resident #1 exhibited increased signs of agitation, such as pacing up and down the hallway stating No one cares about me. Resident #1 declined that there was anything the SOPD could do to assist at this time. There was no documentation regarding the root cause of Resident #1's agitation, or that a referral was made to the facility's LSW. No further social service assessments or interventions were documented for Resident #1. On 9/27/16, a Psychiatry Follow Up Note documented, Staff reports that the patient continues to express life is not fun. He is having a lot of medical issues especially gastrointestinal problems. On 10/18/16, at 9:00 am, the SOPD stated Resident #1 resided on the Sol-Oasis unit, which was specific for residents who needed extra support, which was defined as assistance with, skills groups, socialization, coping challenges, we read the newspaper, and talk about their situations. The programming allows the residents to have positive interaction with the staff. On 10/18/16 at 10:00 am, Resident #1 stated he did not usually participate in activities or Sol-Oasis groups. Resident #1 responded no when asked if the LSW, Sol-Oasis program staff, or others provided additional individual support. When asked what he did during his day, he stated, Just go to appointments and stuff. On 10/19/16 at 8:00 am, Resident #1 was observed during breakfast. A stainless steel knife, fork, and spoon was provided to him. At 5:00 pm, Resident #1 received stainless steel silverware with his dinner meal. Resident #1 was harmed when the facility failed to provide ongoing social services when he was admitted to the facility following a suicide attempt. Resident #1's care plan did not include information on how staff should recognize or act given his known history of suicide attempts. On 9/12/16, Resident #1 threatened suicide using the same method for which he had been previously hospitalized . Resident #1 was sent to the hospital for emergent evaluation of his suicidal ideation and plan. After Resident #1 returned to the facility, new individualized social service interventions were not developed or implemented to address the issues leading up to the suicide attempt, or to recognize and intervene with further signs of suicidal ideation. Resident #1 was noted with continued alterations in his mood state on 9/23/16 and 9/27/16. 2. Resident #5 was admitted to the the facility on 9/6/16, for post surgical rehabilitation following a below the knee amputation of the right lower extremity. [DIAGNOSES REDACTED]. Per an Initial Psychiatric Evaluation Note, dated 9/16/16, Resident #5 had a remote history of 3 attempted suicide attempts. Resident #5's H&P documented he had been living independently in the community until March 2016, when he was in a motor vehicle accident and sustained a number of significant injuries, including multiple fractures. The H&P documented Resident #5s recovery had been complicated by pressure ulcers on his sacrum and right heel, which caused him a great deal of pain. Resident #5's right leg was amputated below the knee on 8/29/16. Resident #5's admission MDS assessment, dated 9/13/16, documented the resident's cognition was intact and he had no depressive symptoms. On 9/9/16 at 9:21 am, nurses' notes documented lab results for stool sample positive for[DIAGNOSES REDACTED] and Resident #5 was on contact precautions. According to the most recent CDC guidelines, others needed to use PPE only if they were going to come in contact with stool or provide personal cares. Strict handwashing would have been enforced. Social outings or interaction with others required no special equipment or restrictions. Resident #5's care plan, dated 9/16/16 and revised on 10/17/16, documented he was at risk of a distressed or fluctuating mood. The interventions included engagement in one to one visits for healthy development of coping skills. A second focus area (date) documented Resident #5 had poor coping skills, and Sol Oasis program staff would work with him on healthy ways to cope. A third focus area dated (date) documented Resident #5 had psychosocial distress related to himself and his social relationships. The interventions documented staff would mediate interactions with family, visitors, other residents, and staff. Resident #5's care plan, dated 9/16/16, also documented he was at risk of substance abuse of opioids related to a history of addiction with poor coping skills and adjustment issues. The interventions included reminding the resident of his need for a plan for recovery and sobriety as a means of improving his judgment; and working with Sol-Oasis program staff on coping, communication, and socialization skills. On 9/9/16 at 4:30 pm, a Social Service note documented the AIT and the LSW visited Resident #5 to educate him after the NP reduced his pain medication. The note documented Resident #5 became upset because my leg was just amputated and told the AIT and LSW to get out of his room. The LSW's response to this was attempted to redirect and did educate resident they would be exiting at this time. It was not clear which coping skills the AIT and LSW had encouraged Resident #5 to develop in response to the reduction in his pain medications while his surgical site from his recent amputation was still in the healing process. A care plan intervention, dated 9/9/16, documented that meaningful activity for Resident #5 was to go outside for fresh air in good weather and that he should be provided access to outdoor areas. On 9/16/16 at 9:41 am, a Social Service note documented Resident #5 had increased agitation and was yelling at staff. The note documented the LSW assisted with adjustment and coping skills, and Resident #5 agreed to utilizing counseling. At 3:41 pm, the LSW documented Resident #5 had completed a psychiatric consult and was adjusting to the facility. On 9/17/16 at 12:26 pm, a Social Services note documented an offer of individual counseling services in the facility, and Resident #1 signed a consent form. Two days later, on 9/19/16, Social Services notes documented the referral was faxed to the counseling agency. Nine days later, on 9/28/16, a Social Services note documented Resident #5 could not be seen by the counseling agency due to insurance coverage issues, and a different provider would be arranged. There was no further documentation in Resident #5's record regarding the status of counseling services, or documentation that counseling services were provided. On 9/28/16 at 3:00 pm, a nurses' note documented Resident #5 was overheard to have an argument with his spouse during which he stated he no longer wanted that individual to be his POA. The note documented the resident's spouse came to the nurse afterwards and told the nurse she was leaving the resident, and identified a number of potential psychosocial issues for Resident #5. There was no documentation of mediation between the Resident #5 and his spouse, as documented in Resident #5's care plan. There was no documentation of a social services referral. There was no documentation in Resident #5's record that social services met with him regarding this incident, or his statement of wanting to change POA's. On 10/5/16 at 10:59 am, a Social Services progress note documented the LSW and AIT met with Resident #5 following a report that Resident #5 threatened to grab the CNA and get the CNA fired. The Social Services note documented, educated (Resident #5) that staff also have rights and they do include being treated in a respectful manner .educated (Resident #5) staff can call the police if they feel threatened. The note did not document what prompted this conversation, and no investigation into the incident was documented. It was not clear how the facility determined the incident was a result of unlawful behavior on Resident #5's part, and not an expression of an unmet physical, mental, or psychosocial need. There was no documentation that LSW provided support to Resident #5 or assisted him to develop coping skills. On 10/5/16, a Nurse Practitioner Follow-Up Note documented According to staff, resident has had some behavioral issues, becoming quite agitated and verbally abusive to staff. The resident tells me when asked about this that he is very frustrated being in isolation due to[DIAGNOSES REDACTED] and after discussion, he does feel the symptoms will improve once he is able to get up and out of his room. The NP assessment documented that Resident #5 was becoming more and more frustrated with the isolation in his room which could be contributing, not only to his agitation, but his perception of pain. On 10/10/16 at 7:31 pm, a Social Services note documented Resident #5's desire to be discharged to the community against medical advice due to, (Resident) is wanting more medications without putting in the work to improve his mood without psychosocial interventions . It was not clear what work Resident #5 was unwilling to do to improve his mood state, or to which psychosocial interventions he was objecting. There was no documentation that the psychosocial interventions were reviewed and revised in light of Resident #5's unwillingness to utilize the ones currently in place. There was no documentation of follow-up on the counseling referral from 9/17/16. On 10/14/16 at 12:48 pm, a Social Service note documented Resident #5 was notified of a room transfer. On that date, he moved to a room on the facility's 200 hall, called the Sol-Oasis unit by the facility. There was no documentation as to the reason Resident #5 required a room transfer, how the change was beneficial to him, or whether he agreed to the transfer. On 10/14/16 at 2:06 pm, a Social Services note documented the SOPD met with Resident #5 regarding the opportunity to transition to the Sol-Oasis program to work on healthy coping during frustrating situations. The note documented Resident #5 would have the opportunity to participate in group programming, as well as, receive visits from program staff. It was not clear if Resident #5 was informed that he had the opportunity to participate in the Sol-Oasis programming without moving rooms. On 10/15/16 at 1:23 pm, a Social Services note documented a SOPD follow up visit with Resident #5 after his transition to the Sol-Oasis program. The note documented Resident #5 and the SOPD discussed football. On 10/17/16 at 10:50 am, the door to Resident #5's room was closed with a sign directing visitors to check with a nurse prior to entering the room. RN #3 stated Resident #5 was on contact precautions and instructed the surveyor that prior to entering the room, a disposable clothing cover, gloves, and a mask must be put on. The DON stated that everyone entering Resident #5's room had to adhere to the use of the PPE. At 1:30 pm, CNA #1 stated a gown, gloves, and mask was used because Resident #5 was on contact precautions. On 10/17/16 at 1:10 pm, Resident #1 stated he was moved to the Sol- Oasis unit for group therapy to deal with my bipolar disorder. Resident #5 stated he had not had any therapy. On 10/18/16 at 1:15 pm, the door to Resident #5's room was closed. Resident #5 stated he was not sure why it was closed. Resident #5 stated before his recent room change, the door was always open. Resident #5 stated he understood he had been moved to the new room so he could participate in Sol Oasis programming, but he liked his previous room better because of the view and air flow. Resident #5 stated that due to his isolation precautions, he was only able to leave the room for appointments outside of the facility. On 10/19/16 at 3:50 pm, the LSW stated because Resident #5 was on isolation precautions, she had to wear gloves, a mask, and shoe coverings whenever she went into his room. The LSW stated she was aware of Resident #5's preference to be outside, but those outings would be arranged by the Activities staff. The LSW stated she was not sure how often they were offered, or how receptive Resident #5 was to going outside. The LSW stated she had offered to take Resident #5 outside, but he always declined. The LSW stated she had not documented either the offers or the refusals because, That's not what he expects from social work visits. I'm there for other things, not to take him outside. During the same interview, the LSW stated she had provided a referral for Resident #5 to have counseling with the provider that typically came into the facility to provide services. The LSW stated she later found out the provider was out of network for Resident #5's insurance company. The LSW stated Resident #5 identified his preferred provider was in a neighboring community, where he had lived prior to his accident. The LSW stated the facility was unable to provide transportation to the neighboring community, so she was waiting for Resident #5 to identify a provider in the local community. The LSW stated she had not given Resident #5 referrals for local providers, but was waiting for the name of a provider from him. The LSW stated she had not documented the work she had done on this matter since finding out the in-house provider could not see Resident #5. During the interview, the LSW stated she was not sure what prompted the increase in Resident #5's agitation and yelling on 9/16/16. The LSW stated, He was probably having a fight with his wife. The LSW stated she had not documented an assessment of Resident #5's psychosocial status at baseline, so was unable to state how she had determined Resident #5's yelling and agitation levels had increased. 3. Resident #6 was re-admitted to the facility on [DATE] with multiple diagnoses, including paranoid schizophrenia. a. Resident #6's October 2016 Physician order [REDACTED]. Resident #6 had been on Risperdal previously, since admission, at varying doses. An 8/20/16 Quarterly MDS assessment, documented Resident #6 exhibited no behaviors or cognitive or decision making impairments, and presented with no signs of depression. The MDS documented he had delusions, however, no hallucinations or psychosis-related behaviors. Resident #6's previous MDS assessments from December 2015 through May 2016 documented no delusions, hallucinations or psychosis-related behaviors. Resident #6's Impaired Cognitive Function Care Plan, revised 4/3/16, documented he was at risk for a cognitive decline related to hallucinations and delusions. The care plan did not include his use of the psychotropic medication or resident-specific behaviors staff were to monitor for. Resident #6's Delirium Care Plan, dated 9/23/15, documented he was at risk for symptoms of delirium. Interventions included staff was to attempt to refocus Resident #6 to something positive when he was delusional. Resident #6's Psychosocial Well-being Care Plan, revised 4/3/16, did not include his use of the psychotropic medication or resident-specific behaviors staff were to monitor for. Resident #6's interventions were updated 8/5/16, to include him attending the Sol Oasis Program Groups and staff was instructed to encourage him to participate in social based groups where he could receive positive feedback for his efforts. A 3/18/16, Psychiatrist note documented Resident #6 had no evidence of psychotic symptoms. The note documented he was stable on a low dose of Risperdal. A 6/10/16, Psychiatrist note documented Resident #6 had no evidence of psychotic symptoms. The note documented a GDR was recommended and the facility was to continue psychosocial and environmental interventions. A 7/15/16, a Psychiatrist note documented Resident #6 had some delusional thinking and denied hallucinations. The note documented the nursing staff reported to the physician that Resident #6 had increased irritability and poor decision making and had experienced delusions about surgical incisions in his buttock area that prevented him from taking showers. The documentation did not include how the delusional thinking affected Resident #6 negatively or non-pharmalogical interventions attempted. In addition, the note documented Resident #6's Risperdal was increased. There were no corresponding nursing notes documenting the delusions or increased irritability and poor decision making in Resident #6's records. A 7/26/16, Social Services' note documented Resident #6 told staff he had received a check and wanted to get the money. Resident #6's record did not document how the check was a delusion. In addition, it did not document how the check affected Resident #6 negatively. A 7/27/16, Psychiatrist note documented Resident #6 had some delusional thinking. In addition, the note documented his Risperdal was increased. A 8/12/16, Psychiatrist note documented Resident #6 experienced delusions of persecution and somatic in nature, however he denied hallucinations. In addition, the note documented his Risperdal was increased. A 8/19/16, Psychiatrist note documented Resident #6 had some delusional thinking but did not describe the delusions or their effect on Resident #6. Resident #6's Social Services' Psychotherapeutic Meeting Notes, dated 6/10/16, 7/15/16, 7/27/16, and 8/12/16, did not document the type and frequency of delusions or hallucinations he experienced. In addition, the notes did not document how they affected him negatively. A 9/29/16, Resident Assessment Note documented Resident #6 had no changes in behavior symptoms and he experienced hallucinations, and was self-isolating. The note did not describe what the hallucinations were. Resident #6's 6/1/16 - 10/18/16 MAR/TAR Behavior Monitoring records, documented staff were to monitor for behaviors to include self-isolation, hallucinations, and rejection of cares. The 6/1/16 - 10/18/16 MAR/TAR Behavior Monitoring records, documented Resident #6 did not experience episodes of hallucinations, self-isolation, or rejection of cares. The 6/1/16 - 10/18/16 MAR/TAR Behavior Monitoring records did not monitor for delusions. On 10/20/16 at 9:50 am, the LSW stated Resident #6 experienced a hallucination of getting a check and he wanted his money. This happened back in July of 2016. She stated he said he had seen the check and did not know what happened to it. She stated he continued to perseverate on the check. Resident #6's guardian was asked about the check and stated he did not receive one. The LSW stated his guardian asked for him to be re-evaluated by the psychiatrist because he was distracting her with continually asking about seeing his financial information and wanting be become his own guardian. The LSW stated she could not tell the difference between his delusions or hallucinations. She stated the facility monitored for all type of delusions and hallucinations to include dysphoric (unhappy) in nature or happy in nature. She stated it was up to the psychiatrist to determine what type of delusions required medications. She stated Resident #6's psychiatrist wanted to see Resident #6's psychosocial health stabilize and his delusions better controlled. The LSW stated she could not find documentation in Resident #6's record that he was being monitored for delusions. Resident #6 was not effectively monitored for hallucinations and delusions to measure the efficacy and continued use of the antipsychotic medication, Risperdal. In addition, Resident #6's clinical record did not include instructions for staff to monitor and document his delusions or lack of them. b. An 8/20/16 Quarterly MDS assessment, documented Resident #6 exhibited no behaviors or cognitive or decision making impairments, and presented with no signs of depression. The MDS documented he had delusions, however no hallucinations or psychosis-related behaviors. Resident #6's previous MDS assessments from December 2015 through May 2016 documented no delusions, hallucinations or psychosis-related behaviors. Resident #6's Psychosocial Well-being Care Plan, dated 4/3/16, did not include his use of the psychotropic medication or resident-specific behaviors staff were to monitor for. Resident #6's interventions were updated 8/5/16, to include him attending the Sol Oasis Program Groups and staff was instructed to encourage him to participate in social based groups where he could receive positive feedback for his efforts. A 7/11/16, Social Services' note documented Resident #6 was upset that he had a guardian and wanted the guardianship revoked. The social services notes, from 5/3/16 to 10/18/16, did not include documentation of guidance provided to Resident #6 related to becoming his own guardian. A 7/18/16, Social Services' note documented Resident #6's guardian contacted the LSW and wanted a letter from a psychiatrist which stated he was incompetent to make his own decisions. In addition, the note documented Resident #6 had a psychiatrist appointment in two weeks and the psychiatrist would assess the resident. A 7/27/16, Psychiatrist note documented Resident #6 had some delusional thinking. The note documented he experienced anxiety because he was not allowed to live independently. A 7/28/16, Social Services' note documented Resident #6 was provided with filters for his hand rolled cigarettes. The note documented he told the Social Services Assistant that he did not want to use them, however, the Social Services Assistant placed one of the filters onto one of his cigarettes. In addition, the note documented Resident #6 took off the filter and stated again he did not want to use them. An 8/12/16, Psychiatrist note documented Resident #6 wanted to manage his own affairs and become his own guardian. The note documented Resident #6 had a legal guardian. The note further documented Resident #6 knew he had a short term memory problem that did affect his day-to-day functioning, however he felt that he could still make decisions for himself. A 8/12/16, Social Services' note documented Resident #6 was angry with his psychiatric consultation and had utilized coping skills and socialization to overcome his anger. The note did not document what services Social Services had offered as support or guidance. A 9/15/16, Social Services' Note documented Resident #6 declined to participate in any open groups available throughout the day. A 9/17/16, Social Services' Note documented Resident #6 declined to participate in a social group, because he needed to roll his cigarettes. A 9/20/16, Social Services' Note documented Resident #6 declined to participate in an open group and the Social Services Assistant educated him that attending groups may help him to achieve his goal of returning to another hall in the facility. On 10/18/16 at 2:25 pm, Resident #6 stated he did not know why he was moved to the current room he was in. He stated he did not mind rolling his cigarettes but it was his prescription to roll them in a group atmosphere. He stated he had a brain injury years ago and does not enjoy things like he used to. He stated he did not feel like people listened to what he wanted. On 10/20/16 at 9:50 am, the LSW stated his psychiatrist wanted to see Resident #6's psychosocial health stabilize and his delusions better controlled before determining if Resident #6 was competent to manage his own affairs. The LSW stated it was not a goal for Resident #6 to move back to the other hall. She stated he could move anytime if he wanted to. She did not know why it was listed as a goal for Resident #6 to move in the Social Services' note, dated 9/20/16, see above. In addition she said to ask the Social Services Assistant who wrote the note. On 10/20/16 at 4:20 pm, the Social Services Assistant stated it was a goal for everyone on the Sol-Oasis hall to transition out of unit to another hall in the facility. She stated they could stay in the Sol Oasis hall if they wanted to. She did not realize this goal was not on his care plan and stated the LSW, herself, and the Sol-Oasis Manager determined goals for residents. Social services did not assist Resident #6 with his psychosocial needs or take his preferences into account. c. A 8/20/16 Quarterly MDS assessment documented Resident #6 had delusions. Resident #6's clinical records contained two Certificates of Service for Guardianships, notarized 2/17/12 and 6/2/15. These documents appointed a guardian for Resident #6. A 7/11/16, Social Services' note documented Resident #6 was upset and had called an attorney's office to request the guardianship be revoked. The note documented the attorney's office reviewed his case and found that Resident #6 did not have a Guardian Ad Litem assigned to him. In addition, the note documented Resident #6 needed a psychiatric evaluation to determine whether he was able to manage his own care. The LSW documented that would happen on the 7/15/16. A 7/18/16, Social Services' note documented Resident #6's guardian needed a letter from his psychiatrist stating Resident #6 was incompentent to make his own decisions. The note documented the psychiatrist was unwilling to do this at that time and he would be reviewing Resident #6 later in the month. On 10/20/16 at 2:00 pm, the LSW stated she had nothing to do with helping residents get guardian ad litem's. It was the court's decision and it was up to the court. She stated Resident #6's psychiatrist still had not given his determination of Resident #6's cognitive status. She stated Resident #6 had a guardian currently. The LSW agreed that people with guardians should have a guardian ad litem as a resident advocate. She stated that since writing the note on 7/18/16, she had not completed further follow up related to Resident #6 securing a guardian ad litem or his desire to become his own guardian.

