Every finding on record at Aspen Park of Cascadia

Based on observation, record review, and interviews it was determined the facility failed to ensure residents were able to use their personal property as needed. This was true for one of one resident (Resident #35) reviewed for residents' rights. This deficient practice created the potential for Resident #35 to experience a violation of her right to use her personal property, loss of trust in staff, and emotional distress when staff changed the orientation of the batteries in her remote control. Findings include: The facility's Quality of Life policy revised 6/4/25 documented The Resident has the right to retain and use personal possessions, including furnishings and clothing, as space permits, to promote homelike environment, unless to do so would infringe upon rights, health and/or safety of others. The Resident's personal property will be treated with respect.1. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses including hypertension, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) and aphasia (inability or impaired ability to understand or produce speech) following stroke.Resident #35's Quarterly MDS Assessment documented she was severely cognitively impaired.2. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, congestive heart failure and hypertension.A Quarterly MDS assessment dated [DATE] documented Resident #10 was moderately cognitively impaired.Resident #35 and Resident #10 were roommates.On 7/21/26 at 9:21 AM, Resident #10 stated Resident #35's TV's volume was loud and kept her awake at night. Resident #10 stated she reported it to the nurse; the nurse turned the volume down but after a while her roommate would turn the TV's volume up. Resident #10 stated this happened every night and she kept calling the nurse to turn her roommate's TV's volume down.The following staff were interviewed on 7/22/26 via telephone:At 5:35 PM, CNA #2 stated Resident #10 would call a few times during her shift because Resident #35's TV was loud. CNA #2 stated she would come into their room and would turn the TV's volume down, Resident #35 would turn it up again, and Resident #10 would press her call light again for staff to lower the volume. CNA #2 stated sometimes she would flip Resident #35's TV batteries so Resident #35 would not be able to turn volume up. When asked what she meant by flipping the batteries, CNA #2 stated it was changing the orientation of the positive and negative ends of one of the batteries.At 5:46 PM, CNA #3 stated Resident #10 would press her call light because Resident #35's TV volume was loud. CNA #3 stated she would ask Resident #35 to use her headphones and explained that she needed to keep her TV volume down. CNA #3 stated Resident #35 did not like using her headphones. CNA #3 stated that she would flip Resident #35's remote batteries as the last resort.At 7:00 PM, CNA #4 stated Resident #10 was recently moved to her current room. CNA #4 stated Resident #10 slept at night but probably did not get the best sleep. When asked why Resident #10 was not getting the best sleep, CNA #4 stated because Resident #35's TV volume was loud at night. She stated Resident #10 would press her call light and CNA #4 would speak with Resident #35 and explain that she needed to turn the TV volume down. CNA #4 stated that Resident #35 would turn the volume back up again, causing Resident #10 to press her call light again. When asked if she reported Resident #10's concerns to the nurse, CNA #4 stated Yes, I did. CNA #4 stated the nurse ask her to talk to Resident #35 that after 10:00 PM it was a quiet time. CNA #4 stated the last resort was to flip the batteries in the remote control so the volume could not be increased, even if Resident #35 pressed the volume.On 7/3/26 at 10:49 AM, Resident #35 was in bed, awake, with the television on. When asked How are you? Resident #35 responded by waving her hand. When the surveyor asked if she could take the remote control, Resident #35 immediately reached for the remote control and held it.The following residents were interviewed on 7/23/26:1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, arthritis, and hypertension.A Quarterly MDS Assessment, dated 7/16/26, documented Resident #2 was cognitively intact.At 10:52 AM Resident #2 was in bed, awake with the TV on. When asked how he would feel if staff took his remote control or flipped the batteries of the remote control without his permission, Resident #2 stated I think I would feel that someone is intruding upon my space. I would find out who did it and go from there.2. Resident #49 was admitted to the facility on [DATE] with multiple diagnoses including hypertension and diabetes.A Quarterly MDS Assessment, dated 5/12/26, documented Resident #49 was cognitively intact.At 11:04 AM when asked how he would feel if staff took his remote control, Resident #49 stated I would feel bad, frustrated because I need the remote control to turn my TV on.3. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including hypertension, chronic obstructive pulmonary disease (COPD - a long-lasting lung conditions that limit airflow and make breathing hard) and pressure ulcer of the sacral area (lower back).An admission MDS Assessment, dated 5/20/26, documented Resident #2 was moderately cognitively intact.At 11:11 AM Resident #4 was in her room sitting on the chair. When asked how she would feel if staff took her remote control, Resident #4 responded It would be invading my privacy.On 7/23/26 at 8:44 AM, the Surveyor informed the LMSW regarding Resident #10's ongoing concern with Resident #35's TV volume being loud at night and disturbing her sleep. The LMSW stated she was not aware of Resident #10's concern and was only made aware of it that morning when LPN #3 reported it to her. The LMSW was also informed of the staff flipping the batteries of Resident #35's of her remote control as the last resort. The LMSW stated staff should have informed the management of Resident #10's concern regarding Resident #35's TV volume being loud. She stated staff should not be flipping the batteries of Resident #35's remote control.

Based on interviews and record review, it was determined the facility failed to ensure residents were provided with a safe, comfortable, and homelike environment. This was true for one of one resident (Resident #10) reviewed for quality of life, whose sleep was affected by her roommate's loud television (TV) volume. This failure created the potential for Resident #10 to be deprived of sleep, affecting comfort and overall well-being. Findings include:The facility's policy titled, Homelike Environment, revised 9/17/25, described Comfortable Sound Levels as Noise levels that do not interfere with hearing, enhance privacy when desired, and encourage interaction during social activities.The facility's policy titled, Quality of Life, revised 6/4/25, documented the facility was committed to providing a safe, comfortable, and enriching environment that supports the physical, mental, and psychosocial health of each resident.Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, congestive heart failure and hypertension.A Quarterly MDS assessment dated [DATE], documented Resident #10 was moderately cognitively impaired.On 7/21/26 at 9:21 AM, Resident #10 stated her roommate's television was loud and kept her awake at night. Resident #10 stated she reported it to the nurse; the nurse turned the volume down but after a while Resident #35 (her roommate) would turn the TV's volume up. Resident #10 stated this happened every night and she kept calling the nurse to turn Resident #35 TV's volume down.On 7/22/26 at 3:56 PM, Resident #10 stated she pressed her call light about 3-4x to ask the nurse to turn Resident #35's TV volume down. Resident #10 stated she heard the nurse saying that they were tired of coming back and forth to their room, so the nurse turned the TV off.On 7/23/26 at 8:44 AM, the Surveyor informed the LMSW regarding Resident #10's ongoing concern with Resident #35's TV volume being loud at night and disturbing her sleep. The LMSW stated she was not aware of Resident #10's concern and was only made aware of it that morning when LPN #3 reported it to her. The LMSW further stated staff should have completed a grievance form regardless of whether the resident requested to fill one out, and should have notified management of Resident #10's concern. She also stated the facility maintains a communication board where staff may enter residents' concern, which they review before their morning meeting/huddle.

Based on review of records, policy review, and resident and staff interviews, it was determined the facility failed to ensure an ongoing resident's concern was recognized and addressed as a grievance. This was true for one of one resident (Resident #10) whose ongoing concern regarding her roommate's TV volume was not addressed. This deficient practice had the potential to negatively affect Resident #10's quality of life and satisfaction with care. Findings include:The facility's policy titled, Grievance Process, revised 8/29/25, documented the Grievance program was utilized to address the concerns of residents, family members and visitors, and the facility should make prompt efforts to resolve grievances. Any associate can assist in the completion of a Grievance form if a resident, family member, or guest expresses concern or comment.1.Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, congestive heart failure and hypertension.A Quarterly MDS assessment dated [DATE], documented Resident #10 was moderately cognitively impaired.2.Resident #35 was admitted to the facility on [DATE] with multiple diagnoses hypertension, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) and aphasia (inability or impaired ability to understand or produce speech) following stroke.Resident #35's Quarterly MDS Assessment documented she was severely cognitively impaired.Resident #10 and Resident #35 were roommates.On 7/21/26 at 9:21 AM, Resident #10 stated Resident #35's TV volume was loud and kept her awake at night. Resident #10 stated she reported it to the nurse; the nurse turned the volume down but after a while Resident #35 would turn the TV's volume up. Resident #10 stated this happened every night and she kept calling the nurse to turn Resident #35 TV volume down.On 7/22/26 at 3:56 PM, Resident #10 stated she pressed her call light about 3-4x to ask the nurse to turn Resident #35's TV volume down. Resident #10 stated she heard the nurse saying that they were tired of coming back and forth to their room, so the nurse turned the TV off.The following staff were interviewed on 7/22/26 via telephone:At 5:18 PM, LPN #2 stated Resident #10 was normally awake at night, and that sometimes she slept and sometimes did not because Resident #35 TV volume was a little loud. LPN #2 stated they had spoken to Resident #35 to keep her TV volume down. LPN #2 further stated Resident #10 would complain about Resident #10's TV volume being loud once or twice during her night shift. LPN #2 stated she would normally enter the resident's concern on their communication board, but probably she did not enter Resident #10's concern because she was able to address and resolve it during her shift. When asked what the communication board was, LPN #2 stated it was an entry the nurses made into their electronic health record system that would be reviewed every morning during the management meeting.At 5:35 PM, CNA #2 stated Resident #10 would call a few times during her shift because Resident #35's TV was loud. CNA #2 stated she would come into their room and would turn the TV's volume down, Resident #35 would turn it up again, and Resident #10 would press her call light again for staff to lower the volume. CNA #2 stated sometimes she would flip Resident #35's TV batteries so Resident #35 would not be able to turn volume up. When asked what she meant by flipping the batteries, CNA #2 stated it was changing the orientation of the positive and negative ends of one of the batteries, so even though she press the remote control the volume would be the same. CNA #2 stated she usually informed the nurse about Resident #10's concern with Resident #35's TV being loud at night. CNA #2 also stated if she was assigned to 300 Hall, Resident #10 would press her call light 90 percent of the time to ask staff to turn down Resident #35's TV volume down.At 5:46 PM, CNA #3 Resident #10 would press her call light because Resident 35's TV volume was loud. CNA #3 stated she would ask Resident #35 to use her headphones and explained that she needed to keep her TV volume down. CNA #3 stated Resident #35 did not like using her headphones. CNA #3 further stated Resident #35 liked the remote control within her reach, so she would flipped the batteries as the last resort and the TV's volume could not be changed.At 7:00 PM, CNA #4 stated Resident #10 was recently moved to her current room. CNA #4 stated Resident #10 slept at night but probably did not get the best sleep. When asked why Resident #10 was not getting the best sleep, CNA #4 stated because Resident #35's TV volume was loud at night. She stated Resident #10 would press her call light and she would speak with Resident #35 and explain that she needed to turn the TV volume down. CNA #4 stated that Resident #35 would turn up the volume back up again, causing Resident #10 press her call light again. When asked if she reported Resident #10 to the nurse, CNA #4 stated Yes, I did. CNA #4 stated the nurse ask her to talk to Resident #35 that after 10:00 PM it was a quiet time. CNA #4 stated the last resort was to flip the batteries in the remote control so that the volume could not be increased, even if Resident #35 pressed the volume.At 8:05 PM, RN #1 stated Resident #10 told her about Resident #35's TV volume being loud when she came to work in the morning. RN #1 stated Resident #10 told her the nurse would come in and turn Resident #35's TV volume down, but Resident #35 would turn it up again once the nurse left the room. RN #1 stated she would enter Resident #10's concern in their communication board if it was an ongoing concern.On 7/23/26 at 8:33 AM, LPN #3 stated she was on duty the night before. LPN #3 stated Resident #10 expressed concern regarding Resident #35's TV volume being loud. She stated a CNA would come to turn the volume down, but Resident #35 would turn it up again. LPN #3 stated she went to the room and explained to Resident #35 the quiet time was after 10:00 PM. When asked what time it was when she spoke to Resident #35, LPN #3 stated it was probably between midnight and 1:00 AM, and Resident #10 did not press her call light again after that. When asked if this was a grievance, LPN #3 stated she did not think it was a grievance because the concern was addressed and resolved during her shift. LPN #3 stated if it was an ongoing concern, she would inform the management.On 7/23/26 at 8:44 AM the Surveyor informed the LMSW regarding Resident #10's ongoing concern with Resident #35's TV volume being loud at night and disturbing her sleep. The LMSW stated she was not aware of Resident #10's concern and was only made aware of it that morning when LPN #3 reported it to her. The LMSW stated, LPN #3 had addressed and resolved the issue the previous night. When asked whether Resident #10's concern constituted a grievance, the LMSW stated yes, it was grievance. When asked why the staff had not considered Resident #10's concern as a grievance, the LMSW stated probably because it was resolved at the time it occurred. She stated if it was an ongoing issue, it would be considered a grievance. The LMSW further stated staff should have completed a grievance form regardless of whether the resident requested one and should have notified management of Resident #10's concern. She also stated the facility maintained a communication board where staff may enter residents' concerns, which they review before their morning meeting/huddle.