Based on observation, staff interview, and record review it was determined the facility failed to ensure residents with limited range of motion and contractures received necessary services to prevent further decline in ROM. This affected 5 of 6 (#2, #4, #5, #9 and #12) residents sampled for limited ROM. Resident #2 was harmed when the facility failed to recognize functional decline and prevent further loss of mobility, which resulted in increased depression, withdrawal, social isolation and pressure ulcers. The failure also created the potential for further decline in the functional range of motion for Residents #4, #5, #9, and #12. 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 had recurrent pressure ulcers in her left hand, which were documented as a result of contractures. On 10/20/16 at 11:00 am, the Administrator provided a packet of Resident #2's medical record forms, which he identified as a time line for the development of her contractures. The timeline included: a. The first entry on the time line was 10/27/15, in which a physician's orders [REDACTED]. An OT Evaluation was completed on 11/4/16. The OT Discharge Summary, dated 11/18/16, documented Resident #2 was issued a right side palm protector and a left hand carrot splint to prevent further contractures. An RNP program was initiated, with the focus of preventing further contractures, skin breakdown, to maintain splinting and provide PROM for left fingers. Resident #2's record documented an RNP program was initiated, with the focus of preventing further contractures, skin breakdown, to maintain splinting, and provide PROM for left fingers. She received RNP services from 11/17/15 to 2/23/16. The RNP interventions were not clearly defined. They did not include the frequency the RNP activities would occur, or provide PROM as was planned by the Occupational Therapist as she indicated on the discharge summary. Dates of RNP activities provided to Resident #2 were inconsistent and sporadic as follows: * 11/17/15 to 11/30/15, 3 sessions, * 12/01/15 to 12/31/15, 11 sessions, * 1/1/16 to 1/31/16, 9 sessions, (PROM was added to the RNP record beginning 1/5/16.) * 2/1/16 to 2/24/16, 8 sessions. b. The timeline documented an OT Evaluation, dated 12/8/15. It documented Resident #2 had contractures and impaired mobility of both upper extremities and shoulders. In the section Integumentary, the OT Evaluation stated .at huge risk for skin breakdown as pt (patient) does not get out of bed and is unable to re-position herself. The section of the OT Evaluation titled Assessment Summary, documented .all digits on L hand are separated with no risk of skin breakdown due to fingers overlapping or nails digging into palm of hand. c. A Progress Note dated 12/8/16, documented the carrot splint was discontinued after LPN #5 met with the occupational therapist. The progress note stated a sheep skin palm protector was applied to her left hand to assist with maintaining skin integrity and to help prevent continued contracture formation. d. Resident #2's Annual MDS assessment dated [DATE], documented impaired cognition, impaired mobility, and contractures. Section M of the MDS documented Resident #2 was at risk of developing pressure ulcers. The analysis of findings in the resident's PU CAA worksheet, dated 2/16/16, documented, .at risk for skin concerns. e. A Physician order [REDACTED]. * OT therapy performed an evaluation on 8/9/16, and goal stated was Pt will be referred to orthotist for splinting needs related to contractures. * An OT Discharge Summary, dated 10/10/16, documented Resident #2 was discharged from OT with her left hand carrot splint to be used for skin integrity. 10/18/16 at 3:25 pm, Resident #2's left hand was observed during cares. RN #1 and the Unit Manager of Sol Oasis unit removed the soft splint from her hand. Measurements were obtained, and the contractured hand was cleansed. Her left hand was fisted, with the left forefinger tucked tightly into the web area between her thumb. The 2 LN's were unable to open her hand to inspect for long fingernails or further skin impairments of the rest of her hand. On 10/19/16 at 2:30 pm, Resident #2 was heard calling for help. Upon receiving permission to enter the room, she asked the surveyor to scratch her forehead. Resident #2 was encouraged to perform the task herself. She was able to bring her head forward, and right arm up towards her face, and rubbed her forehead with a knuckle of her curled right hand. She was then asked if it was possible to open her hand, and was able to open it slightly as to form a cup. She stated it could not open any further. On 10/18/16 at 2:50 pm, RN #1 described the progression of Resident #2's contractures. She stated when Resident #2 was admitted 3 years ago, she was not able to fully open her hands, but she was able to hold utensils. Shortly after that, she was provided with specially designed utensils, and still required assistance with activities such as eating. RN #1 stated Resident #2 had the contractures for approximately a year, worse on her left shoulder, elbow and hand, and developing on her right. She stated the pressure ulcers in that area were recurring. RN #1 stated Resident #2 was on Comfort Care, and refused much of her care, including wearing of the splints. On 10/20/16 at 2:52 pm, OT #1 stated Resident #2 was not cognitively able to understand why she needed to be compliant with wearing the splints, She stated Resident #2 frequently refused to wear the splint, and the staff was instructed to contact the LSW when she refused. OT #1 was questioned why 3 OT evaluations were performed, however, the entire body was not assessed for decline in mobility or ROM. She stated the paper physician's orders [REDACTED]. She stated the OT Evaluations were focused on the left hand. OT #1 stated Resident #2 was documented as having decreased ROM of both upper extremities on the evaluation, dated 12/8/16, because the immobility was due to her [MEDICAL CONDITION], not contractures. The facility failed to prevent contractures for Resident #2, the contractures continued to decline over a 1 year period which resulted in pressure ulcers, inability to feed herself and perform ADLs. 2. Resident #4 was initially admitted to the facility in 2007 and readmitted in 3/11/15, with multiple [DIAGNOSES REDACTED]. Resident #4's 10/1/16, quarterly MDS assessment documented moderate cognitive impairment, functional limitation in ROM in one upper and one lower extremity, OT services between 6/23/16 and 7/14/16, PT services between 1/29/16 and 2/8/16, and that a restorative nursing program was not provided. Resident #4's 7/1/16 quarterly MDS assessment, differed from the 10/1/16 assessment, in that no functional limitations in ROM were noted in either the upper or the lower extremities and OT services were provided for 5 days beginning on 6/6/16. Resident #4's 3/23/16 annual MDS assessment, differed from the 7/1/16 MDS assessment, in that OT services were provided for 4 days beginning on 2/29/16 and PT services were provided between 1/29/16 and 2/8/16. Again, a restorative nursing program was not provided. Resident #4 was observed with her right leg angled forward and both knees bent at a 90 degree angle on: * 10/17/16 at 1:25 pm * 10/18/16 at 8:50 am, during a w/c to bed transfer by CNA #7 * 10/18/16 at 9:00 am, 9:30 am, and 9:55 am to 10:15 am, during direct care and repositioning in bed by the DNS and RN #4, and at 11:15 am, 1:35 pm, 2:20 pm and 3:30 pm * 10/19/16 at 10:30 am, at 10:50 am during a bed to w/c transfer by CNA #2 * 10/19/16 at 3:45 pm, and at 5:45 pm during a w/c to bed transfer by LPN #3 and CNA #8 * 10/20/16 at 8:20 am and 10:10 am, during wound care and dressing change by RN #4. During the w/c to bed transfer observation on 10/18/16 at 8:50 am, Resident #4 said she felt like a yoyo and CNA #7 said that was because her legs don't stretch. On 10/19/16 at 5:45 pm, prior to transferring Resident #4 from the w/c to bed, LPN #3 stated, She's just very contracted. There was no care plan for ROM or contractures and there were no interventions for ROM in other care plan focus areas. RNA Progress Notes/Summary for August and September 2015, contained repeated documentation that Resident #4 liked the RNP and participated willingly. However, a 9/2/15 entry documented, Unable to see today, RNA on the floor and a 9/22/15 entry documented, Res(ident) dc'd per her request. There were no entries prior to that about Resident #4 refusing to participate, or requesting to stop, the RNP. Restorative Nursing Records for September 2015 documented, Unable to see - floor CNA on 9/2/15 and Unable to see, without explanation, on 9/14/16. RNA Progress Notes/Summary for February and March 2016, documented Resident #4 still liked the program but participated less and less during each session and required frequent to constant cueing. Resident #4's Restorative Nursing Records for February and March 2016 documented Unable to see on 2/16/16, 2/22/16, 2/23/16, 3/1/16, 3/2/16, 3/7/16, 3/8/16 and 3/14/16 without explanation. Additionally, across 3/15/16 and 3/16/16 was documented DC, again without explanation. On 10/21/16 at 11:10 am, PT #1 said she was very familiar with Resident #4 and the resident had a significant decline prior to her readmission in 2015. The PT said Resident #4 had genu valgum of the right hip (inward rotation) that was caused by abnormal posture and abnormal muscle tone (hypertonicity) as opposed to contracture. The PT said that consistent ROM wouldn't hurt and could be beneficial from a human touch perspective but it would not change the [DIAGNOSES REDACTED]. On 10/21/16 at 12:25 pm, LPN #4 said she was over the RNP. LPN #4 said Resident #4 may have been discontinued from the RNP in March 2016, because the facility had only one official RNA. LPN #4 said the RNA worked four days a week and there were times the RNA may have been pulled to work the floor instead of the RNP. 3. Resident #9 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. During an interview on 10/17/16, at 11:05 am, Resident #9 stated that her left shoulder had an injury and she now had limited ability to use her arm. She said she was left handed and unable to do her normal activities, such as sewing or personal care because of this injury. She said until recently she could still sew but was not able to use her arm at this time. When questioned, she stated that she did not receive Physical Therapy or Restorative Nursing therapy. Resident #9 identified that to support her left arm and hand, she pulled on her sleeve to hold it up (demonstrating this procedure) and that doing that helped with pain. The Restorative Nursing Program notes for Resident #9 documented a lower extremity range of motion program (undated or signed) but there was no restorative program for her left upper extremities. During an interview with OT #3 on 10/20/16 at 3:00 pm, OT #3 stated that the only therapy Resident #9 was receiving was for her lower extremities. 4. Resident #5 was admitted to the facility on [DATE], following a right BKA due to a right heel pressure ulcer developing wet gangrene. The Physical Therapy Initial Evaluation, dated 9/6/16, was completed in Resident #5's room because of [MEDICAL CONDITION] precautions. The evaluation documented the frequency of visits was to be 5 times a week. Between 9/7/16 and 10/19/16, Resident #5 received physical therapy 15 times, 9 visits in September and 6 visits in October. No documentation was found addressing ROM to his right knee/right lower extremity. On 9/22/16 at 4:07 pm, a Treatment Encounter Note (TEN) documented, Seated lower extremity exercises with 3# for quad, hip flex, adduction and abduction to increase mm strength and improve patients ability to stand and strengthen right recent BKA to prepare for prosthesis. On 10/5/16 at 2:17 pm, a TEN documented Resident #5 completed bilateral lower extremity seated therapeutic exercise on the edge of bed with manual resistance 2x15 reps to increase strength in improve functional mobility. On 10/17/16 at 6:37 pm, a Social Service note completed by LSW, documented Resident #5 stated he had not had skilled therapies. The note indicated the Therapy Director communicated to the LSW that Resident #5 was utilizing skilled therapy 8 times a month until he received his device. A Clinic Orthotic note, dated 10/18/16, documented a knee contraction in extension. It stated, ROM is 0 degree extended position and flexes to 35 degrees. Resident #5 needs to work on single leg strength to improve ability to walk once prosthesis is manageable. I am concerned about the limited ROM in knee flexion. This will hinder the patients ability to walk efficiently if not resolved and worked on. On 10/18/16 at 4:46 pm, a PT note documented, Encourage resident to focus on right knee flexion in preperation of prosthesis. On 10/19/16 at 4:50 pm, a PT note documented Active and active assisted right knee flexion sitting on edge of bed. Therapeutic exercise to improve joint range using static stretching for the right lower extremity targeting knee flexion and knee extension .to increase ROM and to enchance functional mobility. On 10/20/16 at 10:00 am, Resident #5 was sitting in his wheelchair. He stated he went to his appointment for posthesis fitting and was told the ROM in his right knee was not good. They gave me some exercises to do. 5. Resident #12 was readmitted to facility on 3/12/10, and readmitted again on 9/16/16, following hospitalization for pneumonia. Her [DIAGNOSES REDACTED]. A critical care admission note documented Resident #12 did not move her right upper extremity and her right upper extremity was flexed at the elbow and at the wrist. It documented Resident #12's hand was closed. The note stated she was unable to move the right upper extremity; likely secondary to contractures. Resident #12 did not have a plan of care in place reflective of the current contracture of the right upper extremity. Her Care Plan for prevention of skin breakdown did not include the right hand which was contracted in a closed fist position. The Care Plan was not revised or updated to reflect care of the contracture. Resident #12 record was reviewed and did not include documentation, or physician orders, addressing contractures or treatment for [REDACTED]. The DNS stated Quality of Life rounds were completed weekly with therapy staff to identify residents that may need therapy or a Restorative Nursing program. LN #4 and the DNS stated Resident #12 had not received therapy or Restorative Nursing for her right upper extremity.