Based on record review, policy review, observations, and staff interviews, the facility failed to ensure indwelling catheter care was implemented for 1 of 1 resident (Resident #19) whose records were reviewed for catheter care. This failure created the potential for Resident #19 to not receive appropriate catheter care to his suprapubic catheter. Findings include: Review of the facility policy titled, Indwelling Catheters, revised 9/25/25 documented, 1. An indwelling catheter is used only when a resident's clinical condition demonstrates that catheterization is necessary. Care and treatment are provided to help the resident restore their highest level of normal bladder function as possible and to reduce catheter associated complications such as a urinary tract infection .andf. Unobstructed urine flow and drainage bag positioning below the level of the bladder is maintained with drainage bag and tubing off the floor.Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included heart attack, benign prostatic hyperplasia (BPH is a non-cancerous enlargement of the prostate gland) without lower urinary tract symptoms, and presence of urogenital (referring to the urinary and reproductive organs) implants.An admission MDS assessment dated [DATE] documented Resident #19 was assessed to be cognitively intact.The Comprehensive Care Plan dated 7/7/26 documented Resident #19 had a chronic suprapubic catheter with interventions to secure the catheter bag and tubing with a leg strap and to follow physician orders.On 7/20/26 at 12:40 PM, an observation was made during lunchtime meal service in the dining room. Resident #19 was observed to be sitting at the table in a wheelchair where his catheter bag with a privacy cover was affixed to the left side. The catheter tubing was observed to be draped on the ground under the wheelchair.On 7/21/26 at 9:06 AM, an observation was made of Resident #19 receiving in-room therapy services. The therapy staff member was observed holding his catheter bag in an ungloved hand and the catheter tubing was draped on the ground when assisting Resident #19 back into bed.On 7/22/26 at 12:03 PM, the CNO stated indwelling devices, including catheters, require Enhanced Barrier Precautions (EBP) in which staff use gown and gloves for high contact care and expects staff to adhere to the isolation precautions. The CNO stated she expects staff to ensure catheter bags and tubing to not touch the floor because the system could become contaminated. The CNO further stated there are typically as needed orders to change an indwelling catheter for various reasons including breaks in infection control and would have Resident #19's catheter changed.

Based on observation, resident and staff interviews, and record review, it was determined the facility failed to ensure 1 of 2 residents (Resident #44) received oxygen via nasal cannula as prescribed by the physician. This deficient practice created the potential for Resident #44 to experience respiratory difficulties or impaired breathing. Findings include: The facility's policy titled, Oxygen Administration, Safety, Storage & Maintenance, revised 10/10/25, documented, The facility will administer, store, and maintain supplemental oxygen safely in accordance with current standards of practice and licensed practitioner orders. Resident #44 was admitted on [DATE] with multiple diagnoses including COPD, respiratory failure (a life-threatening medical condition where your lungs cannot pass enough oxygen into your blood, or they cannot remove enough carbon dioxide from your body), and dependence on supplemental oxygen. An admission MDS assessment dated [DATE], documented Resident #44 was cognitively intact. Resident #44 physician's orders included the following: -Oxygen at 2 LPM via nasal cannula as needed, dated 5/15/26. On 7/20/26 at 4:30 PM, observed nasal cannula in Resident #44's nares, and the oxygen concentrator was turned off. On 7/20/26 at 4:33 PM, CNA #1 confirmed the concentrator was turned off, and then turned it on. Resident #44 told LPN #1 and the Surveyor she had checked her oxygen saturation with her own personal pulse/oximeter monitor and her oxygen saturation was 82% immediately after the oxygen concentrator had been turned on. On 7/20/26 at 4:37 PM, the Surveyor asked LPN #1 to check Resident #44's oxygen concentrator, she stated it was on and delivering oxygen at 2 LPM. Resident #44 stated right before surveyor and LPN #1 returned to the room to check the oxygen concentrator, she had checked her oxygen saturation again and it had risen to 90%. PubMed Central, accessed 7/28/26, documented, For patients with chronic obstructive pulmonary disease (COPD), the recommended target oxygen saturation range is 88% to 92%. On 7/20/26 at 4:37 PM LPN #1 stated, Resident #44 had a medical appointment earlier in the day and whoever brought her back to her room probably forgot to turn the concentrator on. On 7/23/26 at 10:48 AM, the CNO stated when a resident who requires oxygen is brought back to the room, the CNA is allowed to put the nasal cannula on the resident and turn on the concentrator. She further stated, the CNA who brought Resident #44 back to the room should have put the nasal cannula on her and turned on the concentrator.

Based on record review and staff interview, it was determined the facility failed to ensure a resident was adequately monitored for medication side-effects. This was true for 1 of 6 residents (Resident #37) whose records were reviewed for unnecessary medications. This failure placed Resident #37 at risk for harm if they were to suffer from side-effects of a medication due to a lack of monitoring. Findings include: Resident #37 was admitted to the facility on [DATE] with multiple diagnoses including dementia and heart failure. Resident #37's record included the following physicians' orders: -Mirtazapine oral tablet, (an antidepressant frequently prescribed for appetite stimulation) Give 7.5 MG by mouth one time a day for appetite, start date: 5/19/26 -Hydrocodone-Acetaminophen oral tablet 7.5-325 MG (an opioid pain medication) Give 1 tablet by mouth two times a day for pain, start date: 5/28/25 Resident #37's care plan directed staff to monitor for the following side effects: -Monitor/document effectiveness and potential side effects. Opioid/Narcotic Side-Effects: over-sedation/lethargy, constipation, respiratory depression, nausea and/or vomiting, increased depressed mood, restless agitation, itching/sweating/shaking, change in gait, increased tolerance/pain sensitivity, vital sign changes, headache, date initiated: 2/25/25 -Monitor/document effectiveness and potential side effects. Antidepressant Side-Effects: over-sedation/lethargy, restless agitation, increased confusion/poor concentration, mental status changes, visual disturbances, change in gait/extrapyramidal symptoms (involuntary movements), nausea and/or vomiting, vital signs changes, constipation, urinary retention, headache, weight change, date initiated: 5/18/26 Resident #37's record did not include documentation side effects were being monitored for the use of an antidepressant and an opioid medication. On 7/22/26 at 12:05 PM, the CNO stated, there were not side effect monitors in place for Resident #37's opioid and antidepressant medications and there should have been.

Based on record review, policy review, observations, and staff interviews it was determined that the facility failed to ensure completed medications were properly discarded for 1 of 2 medication carts reviewed. This failure created the potential for medication errors to occur. Findings include:Review of the facility policy titled, Medication Storage and Labeling, revised 10/13/25 documented that, expired or discontinued medications must be removed promptly and disposed of per facility policy.Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses which included unspecified depression and unspecified anxiety disorder.A completed physician's order for sertraline hydrochloride (HCl) oral tablet (antidepressant) with a start date of 4/18/26 and end date of 5/18/26 documented to administer 25 mg by mouth 1 time a day related to depression for 30 days.A Quarterly MDS assessment dated [DATE] documented Resident #23 was assessed to be cognitively intact. The MDS further documented in Section I - Active Diagnoses, that Resident #23 had depression and anxiety. Further review of the MDS, Section N - Medications, Resident #23 was not being treated with antidepressant or antianxiety medications.On 7/23/26 at 11:39 AM an interview and observation of the 300-Hall medication cart was conducted with RN #1. RN #1 pulled Resident #23's medications for review, where one blister package of sertraline HCl 25 mg oral tablet was observed in the medication cart. The blister package had nine green tablets left in the package and an order date of 4/17/26 with orders to administer one 25 mg tablet by mouth one time a day for 30 days. RN #1 stated Resident #23's sertraline HCl 25 mg should have been removed from the medication cart after the last dose. RN #1 stated it is the nurse on the medication cart's responsibility to discard any discontinued or expired medications as soon as they are made aware but stated that medications are not always removed timely. RN #1 further stated that after orders are discontinued or completed the medications should be removed from the medication cart to prevent potential medication errors.On 7/23/26 at 3:37 PM, an interview was conducted with the CNO, and the CEO, CRN, and Administrator-in-Training (AIT) were present. The CNO stated that medications should be immediately removed from the medication cart when they are expired, discontinued, or completed. The CNO further stated it is the nurse on the medication cart's responsibility to remove old or expired medications. The CNO stated removing discontinued or completed medications from the carts is to reduce the risk of medication errors. The CNO stated that completed medications being left in the cart for over two months past the order completion date was not acceptable.

Based on policy review, record review, and interviews, it was determined the facility failed to ensure residents' care plan interventions were implemented as written. Specifically, staff did not follow the resident's care plan regarding the management of his hearing aid and the required storage of his smoking paraphernalia. This was true for 1 of 1 resident (Resident #36) whose care plan was reviewed. This failure created the potential for unmet needs, safety concerns, and a decline in Resident #36's physical and psychosocial well being.a. Resident #36 was admitted to the facility on [DATE], with multiple diagnoses including unspecified hearing loss, stroke, and hypertension.Resident #36's Quarterly MDS assessment dated [DATE], documented, in Section B- Hearing, Speech, and Vision, regarding Resident #36's hearing, had moderate difficulty -speaker has to increase volume and speak distinctly. It also documented there was no hearing or other hearing appliance used in completing the assessment.Resident #36's care plan, initiated 2/20/26, documented she had hearing impairment related to bilateral moderate to severe sensorineural hearing loss. The intervention included Offer [Resident #36] adaptive equipment of headset/amplifier as she accepts.On 7/21/26 at 9:16 AM, Resident #36 was lying in bed and awake. Resident #36 was asked two times how she was doing, Resident #36 replied, I can't hear you. The Surveyor then typed on the laptop in bold, size-28 font: Have you eaten your breakfast? Resident #36 looked at the computer screen but did not respond. The Surveyor typed Do you have a hearing aid? and asked the question while showing Resident #36 the screen. Resident #36 again stated I can't hear you. No headset/amplifier was observed in Resident #36's room.On 7/21/26 at 9:35 AM, the CNO stated Resident #36 had an audiology appointment in 2/2025 and she was not a candidate to use hearing aid.An Audiologist Comprehensive Hearing Evaluation dated 3/27/25, documented Resident #36 had bilateral moderate to severe sensorineural hearing loss between 250Hz - 8000Hz with poor word recognition ability. The Audiologist recommended that Resident #36 use an assistive device, such as a Pocket Talker, to help improve her communication ability. The Audiologist also recommended that Resident #36 use Caption Call Phone which would allow her to read the conversation on a screen when conversing over the phone.A Nursing Note dated 6/25/26 documented Spoke with [Resident #36] regarding [Resident #36's son] concern for her hearing and dentures. Reminded [Resident #36] of a previous audiologist appointment where they stated hearing aides would not be beneficial at this time and stated they suggested hearing amplifiers which [Resident #36] previously declined to use.On 7/22/26 at 10:03 AM, the Activity Director (AD) with the MDS Nurse present, showed the Personal Sound Amplifier, which the MDS Nurse stated was the Pocket Talker. The AD stated Resident #36 tried it about nine months ago and again on 6/30/26, but she refused to use it. The AD also stated Resident #36 tried to use the headphones but did not like them due to too much background noise. When asked about the documentation that Resident #36 tried the Pocket Talker and headphones, the AD stated, Unfortunately I did not document a progress note.On 7/23/26 at 9:33 AM the MDS Nurse, in the presence of the CNO and CEO, stated the Pocket Talker and headphones were not in Resident #36's room due to her refusal to use them.b. A care plan initiated 4/13/22 documented Resident #36 had been assessed as an independent smoker, and her smoking paraphernalia were stored in a lock box in her room.A Smoking Evaluation dated 5/4/26 documented Resident #36 was an independent smoker/nicotine user. Her smoking paraphernalia were stored in a lock box in her room.On 7/21/26 at 3:38 PM, CNA #5 was observed wheeling Resident #36 to the smoking area. Resident #36 had a small black shoulder bag with her. At the smoking area Resident #36 was observed taking a cigarette from the bag. She then took a lighter from the bag and lit the cigarette.On 7/22/26 at 8:42 AM Resident #36 was sleeping. The small black bag was observed hanging on the side of her overbed table.On 7/22/26 at 9:10 AM the MDS Nurse stated residents assessed as independent smokers were provided with a lock box to store their smoking paraphernalia and were given a code to open the box.The Surveyor asked the MDS Nurse to verify where Resident #36 was storing her smoking paraphernalia. In Resident #36's room, the MDS Nurse asked Resident #36 Where is your lock box? Resident #36 replied, What? The MDS Nurse repeated the question, Where is your lock box for your cigarettes? Resident #36 then retrieved a small bag hanging from the side of her overbed table and took a cigarette from the bag. The Surveyor asked the MDS Nurse to ask Resident #36 where her lighter was. The MDS Nurse asked Resident #36 Is the lighter in your purse? Resident #36 took the lighter from the same bag and showed it to the MDS Nurse. The MDS Nurse stated she would provide Resident #36 a lock box to store her smoking paraphernalia.On 7/22/26 at 9:26 AM, the MDS Nurse stated it was appropriate for Resident #36 to store her smoking paraphernalia in a lock box to keep it safe from other residents.

Based on record review and staff interview, it was determined the facility failed to ensure appropriate dementia care planning was implemented. This was true for 1 of 14 resident (Resident #7) whose record was reviewed for care planning. This failure placed Resident #7 at risk for her needs to go undetected when her care plan did not include services to maintain her highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including conversion disorder with seizures (a psychological condition where physical symptoms are caused by psychological trauma, rather than an underlying physical or medical condition), muscle weakness, and osteoporosis. On 10/8/24, Resident #7's medical record documented a new diagnosis of severe dementia with agitation. On 4/30/25 at 5:39 PM, the DON stated she was unsure why Resident #7 did not have services for her diagnosis of dementia on her care plan.

Based on record review and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 14 residents (Resident #39) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed. Findings include: The State Operation Manual, Appendix PP, defined an Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including cognitive communication deficit, anxiety, and schizophrenia. Resident #39's record did not include an advance directive for healthcare. Resident #39's medical record did not include documentation of resources offered for a healthcare advance directive. On 4/30/25 at 3:46 PM, the Social Worker stated the facility did not have a healthcare advance directive for Resident #39.

Based on record review and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 1 of 14 residents (Resident #33) reviewed for bowel management. This failure created the potential for adverse outcomes when Resident #33's physician orders were not followed for bowel management. Findings include: Resident #33 was readmitted to the facility on [DATE], with multiple diagnoses including intellectual disorder, developmental disorders of speech, and anxiety. Resident #33's record documented the following physician orders, dated 5/25/24: - Milk of Magnesia suspension 1200 mg / 15 ml, give 30 ml by mouth as needed for constipation - No bowel movement for 2 days. - Dulcolax Suppository 10 mg, insert 1 suppository rectally as needed for constipation. If no results in 4 hours see Fleet enema order. - Fleet Enema 7-19 gm/118 ml, Give 1 unit as needed for constipation. Resident #33's care plan, revised on 6/25/24, directed care staff to document bowel movements every shift. It also directed staff to monitor, record, and report signs of poor bowel elimination to the physician. Resident #33's bowel record dated 4/1/25 - 4/30/25 documented no bowel movement on the following dates: - 4/21/25 - 4/22/25 - 4/23/25 - 4/24/25 - 4/25/25 - 4/26/25 On 4/30/25 at 4:18 PM, on review of Resident #33's medication administration record, the DON stated they should have administered the bowel protocol.