Based on review of facility policies, observations, record review, and staff, resident, and POA interviews, it was determined the facility failed to ensure 2 of 9 sampled residents (#1 and #2) received care and services required to meet their highest practicable level of physical, mental, and psychosocial well being. This deficient practice resulted in harm when Resident #2 experienced avoidable development of contractures and pressure ulcers, a decline of ROM, inability to perform ADLs, pain, depression, and social isolation. It also placed Resident #1 at risk of harm due to the facility's failure to assess his abdominal pain and initiate appropriate interventions. These practices had the potential to negatively affect all residents in the facility. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Annual MDS assessment, dated 2/10/16, documented Resident #2 was cognitively impaired, bed bound, and fully dependent for all ADLs. A Quarterly MDS assessment, dated 8/8/16, documented Resident #2 was severely cognitively impaired, remained bed bound, and was fully dependent on staff for all her ADLs. On 10/17/16 at 8:20 am, the Unit Manager of the Sol Oasis unit stated Resident #2 was on comfort measures, had bilateral hand contractures, and demonstrated behavior that was described as refusal of cares and self isolating. a. Contractures, ROM deficits, and declining ability to perform ADLs. During the 12 month period from October 2015 to October 2016, Resident #2's record documented increasing contractures of both hands and both shoulders. Skin assessment and incident reports for that period documented she experienced recurring pressure ulcers of the left hand as a result of contractures. Resident #2's care plan included interventions related to ADLs. It stated she was dependent for ADL care (bathing, mobility, transfer, locomotion, toileting) due to cognitive loss and compromising functional ability. b. Palliative Care/Comfort Care. physician progress notes [REDACTED].#2 was receiving palliative care. Her care plan did not include palliative care. c. Pain. The Annual MDS assessment, dated 2/10/16, documented Resident #2's pain intensity rating was 6 on a scale of 1-10. The Quarterly MDS assessment, dated 8/8/16, documented Resident #2's pain intensity was 8. Resident #2's MAR indicated [REDACTED]. The MAR's documented the [MEDICATION NAME] for pain was initially ordered 9/23/14. Resident #2's PRN PAIN MANAGEMENT FLOW SHEET was reviewed, and showed the following: * The flow sheet for August 2016, documented 9 episodes of requests for additional [MEDICATION NAME]. Her pain was documented as between 7 and 10 on a 1-10 pain scale. * The flow sheet for September 2016, documented 5 episodes of requests for additional [MEDICATION NAME]. Her pain was documented as between 5 and 8 on a 1-10 pain scale. * The flow sheet for October 2016, documented 5 episodes of requests for additional [MEDICATION NAME]. Her pain was documented as between 5 and 7 on a 1-10 pain scale. Her care plan did not include chronic pain. d. Depression and Social Isolation. * One part of Resident #2's care plan, created by the Recreation Assistant on 8/11/16, stated a goal of will express satisfaction that her daily routines and preferences are accommodated by staff during inquires. Interventions included Encourage (Resident #2) to engage in independent leisure and assist with set up as tolerated. Offer 1:1 volunteer visits weekly as tolerated. Having reading materials. Doing things with groups of people, socializing. The Recreation Assistant did not establish realistic and measurable goals and interventions given Resident #2's bed bound status and inability to go to unit activities. During an interview with her POA on 10/20/16 at 2:00 pm, the POA stated Resident #2 was unable to hold a book and lacked the ability to concentrate when books on tape were played. Resident #2's record did not include documentation of volunteer visits. Resident #2's Recreation Activity Logs for August 2016, documented 8 individual visits. September 2016, documented 5 individual visits. October 2016 documented 4 individual visits. During an interview with Resident #2's POA on 10/20/16 at 2:00 pm, she stated that in the past, she was able to visit Resident #2 frequently, from 4 times weekly to daily visits. She stated due to a health crisis of another family member, she was unable to visit more than once weekly. She stated she felt that her decreased visit frequency contributed to Resident #2's isolation and depression. * Resident #2's room was located on the Sol Oasis unit. On 10/18/16 at 1:45 pm, the Sol Oasis Program Director (SOPD) described the function of the program. She stated the program provided extra support and life skills for residents 7 days a week and was a transitional program for residents that had a goal of returning home. The SOPD stated the program was aimed at younger residents, many of who may have a psychiatric diagnoses. She described the program as voluntary, with activities of coping, positive choices, and providing 1:1 visits with residents. She stated the program was able to facilitate a clinical liaison in the community for counseling needs. The SOPD stated Resident #2 was admitted approximately 3 years ago from another facility. She stated her mental and physical health had declined, and she felt the program would provide her with extra socialization above and beyond what the facility offered for non-Sol Oasis residents. The SOPD stated all residents in the facility received recreation and volunteer visits. When asked what the Sol Oasis program visits for Resident #2 included, she stated they were mostly 1:1 visits which were called You and Me visits. * Sol Oasis Participation Logs were reviewed. From 9/14/16 to 10/17/16, the log included 7 entries for Resident #2. The entries included a haircut, discussion of her love of Disney, she was consoled during a crying episode, she was brought candy from a run to the store, (2) You and Me activities, and was provided support during a Podiatry procedure. e. Refusal of Care: On 10/17/16 at 10:15 am, Resident #2 was observed as she was offered scheduled medications, which included [MEDICATION NAME]. She refused the medication, and refused the attempts of RN #1 to assess her left hand. Resident #2 said No, no, no, repeatedly in a high pitched voice when her left hand was touched by RN #1. Resident #2's August, September, and October 2016 MARs and TARs included documentation of instances when she refused cares and medications. Additionally, her care plan reflected interventions related to how staff would approach Resident #2 when her behavior resulted in refusal of cares or medications. On 10/18/16 at 2:50 pm, RN #1 reviewed Resident #2's record and stated she often refused care. She described instances of refusal for assistance with turning in bed, medication administration, use of splints for contractures, and getting out of bed. She stated all residents were able to refuse care, but (Resident #2) was on comfort care, so she refused medications and cares often. RN #1 was unable to find care plans related to comfort care or chronic pain in Resident #2's record. Additionally, RN #1 was unable to find formal documentation of Resident #2 being placed on comfort care. She stated it has been more than a year. The facility failed to provide comprehensive assessments and appropriate interventions for Resident #2's physical, mental, and psychosocial needs. The cumulative effect resulted in unaddressed chronic pain, contractures, pressure ulcers, and increased social isolation. 2. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS, dated [DATE], documented Resident #1 was cognitively intact. A Care Plan Focus, dated 4/18/16, documented Resident #1 had expressed suicidal thoughts and was at risk for harming himself related to depression and persistant negative statements. Interventions initiated on 9/15/16, documented Resident #1 focused on fears related to his bowel movements. When this occurred staff were to redirect him to a positive conversation. On 6/14/16 at 6:26 pm, a Nurses' Note documented Resident #1 was, continually stating that he has a bad bowel sensation. On 6/20/16, a Nurse Practioner documented Resident #1 stated that he had regular bowel movements daily but after going still felt the urge to defecate throughout the day. The Nurse Practioner noted that staff stated this had been an ongoing chronic problem for quite some time. The Nurse Practioner documented Resident #1 had been seen by a [MEDICATION NAME], even undergoing a colonoscopy and no pathology was found. On 7/22/16, the facility received a physician's orders [REDACTED]. On 9/17/16, [MEDICATION NAME] powder, one tablespoon daily, was discontinued although Resident #1 continued to receive it through 9/29/16. A bowel care protocol was put in place on 9/29/14, which included: * Give Milk of Magnesia 30 mLs at bedtime when there has been no bowel movement for three days. If no result from Milk of Magnesia, give a [MEDICATION NAME] suppository on the next shift. * If no results from the suppository within 2 hours, provide a Fleets enema. * Call MD if no results from Fleets enenam. CNA Flowsheets for the month of September 2016, documented Resident #1 did not have a bowel movement 9/2/16 through 9/5/16. No documentation was found that indicated the bowel care protocol was initiated. Further, no documentation was found in Nurses' Notes to indicate there was a concern, interventions were initiated, a physical assessment completed, or that the physician was notified. On 9/12/16 at 5:53 pm, a Social Service note, completed by the LSW, documented Resident #1 stated he was suffering and wanted to have a bowel movement but could not. The LSW documented that Resident #1 said that if he had a sharp object he would end the suffering and take his life. Resident #1 was transferred to the ER for voicing suicidal thoughts. A nursing assessment completed prior to, or upon return from, the ER, was found in Resident #1's medical record

Based on observation, record review, and resident and staff interviews, it was determined the facility failed to ensure the necessary nursing care and services were provided to promote the healing of pressure ulcers, and to prevent pressure ulcers from reoccurring after they were healed. This was true for 3 of 3 (#2, #3 and #5) sampled residents reviewed for pressure ulcers. Resident #2 was harmed when the facility failed to ensure interventions were utilized to prevent contractures of her hand that resulted in recurrent pressure ulcers. Residents #3 and #5 were at risk of harm related to the facility's failure to promptly assess existing pressure ulcers, and implement interventions. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 experienced an avoidable decline in functional status, contractures, and pressure ulcers as described in the following examples: a. An OT Evaluation, dated 12/8/15, documented contractures, and impaired mobility of both upper extremities and shoulders. In the section Integumentary, the OT Evaluation stated, .at huge risk for skin breakdown as pt (patient) does not get out of bed and is unable to re-position herself. The section of the OT Evaluation titled Assessment Summary, documented, .all digits on L hand are separated with no risk of skin breakdown due to fingers overlapping or nails digging into palm of hand. A Progress Note, dated 12/8/15, documented a therapeutic carrot (orthosis shaped like a carrot) was discontinued after LPN #5 conferred with the occupational therapist. The progress note stated a sheep skin palm protector splint was applied to Resident #2's left hand to assist with maintaining skin integrity and to help prevent continued contracture formation. A communication form to Resident #2's physician titled CHANGE OF STATUS, was dated 12/9/15. The form stated, Due to contractures and facility attempts to offload contracted areas, skin breakdown unavoidable at this time. Resident #2's Annual MDS assessment, dated 2/10/16, documented impaired cognition, impaired mobility, and contractures. Section M of the MDS documented Resident #2 was at risk of developing pressure ulcers. The analysis of findings in Resident #2's pressure ulcer CAA worksheet, dated 2/16/16, documented she was, .at risk for skin concerns. A form titled Skin Integrity Report, described a pressure ulcer on Resident #2's left hand. It was initiated on 4/5/16. The report described the pressure ulcer as Stage II. The pressure ulcer was documented as becoming 100% [MEDICATION NAME] by 4/18/16. Further weekly assessments noted the area was healed as of 6/27/16. A physician's orders [REDACTED]. A form identified as Skin Check.-V 1, dated 4/05/16, included documentation of a bruise on Resident #2's left hand forefinger with a small open area. The wound was documented as a pressure wound. The wound was documented on the Skin Check forms on 4/12/16 and 4/19/16. On Skin Check forms dated 5/3/16, 5/10/16, 5/17/16, and 5/24/16, Resident #2's left forefinger was documented as bruised. A Skin Check form, dated 5/31/16, documented a small callused area on the left forefinger. In a Quarterly MDS assessment, dated 8/8/16, Resident #2 was documented to be at risk of developing pressure ulcers. The assessment did not identify the resolved pressure ulcer of her left hand that was noted on 4/5/16. A Skin Check form, dated 8/9/16, documented Resident #2 had small open areas on her left hand between her thumb and forefinger. It stated the finger brace may be rubbing in that area. It was documented as a Stage II pressure ulcer. An OT Discharge Summary, dated 10/10/16, documented Resident #2 was discharged from OT with a left hand carrot splint to be used for skin integrity. A form titled Skin Integrity Report, described the pressure ulcer on Resident #2's left hand. It was initiated on 10/7/16, and documented additional skin assessments on 10/11/16 and 10/17/16. The report documented the pressure ulcer as unstageable. A Skin Check form, dated 10/11/16, documented Noted creamy yellow matter to hand. Resident declining to open hand to be evaluated. On 10/18/16 at 3:25 pm, Resident #2's left hand was observed during cares. RN #1 and the Unit Manager of Sol Oasis unit, also an RN, removed the soft splint from her hand. Measurements were obtained, and the contractured hand was cleansed. Her left hand was fisted, with the left forefinger tucked tightly into the web area between her thumb. The 2 RN's were unable to open Resident #2's hand to inspect for long fingernails or further skin impairments of the rest of her hand. Resident #2's left hand also had a large crusty finger-like growth, which the Unit Manager called a skin tag. It was in the knuckle area between her left third and fourth fingers and extended out approximately 1.5 cm. On 10/18/16 at 2:50 pm, RN #1 described the progression of Resident #2's contractures. She stated when Resident #2 was admitted 3 years ago, she was not able to fully open her hands, but she was able to hold utensils. Shortly after that, she was provided with specially designed utensils, and still required assistance with activities such as eating. RN #1 stated Resident #2 had the contractures for approximately a year, worse on her left shoulder, elbow and hand, and developing on her right. She stated the pressure ulcers in that area were recurring. 2. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #3's 10/5/16 admission MDS assessment documented intact cognition and 1 unstageable PU present on admit. The PU CAA Worksheet, dated 10/6/16, documented, .pressure area to spine related to kyphosis and decreased mobility due to vertebral fractures. Care plan focus areas included the risk for skin breakdown related to impaired mobility, initiated 9/29/16; and, actual skin breakdown, pressure injury noted on admit, initiated 10/4/16, six days after Resident #3 was admitted to the facility. Resident #3's Transfer Orders/Instructions, dated 9/27/16, contained the handwritten entry, Wound care(:) [MEDICATION NAME] Santyl once daily spine 9/28/16. A Progress Note, dated 9/28/16 at 6:30 pm, documented Resident #3 was admitted to the facility with a Braden score of 18, indicating she was at risk of pressure ulcers; and, See nursing admission assessment (UDA) for detailed clinical findings. A Nursing Assessment - Initial (Admission) v3, dated 9/29/16 (one day after admit), documented, Kyphosed back, wounds to bony prominences, dressed with border gauze. It did not include a comprehensive assessment of the wound and no other UDA regarding the back wound was found in Resident #3's EMR or paper chart. On 10/21/16 at 8:20 am, RN #7 was observed as she provided wound care and dressing change per orders to Resident #3's mid-spine PU. The RN did not measure the PU and said measurements were obtained earlier in the week. The RN said the PU was about the same as when the resident was admitted . The PU was approximately 3 cm long by 2 cm wide with a film of pale yellow slough over 3/4 of the wound bed and deep purple/red color to the surrounding skin. On 10/21/16 at 9:00 am, RN #3, who identified herself as the Skin Integrity Coordinator, provided Resident #3's Skin Integrity Report which included Weekly Data Collection. The Report documented 9/28/16 as the Initial Wound Date for the mid-spine unstageable PU with slough. The Report documented comprehensive assessments were completed on 10/5/16, 10/11/16, and 10/19/16. The Report did not include a comprehensive assessment for 9/28/16 or 9/29/16. In addition, the 10/5/16 and 10/11/16 assessments documented the PU wound bed was 100% slough and the depth was < 0.1 cm. RN #3 said she was instructed to document less than 0.1 cm when the wound bed was covered with slough or eschar because we know the skin is broken. RN #3 looked for a UDA related to the 9/29/16 initial nursing assessment and said she did not find anything. The RN said she would keep looking. On 10/21/16 at 11:30 am, RN #3 provided a 9/26/16 Wound Care Progress Note (2 days before Resident #3's admission to the facility), which documented an initial consult for a wound on Resident #3's mid back/[MEDICATION NAME] spine area and, Unstageable pressure ulcer .mid back/spine bony prominence .measures 3.7 x 2.2 cm, with an area of well-adhered yellow slough in the center measuring 2.2 x 1.1 cm. Depth is undetermined . The facility did not provide other documentation regarding the PU. 3. Resident #5 was admitted to the facility on [DATE], following a right BKA due to a right heel pressure ulcer with development of wet gangrene. An MDS assessment, completed on 9/13/16, documented Resident #5 was cognitively intact, had a stage 4 pressure ulcer to the sacral region, and required extensive assistance of staff for bed mobility, transfers, and toileting. A Care Plan Focus, dated 9/7/16, documented Resident #5 required assistance/was dependent on staff bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. A Care Plan Focus, dated 9/8/16, documented Resident #5 was at risk for skin breakdown. Interventions in place included repositioning every two hours as Resident #5 allowed, offloading pressure points as he allowed, and utilizing positioning devices, as appropriate, to prevent pressure over bony prominences. A physician's orders [REDACTED]. CNAs documented turning and repositioning Resident #5 every 2 hours as he allowed, on a flowsheet. From 10/1/16 through 10/17/16 there were 204 opportunities to turn Resident #5. Of the 204 opportunities, 36 did not include documentation that Resident #5 was turned or repositioned. The remaining 168 opportunities had a Y documented signifying Resident #5 was turned or repositioned every 2 hours around the clock. On 10/17/16 at 1:10 pm, Resident #5 was lying on his back on a low air loss bed. The head of the bed was raised placing him in a sitting position. The sole of his left foot was flat against the footboard of the bed. On 10/18/16 at 9:50 am, Resident #5 was lying on his back with the head of the bed raised to enable a sitting position. On 10/18/16 at 1:15 pm, Resident #5 was lying on his back. Upon interview, Resident #5 stated No, they have not offered to reposition or turn me every two hours. They turn me when I use the bedpan. This bed does not have a lot of room. His left foot was flat against the footboard. On 10/20/16 at 10:00 am, Resident #5 was lying on his back with the head of bed raised to a sitting position. He stated, They tried turning me last night. It didn't work too good. I felt like I was going to roll off the bed. I think they are going to try to get me a bigger bed.