Based on record review and staff interview, it was determined the facility failed to ensure services provided met the professional standards. This was true for 3 of 14 residents (#19, 27, and 44) whose physician orders were reviewed. This failure created the potential for residents to suffer harm from adverse effects during medication administration. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses including spastic quadriplegic cerebral palsy (paralysis of all four limbs with muscle stiffness due to brain damage or abnormal development), and constipation. Resident #19 used a percutaneous endoscopic gastrostomy tube (a PEG-tube is a feeding tube surgically placed directly into the stomach through the abdominal wall) for medication, nutrition, and hydration. Resident #19's medical record documented a physicians dietary order, dated 11/9/20, directing she was not to take any medication, nutrition, or hydration by mouth. Resident #19's medical record documented the following physician orders, dated 4/10/24: -Acetaminophen liquid 160 mg/ 5 ml, give 30 ml by mouth every 4 hours as needed for pain, not to exceed 3 grams in 24 hours. -Acetaminophen liquid 160 mg/ 5 ml, give 30 ml by mouth two times a day for pain. On 4/30/25 at 4:47 PM, the DON stated it is not safe for Resident #19 to take any medications by mouth and the acetaminophen orders were incorrect. She added, each nurse who administered the orders gave the medications through her PEG-tube but should have clarified the orders. 2. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (paralysis) affecting his right/dominant side, dementia, and dysphagia (difficulty swallowing). Resident #27's medical record documented a physician order, dated 9/17/24, directing: -Metamucil Oral Psyllium Powder 48.57%, give 1 tablespoon by mouth before meals and at bedtime for stool bulking, administer in applesauce. On 4/30/25 at 4:50 PM, the DON stated it was irregular for Metamucil powder to be given in applesauce and at the time it was written that way for resident preference. The DON added the order must have been old and should have been updated to give Resident #27 psyllium capsules when his diet order changed from crushed medications to whole. 48402 3. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including irritable bowel syndrome and hemorrhoids. A physician order, dated 9/13/24, documented: -Polyethylene Glycol 3350 Oral Powder, 17 grams per scoop. Give 30 ml by mouth one time a day for bowel care. On 4/30/25 at 7:34 AM, On review of the physician order, LPN #1 stated she had never paid attention to the order, but she would never give the medication in 30 milliliters of liquid. She also stated the order needed to be clarified.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents Minimum Data Set assessment included correct information. This was true for 1 of 14 residents (Resident #4) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, generalized anxiety disorder, and legal blindness. Resident #4's medical record included documentation of a PASRR Level I screening, dated 7/6/23 that identified she had mental illness diagnoses of depression and anxiety. Resident #4's medical record included documentation of an abbreviated PASRR Level II screening, dated 7/10/23 that identified she had diagnoses of severe mental illness per PASRR criteria, the treatment she was receiving was appropriate, and was exempt from any further evaluation. Resident #4's Annual MDS Assessment, dated 2/27/25, documented section A1500, PASRR Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability, or a related condition? The answer for this question was documented as no. On 4/30/25 at 5:17 PM, the MDS Coordinator stated, Resident #4 has serious mental illness diagnoses and the MDS assessment is not accurate and section A1500 should have been marked yes.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications. This was true for 1 of 2 residents (Resident #1) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if Resident #1 was to self-administer oral medications inappropriately. Findings include: The facility's Self-Administration of Medication policy, implemented 11/28/17, stated the facility's Interdisciplinary Team should at a minimum consider the following: - The medication appropriate and safe for self-administration - The resident's physical capacity to swallow and to open medication bottles - The resident's cognitive status - The resident's capability to follow directions - The resident's ability to understand what refusal of medication is - The resident's ability to ensure that medication is stored safely and securely. Resident #1 was readmitted to the facility on [DATE], with multiple diagnoses including need for assistance with personal care, anxiety, and major depressive disorder. A physician order, dated 3/17/24, documented Tums tablet, chewable, give 1,200 milligrams (mg) by mouth one time a day for supplement. A Self-Administration Evaluation, dated 6/24/24, documented Resident #1 was given the approval to effectively self-administer her nebulizer treatments, the evaluation did not include documentation she was assessed for safety to take other oral medications independently. Resident #1's care plan, revised on 4/15/25, documented the licensed nurse (LN) is to validate each shift for appropriate self-administration of medications. It also documented Resident #1 should be able to identify the lock box code to prevent unauthorized access to the medications. On 4/28/25 at 4:30 PM, Resident #1's bedside table was observed to have one green and one orange round tablets on the tabletop next to an empty medication cup. On 4/28/24 at 4:43 PM, upon observation of the tablets, LPN #1 stated Resident #1 takes the medications as a calcium supplement and the nurse from prior shift left them on Resident #1's bedside table for her to take when she was ready. She also stated Resident #1 was not evaluated for self-administration of the calcium supplement.

Based on observation and staff interview it was determined the facility failed to ensure infection control practices were implemented during medication observation. This had the potential to affect all residents in the facility when LPN #1 dropped an oral tablet and picked it up with her ungloved hand. Findings include: On 4/30/25 at 7:24 AM, during medication administration, LPN #1 was observed dropping a pill onto the top of the medication cart and picked it up with her ungloved hand, placed it in a medication cup, and administered it to the resident. On 4/30/25 at 7:27 AM, LPN #1 stated it was an infection control concern because it touched the top of the cart, but she did not feel an infection control concern was identified when she touched the pill with her ungloved hand.

Based on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 40 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: FDA Food Code Section 3-305.11(A) documented food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. FDA Food Code Section 4-602.13 documented nonfood-contact surfaces of equipment shall be cleaned at frequency necessary to preclude accumulation of soil residues. FDA Food Code Section 6-501.14(A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials. On 4/16/24 at 9:46 AM, the following observations were made in the kitchen: - The gas stovetop was observed to have food debris around the burners. A dark-colored buildup of food residue covered the metal grates above the burners. - A sticky residue, covered with dust, was observed on the shelf in the cooking area which stored the clean steam table pans upside down. - The shelf above the steam table which stored the clean trays and plate covers was observed to have a sticky residue, covered with dust. - The steam table surface was observed to have a brown-tinged residue between the steam pan openings. - The dry storage area was observed to have a buildup of food and food packaging debris and dust under the storage shelves. - The bottom shelf of the dry storage shelves measured 3.5 inches from the floor. The bottom shelf contained a mesh bag of onions and boxes of other food items. - The floor ventilation register in the dry storage room was covered with dust. - The storage rack for the #10 cans, next to the cook area, was observed to have dust and debris underneath it. On 4/16/24, the cleaning schedules were reviewed with the Dietary Manager. The schedules documented the stovetop burners were to be cleaned every Saturday and had not been cleaned on Saturday, 4/13/24. The schedules documented the cook area shelves were cleaned weekly on Tuesdays. Additionally, the schedules documented the steam tables were cleaned daily by the AM and PM shifts. The Dietary Manager stated the debris on the cooktop, cook area shelf, and steam table should have been removed when cleaned. He stated the floors were cleaned nightly and the areas under the shelves should have been cleaned at the same time. The Dietary Manager stated he did not know why the areas were not clean. He stated the storage shelves should have been at least 6 inches above the floor and were not.

Based on observation and interviews the facility failed to ensure all staff implemented measures to prevent contamination of surfaces in common areas with potential for cross contamination and spread of infectious organisms from one person to another or from a contaminated surface to a resident. These failures potentially affected nine randomly observed residents who ate in the dining room and all residents who consumed water or ice from the nourishment center ice/water dispenser and placed them at risk for infection. Findings include: During the entrance interview on 6/10/20 at 9:30 AM, the administrator said the facility was COVID-free with no residents or staff testing positive for COVID-19 and no residents on transmission-based precautions for COVID-19. The administrator reported a low incidence of COVID-19 in the community and county but acknowledged risk due to close proximity to a Washington State college town with co-mingling of persons from the two communities. 1. During observation of the 300 resident hall on 6/10/20 at 10:54 AM housekeeping staff HK1 exited resident room [ROOM NUMBER]. HK1 placed cleaning cloths on the housekeeping cart in the corridor then removed gloves and washed hands with soap and water. Resident R6 called from resident room [ROOM NUMBER] asking for ice water. HK1 re-entered room [ROOM NUMBER] and went to the window bed. HK1 took R6's water pitcher from the room to the nourishment center down the hall. HK1 placed the water pitcher directly on the tray of the ice/water dispenser and activated controls to add ice/water to the pitcher. HK1 took the filled pitcher back into room [ROOM NUMBER]. HK1 used hand sanitizer gel then resumed housekeeping duties. HK 1 did not disinfect or sanitize the outside of the water pitcher before taking it from or returning it to the resdent room and did not disinfect or sanitize the surface of the ice/water dispenser. 2. During the lunch meal observation on 6/10/20 from 12:15 PM to 12:40 PM, nine residents each sat at a separate table. Six staff fed residents, one staff to one resident, and/or assisted with the meal service. Five staff wore cloth face covers (cloth face masks) and one staff wore a surgical mask. Six resident's cloth face covers were placed directly on the dining tables with no protective barriers between the surface of the tables (table top) and the face covers. Two cloth face covers hung freely on wheelchair handles and one randomly observed resident R7 wore a cloth face cover on her forearm. The administrator entered the dining room at 12:23 PM. The administrator immediately obtained a paper towel and spread it out on the dining table. The administrator redirected R7, removed the face cover from R7's arm, and placed the face cover with the outside of the face cover down on the paper towel. The administrator confirmed it was the facility expectation that a barrier be used when masks or cloth face covers were placed on tables in the communal dining room to prevent contamination of the table by the mask/face cover or contamination of the mask/face cover by the table surface. Licensed nurse LN1 was in the dining room. She said she was a charge nurse. LN1 said she was aware masks and face covers should be placed on barriers to prevent cross contamination. LN1 said she did not notice the masks/face covers on the tables without barriers until questioned by the surveyor. In an interview on 6/10/20 at 1:40 PM the facility Infection Control Preventionist (ICP) was informed of the observations regarding face covers on dining tables with no barriers and staff filled a soiled water pitcher directly from the communal ice/water dispenser. ICP said all staff were educated on proper storage of face masks/covers intended to be re-used. ICP said barriers should be first placed on the table and then the face mask should be placed with the outside of the mask/face cover down on the barrier. ICP said the masks/ face covers could be hung by the ties if not in contact with objetcs but ideally the facemasks should be stored in a breathable paper bag. Regarding the water pitcher, ICP said HK1 did not provide resident care and was trying to give prompt service to R6 by responding to his request When asked what she expected HK1 and others to do when a resident asked for ice water; ICP said staff should get a new water pitcher to change out with the used/soiled pitcher. ICP said; or staff could bring ice and water to the resident's room to refresh the water pitcher. ICP confirmed the resident's water pitcher was considered soiled or contaminated and it should not have been taken into the nourishment center. ICP further stated; the used or soiled water pitcher definitely should not contact surfaces of the ice/water dispenser. ICP concluded both the dining room practices with the face coverings and the re-filling process for the water pitcher created potential for cross contamination. ICP said the facility expected all staff in all disciplines to practice and implement infection control standards at all times.

Based on staff interview, policy review, and record review, it was determined the facility failed to ensure a second bed-hold notice was provided to a resident or their representative upon transfer to the hospital. This was true for 1 of 2 residents (Resident #17) who were 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/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold Readmission Policy, dated 11/28/17, documented the facility issued two notices related to bed-holds, as follows: * The first notice was provided in the admission packet. * The second notice was provided to the resident at the time of transfer, or in cases of emergency transfer, within 24 hours of the transfer. * The notice provided information to the resident that explained the duration of the bed-hold. Resident #17 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #17 was transferred to the hospital on [DATE], and readmitted to the facility on [DATE]. Resident #17's record did not include documentation he received a second bed-hold notification when he was transferred to the hospital. On 1/31/19 at 11:59 AM, the LSW stated Resident #17 did not receive a second bed-hold notification.

Based on staff interview and record review, it was determined the facility failed to ensure information was provided to the receiving hospital for emergent situations for 1 of 2 residents (Resident #17) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to lack of information. Findings include: Resident #17 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A discharge MDS assessment, dated 1/3/19, documented Resident #17 was discharged to an acute care hospital. A Nursing Progress Note, dated 1/3/19 at 1:10 PM, documented Resident #17 had a change of condition, Emergency Medical Services was notified, and Resident #17 was transported to the hospital via emergency transport. Resident #17's record did not include documentation his physician was notified and ordered the transfer to the hospital and information regarding Resident #17's status was conveyed to the hospital. On 1/31/19 at 11:06 AM, the DNS stated the facility did not fill out the Transfer Form when Resident #17 had a medical emergency and needed to be sent to the emergency room quickly. The DNS stated Resident #17's record did not include documentation the Transfer/Discharge Form and paperwork were provided to the paramedics, a physician's orders [REDACTED].

Based on staff interview, policy review, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 3 of 15 residents (#27, #32, and #46) reviewed for standards of practice. Resident #27 BG levels were high and the physician was not notified timely and her insulin orders were not correctly transcribed to the MAR. Resident #32's [MEDICAL CONDITION] (high BG level) care plan was not followed and action taken in response to Resident #46's [MEDICAL CONDITION] were not documented. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practice. Findings include: The facility's [MEDICAL CONDITION] and Diabetic Coma policy and procedure, dated 10/31/17, documented, It is important to treat [MEDICAL CONDITION] as soon as it is detected. If not treated, a condition called ketoacidosis (diabetic coma) could occur . If the resident's blood glucose is over 240 mg/dl and is not on sliding scale insulin, call the physician for directives. 1. Resident #27 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #27's (MONTH) 2019 physician's orders, dated 1/8/19, documented Resident #27 was to receive an injection of 14 units of [MEDICATION NAME]before meals and the injection was to be held if her BG levels were less than 70 mg/dl. Resident #27 was also to receive an injection of 58 units of Letemir insulin at bedtime and the injection was to be held if her BG levels were less than 70 mg/dl. Resident #27's (MONTH) 2019 physician's orders did not include [MEDICAL CONDITION] parameters regarding when to notify the physician. Resident #27 was not on sliding scale insulin. Resident #27's diabetes mellitus care plan, dated 11/14/18, documented, if hyperglycemic (greater than 300 mg/dl) follow sliding scale (if applicable) or contact the physician and follow orders. Document treatment/interventions and symptoms/assessment in progress notes. The care plan parameters for notification of the physician was not consistent with the facility's policy. Resident #27's MAR, from 1/8/19 to 1/15/19, documented Resident #27's BG levels were greater than 300 mg/dl, as follows: - On 1/8/19 at 5:30 PM = 321 mg/dl - On 1/8/19 at bedtime = 332 mg/dl - On 1/9/19 at 11:30 AM = 352 mg/dl - On 1/9/19 at 5:30 PM = 316 mg/dl - On 1/9/19 at bedtime = 437 mg/dl - On 1/10/19 at 11:30 AM = 322 mg/dl - On 1/11/19 at 7:30 AM = 339 mg/dl - On 1/11/19 at 11:30 AM = 303 mg/dl - On 1/11/19 at 5:30 PM = 362 mg/dl - On 1/11/19 at bedtime = 465 mg/dl - On 1/12/19 at 11: 30 AM =337 mg/dl - On 1/12/19 at 5:30 PM = 361 mg/dl - On 1/12/19 at bedtime = 382 mg/dl - On 1/13/19 at 7:30 AM = 316 mg/dl - On 1/13/19 at 11:30 AM = 335 mg/dl - On 1/13/19 at 5:30 PM = 428 mg/dl - On 1/13/19 at bedtime = 449 mg/dl - On 1/14/19 at 7:30 AM = 329 mg/dl - On 1/14/19 at 11:30 AM = 399 mg/dl - On 1/14/19 at 5:30 PM = 354 mg/dl - On 1/14/19 at bedtime = 360 mg/dl - On 1/15/19 at 11:30 AM = 339 mg/dl - On 1/15/19 at 5:30 PM =356 mg/dl A Nurse's Progress Note, dated 1/13/19 at 10:18 PM, documented the physician was notified by fax of Resident #27's BG level before dinner (5:30 PM) was 428 mg/dl and her bedtime BG level was 449 mg/dl. A Nurse's Progress Note, dated 1/14/19 at 11:05 AM, documented the physician replied to the fax on 1/13/19, requesting information on how much insulin Resident #27 was currently receiving. The note stated the licensed nurse sent Resident #27's current insulin orders to the physician by fax. A physician's order for Resident #27, dated 1/15/19 at 7:00 PM, 2 days following the 1/13/19 notification of high BG levels, documented to increase the amount of the Letemir insulin injection from 58 units to 70 units daily. Resident #27's (MONTH) 2019 MAR, dated 1/15/19 at 7:00 PM, documented Resident #27's Letemir insulin was increased to 70 units at bedtime and the injection was to be held if her BG level was less than 70 mg/dl. The physician was not notified of Resident #27's BG levels that were greater than 300 mg/dl on 1/8/19, 1/9/19, 1/10/19 - 1/12/19, twice on 1/13/19, 1/14/19, and 1/15/19, per her care plan. Resident #27's record documented the physician was notified via fax on 1/13/19 of her BG levels that were greater than 400 mg/dl and the physician responded with new insulin orders on 1/15/19. The physician orders did not include parameters of when to notify the physician of Resident #27 [MEDICAL CONDITION]. The (MONTH) 2019 MAR documented Resident #27's BG levels greater than 300 mg/dl from 1/16/19 to 1/18/19 as follows: - On 1/16/19 at 5:30 PM = 472 mg/dl - On 1/16/19 at bedtime = 473 mg/dl - On 1/17/19 at 7:30 AM = 325 mg/dl - On 1/17/19 at 11:30 AM = 405 mg/dl - On 1/17/19 at 5:30 PM = 386 mg/dl - On 1/17/19 at bedtime = 382 mg/dl A Nurse's Progress Note, dated 1/16/19 at 7:06 PM, documented Resident #27's BG level before (5:30 PM) dinner was 472 mg/dl and the physician was notified via fax. A Nurse's Progress Note, dated 1/17/19 at 12:29 PM, documented Resident #27's BG level before lunch was 405 mg/dl. The physician was notified Resident #27's BG level before lunch was 405 mg/dl by fax. A Physician's Order for Resident #27, dated 1/18/19 at 11:21 AM, documented to increase [MEDICATION NAME]injection by 2 units every 2 days until her fasting BG level was between 150 to 200 mg/dl and to increase her [MEDICATION NAME]to 20 units before meals. The physician was not notified of Resident #27's BG levels that were greater than 300 mg/dl per Resident #27's care plan. Resident #27's record documented the physician was notified via fax on 1/16/19 of her BG levels that were greater than 400 mg/dl and the physician responded with new insulin orders on 1/18/19, 2 days later. The new orders did not include [MEDICAL CONDITION] parameters for Resident #27. Resident #27's (MONTH) 2019 MAR, dated 1/18/19 at 5:30 PM, documented to inject 20 units of [MEDICATION NAME]before meals and to hold the injection if her BG level was less than 70 mg/dl. Resident #27's (MONTH) 2019 MAR, dated 1/18/19 at 7:00 PM, documented to inject 72 units of Letemir insulin one time a day at bedtime and to hold the injection if her BG level was less than 70 mg/dl. The Letemir insulin was order was transcribed to Resident #27's MAR to be administered at bedtime and was increased by 2 units to equal 72 units at bedtime. The physician did not write [MEDICAL CONDITION] parameters on when to be notified. On 1/31/19 at 2:09 PM, the DNS stated Resident #27's BG levels were running high in the month of (MONTH) and the physician was adjusting the routine insulin to get her BG levels down. The DNS was unable to provide a physician's order for Resident #27's [MEDICAL CONDITION] parameters of when to notify the physician. The DNS stated the physician should have been called on 1/13/19 at 5:30 PM when Resident #27's BG level was 428 mg/dl and again should have been called on 1/13/19 at bedtime when her BG level was 449 mg/dl. The DNS stated her expectation for the licensed nurses was to notify the physician by phone not fax when residents' BG levels were out of [MEDICAL CONDITION] parameters. The DNS stated Resident #27 did not receive sliding scale insulin and did not have [MEDICAL CONDITION] parameters. The DNS stated there should have been a physician's order written, the order transcribed to the MAR, and [MEDICAL CONDITION] parameters included on Resident #27 care plan. The DNS stated the nurse did not transcribe the full physician's order on 1/18/19. On 1/31/19 at 2:11 PM, the Director of Clinical Operations stated Resident #27's diabetes mellitus care plan should have been person centered to notify the physician if BG levels were greater than 400 mg/dl, not the facility's standard of 300 mg/dl or the facility's policy of 240 mg/dl. The Director of Clinical Operations stated Resident #27's [MEDICAL CONDITION] parameters on when to notify the physician should have been documented in a physician's order, then transcribed onto the MAR, and the care plan updated. The Director of Clinical Operations agreed the facility did not follow the facility's [MEDICAL CONDITION] policy. On 1/31/19 at 2:15 PM, the Director of Clinical Operations and the DNS stated Resident #27's physician's order on 1/18/19 for the [MEDICATION NAME]was not transcribed accurately on the MAR. The DNS stated fasting meant Resident #27's BG level should have been checked in the morning before breakfast and the [MEDICATION NAME] should have been administered in the morning before breakfast not at bedtime. 