Based on record review, observation, and staff interview, it was determined the facility failed to ensure 1 of 8 residents (Resident #34) did not develop pressure sores while in the facility when *the resident's skin breakdown care plan was not updated to reflect current interventions; *interventions to prevent further pressure sores and help current sores heal were not implemented as ordered; *the resident's input on preferences, needs, goals, and alternative interventions were not provided with resident refusals; *the resident's body alignment in the wheelchair was not addressed; and, *the wheelchair cushion positioning was not assessed proper placement was not ensured. The failure resulted in harm when the resident developed an unstagable pressure sore and a suspected deep tissue injury. Resident #34 was admitted to the facility 9/26/2011 with multiple [DIAGNOSES REDACTED]. The resident's 6/30/15 quarterly MDS documented the resident as cognitively intact, had no resistance to care, was at risk for developing pressure sores, had pressure reducing devices to her chair and bed, and was on a turning/repositioning program. The resident's care plan, initiated 10/10/14, documented the resident was at risk for skin breakdown due to the resident's preference to sleep in her recliner and wheelchair. Interventions for skin breakdown, all created on 10/10/14, included: -encourage repositioning in wheelchair-recliner every 2 hours and prn; -evaluate for any localized skin problems; -evaluate skin risk factors per protocol; -if resident chooses not to use cushion in recliner place blanket under her while in recliner as she will allow; -monitor skin for signs/symptoms of skin breakdown; -observe skin condition with ADL care daily and report abnormalities; -pressure redistribution surfaces to recliner as resident will allow; -pressure redistribution surfaces to wheelchair as per protocol; -provide patient and/or healthcare decision maker education regarding risk factors and interventions; and -weekly skin assessment by license nurse. No revisions were made to the skin breakdown care plan after 10/10/14. The care plan did not reflect efforts seeking alternatives to address the resident's risk of skin breakdown when she refused. The care plan was not revised to modify prevention strategies. A 7/28/15 nursing note documented the resident had a new skin concern on her buttocks, and the resident was encouraged to turn, but the resident continued to sit in the wheelchair, reluctant to move. The documented intervention was to encourage the resident to turn. There was no documentation as to why the resident stated she was reluctant or what the facility did to address the identified barriers. Documentation of similar reluctance from the resident, and encouragement from the facility, was noted on 8/1, 8/5, and 8/8, without identification of reasons for the resident's reluctance, or how the faciity attempted to address those barriers. Aside from those three instances, no further encouragement from the facility was documented during the month of August 2015. No care plan revisions were noted. On 8/17/15 a communication form to the physician documented the reddened area on the coccyx was becoming more red. No further assessments or interventions were documented at that time. A PT (physical therapist) note on 9/16/15 documented when the resident stood up from her chair, a soiled pad was observed by the therapist with what appeared to be drainage on the pad. It documented the drainage was reported to the Rehab Manager, who investigated the situation with the nurse manager. In addition, PT notes on 9/15/15 and 9/17/15 documented the resident slumped to the left in her wheelchair. Follow up on the resident's alignment and positioning in the wheelchair was not documented, and investigation of where the drainage came from was not documented. On 9/19/15 the resident's previously noted area to the coccyx was tender. The resident was provided education, with no identification of the root cause of resident refusals or attempt to address her objections. No new interventions were implemented. A physician order [REDACTED]. It documented the resident refused to offload properly and sleep in her bed, in addition to a preference to sleep in her wheelchair and sometimes the recliner. An SBAR communication form dated 9/22/15 documented the resident had an unstageable pressure ulcer on the left ischial tuberocity and lower superior area of the posterior thigh measuring 8cmx3cmx<0.1cm, with 95% slough and 5% eschar tissue. Treatment orders were obtained, along with an order for [REDACTED]. A change of condition note dated 9/22/15 documented the resident was educated regarding lying in bed to offload. The September 2015 MAR indicated [REDACTED]. On 9/29/15, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 9/28/15 the resident's nutritional assessment documented the resident was not meeting calculated nutritional needs and lost 15.9% of her weight in 60 days. There is a potential the weight loss relates to the development of pressure sores. Refer to F-325 for more details. On 9/30/15 at 11:15 a.m., the resident's wound was observed. There was an approximately 9 inch purple colored round area on the resident buttocks, which did not blanch. The area started in the middle of the resident's bottom and ended just after the gluteal fold on the back of the thigh. On the left leg at the gluteal fold, a 7cmx3cmx<0.1cm wound was observed with another wound inside this area. The outer wound area was yellow with less than 0.1cm depth. The inner wound was approximately 2.5cmx2.5cm (this inner wound was not measured by the wound nurse separately from the wound area surrounding it) with 90% slough, 5% granulation, and 5% necrotic tissue. The wound had a strong odor. Another wound, identified by the wound nurse as new, was lateral and superior to the aforementioned wound. The wound was 0.5cmx1.2cm, did not blanch, and was black in color. The wheelchair cushion at this time was observed to be an inch short of the edge of the wheelchair seat. When the resident stood there was a visible crease across the skin on both legs where the edge of the wheelchair cushion had been. On 9/30/15 at 12:15 p.m., The resident reported she awakened in her wheelchair at 2:00 a.m. and had to request assistance to bed. She stated she slept in her bed when she was at home and that her bottom felt better when she laid down. On 10/1/15 at 1:35 p.m., the occupational therapist (OT) stated the resident's routine was to stay in her wheelchair or recliner. When asked about the wheelchair cushion and if it should line up with the edge of the wheelchair or be about an inch short of the edge, to where it was putting a crease in the resident's skin, she stated it had to be turned 90 degrees from its current position to fit in the wheelchair properly. She stated wheelchair cushions would be assessed with [REDACTED]. There was no documentation of staff education regarding the positioning of the wheelchair cushion in the seat or re-assessment of the efficacy of the current cushion. When asked about the resident's tendency to lean left, she stated she was unaware of the leaning and did not assess this. The facility failed to recognize or address the resident's body alignment in the wheelchair as a risk factor, and was not addressed. In addition, the facility did not recognize the possibility of the resident's wheelchair cushion being improperly placed as a risk factor and this was not addressed. There was no assessment or education to ensure proper placement by staff. The manufacturer's specifications for the wheelchair cushion in use for the resident documented the resident was on an EquaGel General Cushion. The specifications did not document the cushion had pressure-relieving qualities, corrected lateral lean, or was appropriate to be used for pressure ulcer prevention or healing. On 10/1/15 at 3:00 p.m., UM #1 and the wound nurse (WN) were interviewed regarding the resident's pressure sores. The WN stated the resident primarily needed to be offloaded, and if the resident refused the bed to offload then the resident would offload by transferring from the wheelchair to recliner. She stated the head of the recliner needed to be less than 30 degrees for optimal offloading. The WN stated the resident's use of the recliner wasn't routinely documented, and placing the recliner at less than 30 degrees for offloading was not documented in the care plan. UM #1 and the WN were unsure of social work involvement regarding the resident's refusals to offload out of the wheelchair. The WN stated the resident did not use her bed, because it was uncomfortable to lay flat. The WN stated the new lateral area found on 10/1/15 was a suspected deep tissue injury. UM #1 was unsure of the results of the investigation of drainage found by PT on 9/16/15. On 10/1/15 the resident record documented the first social services consult related to the resident's refusals. The resident developed an unstageable pressure ulcer and suspected deep tissue injury when the facility failed to recognize and assess factors that placed the resident at risk for developing pressure ulcers, implement interventions for pressure ulcers in accordance with the residents preferences, and revise the resident's skin breakdown care plan. The facility identified the resident had risk of skin breakdown due to refusals to lay down or get out of her wheelchair; it could not be determined why the resident refused to offload out of the wheelchair, or if encouragement on offloading was an effective intervention to prevent pressure sores. Social work involvement was not documented regarding refusal. Discussion with the resident regarding her condition, options for preventing and treating pressure sores with alternatives to refused interventions, or the resident's concerns regarding pressure sores including her preferences, needs, and goals, were not documented. The facility documented the resident had a history and preference of not utilizing her bed; the resident reported she awakened in her wheelchair at 2:00 a.m. on 9/30/15 and had to request assistance to bed. In addition, the resident had skin breakdown without re-assessment of risk factors or interventions that addressed possible root causes of the skin breakdown before 9/22/15. The facility identified the resident's tendency to lean left and no interventions addressed this; assessment and education on positioning of the cushion in the wheelchair was not documented. The skin breakdown care plan was not updated after 10/10/14. Interventions to offload the resident out of the wheelchair were not implemented as ordered; the resident did not exit the wheelchair from 9/26/15 to 9/29/15.

Based on observation, staff interview, and record review, it was determined the facility failed to identify and completely assess severe weight loss in a timely manner, and prevent further weight loss, for 1 out of 23 residents (Resident #4). The failure resulted in harm when Resident #4 experienced a severe weight loss of 7.9% in 31 days; the facility did not attempt to determine the causes for this severe weight loss for 15 days, by which time the resident had already lost an additional 2.5 lbs. Findings include: Resident #4 was admitted [DATE] with multiple diagnoses, including dysphagia and dementia. The 6/20/15 Quarterly MDS Assessment coded the resident: *Had a BIMS of 2 (severe cognitive impairment); *Required extensive one-person assistance when eating; *Experienced significant weight loss over the previous 6 months; *Provided a mechanically altered diet; *Held food in the mouth/cheeks when eating; and, *Experienced coughing/choking during meals. The July 2015 ADL Care Plan documented the resident required extensive assistance with eating (initiated 11/20/14). The Nutrition Care Plan (initiated 11/21/14) documented the resident was at nutritional risk related to poor intake-dysphagia, decreased cognition-decline . and documented the interventions as: *Honor food preferences within meal plan (initiated 11/21/14); *Provide small portions (initiated 11/21/14); *Monitor for changes in nutritional status (change in intake, ability to feed self, unplanned weight loss/gain .) (initiated 11/21/14); *Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake (initiated 11/21/14); *Provide diet as ordered (initiated 11/21/14); *House supplement as ordered (initiated 11/21/14); *Encourage patient to come to dining room for meals (initiated 11/21/14); *Offer/encourage fluids of choice (initiated 1/13/15); and *Weigh monthly and alert dietitian and physician to any significant loss or gain (initiated 3/31/15). The June 2015 Physician Recapitulation orders documented: *Chart amount of meals taken, if 50% of meal not consumed offer substitution (started 11/14/14); and, *Weigh every day shift every 1 month on the 1st day . (started 12/1/14); *Regular/liberalized diet, dysphagia puree texture, thin liquids (started 1/12/15); *House supplement with meals (started 6/16/15). The 4/22/15 Speech Therapy Discharge Summary documented, Puree texture remains the safest and most efficient diet for this resident; however, she can tolerate dysphagia advanced items on special occasions (i.e. cake with activities) with supervision, setup, and ample time. Setup should include cutting items into small pieces and/or adding moisture to dry items; supervision should include watching for pocketing or inability to chew a bit after a while, then she should be encouraged to drink liquids and/or spit the item out to avoid choking hazard. Resident should be routinely encouraged to alternate liquids and solids with all po (oral) intake. The interventions documented in the speech therapy plan were not documented in the care plan. Refer to F280 for more details. Further, these recommendations were not clearly communicated with the care team; if the resident preferred solid food to pureed food, it could not be determined the resident would recieve assistance per those recommendations. Refer to F309 for more details. The June Weights and Vitals Summary documented on 5/1/15 and 5/4/15 the resident was 126.5 lbs, and weighed 116.5 lbs on 6/1/15. On 6/15/15, the resident weighed 114 lbs. The resident lost 10 lbs in 31 days, a severe weight loss of 7.9%, then 15 days later had lost another 2.5 lbs. The 6/16/15 Nutritional Assessment documented the resident had a 9.8% weight loss in one month, indicated significant weight loss, and documented there was no previous weight loss trend. It summarized, Pt (patient) has had sig (significant) weight loss of 9.8% over this last month, from 126.5lbs to 114 lbs with BMI at 19.6 normal weight. Pt is on puree diet and assisted with all meals in DR (dining room) . This Nutritional Assessment went on to document unintended weight loss was related to decreased intakes with decline/advanced age. It calculated caloric needs for the resident as 1,953 calories a day and indicated the resident's intake was not meeting this caloric need. Interventions for the significant weight loss included adding a house supplement to the breakfast meal, encouraging intakes of more than 50% (and offering a substitute if not), and offering snacks between meals. This assessment did not address why the resident lost 10 lbs in 1 month (changes in the resident's intake status, if there was an underlying medical cause of the weight loss, etc.). On 7/17/15 at 8:45 a.m., during interview with the Dietician, she stated monthly weights were taken the 1st through 3rd day of the month, then re-weights are taken the 4th and 5th. These weights were then reviewed by the Dietician for all residents each Thursday. According to this process, review of the significant weight loss should have been completed 6/11/16; however, the assessment was completed done until 5 days after this date. On 6/18/15 a faxed notification documented the MD was notified of a weight loss of 23 lbs (16.8%) over 6 months and 14.5 lbs (11.3%) over 3 months. The physician's response was documented as, okay. The June 2015 ADL record documented 8 instances the resident refused meals and 9 instances the resident ate 25% or less of a meal (90 meals offered in June 2015). It also documented the resident refused the bedtime snack 25 of 30 times it was offered. It could not be determined from the medical record why the resident refused meals or snacks, or if the resident was offered more food when she did not eat more than 50% of the meal, as physician ordered. On 7/17/15 at 8:45 a.m., the Dietician was interviewed about Resident #4's severe weight loss in June. She stated the decreased weight loss documented on 6/1/15 (116 lbs) was first reviewed on 6/16/15 (15 days after significant weight loss was identified). She confirmed interventions included increased house supplement three times a day, monitoring intakes, and continuing the current interventions (encouraging snacks between meals). When asked why the resident was refusing the HS snack, she stated she did not know. She stated additional calories were added to her diet, but confirmed this was not documented in the resident's medical record. She also stated it was not documented if the resident was offered more food when meal intake was less than 50%. She stated the resident is expected to lose weight because of aging, however clinical documentation of this could not be determined. On 7/17/15 at 11:24 a.m., the Dietician stated the MD was notified once of the weight loss in June and his reponse was okay. She stated the family was notified but that is the extent of involvement from the MD and family. The resident was harmed when she experienced a 7.9% weight loss in 1 month, wasn't re-assessed following this event for 15 days, and lost another 2.5 lbs during this time period. In addition: * The assessment documented there was no previous weight loss trend, yet the assessment did not attempt to determine possible reasons (e.g. decreased meal intake, refusal of snacks, decreased physical function, underlying medical condition) for why the resident experienced a severe weight loss in one month; * Physician and family involvement in slowing or reversing the severe weight loss was minimal; * The etiology of the weight loss was documented as aging/decline without investigation or clinical documentation of this conclusion; * Physician notification did not occur until 17 days after the weight loss was discovered; and * The facility failed to assess or determine why the resident refused snacks or whether additional food was offered with consumption was measured at less than 50-percent. It could not be determined if the resident's meal intakes would have improved had solid foods, rather than pureed textured foods, were offered as this information was not communicated by Speech Therapy to the Care Team (refer to F309) and Speech Therapy recommendations for high-caloric interventions, and offering more food with decreased meal intake were not documented in the Care Plan (refer to F280). On 7/17/ at 6:30 p.m., the Administrator and DON were notified of this issue.