2. Resident #32 was admitted to the facility, on 1/17/18, with [DIAGNOSES REDACTED]. Resident #32's diabetes mellitus care plan, dated 1/17/18, directed staff to notify the physician if her blood glucose level was greater than 300 mg/dl and to document the assessments, her symptoms, and the treatments and interventions in the progress notes. Resident #32's (MONTH) 2019 Physician's Orders documented BG level checks to be completed at bedtime. Resident #32's (MONTH) 2019 physician's orders did not include [MEDICAL CONDITION] parameters on when to notify the physician. The (MONTH) 2019 MAR documented Resident #32's BG levels greater than 300 mg/dl from 1/2/19 to 1/28/19 as follows: - On 1/02/19 at 9:00 PM = 304 mg/dl - On 1/09/19 at 9:00 PM = 352 mg/dl - On 1/19/19 at 9:00 PM = 336 mg/dl - On 1/22/19 at 9:00 PM = 324 mg/dl - On 1/28/19 at 9:00 PM = 361 mg/dl On 1/31/19 at 12:30 PM, the Director of Clinical Operations stated although there was no physician's order for Resident #32's BG level threshold for notification of the physician, Resident #32's BG level threshold was 350 mg/dl per the alert in the electronic MAR and 300 mg/dl per her care plan. On 1/31/19 at 2:00 PM, LPN #1 stated the facility's [MEDICAL CONDITION] policy included notification of the physician when a resident's blood glucose was greater than 400 mg/dl unless the resident had physician's orders for other parameters. LPN #1 stated Resident #32 did not have an order for [REDACTED]. LPN #1 stated Resident #32 did not have BG levels higher than 400 mg/dl. LPN #1 stated he was not aware the facility's Hyperglycemic and Diabetic Coma policy documented licensed staff were to notify the physician if residents' BG levels were greater than 240 mg/dl. On 1/31/19 at 2:09 PM, the Director of Clinical Operations and the DNS stated Resident #32 did not have a physician's order for [MEDICAL CONDITION] parameters and the facility was not following her care plan of notifying the physician when her BG levels were greater than 300 mg/dl. The facility policy/procedures, electronic record alerts, and staff understanding of what BG constituted [MEDICAL CONDITION], were inconsistent. The policy identified 240 mg/dl, staff interview identified 300 mg/dl, the alert in the e-MAR system was 350 mg/dl and the leadership staff indented 400 mg/dl. 3. Resident #46 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A discharge MDS assessment, dated 1/2/19, documented Resident #46 was discharged to an acute care hospital and not anticipated to return to the facility. A Nurse's Progress Note, dated 1/2/19 at 6:31 PM, documented Resident #46 was admitted to a hospital and would not come back to the facility due to the physician's preference to monitor him more closely. Resident #46's record did not include a physician's order to discharge him to the hospital. On 1/31/19 at 3:54 PM, the DNS stated Resident #46 was at the physician's office for an appointment on 1/2/19 and the physician called the facility and stated Resident #46 was going to be admitted to the hospital from the physician's office. The DNS was unable to provide documentation Resident #46 was a direct admit from the physician's appointment on 1/2/19, reason for admission to the hospital, and a physician's order to discharge him to the hospital.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure a resident who entered the facility without a pressure ulcer, remained free from pressure ulcers. This was true for 1 of 7 (#3) residents sampled for pressure ulcers. Resident #3 was harmed when he developed a Suspected Deep Tissue Injury (SDTI) while in the facility which later became a Stage IV pressure ulcer. Findings include: Resident #3 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #3's 4/22/16 Admission MDS assessment documented the following regarding his status: * Severely impaired cognition with a BIMS of 4 * Required extensive assistance of one person for bed mobility, transfers, dressing, and personal hygiene * Totally dependent on staff for bathing * Required limited assistance for eating * Functional limitation in ROM to upper/lower extremities, and lower extremity impairment on both sides * At risk of developing a pressure ulcer * Did not have one or more unhealed pressure ulcer(s) at Stage 1 or higher * Had no other ulcers, wounds, or skin problems * His skin and ulcer treatment was, pressure reducing device for bed and chair. * He was not on a turning or repositioning program. Resident #3's care plan documented: * Resident #3 was at risk for impaired skin integrity related to fragile skin, painful overgrown toenails, initiated on 4/15/16. This plan was revised on 6/7/16 to reflect the DTI to his right and left heels. * Referral to podiatrist, initiated on 4/29/16. * Pressure reducing mattress and w/c cushion to protect his skin, was initiated on 4/18/16. This was revised on 6/1/16 to include heel lift boots to both feet at all times while he was in bed and in his w/c to protect his skin. Staff were to check often throughout shift to ensure the boots were in place and fitting properly. * His skin was to be kept clean and dry and lotion used on dry skin, initiated on 4/15/16. Resident #3's care plan did not document the need to float his heels or assist him with turning or repositioning. Resident #3's 4/15/16, Patient Nursing Evaluation documented: * He had no pressure ulcers. * He did have a non-pressure ulcer present. * Comments included, Found bruising, scab and abrasion to bilateral extremities during assessment. Skin is pink, warm and very dry. Heel firm, ingrown toenails to L great toe. Resident #3's PN, IDT notes, Physician order [REDACTED]. * 4/29/16 PN at 1:02 pm - Resident #3 was referred to a podiatrist for overgrown toenails. * 5/2/16 PN at 4:57 pm - Resident #3 went out for his medical appointment and was prescribed [MEDICATION NAME] 50 mg PO TID x 7 days then, 1 PO PRN for feet pain. * 5/3/16 - Podiatrist notes documented, All of the patient's toenails are excessively elongated. Patient has pain with palpation of the toenails, one through 5 bilaterally. All of the patient's toenails are yellow in color, they exhibit crumbly subungual debris, and are misshapen. Resident #3's toenails were debrided. Instructions provided by the Podiatrist were, Check feet daily, wear good shoes, replace shoes regularly. The Podiatrist diagnosed Resident #3 to have [MEDICAL CONDITION] and onychomycosis (fungal infection of the nail). The Podiatrist recommended elevation of Resident #3's feet and compression stockings. Resident #3's clinical record did not include documentation that the Podiatrist's instructions and recommendations to check Resident #3's feet daily, to elevate his feet, and apply compression stockings, were implemented. Following the 5/3/16 Podiatry assessment, Resident #3's care plan was not updated to include the use of heel protectors related to his [DIAGNOSES REDACTED]. * 5/25/16 - A Physician order [REDACTED]. Consider adding a med(ication) for this? Having difficulty working (with) therapies d/t reluctant to put feet on the floor. The physician ordered [MEDICATION NAME] 300 mg PO QHS. Resident #3's record did not include documentation that the condition of his feet were assessed at this time. * 6/1/16 PN at 1:28 pm, stated, .rated pain at 8/10. Meds per order .Working with therapy this am. Therapy looked at his heels after complained of pain. 2 areas noted on both heels. Reported to wound team, waiting for treatment recommendation, heels floated on pillows. * 6/1/16, PN at 3:58 pm - The wound nurse assessed Resident #3's feet and documented the following, Left heel - Pressure, measuring 1 cm x 1.3 cm x 0 cm, stage, Suspected Deep Tissue Injury. Right Heel - Pressure, measuring 3 cm x 6 cm x 0.1 cm. Stage, SDTI. Dark grey colored skin along edge of heel with approx. 3 cm x 2 cm x 0 cm area on the medial aspect of wound that appears to be old calloused area with white/grayish yellow non viable tissue peeling away. Unable to visualize base of wound r/t non viable tissue in wound on medial aspect and intact discolored skin on rest of wound which is boggy upon palpation (SDTI). Right ankle outer - Pressure, measuring 2 cm x 2 cm x 0 cm. Stage, SDTI. Heel lift boots placed and care planned for use in bed and w/c to protect skin. * 6/2/16, PN at 4:30 pm - Resident #3 was seen by his physician and the LN on duty informed the physician via phone about the DTIs that were found on 6/1/16. Resident #3's physician was very pleased to hear the heel lift boots were initiated and skin prep to wounds Q shift TID were ordered. * 6/7/16, PN - The Wound Nurse assessed Resident #3's wound and documented the following, Left heel - Pressure measuring 1.2 cm x 1.6 cm x 0 cm. Stage, SDTI. No change to appearance. Remains an intact DTI. Recommend no tx change at this time. Right heel - Pressure measuring 3.2 cm x 6.8 cm x 0.2 cm. Stage, SDTI. Pain when cleaned with NS. R heel and malleolus areas have merged to current DTI. Purple in color. DTI has open area in center (0.2 cm x 0.2 cm) with small amount bloody drainage present. Wearing heel lift boots. Recommend tx be changed to honey hydrogel covered with foam dressing. * 6/7/16 - Physician order [REDACTED]. DTI to R heel appears to be deteriorating and has merged with malleolus area. Ok for wound clinic consult? In the meantime, ok for honey hydrogel and foam dressing, change daily and PRN? 2. Ok for multivitamins with minerals one tablet PO daily to promote wound healing? Resident #3's physician said yes to all requests. * 6/9/16, PN at 10:39 am - The IDT met to review skin areas on Resident #3's heels and documented that the Wound team noted the areas to be DTIs. The PN documented that Resident #3 did not wear shoes due to toenail pain and currently wore slippers socks. The PN documented Resident #3 was to wear heel lift boots at all times in bed and in his wheelchair. It noted the MD gave orders, as well as, approved the request for Resident #3 to go to the wound clinic. * 6/15/16 - A Wound Clinic note at 12:30 pm stated, .first noted on 6/1/16. He has a rapid decline in the level of functioning in the month of April .has become very dependent due to poor mobility and now very painful ulcer on the right greater than the left foot. Wound measurement and treatment included: - Right calcaneous wound, open, measuring 4 cm x 6 cm x 0.1 cm, limited to skin breakdown, with medium amount of serous drainage. Treatment provided and new orders included, Debridement of the right wound. Clean wound with clean cleanser - DiDakSol, Iodosorb, [MEDICATION NAME] (plain), [MEDICATION NAME] (foam dressing), secure with [MEDICATION NAME]. - Left Calcaneous wound, open, measuring 0 cm x 0 cm x 0 cm, limited to skin breakdown. Treatment was provided and new orders included, Bordered foam Iodosorb, [MEDICATION NAME], secure with [MEDICATION NAME]. - Continue the off-loading boots on the feet at all times. - [MEDICATION NAME] 100 mg one tablet oral by mouth two times a day for infected ulcer starting 6/15/16. - Resident #3's right heel wound was assessed at the Wound Clinic as Stage 4 and the left heel wound was assessed as unstageable. * 6/21/16, PN at 7:18 pm - IDT notes documented, Skin issue to bilat(eral) heel DTI and right lateral ankle DTI, it appears that cause of source of DTI's is unknown at this time but potentially related to not wearing shoes and having hallucinations, increased behaviors, delusions that resulted in refusing cares at times in his room as well as the DR, he has foot pedals in his w/c and when agitated may have resulted in kicking feet on w/c pedals. On admission resident was identified for potential skin at risk and a pressure reducing mattress and w/c was in place as well as heel lift boots bilaterally. Resident also went to podiatrist for a painful ingrown toenail. Resident #3's Weekly Skin checks documented the following: * 4/24/16, From looking (at) resident skin is clean, dry and intact, small old bruises on arms and no [MEDICAL CONDITION] on feet. Resident refused skin check by this LN. * 5/8/16, ST on right arm and left arm, resident refused skin check. * 5/15/15, Resident skin is clean, very dry, and not intact. 1 skin tear on right elbow and 1 skin tear left arm. Both have treatments and are healing. * 5/22/16, WSC comments, Resident skin is clean, dry and pink, along with very flaky. Heels firm and intact . * 5/29/16, Resident skin is clean, very dry and not intact. 4 old purple bruises right arm and 1 scabbed old skin tear covered with [MEDICATION NAME] and [MEDICAL CONDITION] on lower bilateral extremities. * 6/5/16 Residents skin is clean, very dry and not intact. 12 scabbed areas covered with [MEDICATION NAME] and 1 plus [MEDICAL CONDITION] on lower bilateral extremities. Will continue to monitor. The section of WSC to document if Resident #3 had a new suspected pressure ulcer or DTI and/or new non-pressure related skin condition, was not completed. * 6/12/16, Resident's skin is clean and dry with heels firm and not intact. Open areas to both heels covered with [MEDICATION NAME] that are clean, dry and intact. * 6/19/16, Pressure areas to bilateral heels, senile purpura to bilateral forearms. Dry flaky skin from healed skin tears. No new skin issues noted from last skin check . Resident's #3's Bates-Jensen Wound Assessment Tool (BWAT) contained spaces to document the date of each assessment, site, wound type, measurement in cm, stage, treatment/evaluation. The following were documented: * 6/1/16, Right ankle outer, Pressure, 2 cm x 2 cm x 0 cm, SDTI. Initial assessment, heel lift boots placed and care planned for use in bed and w/c to protect skin. * 6/1/16, Left heel, Pressure, 1 cm x 1.3 cm x 0 cm, SDTI. Initial assessment, heel lift boots placed and care planned for use in bed and w/c to protect skin. * 6/7/16, Right heel, Pressure, 3.2 cm x 6.8 cm x 0.2 cm, SDTI. Assessed by wound team. Pain when cleaned with NS. R heel and malleolus areas have merged to current DTI. Purple in color. DTI has open area in center 0.2 cm x 0.2 cm, with small amount bloody drainage present. Wearing heel lift boots. Recommend tx (treatment) be changed to honey hydrogel covered with foam dressing. * 6/7/16, Left heel, Pressure, 1.2 cm x 1.6 cm x 0 cm, SDTI, Assessed by wound team. No change to appearance. Remains an intact DTI. Recommend no tx (treatment) change at this time. Continues to wear heel lift boots. * 6/21/16, Right heel, Pressure, 4 cm x 7 cm x 0.6 cm, Unstageable. . 75% eschar and 25% slough. No granulation or [MEDICATION NAME]. No recommendation to change orders at this time. Pain rated at 3/10 during treatment of [REDACTED]. * 6/21/16, Left heel, Pressure, 1.1 cm x 1.1 cm x 0 cm. SDTI. .No treatment changes recommended at this time . * 6/7/16 MAR indicated [REDACTED]. On 6/23/16 at 9:40 am, the two Wound Nurses were interviewed regarding Resident #3's development of a SDTI. Wound Nurse #1 said they had provided Resident #3 with a pressure reducing mattress and w/c cushion upon admission. She said the heel lift boots were initiated when Resident #3's wound was discovered on 6/1/16. Wound Nurse #2 said the heel protectors were not provided upon admission because Resident #3's heels were assessed as firm with no skin impairment at that time. Wound Nurse #2 stated Resident #3 was being assisted with repositioning while in bed and his heels were being offloaded, as per their standard nursing practice. On 6/23/16 at 10:55 am, the DON was asked about the development of SDTI and subsequent Stage 4 PU. The DON said it was difficult for them to determine the cause of the DTI due to Resident #3's behavior. She said Resident #3 could have kicked his w/c foot pedals during episodes of confusion, hallucinations, and agitations. The DON indicated Resident #3 was provided with heel protectors, but did not know for sure if he wore them daily. The DON said there was no documentation that Resident #3 kicked his w/c, but it was possible he kicked the w/c or other objects due to his behaviors. When asked if Resident #3's foot pain was assessed on 5/25/16 when he complained of pain and was reluctant to put feet on the floor, the DON said Resident #3's foot pain appeared to be [MEDICAL CONDITION] related and he was prescribed [MEDICATION NAME]. Resident #3 was harmed when the facility failed to ensure he wore heel protectors while in bed and in his w/c, after he was diagnosed with [REDACTED]. The facility did not implement new interventions to protect his skin, such as heel protection or offloading of his heels and did not implement the Podiatrist's instructions and recommendations to check Resident #3's feet daily, elevate his feet, and apply compression stockings.