Based on observation, record review, and staff and resident interview, it was determined the facility failed to provide necessary care for residents at risk for developing pressure ulcers. This was the case for 2 of 4 (#2 & #5) sampled residents reviewed for pressure ulcers. The deficient practice caused harm to Resident #5 when the facility failed to implement interventions to prevent the resident from developing a stage III pressure ulcer to his right heel. Resident #2 did not have a pressure reducing cushion in his wheelchair as care planned. Findings Include: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE], documented: *BIMS score: 12, cognition moderately impaired. *Rejection of cares: No, behavior not exhibited *Bed mobility, transfers, dressing, toilet use, personal hygiene and bathing - Extensive 1 person assist for *Eating: Independent set up only. *Functional limitation in Range of Motion: Upper extremity, impairment on one side. Lower extremity, impairment on one side. *Urinary continence: Occasionally incontinent. *Bowel continence: Frequently incontinent. *Risk of Pressure Ulcers: Yes *Unhealed pressure ulcer- Stage 1 or higher: No. The resident's Significant Change MDS dated [DATE], was the same with the following exceptions: *BIMS: 8, cognition moderately impaired. *Bed mobility, transfers, dressing and toilet use: Total 2 person assist. *Personal Hygiene: Limited 1 person assist. *Urinary continence: Frequently incontinent. *Bowel continence: Always incontinent. *Unhealed Pressure ulcer Stage 1 or higher: Yes. *Number of unstageable pressure ulcers ...1. *Pressure ulcer length: 6.0 cm (centimeter). *Pressure ulcer width: 7.5 cm. *Pressure ulcer depth: (blank) *Skin and Ulcer treatment: Check all that apply; A. Pressure reducing device for chair. B. Pressure reducing device for bed. C. Turning/ repositioning program was not checked as implemented. The resident's Braden scale- For Predicting Pressure Sore Risk documented: -10/3/13: 19, "Mild Risk: Total score 15-18." -1/19/14: 13, "Moderate Risk: Total score 13-14." -1/30/14: 17, "Mild risk." The resident's care plan documented: *Focus: "Potential for unavoidable skin breakdown...Blood blister to right heel with debridement on 1-8-2014 to reveal unstageable pressure ulcer." *Interventions: -"Elevate heels off of bed with pillows as resident allows." Initiated 5/30/13 Revised 1/17/14. -"Use draw sheet for lifting and repositioning." Initiated 5/30/13 -"Assist to turn and reposition as needed." Initiated 5/30/13 -"Pressure reducing/relieving devices as ordered." Initiated 5/30/13 -"Weekly skin assessment." Initiated 5/30/13 -"OT (Occupational therapy) eval(uate) and treat related to decreased PO(by mouth) intake and need for built up utensils." Initiated 11/8/13 -"OT recommends use of built up utensils to promote self-feeding (and) (increase) nutritional intake." Initiated 11/25/13 -"NP (Nurse Practitioner) notified of ADL decline - new order for labs." Initiated 12/9/13 -"treatment of [REDACTED]." Initiated 12/11/13 -"MD ordered treatments to pressure ulcer right heel." Initiated 1/8/14 *Focus: "Self Care Deficit ... " *Interventions: -"Adjust level of care according to individual needs and report persistent changes to physician and family." Initiated 7/26/13 -"Nonslip footwear when OOB (out of bed)." Initiated 10/25/13 "To L(left) foot until ulcer resolved (and) boot removed." The second section of this intervention was hand written and did not have an initiation date. -"Res.(ident) may not always be able to make needs known staff to anticipate and meet his needs." Initiated 10/25/13 - " W/c(wheelchair) as primary means of locomotion on and off the unit self/staff propelled." Initiated 10/25/13 * Focus: "I have potential for chronic/progressive decline ... " *Interventions: -"Use verbal and physical prompts so that I will be able to remember what to do when asked." Initiated/Revised 5/30/13 *Focus: "Risk for falls ... *Interventions: -"Concave mattress to define edge of bed." Initiated: 10/6/13 *Focus: "Alteration in Skin Integrity r/t: Foot ulcer." *Interventions: (All initiated 2/21/14) -"Administer medications as ordered." -"Weekly wound measurements." -"Daily foot care and observe for s/s (signs and symptoms) of infection." -"Inspect and monitor feet for redness, [MEDICAL CONDITION], open area or injury. Report any abnormal findings to physician." -"Monitor for s/s of pain and administer pain medication as ordered." -"Weekly skin assessment per protocol." *Focus: "Potential for decline with ambulation." *Interventions: -"FYI:(for your information) wound on lateral aspect right heel. When working with res(ident) take heel cushion off and put grip sock on right foot and shoe on left." Initiated 2/21/14 Behavior Monthly Flow Sheets for November 2013 through March 2014 documented the resident had a few behaviors related to throwing things, being " jittery " and threatening to leave in November with no behaviors exhibited after that. The flow sheets did not identify or track any behaviors related to the refusal of care. The resident's TAR (treatment administration record) dated November, December 2013, January, February, and March 2014, documented the resident was provided: *Float heels with pillows while in bed. Start date: 5/29/13. The Interdisciplinary Team notes (IDT), Nurse Practitioner Wound Clinic (NPWC), facility Skin Nurse Skin Integrity report (SNIR), SN IDT note, MD orders, Resident's TAR, Labs, documented: *IDT Notes from 9/1/13 through 12/4/13 noted no significant change in condition related to [MEDICAL CONDITION], complaints of pain, the presence of wounds, etc. A 10/12/13 night shift note documented the resident had a " pressure reducing device for bed " which was not identified and the resident was " not " on a turning schedule. *IDT: 12/7/13 Nsg, "Res(ident) (with) some weakness this AM when being assisted out of bed(crossed out) chair. 2 CNA's were attempting to stand res(ident), who is usually a 1 person assist. CNA's were unable to hold all of resident's wt.(weight) (and) he had to be lowered to the floor. (No) injuries occurred." *IDT: 12/8/13 4:35 am Nsg, "Staff states res. (increase) in confusion. Example: Resident was attempting to bite plate and eat it at dinnertime. Staff also state Resident has had a great change in strength; no longer able to assist him one person transfers. Will cont. to monitor." *IDT: 12/8/13 5:00 pm Nsg, "140/90, R(respirations)-24, P(pulse)-92, T(temperature)-99.9, O2 (oxygen saturation) 96% RA (room air). PERRLA (pupils equal, round, reactive, light accommodation), (heart) RRR (regular, rate and rhythm), Lungs diminished (at) bases, B.S.(bowel sounds) x 4, abd(abdomen) soft non tender, Resident 'Shivering and unable to warm up,' notified N.P. of (change) of condition,... N/O(new order) CXR (chest xray), CBC (complete blood count), CMP (comprehensive metabolic panel) and ammonia. *IDT: 12/9/13 5:00 am Nsg, "..T 99.6... Labs drawn, except UA(urine analysis) not obtained. Attempted to arouse resident, would not awaken. Resident has been asleep since 1900(7:00 pm). Will attempt to obtain UA again. Cont. to monitor for (changes) in condition." A change in condition was noted; however, the care plan was not modified to address these changes including a plan for more frequent repositioning *NP visit: 12/9/13, "Following up with the patient who over the weekend had a change in condition. He exhibited some increased confusion and generalized weakness, had to be helped lowered to the floor. He did have fever and some diminished breath sounds. Chest xray was obtained, negative for any pneumonia or pneumothorax. We did obtain also some blood work which shows slightly elevated white count at 12.9 and elevated ammonia at 46. In speaking with (resident) today, he notes that he is feeling ill, just kind of crummy, but nothing specific. He did have a slight headache. He is not necessarily having any trouble breathing or pain anywhere. His appetite has been slightly poor over the last few days. He just wants to stay in bed. His wife is at his side, has not noticed any specific changes other than just not feeling well." *Examination: -General: "The patient is lying in bed. He is alert and makes eye contact to answer questions, but generally seems sedate. Appears in no physical distress." Musculoskeletal: "No [MEDICAL CONDITION] to lower extremities." *Assessment and Plan: "Fever, very mild at 99." "Concern is for an infection. Will go ahead and get a urine sample, rule out urinary tract infection. He has had some generalized weakness and confusion. We have safety measures in place to ensure that he does not fall and with the elevated ammonia level will go ahead and start him on some [MEDICATION NAME]." *IDT: 12/9/13 3:00 pm Nsg, "N/O start [MEDICATION NAME] 30 ml(milliliter) Q.D. (every day), CBC, CMP, ammonia 12/13/13." *IDT: 12/11/13 2:30 am Nsg, "T-98.1 O2 91% P-90 R-18 BP(blood pressure) 138/72. No adverse effects to [MEDICATION NAME] noted. Res. was alert but confused per baseline. *IDT: 12/11/13 2:30 pm Nsg, "98, 126/80, 73, 18, 93% RA (No) s/sx(sign/symptoms) ADR (adverse drug reaction) to [MEDICATION NAME]. Res very tired this shift, (increase) weakness requiring more assistance from staff ... No anxiety, agitation noted... *IDT notes for12/12-21/13 documented the resident continued on antibiotics for a UTI and spent time in bed in the afternoon and slept through the night. Neither the notes nor the care plan address how often he is repositioned. Nor do the notes address any redness or bogginess of the heel prior to 12/23/13. *IDT: 12/23/13 5:45 am, Nsg, "(No) latent s/s of ADR to Abx for UTI. Iodine (and) [MEDICATION NAME] applied to (right) heel for Blood Blister, will cont. to monitor for changes. resident has had (no) c/o pain/discomfort (with urination r/t UTI." *MD order: 12/23/13, Change in patient status / purpose of fax: "Blood blister to (right) heel. Iodine (and) [MEDICATION NAME] until resolved?" Physician order/response: "Ok- elevate heels in bed, foot/heel protectors" The order did not give parameters for frequency of the dressing change. The new order for foot/heel protectors (both heels) had not been added to the care plan. During the survey the resident was observed with a heel protector on the right foot not on the left foot (see observation below). *IDT: 12/25/13 4:20 am, Nsg, "Dsg (changed) to (right) heel as per order." The 12/25 IDT note was the first note after the blood blister was documented on 12/23 at 5:45 am, which was approximately 48 hours later. The IDT note did not document an assessment to the right heel for 12/24. *TAR: The resident's December TAR documented a 15 pound (#) weight loss. The resident weighed 261# on 12/23 and 246# on 12/30/13. The TAR documented skin checks done on the night shift with skin intact on 12/3, 12/10, and 12/17 and not intact on 12/24. *NP: 1/6/14, "Did have a change in condition with regards to an infection. This was treated. He has recovered quite nicely. He does have an ulceration on his right heel from a blister that popped. This is healing nicely. Followed by our nursing staff and wound care team. In speaking with (resident's name) today, he notes that he is doing well. He is not having pain anywhere except for on his heel when he hits it just right. Denies any trouble breathing, that his appetite has been excellent. He thinks he has lost about four pounds which he is okay with." *Examination: Musculoskeletal- "No [MEDICAL CONDITION] to lower extremities. Right lower extremity with wound wrapping in place and Prevalon boot." *The IDT notes did not document the status of the resident, or the wound from 12/25 to 1/7/14. The NP documented the wound was healing nicely; however, there was no evidence that it was measured or assessed to identify if it had gotten better or worse. *SNIR: Initial Date: "1/8/14" -Initial Status: "IHA" (In house acquired). -Stage: "U" (Unstageable). -Circle Primary Type of Wound: "Pressure" *SN IDT: 1/8/14 12:00 pm, Nsg, "Wound note. Res seen by wound team for (right) heel. Wound measuring 6 cm x 7.5 cm ( with) min(imal) SS(serosanguinous) drainage. Wound NP debrided escar tissue. Wound bed is 20% escar (and) 80% dermus (with) healthy wound edges (and) healthy surrounding tissues. D/C current treatment orders, start clean (with) wound cleanser, apply Santyl to escar tissue only, and cover (with) a foam dressing to entire wound daily. Wound team will cont. to follow. This is the first documentation of the size of the wound which measured 6 cm x 7.5 cm, 12 days after the wound was first documented on 12/23, and the first time the SN had documented on it with the NPWC. The treatment which was initially ordered on [DATE], and not clarified as to how often the dressing was to be changed, was changed on the first visit of the NPWC. *NPWC: 1/8/14, Chief Complaint: "Right lower extremity deep tissue injury." Subjective: "He now has developed a deep tissue injury to his right lower extremity... Once it was noted that he had a deep tissue injury, they have attempted to utilize a Prevalon boot. The patient has apparently refused that as well. Today he has an area of eschar at this right heel and some necrotic callus. Extremities: "The patient's right heel has an area of concern that measures 6.0x 7.5 cm x surface. It is about 10% eschar and 90% necrotic callus. There is no obvious open area. The periwound area is clean, dry and intact. There is no discharge." -Plan: "Unfortunately, the patients dietary issues combined with his history of dementia makes him high risk for developing wounds such as these. Due to some refusal of offloading, his poor intake and his inability to comply with positioning, this wound was unavoidable. I do believe we can heal this quite nicely and in fact I utilized a 5 mm (millimeter) curet to remove much of this callus. I did get into some bleeding subcutaneous tissue but the majority of the tissue that I see is still dermal tissue. I was able to remove some surface eschar from a small area; however, much of that eschar still remains. We will utilize Santyl to the eschar area, cover the remainder of the wound area and try to keep a moist wound healing environment. I spoke with the patient at length regarding offloading and diet issues. Recommend we use Prevalon boots and keep his heel floated at all times. The patient reports his understanding. We will continue to work with him and follow him weekly and p.r.n." The NPWC documented the resident, "apparently has refused to have heels floated." However, there was no evidence of this in the medical record and the care plan did not address refusals or attempts to find an alternative if the resident did refuse to have his heels floated. *NPWC: 1/14/14, Objective : Extremities: "Right heel wound laterally measures 3.2 x 2.1 x 0.2, it is 100% eschar. Periwound area is clean, dry and intact. there is no periwound [DIAGNOSES REDACTED] or induration. there is mild amount of discharge, no odor." Plan: "Continue to offload, continued to treat with Santyl." *MD order: 1/15/14: Change in patient status/ purpose of fax: "Res has an order to ensure res walks to meals. Res. does not amb(ulate) (at) this time d/t (due to) decline/weakness. Also has a wound to (right) heel (and) is non wt(weight) bearing (at) this time. May we d/c (discontinue)? Thanks!" Physician order/ response: "OK." The facility obtained an order to discontinue the resident's walking program to meals, due to his decline and was non weight bearing due to the pressure ulcer he had acquired in December. *IDT: 1/17/14 2:20 pm, Nsg, " Res. frequently crosses legs (at) ankles and prefers this positioning. Floating heels has been done (with) resident (and) frequently he reverts back to crossing legs. Res. utilizing prevalon boot currently. N.O.(new order) PT/OT eval (and treat) received this wk (week) to promote strength. Res. has been unable to participate in walk to dine d/t physical inability. Spouse frequently brings snacks to res. and reminds him to (not) cross legs." *NPWC: 1/22/14, Subjective: " ...developed a heel ulcer due to some confusion and inability to offload himself. Once this area was discovered, we have had excellent progress in healing this. It has been offloaded appropriately with the Prevalon boot with aggressive wound care. The patient has improved dramatically. There was 1 large wound that is now down to 2 smaller wounds. There is no fever or chills." Extremities: His left heel wound is now 2. The medial wound is 2 x 1 x essentially less than 0.51 with 100% granulation tissue. Periwound area is new epithelium. The lateral wound is 1.5 x 2.4 x essentially surface. It is very thin loose slough. Periwound area is new epithelium. there is mild amount of serosanguineous drainage, no odor." With the treatment and the use of the Prevalon boot, which was implemented after the pressure ulcer developed, the wound was noted to be healing. The NPWC documented the wound to be the left heel, with no other documentation of left. Documentation had been on the right heel, prior to and after this. *NPWC: 2/12/14, Objective: Extremities: Right lateral heel has a wound that measures 2 x 2 x 0.3, 95% slough in the wound bed, 5% granulation tissue. Periwound area is slightly macerated." Assessment: "Pressure ulcer of the right heel, unstageable." Plan: "Likely this will be a Stage III." I recommend we continue offloading with Prevalon boots and monitor him weekly." *NPWC: 2/26/14, Objective: Extremities: "The patient has mild lower extremity [MEDICAL CONDITION]. His right heel wound measures 1.8 x 1.6 x 0.5. It is 100% slough in wound bed." Plan: "Due to the amount of slough in the wound bed, I did elect to sharply debride. Postdebridement measurement is 1.8 x 1.6 x 0.5." *IDT: 2/26/14 3:00 am, Nsg, "Res. Found sitting on floor at 0015." 1/2 bilateral side rails and non-skid socks were in place at time of fall. Note: It was documented that the resident had non-skid socks in place, not Prevalon boots. *NPWC: 3/5/14, Objective: Extremities: "Right heel lateral aspect wound measures 1.7 x 1.0 x 0.2. Wound bed is 50% granulation, 50% adherent slough. " Assessment: "Right heel pressure ulcer, unstageable." Office Progress Note: Plan: "Recommend we change this from Iodosorb to [MEDICATION NAME] AG to the wound bed, cover dressing and continue to offload as we have with Prevalon boot and frequent turning due to his improvement in his overall condition. We are reversing his change in condition to reverse the unavoidable, as I stated previously, he is improving and he is continuing to heal nicely... " *NPWC: 3/26/14, Subjective: "(Resident's name) has a stage 3 pressure ulcer. It has historically been improving over the last few weeks; however, we are having some moisture balance issues today. It is a little bit damp with some maceration." Objective: Extremities: "His right lateral heel wound measures 1.5 x 2 x 0.4, 20% granulation tissue in the wound bed." On 4/7/14 at 1:35 pm, the surveyor observed the resident seated in his w/c beside his bed. The resident had a blue boot on the right foot and the left foot had a black shoe on it. On 4/7/14 at 2:05 pm, the surveyor observed the resident in bed. The resident had a blue boot on the right foot and the left foot had a beige colored anti-skid sock on it. The resident's heels were not floated and the left foot did not have a heel protector. On 4/8/14 at 8:00 am, the surveyor observed the resident in bed, on his back. The resident's right foot had a blue boot on it. The left foot was bare, and both heels were directly rested on the bed. The resident was asked how he thought he had gotten the sore on his right heel. The resident stated, "I don't know, they say it was from crossing my leg and putting pressure on it. It hurts when I walk on it, so I don't walk on it as much. It's healing from the inside out." The resident was asked how often the dressing was changed and if the boot bothered him and he replied, "Once a day. No it doesn't bother me." The surveyor clarified with the resident why he only had 1 boot on the right foot and asked him if it would bother him to have a boot on both feet, the resident answered, "Nope." CNA #11 and CNA #18 provided morning cares for the resident. When the boot was removed from the right foot the heel had a dressing in place. CNA #11 attempted to put the resident's beige non-skid socks on his feet and stated, "This sock is too tight I am going to get a little bit bigger one." CNA #11 left the room and returned with a pair of gray non-skid socks, which were put on the resident, with a blue boot to the right foot and a black shoe to the left foot. On 4/8/14 at 10:35 am and 11:15 am, the surveyor observed the resident seated in his w/c in his room. The resident's right foot had a blue boot on it and the left foot had a black shoe on it. On 4/8/14 at 12:40 pm, the surveyor asked LN #20 what he knew about the development of the pressure sore to the resident's right foot. The LN stated, "I don't know much about it. I worked the night shift til 3 weeks ago. From what I have seen it looks like it is getting better. They have changed the dressings because it was too wet. He doesn't complain about pain when I ask him." On 4/8/14 at 2:02 pm and 3:00 pm, the surveyor observed the resident in bed on his back, with the blue boot on the right foot and a gray non-skid sock on the left foot. The heels were directly on the bed. On 4/8/14 at 3:10 pm, the surveyor asked the SN if the MD order for the resident's heel protectors were for 1 boot or for 2, she stated, "I think there should be orders for both." The surveyor and the SN observed the resident in bed. The SN verified both feet were on the bed, with the blue boot on the right foot and the gray nonskid sock on the left foot. The SN stated, "I thought the left should be floated. I will have to look." The SN was asked if she thought it was ok that the feet were not floated as ordered, and she stated, "No, they should be floated, both of them." The SN checked the resident's TAR and stated, "He has an order for [REDACTED]." On 4/9/14 at 8:42 am, the surveyor observed the resident seated in his w/c by the nurses station. The right foot had a blue boot on and the left foot had a black shoe on it. The surveyor asked the resident how his foot was, he stated, "Not too bad today. They are going to come and change it today." The surveyor stated that's good and the resident stated, "Yeah, will be good to get this boot off and a shoe on so I can walk some." On 4/9/14 at 9:17 am, the surveyor met with the DON and CMO. The surveyor asked them what interventions had been put in place to prevent skin breakdown when the resident became acutely ill in December. The DON stated, "We noticed a decline starting in November. He had difficulty with self-feeding. He was moved to an assist table. His wife came in to help feed him and brought him food." The surveyor asked how did you change the physical care of the resident when you identified he had begun to decline? The DON and MCO did not respond. The CMO and DON were asked why the resident had 1 blue boot instead of 2, and the DON stated, "I don't know if at one point he had 2 boots." The surveyor asked if the boots were on the care plan, she stated, "They are not, I already checked it." The surveyor asked about the resident's rejection of cares and no behaviors since November, and the DON stated, "He is definitely doing a lot better." The DON and MCO were asked about the care plan that stated "as needed" for repositioning, the DON and MCO did not respond. The surveyor asked why the care plan related to offload heels was written for, 'as the resident allows', the DON stated it was because, "He moves his feet." On 4/9/14 at 9:45 am, surveyor observed LN #22 change the dressing to the resident's right heel. The LN asked the resident if he was having pain, the resident stated, "No." The left foot had a gray nonskid sock on and was floated on a folded pillow under the left ankle. The right foot had a blue boot on and was directly on the bed. The right heel did not have a dressing on it, LN#22 stated, "It fell off in the shower this morning." The LN was asked what she thought might have caused the pressure ulcer and stated, "It was the way he was resting it on his foot pedal." On 4/9/14 at 2:25 pm, 3:15 pm and 4:52 pm the surveyor observed the resident seated in his w/c with his right foot in a blue boot and the left foot had a black shoe on it. On 4/9/14 at 3:00 pm, the DON stated to the surveyor, "We are still looking at (resident's name), the regulations and the guidelines. We recognized the decline. I don't feel it happened in December. His bed mobility did not change, they are still providing assist." The surveyor stated the concerns of the skin breakdown prevention, not being care planned, or changed when the decline occurred, whether in October or in December when he became acutely ill. The surveyor asked the DON, what new interventions for the skin do you have, the DON did not respond. On 4/10/14 at 8:57 am, the surveyor observed the resident in bed, eating breakfast. The resident had blue boots on both feet, with a pillow under his feet, with the heels directly on the pillow, not floated. The surveyor asked the resident how he liked the new boots, and he stated, "Wonderful, that heel will get better." On 4/10/14 at 9:10 am, the surveyor and the DON went into the resident's room and observed the resident's heels. The DON agreed the resident's heels were on the pillow and not floated. On 4/10/14 at 3:55 pm, 2 surveyors met with the Administrator, DON and CMO. The Administrator presented the timeline of the resident from admission to the facility. During the presentation the Administrator stated the resident was "Placed on a multi-layer Visco mattress when he was admitted ." The surveyor asked about the intervention of the mattress being changed to a concave mattress d/t to falls in October. The DON stated "I am sure he is on one of our new facility mattresses." The Administrator stated, "From May 2013 through December 2013 the resident went without skin issues. During his entire medical stay his conditions have fluctuated d/t multiple comorbidities. There were no changes made directly to his plan of care related to his decline as it was not needed during the first part of December." The surveyor asked, at what point during a resident's decline do you start to make changes on a care plan, and the MCO stated, "So you are looking for a physical intervention, because I think there was a lot of medical interventions." The MCO stated, "He(resident) even told me that he moves his feet too much to float his heels with a pillow. How can it be pressure in bed if he is moving his feet." The surveyor stated, if he is constantly moving his feet maybe there is an element of friction, and the CMO stated, "I thought friction doesn't count for pressure sores." The facility identified the resident had a decline in his meal intake in November 2013 and implemented built up utensils. In December 2013 the resident had declines in ADL's with increase confusion and behaviors and the development of a UTI. The resident's care plan for skin break breakdown which was initiated when the resident was admitted was not revised until 1/17/14, which was 17 days after the resident developed the pressure ulcer. The care plan did not document changes in interventions to accommodate the resident's decline, or any refusals, to protect the resident's skin from breakdown. The Care plan's intervention of turn and reposition, initiated 5/30/13, had no parameters and had not been implemented, per staff documentation on 10/12/13 and the MDS's dated 11/18/13 and 1/8/14. The record did not document the resident had been informed of the possible consequences of skin breakdown when interventions were refused, prior to the NPWC discussion with him on 1/8/14, which was after the development of the pressure ulcer on 12/23/13. Observations at the time of the survey revealed the resident's heels were not consistently floated and the left foot did not have a heel protector as ordered on [DATE]. 2. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #12's most recent quarterly MDS assessment, dated 3/23/14, documented in part: * Intact cognition with a BIMS of 13; * Extensive assistance needed with 1 person for bed mobility, transfers, eating, personal hygiene and bathing; * Totally dependent with 1 person for toilet use and locomotion on and off the unit; * At risk for pressure ulcers; and, * One stage 2 pressure ulcer present upon admission. March 2014 recapitulated physician's orders [REDACTED]. * "Float heels with pillows in bed as resident allows;" * "Pressure reducing mattress to bed;" * "Pressure-redistribution cushion to chair;" * "Repositioning, showering and lying down education by LN to resident every shift. - Night Shift, Day Shift Everyday;" * "Skin at risk assessment-Check skin completely. Is skin intact? Y/N (Yes/No) - Day Shift Specific days of week: Wed(nesday);" and, * "WOUND TO LEFT COCCYX. CLEAN WITH WOUND CLEANSER AND APPLY FOAM DRSG Q (Dressing every) 3 DAYS. - Night Shift Everyday." Resident #12's March 2014 Care Plan documented in part: * Focus - "Resident has impaired skin integrity r/t (related to) pressure ulcer to coccyx secondary to: nutritional deficit, immobility, non-compliance with therapeutic regime;" and, * Interventions - "...Document on flow sheet: mark "Y" (Yes) - skin intact. Mark "N" (No) - skin not intact; Monitor healing process and notify MD and responsible party if no improvement. Change treatment as indicated; Weekly skin assessments and measure pressure ulcers." A Nursing Assessment form completed on 3/11/14 documented on a body diagram Resident #12 had a 1 cm (centimeter) by 1 cm open wound to the left buttock. Interdisciplinary Progress Notes for Resident #12 on 3/11/14, "...Open area on Lt (left) buttock 1cm x (by) 1 cm...;" and on 3/26/14, "Wound Note. Lt buttock wound on admit measured 1 cm x 1 cm stage 2 (with) orders for [MEDICATION NAME] (with) a cover of [MEDICATION NAME] Q (every) 3 days. Res.(ident) seen by wound nurse today. L (left) buttock has superficial wound measuring 1 cm x 0.7 cm (with no) depth (and no) drainage at this time, healthy edges (and) surrounding tissues. D/C (discontinue) current drsg (dressing changes and) start: L buttock clean (with) wound cleanser, apply [MEDICATION NAME] to wound bed and cover (with) border gauze, Daily (and) PRN (as needed). Will cont(inue) to monitor. Educated res. on being in bed (and) off loading left buttock as much as possible between meals (and) smoke breaks." The March 2014 Treatment Administration Record (TAR) for Resident #12 documented the left buttock wound orders were implemented as ordered. The skin at risk assessments were completed as ordered and documented the skin was not intact. Interdisciplinary Progress Notes for Resident #12, dated 4/5/14, documented in part, "...pt. got tx (treatment) to coccyx/buttocks (at) 2300 (11:00 p.m.) for wound. Cleansed (with) wound cleanser, applied [MEDICATION NAME], skin prep (and) island gauze drsg. (No) drainage from site. (No) drsg was on prior to tx (treatment)." The April 2014 TAR for Resident #12 documented skin at risk assessments were completed as ordered. The skin assessment dated [DATE] documented the skin was not intact. The skin assessment dated [DATE] documented the skin was intact. On 4/10/14 at 1:55 p.m., LN #4 was asked if she had any skin assessment sheets or pressure ulcer sheets for Resident #12's pressure ulcer. She stated, "I don't have anything." On 4/10/14 at 2:00 p.m., LN #5 was asked if she had seen the left buttock wound on Resident #12 since she had documented 4/9/14 the skin was intact on the skin at risk assessment. She said she had not seen the wound for a while but the night nurse reported there was a layer of skin over the wound. On 4/10/14 at 2:05 p.m., Unit Manager (UM) #6 was asked how the wound nurse was notified of

Based on observation, interview, and record review the facility failed to develop and implement systems to prevent pressure ulcers, to accurately identify and document occurrence of pressure ulcers, and to ensure timely and accurate assessments of pressure ulcers. The facility did not provide timely physician notification of new or worsened pressure ulcers and failed to obtain pressure ulcer treatment orders form the physician. This was true for 2 of 4 residents, #s 3 and 29, reviewed for pressure ulcers that developed at the facility. 1. The facility failed to inform the physician about a pressure ulcer for 8 days and Resident #3 subsequently developed an unstageable pressure ulcer, which constituted actual harm; and 2. The facility failed to implement treatment and preventive measure when the facility was aware Resident #29 disturbed a callous on her heel exposing vulnerable fragile skin. Resident #29 developed a full thickness pressure ulcer on her heel, which constituted actual harm. Findings included: The State Operations Manual (SOM) Appendix P defines pressure ulcer as any lesion caused by unrelieved pressure that results in damage to the underlying tissues. Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. The SOM also defines an "avoidable" pressure ulcer as the development of a pressure ulcer when the facility did not evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that were consistent with resident needs, goals and recognized standards of practice; monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate. The National Pressure Ulcer Advisory Panel (NPUAP) defined pressure ulcer stages as: * Stage I - Intact skin with nonblanchable redness * Stage II - Partial thickness pressure ulcer with partial thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister * Stage III - Full thickness tissue loss * Stage IV - Full thickness loss with exposed bone, tendon, or muscle. * Unstageable - Full thickness loss in which depth of the ulcer is completely obscured by slough and/or eschar (dead tissue). Until enough slough and/or eschar are removed to expose the base of the wound, the true depth of the wound cannot be determined, but it will be either a Stage III or IV. A suspected deep tissue injury is characterized by purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated [DATE], documented the resident had a dime sized blister/pressure ulcer on her coccyx. The resident's admission MDS assessment, dated [DATE], documented the resident required extensive assistance of one to two people for bed mobility and transferring; was at risk for skin breakdown and had a Stage I and a Stage II pressure ulcer present on admission. The resident was triggered for skin and ulcer treatments including a pressure reducing device for the bed, turning/repositioning program, and ulcer care. The corresponding care plan, dated [DATE], indicated Potential for Skin Breakdown related to, "decreased independent mobility, B&B (bowel and bladder) incontinence and Alteration in Skin Integrity related to, blister to coccyx X(times) 2 along with redness, bruises, and scratches." Interventions included: * Turn every 2 hours as resident allows, document on TAR, * Keep skin clean and dry, * Pressure relieving devices as ordered, * Provide pericare after each incontinent episode, * Report new open areas to LN, * Document if skin is intact on flow sheet, and * Weekly skin assessments. Although Resident #3 was admitted with a pressure ulcer to the coccyx, his care plan was not updated to include a "LAL (Air) mattress... to provide pressure relief" and to "lay down between meals as resident allows" until [DATE]. On [DATE] the care plan re-enforced, "Monitor for skin breakdown to peri-area with peri-cares - notify floor nurse of any areas of concern." The quarterly MDS assessments, dated [DATE] and [DATE], documented the resident was at risk for skin breakdown but had no, "stage I or greater (pressure ulcers), (no) scar over bony prominences." Review of Nursing Notes (NN), Care Plan (CP), Physician Orders, contained no further documentation of concerns with pressure ulcers between [DATE] and [DATE]. On [DATE], LN #2 documented a 0.1 cm x 1.0 cm coccyx wound that she observed on ,[DATE] that was consistent with the NPUAP definition of a Stage II pressure ulcer. The [DATE] documentation included descriptions of the wound as LN #2 observed it on [DATE] and [DATE]. The [DATE] nursing note further documented, "Area assessed today and noted area measuring 1.5 cm X 1.8 cm edges macerated health skin surrounding center non-blanching discoloration (with) hard tissue felt underneath..." The facility documented weekly skin checks on ,[DATE], ,[DATE], and ,[DATE], which showed the resident's skin was intact. This skin check information did not indicate the Stage II pressure ulcer observed by LN #2 on ,[DATE], ,[DATE], and ,[DATE]. On [DATE], LN #2 documented the resident's primary care physician's office was notified and staff were instructed to refer the resident to the wound clinic and to start treatment with a [MEDICATION NAME] agent. A faxed order, dated [DATE], instructed staff to obtain an OT (Occupational Therapy) evaluation and treatment if appropriate. On [DATE] an OT documented, "(Resident) evaluated in w/c (wheel chair)... continues to sit (with) pelvis posturing tilted. A cushion (with) a coccyx cut out will be trailed." Five days later, the OT documented the cushion was modified with a cutout to decrease pressure to the coccyx area. Resident #3 was visited by the Wound Clinic Nurse Practitioner (NP-C) on [DATE], four days after the referral. The [DATE] wound clinic notes documented the wound now measured 1.5 X 1.4 X 0.1 cm and was "unstageable" with 100% slough in the bed. The NP-C documented, "I believe this was likely a deep tissue injury, it is now evolving into a pressure ulcer. The patient has had excellent preventative measures in place since she was first admitted back in November... such as 2 hour turning, air mattress, 2 hours turning not involving the supine position, barrier cream and frequent skin assessments. Despite all these implementations the patient developed likely a deep tissue injury and this has now progressed to an unstageable pressure ulcer. Due to the patient's history as well as current circumstances I believe this wound is unavoidable." A [DATE] Wound Clinic NP-C note documented, "Unfortunately, with poor protein intake coupled with dementia, this will be very difficult to heal. This may very well worsen. We will continue to follow and try to keep this stable. I will follow-up with this patient in 2 weeks." On [DATE], the Wound Clinic NC-P documented, "(Resident's) wound quality is improved. She has no slough in the wound bed...measures 1.5 x 1.6 x 0.5 cm Wound bed is 100% granulation tissue." On [DATE] the Wound Clinic NC-P documented, "(Resident's) wound is still present. In fact, the wound bed is mostly granulation tissue now. She has progressed to a Stage 3 pressure ulcer...that measures 2.2 X 0.6, 90% granulation tissue and 10% slough." The resident expired on [DATE]. The DNS, Corporate Nurse, and facility Administrator were interviewed on [DATE] at 3:25 PM. During the interview the DNS acknowledged that LN #2 had not documented the resident's skin condition as observed on ,[DATE], ,[DATE], and ,[DATE] until [DATE], eight days after the initial observation of an open area on the resident's coccyx. The DNS stated that LN #2 had texted her on ,[DATE] and ,[DATE] regarding Resident #3's skin issues. The DNS stated that although she assessed the resident's coccyx wound on [DATE], she did not document the observation, notify the resident's physician of the new pressure ulcer, or provide direction to staff concerning the wound. When asked if she had checked the resident's care plan or ensured the information had been passed on to other shifts, the DNS said "No." The DNS later returned with a treatment sheet for [DATE] that documented Resident #2 was turned every 2 hours, positioned off her back beginning on [DATE], and encouraged to lay down between meals, starting [DATE]. NOTE: The resident's physician was not contacted, nor were physician treatment orders procured and implemented for eight days after initial discovery of the resident's coccyx pressure ulcer. When asked if nursing staff had monitored the resident's coccyx between [DATE] and [DATE], the DNS stated the normal semi-weekly skin checks would have been conducted. The discrepancies between the weekly skin checks and LN #2's findings were then discussed. The DNS indicated she was not aware of the discrepancies. On [DATE] the facility faxed additional documentation, however the information did not resolve the concerns. Resident #3, who had a history of [REDACTED]. The LN who made that initial observation did not document the assessment until eight days after making the observation. During this time, two other nurses performing weekly skin checks documented the resident's skin was intact. Additionally, the resident's physician was not notified of the pressure ulcer until [DATE]. Between [DATE] and [DATE], a period of 12 days, the resident's coccyx wound deteriorated from an "open area" that measured 0.1 X 1.0 to an unstageable pressure ulcer that measured 1.5 cm X 1.4 cm with 100% slough. 2. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission nursing assessment, dated [DATE], and MDS admission assessment, dated [DATE], documented the resident was alert and oriented to person, place, time and situation, had poor decision making skills, used a wheelchair independently, and was at risk for skin breakdown, although her skin was intact at that time. The resident's CAA worksheet for pressure ulcers, completed on [DATE], documented the resident had [DIAGNOSES REDACTED]. The resident's [DATE] care plan documented staff were to complete weekly skin assessments. LN weekly skin checks for June, July, and [DATE] documented the resident's skin was intact and Braden Skin Assessments conducted in July and August documented the resident was at no risk for skin breakdown. However, there was no documentation in the NNs or other nursing records that provided a full assessment of the resident's skin condition in relationship to her diagnoses, medications, past history of [MEDICAL CONDITION], or recognized her mobility style. For example, there was no documented assessment of skin turgor, rashes, dryness, calluses, tender or sensitive areas or how the resident accomplished wheel chair and bed mobility or whether her mobility style could create breakdown over pressure points. Nurses Notes, dated [DATE], documented Resident #29 had a 3 cm X 3 cm blister on her left heel. An investigation into the blister documented the resident's daughter told LN #5 on the evening of [DATE] that the resident had picked off a callus from her left heel. The daughter stated there was no blister to the resident's left heel at that time. The resident's medical record did not include any documentation of the daughter's report, or that the resident's left heel had been assessed by LN #5 or any other facility staff on [DATE]. No interventions were implemented to protect the resident's left heel until after the physician had been notified on [DATE] that the callus had been removed and a blister had developed. A NN, dated [DATE], documented a hospice physician was contacted that day and a new orders were received for wound treatment and a consult with the wound clinic. On [DATE] at 2:00 pm, the DNS documented a late entry for [DATE] the, "... resident demonstrated that she pushed self propels (wheel chair) with ... feet by first touching ground with heel ... she demonstrated how she moves herself up in bed ... used both upper extremities, while pushing (with) left leg and left heel into bed ... Raised clear fluid filled blister appears to be (related to) friction/trauma of resident self-propelling (wheelchair), pushing self-up in bed, (Care plan) updated for heel protectors, assist (with) repositioning (and) moving up in bed (every 2 hours) and lotion to (bilateral lower extremities)/feet BID (Twice per day)... Hospice and MD aware of (left) heel." On [DATE] the Wound Care Clinic visited the resident. The NC-P documented, "The patient has an intact blister...left heel blister 3 X 3 cm. She has 1 - 2 + [MEDICAL CONDITION] of her lower extremities bilaterally...Due to large amount of fluid in this blister, I do not believe it will reabsorb. This does need to be removed today. We will go ahead and cover this up with foam dressing. She has been off loaded with padded heel protectors, will continue to do so. I have asked her to increase her protein in her diet and this should likely heal nicely..." Skin Integrity reports dated [DATE] and [DATE] did not stage the wound on the foot, documented there was pain, and measured it as 3 x 3 cm on [DATE] and 1.9 by 2.5 cm on [DATE]. There was no mention of the condition of the resident's right foot in NNs or skin check documents between [DATE] and [DATE]. Resident #29 was observed on [DATE] at 1:45 and 1:55 pm. RN #6 was present during the observation and removed a dressing from the resident's left heel. The foam dressing contained a moderate amount of serous fluid with no odor. A large wound was observed on the resident's left heel with a full thickness of skin missing. The wound measured approximately 4.5 cm by 4.5 cm with irregular, thickened, macerated edges. There was a dime sized puffy, dusky colored spot on the outer aspect of the upper right heel. Resident #29 was alert and oriented to person and place and time of day during the observation. She explained she had picked skin off of her heel and used her heels to push her wheel chair and to help move herself up in bed. Note: A Federal Surveyor, who accompanied the state team, was asked by the state surveyor to do a joint observation of the wound. The Federal Surveyor commented that the wound looked "much larger" than 3 cm x 3 cm. LN #6 was interviewed on [DATE] at 2:00 pm. When asked to describe the wound, LN #6 stated she did not have a lot of experience with this type of wound and didn't really know how to describe it as far as staging and condition. When asked to use regular, everyday terms, LN #6 the heel was open and had yellowish white skin around it. On [DATE] at 2:35 pm, the DON and the facility's wound nurse (LN #1) were interviewed. The wound care nurse was asked when she first saw Resident #29's heel wound. She stated she saw it with the wound care team on [DATE]. When asked if it was unusual for her not to see a new wound for 3 days, LN #1 stated it can take three or four days for her to see a wound, depending on what day of the week it was discovered and other issues. The DNS was asked why the wound was called self-inflicted. She stated because the resident had picked off her own callus which led to the blister and subsequent deterioration. When asked if the resident's skin had been assessed, prior to the discovery of the pressure ulcer, (for dryness, calluses, self-propelling in her wheel chair and repositioning in bed using her heels), the DNS stated assessments other than the weekly skin checks and the Braden scale were not conducted. When asked if the LN who had talked to the resident after she removed the callus on the evening of [DATE] had assessed the skin under the callus or taken any specific measures to protect the newly uncovered skin. The DNS stated, "No." On [DATE] the facility faxed additional documentation, however the information did not resolve the concerns. The facility failed to complete full and accurate assessments of Resident #29's risk for developing skin breakdown and her overall skin condition based on medications, diagnoses, dry and callused skin condition, and using her heels to self-propel her wheel chair and reposition while in bed. In addition, on [DATE], a facility LN was told the resident had picked off a callus from her left heel. The LN did not assess the skin after the callus was removed, nor implement preventative interventions to protect the fragile skin. Subsequently, a blister developed and progressively worsened on the resident's heel. Although aware of the risks for skin breakdown that occurred to the resident's left heel, the facility failed to assess or implement preventative/protective measures for the resident's right heel.

Based on observation, staff/resident interview and record review it was determined the facility did not ensure 2 of 4 residents (#s 7 & 11) reviewed for pressure ulcers did not develop pressure ulcers unless clinically unavoidable. Resident #7 was harmed when he developed pressure ulcers that included a pressure ulcer on the left tuberosity that progressed to a Stage IV, a pressure ulcer to the coccyx that progressed to a Stage IV, and a pressure ulcer to the right hip that developed to a Stage IV. The resident developed subsequent infections to the wounds and experienced pain, and during the survey, was bedfast related to wound healing. Resident #11 developed a Stage II pressure ulcer to his left heel that was not monitored frequently and progressed to an unstageable pressure ulcer with eschar. In addition, 1 of 4 residents (#1) was readmitted to the facility with two Stage II pressure ulcers that were identified and no further care was documented. Findings include: 1. Resident #7 was originally admitted to the facility on [DATE] with [MEDICAL CONDITION] (MS) and diabetes. He was discharged to a hospital for pressure ulcer care on 3/17/10 and returned to the facility on [DATE]. A physician progress notes [REDACTED]. "The patient is seen in followup for multiple pressure ulcers, including bilateral hips, as well as gluteal region. The patient had extensive bedside debridement performed last visit last week, and now we have been utilizing VAC therapy on the sacral ulceration. He continues with nutritional support, and his [MEDICATION NAME] is within normal limits. We have him on a Clinitron off-loading mattress surface..." "Diagnoses: [REDACTED]. 2. Right hip, stage III, now appears to be clinically showing itself as a stage IV pressure ulcer. 3. Left ischial tuberosity ulceration, improved. PLAN: 1. We will suspend the VAC and switch to Santyl to the sacral ulceration to help enzymatically clean up the tissue. We will also use this to the right hip ulceration as well. We will continue with our local wound care modalities to the left IT (ischial tuberosity) ulcer. Of note, the patient is on a Clinitron mattress, but clearly it does not improve the quality of his ulcerations, and as a result I do feel we can stop this and switch to a stage IV low air loss mattress. Also from my standpoint, it is okay to transfer the patient back to his extended care facility... 2. Ultimately given the extensive size of the sacral ulceration and more importantly the depth, I do feel that this will likely require a surgical flap closure in the future, which we can arrange once he is back at his extended care facility." The resident's annual MDS assessment, dated 4/26/09, documented: *Cognition- modified independence (No memory deficits) *Resists care *Extensive assistance for bed mobility *Total dependence for transfers *Full loss of voluntary movement for both legs *Incontinent of bowel and bladder (B&B) *No pressure sores The quarterly MDS assessment, dated 1/17/10, documented: *Cognition- modified independence (short term memory loss) *No behaviors *ADLs still extensive to total assist *Incontinent B&B *No pressure sores A significant change MDS, dated [DATE], documented: *Cognition- modified independence (short term memory loss) *Resists care *ADLs still extensive to total assist *Incontinent of bowel and with indwelling catheter. *Pressure sores- 2 Stage III, 2 Stage IV The quarterly MDS, dated [DATE], documented: Cognition- modified independence (short term memory loss) *Resists care *ADLs still extensive to total assist *Incontinent of bowel and with indwelling catheter. *Pressure sores- 2 Stage II, 1 Stage III *Moderate pain daily The care plan was not dated, but documented, "Last Care Plan Review Completed: 5/17/10" on the bottom of page 1 of 14. A problem was identified for alteration in skin integrity that included, "readmitted with pressure ulcers coccyx/sacrum, right trochanter/hip, left ischium/hip. Contributing factors include: Noncompliance with repositioning although educated on risks, Resident prefers to lie on his back, increasing pressure and skin/skin contact to ischial area. Staff continues to educate resident on importance of (every 2 hour) turning schedule, resident has improved compliance since initial order for bedrest but does have episodes of non-compliance. Date initiated: 6/23/09 Revision on 8/29/10." Goals included, "(Resident #7) will not develop further avoidable skin issues for the next 90 days. Decubitus ulcer will improve." The following interventions were documented: *Keep (resident's) peri area clean and dry as he will allow. When he refuses cares, notify the nurse for inteventions (sic) to reduce refusals. Date initiated: 6/23/09. *Low air loss mattress with alternating pressure to reduce risks due to refusals to reposition. Date initiated: 6/23/09. *Resident currently on bedrest but does utilize pressure relieving cushion to wheelchair to assist in pressure relief. Date initiated: 6/23/09. Revision on: 8/23/09. *Turn and reposition at least every 2 hours as (resident) will allow; use under pad to reposition, lifting resident to reduce risk of shearing factors as able. Date initiated: 6/23/09. *Staff to re-approach resident with refusals to be addressed with him at the time of resusal (sic) with consistent education as he allows regarding risk factors or refusals including worsening wounds, infection,[MEDICAL CONDITION], hospitalization , possible death. Date initiated 6/23/09. *Res(ident) refuses to wear preventive boots. Elevate lower legs on pillows when in bed as he will allow or allow him to wear Spenco boots. Float heels as resident allows. Date initiated 6/23/01. Revision on 1/26/10. *Treatments/dressings as ordered. Wound clinic visits as scheduled. *Nurse to monitor positioning each shift and document education if resident refuses repositioning. Date initiated 9/29/09. *(Resident #7) to remain on bedrest until pressure areas resolve to prevent decline in wound due to noncompliance with down time. Date initiated 9/29/09. Revision on 8/29/10. *Res is currently on 24 (hour) bed rest. Date initiated 6/15/10. The resident was being treated at a local wound clinic. None of the progress notes related to his treatments were in the resident's chart or facility. The Administrator called the wound clinic and requested faxed copies of the progress notes for the resident visits. They were provided to the surveyor on 9/10/10. The following documentation was contained in wound clinic progress notes: 2/16/10- "Chief complaint: Nonhealing left ischial tuberosity pressure ulcer...The patient is now at strict bed rest with the head of the bed no greater than 30 degrees and side-to-side turning..." (Note: There was no evidence that either of these interventions were care planned at this time. Nor documentation provided to determine the resident was being turned). "...He continues with negative-pressure wound therapy to the area of [MEDICATION NAME] was initiated secondary to wound infection, tailored per culture results positive for Proteius mirabilis, and Escherichia coli (Ecoli). Upon visit today, it was the only time he was up in his chair during transport, which took at least an hour." The [DIAGNOSES REDACTED]. The treatment plan included: continued strict bed rest with side to side turning off left IT, continued negative-pressure wound therapy with [MEDICATION NAME] Silver to right pretibial wound, X-ray pelvis to assess for osteo[DIAGNOSES REDACTED] and fax to clinic, continue [MEDICATION NAME]. Also, "Upon transport, it is recommended that the patient not be up in his chair and be transferred only by gurney to prevent any pressure injury during transport. At next visit, recommend that the skilled nursing facility staff member to be present to discuss care plan. The patient will follow up in 1 week for recheck." 3/10/10- "(Resident #7) presents today for evaluation of a left ischial tuberosity pressure ulcer. However, today, he arrives, in addition, with a right sacral pressure ulcer...The staff who is here with him states that they are unclear how he has had further breakdown, as they have been following our instructions explicitly. When questioned further, they note that he is up only for meals, but he takes between 4 and 5 hours per meal, putting him up potentially 15 hours a day sitting upright..." The Physical examination documentation included: Left IT ulcer improved and measured 2.1 x 3.1 x 0.3 cm. with 90% granulation tissue and 10% [MEDICATION NAME] and slough in the base. The right sacral area measured 7.7 x 4.4 cm with essentially no depth and covered with eschar. Examination of the perineum "demonstrates an ulcer measuring 2.4 x 4.8 x 0.1 cm and appears to where his suprapubic catheter has been creating pressure." The right greater trochanter measured 2.9 x 4.4 cm with 100% eschar. "Impression: Multiple new areas of pressure probably due to his suprapubic catheter tubing and being upright too much, this despite having strict bed rest ordered at his last visit." The plan was to put the wound vac on hold, assist with feeding so he can eat in less than an hour, off loading with air mattress and every 2 hour turn schedule, apply [MEDICATION NAME] Ag and [MEDICATION NAME] to left IT and perineum to be changed daily and as needed (prn). [MEDICATION NAME] and foam to the eschar on the R sacrum and R hip. Anchor the catheter to abdomen or thigh and follow up in one week. 4/28/10-" (Resident #7) is seen in followup after an extended stay at (hospital) where we were following him due to recent deterioration...The patient is on a low air-loss mattress. He is now back at (facility). We are using Santyl on the open ulcer sites. Physical examination documented, coccygeal ulcer is 5 x 5 cm with depth of 1.5 cm. The skin that tracks distally from the ulceration for about 2 to 2.5 cm is now showing full-thickness injury as well. The left IT has a necrotic, large ulceration that has clearly deteriorated recently. It measured 2.3 x 2.7 cm. Once debrided, the ulcer tracks in about 3 cm directly down to the periosteum of the IT. Cultured with no signs of [MEDICAL CONDITION] but odor present. The right hip ulcer also is deeper today. It is a full-thickness necrotic ulceration that, once debrided, clearly shows a stage IV pressure ulcer. Measures approximately 3 x 2.5 cm. No evidence of infection. Plans included continued bed rest on a low-air-loss mattress and 2-3 hour turning schedule. A culture of left IT, and follow up in 2-3 weeks. 5/19/10- "(Resident #7) is seen in followup for multiple stage 4 ulcerations including on the coccyx, left IT, and right hip. The patient had extensive debridement done...at last visit...culture obtained...positive for Proteus...started him on Cipro...Xray of the pelvis was negative for osteo[DIAGNOSES REDACTED] on 4/30/10...He does have some pain today in the coccyx area..." Plan for continued antibiotic solution soak for 15 minutes and then Santyl on all the ulcerations. Off loading, moisturize the pretibial regions of legs daily and followup in 3-4 weeks. 6/21/10- Physical exam included right hip ulcer 2.5 x 1.8 cm with no depth. "There is bioburden buildup without signs of surrounding inflammation or infection, exposed bone." The coccyx ulcer- 3.2 x 2.4 cm with a straight-down depth of 0.5 cm and tunneling circumferential ranging from 0.3 x 2.0 cm with greatest at 12 o'clock position. Left IT down to palpable bone. Measured 2.5 x 2.0 cm with a straight down depth of 3.0 cm and tunneling of 2.5 cm, no signs of infection with surrounding skin that looked healthy. Treatment plans continued bedrest and pressure relief, another Xray to determine evidence of osteo[DIAGNOSES REDACTED], continued dressing treatments and nutritional efforts. 7/20/10- "(Resident #7) presents from (facility). He arrived over an hour and one-half late and arrived with no paperwork, a common problem we have been having with (facility). The patient is seen for evaluation of a left IT, right hip and a coccyx pressure ulcer...The patient is supposed to be at strict bed rest but notes that he is up for all of his meals and sits up in bed part of the day as well..." The following measurements were documented: *coccyx- 2.2 x 1.2 x 0.5 cm with small amount of tunneling. *Right hip- 2.1 x 1.9 x 0.2 cm. *Left IT- "the worst ulceration" 1.3 x 2.8 x 2.5 cm with 3 cm of tunneling. Recommendations again clearly stated, "...complete bed rest as previously ordered. No sitting up in bed. The head of the bed is to be less than 30 degrees at all times and flat when not eating." 7/27/10- "(Resident #7) arrives from (facility) again today with no paperwork and again with the wrong dressing on...We are having a significant amount of difficulty in managing the patient as each week he arrives without having done what was asked... I reviewed his chart, the patient did improve his left IT with the wound VAC and has since deteriorated significantly. I am concerned about replacing the wound VAC as they do not seem to follow our instructions and it could cause significant damage if he is up sitting and has pressure on his left IT and a wound VAC in place..." Measurements included: * Coccyx- 2.3 x 1.5 x 0.2 cm with about 1 and 1/2 cm undermining. * Left LT- 1 x 1.5 x 3.5 cm. * Right hip- 2 x 2.6 x 0.1 cm. "This is one wound that does actually appear to be improved." 8/4/10- "The patient comes in today with appropriate dressings on. He has had no problems other than he developed some diarrhea last evening. Measurements included: *Right hip- 2.2 x 1.7 cm with depth at 0.1 cm, no tunneling. *Coccyx- 1.2 x 2.1 cm depth of 0.3 cm with a small amount of tunneling. *Left IT- 2.1 x 0.1 cm depth of 2 cm down to bone, tunneling 2.5 cm. Plan for this was surgery of flap closure. If not available local the resident would need to be sent to (out of state) for the procedure. 9/1/10- The resident still had Stage IV pressure ulcer to left IT. He was accompanied to this visit by a friend. The resident and friend expressed concern over the lack of activity because of the bedrest orders. The option of surgery in (another state) was discussed. The resident was to be referred to a physician in (another state). The plan was for continued bedrest and turning with head of bed less than 30 degrees at all times. Dressings were to be continued. On 9/8/10 at 2:30 pm, a meeting was held with the Administrator, DON and the Corporate Nurse Consultant. Five surveyors were present. The record review had been completed for Resident #7. The facility's record did not contain documentation of monitoring for pressure ulcers with measurements, staging and other descriptions of his wounds. These were requested. The DON said she had these "skin sheets" and would provide them. The DON was asked if there was any documentation to determine the frequency of turning the resident while he was in bed. The DON said these could be provided. The surveyor then requested that they provide a time line of documentation indicating when all of the resident's wounds had began and how they had progressed. Also, the documentation needed to include treatments and/or changes in treatments. On 9/9/10 at approximately 10:00 am, the DON and Administrator provided the surveyor with a hand written page that indicated when Resident #7 was originally admitted (12/7/00) and a readmission date of [DATE] from a hospital stay (no explanation of why he had been hospitalized ). The documentation indicated the resident's last hospitalization for wound treatment on 3/17/10 and his return to the facility on [DATE] with wounds still present upon readmission. Attached to this page was a treatment form for August 2010. One section of the form indicated "Reposition every 2 hours." Days 1-5 were crossed out. Day 6 through 21 were documented with initials in the night and evening sections with zeros in the day section. The DON explained the nurses work 12 hour shifts so they just document in two areas. Days 7, 13 and 19 were not fully documented as initials had not been added for one 12 hour shift on each of these days. Also, the DON said they had changed forms. The new forms were also attached. A form for August from day 22-31 was attached. A September 2010 form was attached and on this form each shift was being initialed from days 1-9. There was nothing prior to August 2010. In addition, nine facility "Pressure Ulcer Documentation Forms" were provided. They documented: *Coccyx/Sacrum- Staging and pressure sore descriptions and measurements. These were for 8/2, 8/13 (11 days), 8/19, 8/25 and 9/2 for 2010. *Right trochanter- Staging and pressure sore descriptions and measurements. These were for 4/28, 5/5, 5/13, 5/18, 5/25, 6/1, 6/7, 6/16 (9 days), 6/23, 6/29, 7/13 (14 days), 7/21, 8/2 (12 days), 8/13 (11 days), 8/18, 8/25, 9/2 and 9/3/10. *Left IT- Staging and pressure sore descriptions and measurements. These were for days 4/9, 4/28 (19 days), 5/5, 5/13, 5/18, 5/25, 6/1, 6/7, 6/16 (9 days), 6/23, 6/29, 7/13 (14 days), 7/21, 8/2 (14 days), 8/13, 8/18, 8/25 and 9/2/10. The forms all had a "request for date of onset" of the pressure ulcer which was not documented. The space for present on admission was checked, "yes." The facility sometimes went 8 days before pressure ulcer assessment was done and as long as 19 days as indicated above. The facility documentation for the coccyx pressure ulcer was staged at a II - III. The right trochanter was consistently staged at a II. The left IT was staged from a III to a IV. The last entry for 9/2 indicated it was a stage III. The wound clinic note dated 5/19/10 indicated "multiple stage 4 ulcerations including on the coccyx, left IT, and right hip." The left IT was being scheduled for a surgical flap repair and was non healing at a stage IV. These forms for February and March 2010 documentation were not provided. The resident was already seen at the wound clinic by 2/16/10. Nurses progress notes were reviewed from the current record. They were dated from 5/5/10 through 9/2/10. These notes were not daily but occasionally more than one time in a day. A minimum of ninety-three entries were documented in this time frame. The following nurse notes were documented related to education given or refusal to turn in bed: 5/10/10, (2:30 am)- "...Expressed frustration over slow healing of wounds stating 'It's not my fault' Redirected away from fault-finding and to what he could do to help healing process such as turning freq(uently)..." 5/13/10, (2:00 am)- "...Turned every 2 (hours) unhappy but a little more cooperative." 7/23/10, (10:30 am)- "...complete bed rest per wound clinic orders. Res(ident) is (every 2 hours) turn schedule. Res compliant (with) cares and medication..." 7/30/10, (5:00 am)- "Resident ref(used)to let nurse do wound care or cath(eter) care. He was asked at a later time 3 times and stated, 'No I don't want to be moved'. When asked if he would let staff draw his PT/INR (a blood test for anti-coagulant therapy) he stated, 'No I don't trust you'." (The next note on the same day indicated the PT/INR were drawn. Nothing was documented about continued refusals to be turned. Nothing indicated that an attempt was made to have another staff offer the care/treatments). On 9/9/10 at 2:45 pm, the surveyor again spoke with the Administrator and DON. The surveyor explained that the information provided did not appear to go back to the onset of the pressure ulcers for Resident #7. The administrator indicated she would provide that information. The surveyor asked if documentation could be provided that would indicate when the resident had been placed on a specialized mattress for pressure prevention. In addition, another request was made specific to education provided for the resident. On 9/10/10 at 8:00 am, the DON and Administrator met with the surveyor to provide the above requested items. The Administrator indicated the resident was non-compliant with turning. She said he really can't use his side rails now. He has been receiving restorative to help him use them for help in repositioning. She showed the surveyor a request that was made to the State agency for reimbursement regarding a specialized mattress for the resident. In this documentation was a date of onset for pressure ulcers of 2/2/10. Documentation indicated from 2/2/10 to 3/13/10 the resident was on a "LAL mattress." The Administrator said this was an air mattress. She indicated it was a low loss, but not an air exchange mattress which the resident did not like. The documentation indicated the resident had been on a "Hill Rom Cin(illegible)" bed starting on 3/13/10. The Administrator explained that this bed was recommended by the wound clinic and was also referred to as a "sand bed." The resident did not like it and was later placed on an air bed again. A letter was provided by a wound nurse. It was not dated but was signed by the RN wound nurse. In this letter the documentation indicated the resident developed a Stage II pressure ulcer on the left ischium on 2/5/10. She indicated the resident had advanced MS, and was bed ridden. She stated he could sit up in his wheel chair and did so for 2 hours a day but often refused to be put back to bed and refused repositioning. He eventually developed 3 more pressure ulcers because he laid on his right hip with the wound vac on his left. It was concluded he needed an upgrade to his bed and he was placed on a Hill Rom bed on 3/13/10. Part of a care plan, dated as last reviewed 1/26/10, contained the following updates to interventions: *Bedrest x 1 week and evaluate 5 wounds on coccyx and R(ight) ischium 1/28/10. Coccyx resolved 2/11/10. *Strict turning regimen every 2 hours. *2/11/10- Wound vac placed L ischium Stage II. *2/10/10- Stage II- R trochanter, R peri-scrotal, L sacral. *2/19/10- Anti-fungal powder until resolved. Monitor for s/s(signs/symptoms) of infection. Monitor until resolved. *3/10/10- Wound vac on hold.-Coccyx eschar, R trochanter eschar- Stage II x L ischial area. Hill Rom bed. - [MEDICATION NAME] barrier cream to periscrotal area.- Cont(inue) reposition every 2 hours. HOB < 30 degrees. Also attached were physician orders [REDACTED]. Nurse progress notes were then provided from 4/15/10 (readmission) through 5/3/10. Documentation was as follows: 4/15/10, (10:00 am)- Noted he was readmitted from the hospital. The wounds he had were noted and a suprapubic catheter. 4/20/10, (10-2 am)- "...Up in w/c for meals. Propels self... c/o (complaints of) pain to coccyx area..."(The resident should have been on strict bed rest at this time). 4/20/10, (7:00 pm)- "...Up in chair for meals..." 4/21/10, (10-1:30 am)- "Resident up in w/c (wheel chair) for multiple hours today. Able to propel self. Down to DR (dining room) for meals....Concerns of pain while turning in bed..." (No indication of education of attempts to get him to lay down). 4/21/10, (10:00 am)- "Res OOB (out of bed) since breakfast educated on risks and benefits of staying in bed. States, 'I don't care. I want to stay up until after lunch'." 4/21/10, (2:10 pm)- "Res still in w/c educated to lay down. States, 'I'm going to the food meeting. I don't want to lay down.' educated on risks and benefits of staying in w/c with wounds. Res still states 'I will not lay down right now'." (Note: No indication of involving Social Worker or that facility had worked with resident about plans for day and how he could have been involved with food meeting of importance to him. It is not clear in the notes why he was getting up for meals as he was ordered on bed rest at this time and notes do not indicate he got up for meals because of his request). 4/22/10, (4:10 pm)- "...Res needs a care plan developed r/t (related to) intake of meals. Wound clinic to clarify (amount) of time res up in w/c is pot(ential) flap canidate (sic). Res non compliant with turning positioning will f/u (follow up) next week." The signature was illegible. Under this note signatures were also from an RN, the social worker and a staff who did not identify discipline. 4/22/10, (4:00 pm)- "...He is up in wheelchair for meals and back in bed after meals. C/O pain and discomfort while in wheelchair. Is relieved with reposition..." 4/24/10, (6:30 pm)- "...w/c for meals..." 4/26/10, (1:00 am)- "...Diet compliance poor; will eat in dining room then later order pizza delivery or snacks on potato chips or snack foods brought in by friends." 4/28/10, (6:15 pm)- "Spoke with res RE: wound healing/OOB times, Res states he wants his wounds to heal. I explained to res that healing his open areas is a team effort. He must lay down and he must be side to side. Explained to res he may get OOB for meals if he wishes but must lay down immediately (sic) after eating. Res agreed to those terms and appears to understand and eager for wounds to heal." 4/29/10, (6:00 pm)- "Cares- Non compliant with wound care, to wound clinic orders received to be discussed with SS (social services), Res, Admin(istrator) regarding a contract." (Note: A copy of a contract was not provided. Social service notes provided covered only July 2010. There was no mention of a contract. However, a "Geriatric Depression Scale" was completed. The resident agreed that he was depressed and wanted to start taking an anti-depressant medication). The last two notes were on 5/3 and related to Xrays ordered and completed related to determining if resident had osteo[DIAGNOSES REDACTED]. The notes in the record started on 5/9/10 as stated above. The facility "Behavior Monthly Flow Sheet" for June 2010, was reviewed. The resident was being monitored for anxiety, agitation and screaming profanity. There was documentation that he was agitated on day 17 one time. There was no other behavior documented for the month. The form was missing any documentation for days 10, 18, 24, 29 and 30. (Note: He was not being monitored for resistance of care). The forms then changed for July, August and September 2010. They did not include interventions for behaviors. -July- He was being monitored for verbal abuse and hoarding. He had one episode of verbal abuse documented for day 6 and one for day 15. Hoarding was documented for days 2, 3, 6 and 15. No documentation for days 4, 5, 16 and 18. (Note: He was not being monitored for resistance of care). -August- Monitors for hoarding and verbal abuse. No behaviors all month. -September- For day 1 and 2 there was a plus mark documented for day and evening shift on each day. The direction on the form indicated that staff should document the behavior with the number of episodes for the behavior or a C for continuous behaviors and initial. Day 6 documented he engaged in verbal abuse 2 times on day shift. No other behaviors documented. All of these forms from July to September had areas that were left blank on one or more shifts for one or more days. Nurse progress notes documented: 5/14/10, (12:30 am)- "Res found to have a blister on his left thigh, about dime size. It is intact (with) reddness (sic) around the border. Res is on strict bed rest, turned every 2 hours. It seems to have been caused by the friction when turning side to side..." 5/18/10, (6:15 pm)- "...Blister on left hip has popped, measures 0.4 cm x 1.0 cm..." 6/7/10, (4:45 pm)- "Blister to L hip has resolved..." 7/9/10, (6:00 pm)- "Blister to L hip found..." 7/10/10, (2:30 am)- "Blisters on L hip remain intact..." 7/12/10, (5:00 am)- "(Dressings changed) by eve(ning) nurse. Res c/o bed being too hard. Pressure has not been adjusted recently. Res continues with turning schedule as tolerated." 7/12/10, (8:45 pm)- "(New Order): Check bolsters in air bed to make sure they are inflated every shift and cleanse blister to L hip with wound cleanser..." (Note: This was not on the current care plan. Treatment sheet flow record documents that checking the air bed bolsters to ensure they were inflated was added on the same sheet as the two hour turn schedules. The facility provided forms for August and September. Nothing was provided for July 2010). 7/13/10, (5:00 pm)- "...L hip has 2 opened blisters anterior measures 1.5 x 0.6 posterior measures 1.6 cm x 1.0 cm - this was previously healed and has reopened..." 7/18/10, (8:00 pm)- "Res is on bedrest with full skin check completed. Old ulcers had bandages on and res is due for dressing change tonight. RN noted two red spots the size of a pea on res L hip will continue to monitor..." 7/21/10, (12:30 pm)- "...L hip anterior open blister measures 2.0 cm x 0.9 cm L hip posterior open blister measures 1.0 cm x 0.4 cm..." 7/23/10, (10:30 am)- "Res (alert and oriented) on complete bedrest per wound clinic orders. Res on every 2 hour turn schedule. Res compliant with cares and medication..." 8/2/10, (5:00 am)- "...Open blisters on L hip have skinned over, however fragile..." During interview, on 9/9/10 at 1:25 pm, the DON said the pressure ulcers to the left hip did not have depth and were almost healed. She indicated she had personally assessed them and shared her documentation. The two areas were very small and healing. The Pressure Ulcer Documentation Form was provided for the new areas to the L hip. The documentation was for 8/13/10, documented by DON and determined a Stage II pressure ulcer, 2.2 cm x 1.5 cm without depth. The next 3 days were for 8/18, 8/25 and 9/3/10. On 9/3/10 the wound was staged 1-2, 0.2 cm x 0.2 cm without depth. The resident was interviewed on 9/8/10 at 7:15 am, and he stated he thought he may have to have surgery related to one of his wounds. The surveyor asked if he had been in bed a lot. He said, "That is an understatement. I am in bed all the time." The resident was observed on all days of observation 9/7/10 through 9/10/10 and again on 9/13/10 in bed. He was observed to have changes in his postioning. The facility failed to prevent pressure ulcers for Resident #7. Monitoring was not accomplished weekly or more frequently as his wounds were deteriorating. The facility did not have copies of progress notes from the wound clinic. There was documentation from the wound clinic that indicated the resident came for treatments with the wrong dressings on his wounds. When the resident came back from the hospital the facility did not indicate knowledge that he should not be up in his wheel chair. The resident, after being in bed so long, became resistant to staff attempting to get him to lay down. There was no evidence of the nursing staff involving the social worker. There was no documentation provided that the resident had engaged in this non-compliance when his pressure ulcers first developed in February 2010. There was no documentation of early attempts to educate the resident or involve him and negotiate the best care for him to prevent pressure ulcers. 2. Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital for treatment related to [MEDICAL CONDITION] and [MEDICAL CONDITION] She was readmitted to the facility on [DATE]. The resident's readmission MDS, dated [DATE], documented the resident had two Stage II pressure ulcers. The care plan was not dated but indicated, "Last care plan review completed: 8/10/2010." A problem initiated 11/2/09 identified, "Skin, fragile potential for skin breakdown and infection." Interventions included: "*Lotion and treatments to skin as ordered. Avoid hot water and irritating soaps. *Moniter (sic) suprapubic catheter site for signs of reddness (sic) or infection. Keep clean, dry, and free of irritants. Moniter (sic) catheter for leakage and notify urology clinic if leaking occurs. *Pressure reducing cushion in wheelchair. Assure that resident is changing position to relieve skin or pressure. *All staff to be aware of resident's skin fragility *LN to do assess and documetn skin condition/location weekly and prn." (NOTE: All interventions dated as initiated on 11/5/09). The admission nursing assessment, dated 5/14/10, contained a "Norton Plus Pressur