Based on observation, resident and staff interview, and record review, it was determined the facility did not ensure adequate supervision to prevent accidents. This was true for 1 of 6 residents (Resident #3) sampled for falls. Resident #3 was harmed when she was transferred improperly by facility staff and fell , sustaining a left wrist fracture. Resident #3 experienced a decline in her function as a result of the fracture, delaying her return to her home in the community, and prompting a change in her mood state. Findings included: Facility policy for Patient Mobility - Safety, Release Date 4/28/13, included, for Components of the Saf-Lift program: 1. b) Training. g) On-going evaluations. h) Accountability. 5. Gait belts are used with patient requiring "hands on" assistance unless contraindicated, for the primary purpose of staff and patient safety. Gait belts are considered part of a direct care staff's uniform. 10. Staff training includes, but is not limited to: c. 7) Gait belt. As part of the actual training, trainers have the class participants verbally describe and then actually demonstrate/practice their proficiency with each skill. 11. Every department has a role in making the ambulation and transfer programs successful. Each department should know what his or her individual responsibilities are: h. Employees 1) Comply with parameters of the Saf-Lift Program. 6) Encourage patient participation on Saf-Lift practices through education and communication as appropriate. Resident #3 was admitted to the facility on [DATE] for rehabilitation following a fall with a right femur fracture at home. She was readmitted to the facility on [DATE] following a brief hospitalization for a gastrointestinal (GI) bleed. Resident #3's Admission MDS assessment, dated 1/7/13, coded: *Minimal cognitive impairment. *No depression. *Extensive assistance from one person required for bed mobility, transfers, and toilet use. *Extensive assistance from one person required for dressing and hygiene. *Limited assistance from one person required for wheelchair mobility. *Ambulation did not occur. *Continent of bowel, occasionally incontinent of urine. On 2/6/13 at 1:00 PM, a facility Resident Event Report Worksheet documented: * Post-Fall Investigation, "While transferring from commode to bed, R (resident) was standing, had already pulled up pants (and) tied them, then R went to sit down before turning to face bottom towards bed. R fell to floor, landing on buttox (sic) (and left) arm while trying to brace self." *Investigation Interviews with CNA #1, "She (Resident #3) was using the commode, then she got up like normal. pulled her pants and tied them like normal. So I moved the commode out from under her then she just sat down without anything behind her (and) fell to the floor." *Investigation Interviews with the licensed nurse, "CNA (name) was transferring R from commode to bed. R on phone with daughter whole time on commode (and) during transfer. No gait belt in use. After R was standing clothes (and) everything ready to get back in bed, commode had already been moved to side so R could turn (and) get into bed easily. R started to sit without looking or feeling if something was behind her (and) fell to floor. Landing on buttox (sic) (and) attempting to brace self from fall with (left) wrist. C/O (complained of) severe pain to (left) wrist, no visible bruising, moderate deformation at wrist. Pain with adduction of hand (and) flexion of fingers. Pain to elbow with extension. Oxycodone 5 mg given. Ice applied. Arm immobilized." *PI recommendations, "Gait belt during transfers" and "Phone needs to off (sic) during all transfers." *An attached sheet documented, "IDT (Interdisciplinary Team) review of fall on 02/06/2013. Resident had just been toileted on her commode. She stood up. tied her pants, and the CNA prepared to remove her commode to transfer her back to bed. The resident did not know she had the commode removed, and went to sit back down, falling on to her right arm and buttocks. The CNA was getting ready to sit the resident on the bed and did not have the gait belt on her. Staff counseling provided to be hands on and gait belt with all residents unless they are independent per therapy." A hospital emergency room record for Resident #3, dated 2/6/13 at 2:12 PM, lists a primary [DIAGNOSES REDACTED]. Skin over the site is intact." a. Functional Indicators: Resident #3's nurse's Progress Notes documented: *1/27/13 at 3:50 PM, "Resident is a 1 person assist with transfers and ADLs..." *1/28/13 at 10:00 PM, "Resident is a 1 assist (with) transfers, propels self in w/c (wheelchair). *1/29/13 at 6:24 PM, "...1 standby assist (with) transfers, propels self in w/c..." *1/30/13 at 6:00 PM, "...1 standby assist (with) transfers, propels self in w/c..." *2/1/13 at 10:00 PM, "...1 standby assist (with) transfers, propels self in w/c..." *2/2/13 at 5:46 PM, "Transfers with 1 assist and 1 assist with ADLs." *2/3/13 at 1:19 PM, "Up with assist of 1 with platform walker..." *2/4/13 at 10:00 PM, "...1 standby assist (with) transfers, propels self in w/c..." *2/5/13 at 10:00 PM, "Resident is a 1 standby assist (with) transfers, propels self in w/c..." *2/6/13 at 10:44 PM. "Resident returned to facility from (acute care hospital) via non-emergent ambulance...Brace wrapped in ACE bandage to left arm...One person transfer assist..." *2/7/13 at 10:11 AM, "Resident received fall while transferring in room. Resident was talking on phone at time of fall (ear piece). when (sic) resident was interviewed for fall she stated that she was 'probably' distracted and not paying attention to what was going on. Resident was not wearing a gait belt at time of fall. Resident will now have a gait belt on during all transfers and will be a 2 person transfer at this time d/t fracture. Resident has also agreed to turn phone off during all cares." *2/8/13 at 12:39 PM, "IDT review of fall on 02/06/2013. Resident had just been toileted on her commode. She stood up, tied her pants, and the CNA prepared to remove her commode to transfer her to bed. The resident did not know she (the CNA) had the commode removed, and went to sit back down, falling on her right arm and buttocks. The CNA was getting ready to sit the resident on the bed and did not have the gait belt on her. Staff counseling provided to be hands on and gait belt with all residents unless they are independent per therapy." *2/10/13 at 10:54 AM, "Resident is a 2 person assist with gait belt at this time..." *2/11/13 at 6:12 PM, "Resident is an assist of 2 since fall onto (left) arm...daughter in (at) bedside all day, pushed resident t/o (throughout) facility..." *2/13/13 at 6:22 PM, "Resident is assist of 2 since fall onto (left) arm. Resident's daughter in a (sic) bedside all day, pushed resident (in wheelchair) t/o facility again today..." *2/14/13 at 9:54 pm, "Two person assist with transfers." *2/15/13 at 8:35 PM, "...up with assist x 2..." *2/16/13 at 5:37 PM, "...assist of 2 since fall onto (left) arm...daughter in a (sic) all day, pushed resident t/o facility again today..." Resident #3's PNs continued to document 2 person assist, and her daughter helping her to propel her wheelchair throughout the facility, until 2/26/13 when Resident #3 was discharged from the nursing facility to the acute care hospital for a GI bleed. NOTE: For the purposes of assessment, the physical and occupational therapy progress reports use the following functional scores, to describe how much assistance a resident required with a functional activity: NA = Not Addressed 1.0 = Complete Dependence (No contribution from the patient.) 1.7 = Near Total Dependence (Only partial assistance from the patient.) 2.0 = Maximum Assistance, required 75-90% (percent) assistance 2.5 = Moderate - Maximum Assistance, required 50-75% assistance . 3.0 = Moderate Assistance, required 40-50% assistance. 3.5 = Minimal to Moderate Assistance, required 25-40% assistance. 4.0 = Minimal Assistance, required 25% or less time or effort to complete. 4.5 = Contact Guard Assistance (CGA). 5.0 = Stand-by Assistance (SBA), no physical assistance beyond set-up, supervision, or cues. 6.0 = Modified Independent, no assist, but equipment and extra time. 7.0 = Complete Independence, no assistance, no equipment. Resident #3's Physical Therapy (PT) progress notes documented: *Week of 12/31/12 - 1/7/13: Bed mobility score was 3.5, transfer score was 3.5, gait score was 3.0. Goal of rehabilitation was for Resident #3 to reach her prior level of function and return home independently. *Week of 1/7/13 - 1/14/13: Bed mobility 5.0, transfers 4.0, gait 4.5. *Week of 1/14/13 - 1/21/13: Bed mobility 6.0, transfers 5.0-6.0, gait 5.0. *Week of 1/21/13 - 1/28/13: Bed mobility 7.0, transfers 6.0, gait 5.0. *Week of 1/28-13 - 2/4/13: Bed mobility 7.0, transfers 6.0, gait 5.0-6.0. *Week of 2/4/13 - 2/11/13: Bed mobility 4.5-5.0, transfers 2.0-3.0, gait NA. The comparative statement area of the form documented, "Pt (patient) (with) recent fall in room resulting in a fx (fracture) (left) distal radius (and) ulna and immobilized in a splint cast (with) no WB (weight bearing). Pt now (with) TDWB (touch-down weight bearing) (right) LE (lower extremity), NWB (non-weight bearing) (left) UE (upper extremity). End-stage (right) shld (shoulder) OA (osteoarthritis). PT is transferring easier but now requires assist x 2 and is unable to use platform walker." (NOTE: This indicated a measurable functional decline from the previous week.) *Week of 2/11/13-2/18/13: Bed mobility 4.5-5.0, transfers 4.0, gait 2-3 steps, 3.0. Resident #3's Occupational Therapy (OT) Progress Reports documented: *Week of 12/31/12 - 1/7/12: Upper Body (UB) dressing 4.5, Lower Body (LB) dressing 2.0, toilet transfer 2.0. Discharge planning goal was listed as, "Home." *Week of 1/7/13 - 1/14/13: UB dressing 3.0, LB dressing 2.5-3.0 with adaptive equipment (AE), toilet transfers 3.0. * Week of 1/14/13 - 1/21/13: UB dressing 5.0-6.0, LB dressing 3.0 with AE, toilet transfers 3.5. *Week of 1/22/13 - 1/28/13: UB dressing 6.0, LB dressing 3.0, toilet transfer 4.0. *Week of 1/28/13 - 2/4-13: UB dressing 6.0, LB dressing 4.5, toileting with commode 4.5-5.0. The comparative statement area of that form documented, "Pt able to progress to CGA/SBA (with) toileting at bedside commode needing (assistance) to hold commode only. Pt able to manage LB garments (and) peri care (with) SBA only due to fair balance at FWW (front-wheeled walker)." *Week of 2/5/13 - 2/11/13: UB dressing 1.7, LB dressing 1.0, toilet with BSC (bedside commode) 1.0. (NOTE: This assessment indicated a measurable functional decline from the previous week.) *Week of 2/11/130-02/18/13: UB dressing 2.0, UB dressing 1.7, toileting with BSC 1.7. *Week of 2/18/13 - 2/25/13: UB dressing 2.5, LB dressing 1.7, toileting with BSC 1.7. Resident #3's Late Loss ADL Flow Sheets documented the following amount of assistance required for toileting, transfers, and bed mobility: *1/1/13-1/9/13: Extensive assistance to dependent on 2 people. *1/10/13-2/6/13: Extensive assistance of 1 person. *Starting with Evening shift on 2/6/13: Extensive assistance to dependent on 2 people, until 2/26/13. NOTE: On 2/26/13 Resident #3 was discharged from the facility to the acute care hospital for a GI bleed. b. Mood Indicators: On 2/11/13, an Occupational Therapy Assistant Weekly Progress Report documented, "Pt showing (increased) anxiety (with) all...ADL...Pt was reluctant to do any type of ROM (range of motion) to (left) UE (upper extremity). Skilled OT is required to assess (and) address anxiety..." On 3/14/13, an MD progress noted documented, "Depressed. Angry about her broken wrist. Not interested in trying an anti-depressant. f/u (follow-up) on (left) wrist and (right) femur fracture - being followed by (orthopedic doctor's name). He wants her in wrist brace for another 4 weeks...PT slow...(Resident #3) discouraged about being at (nursing facility). (Daughter) has raised the possibility of antidepressants but (Resident #3) adamantly against it...Assessment: situational depression. Plan: discussed options. Cont. to monitor." On 3/27/13, a Nutrition Services Visit Note documented, "Noted by nursing staff that she refuses pain meds, as well as antidepressants..." On 4/15/13, an MD progress note documented. "...situational depression - 'doing fine' (though here (with) friend rather than alone or (with) (daughter) - so may not be completely candid about this issue.)" On 4/17/13, a Health Status Note (identified by the facility dietician as documentation of an inter-disciplinary discussion) documented, "She has refused foods, refused supplements, refused snacks, and even though she agrees she is depressed, has refused an anti-depressant..." This note was electronically signed by the DON. On 6/4/13 at 9:30 AM, Resident #3 was interviewed. She stated at the time of the fall on 2/6/13, "I was almost ready to go home. Now I don't know when I will be ready to go home. I might have to go live with my daughter. I was done with the commode and the CNA moved it. She did not tell me she was moving it. I can't see out of my right eye, so I couldn't see it had been moved. She should have helped me to stand from the commode, then moved the wheelchair behind me to sit. When I reached back, there was nothing to sit on. She was not helping me, and didn't have one of those belts so she couldn't catch me when I fell . I broke my wrist." Resident #3 held up her left wrist and stated, "Look at it. It will always be that way now." The surveyor observed a round smooth lump under the skin on Resident #3's left wrist, approximately 2" in size. Resident #3 stated she had been talking on her cell phone (via a hands-free ear piece) the whole time, "but she still should have told me she was moving the commode. I could still hear her. I just couldn't see on that side, so when she didn't tell me she moved it I thought it was still there." On 6/5/12 at 2:10 PM, the Administrator and DON were interviewed about Resident #3's fall and fractured wrist. The DON stated, "Resident #3 was being transferred to the commode. The CNA stood her (Resident #3) up, moved the commode from behind her, but did not tell (Resident #3) she had moved the commode. She (the CNA) was not using a gait belt. (Resident #3) fell ." The Administrator and DON were asked about Resident #3's visual field deficit. The DON stated the facility became aware of Resident #3's visual field deficit during the investigation into her fall. The DON stated Resident #3 was likely distracted during the transfer due to being on her cell phone at the time. The DON was asked if the CNA had recognized Resident #3 may have been distracted by this, and used either extra caution with the transfer, or requested Resident #3 terminate the call until after the transfer was complete. The DON stated, "I don't know." The DON and Administrator were asked about mood state changes for Resident #3 after her fall. The surveyor requested the DON review the information in the OT notes, nutrition notes, and the MD progress notes. The DON stated, "I'll look into it." The DON was asked for care plan updates in regards to Resident #3's statements she was depressed, and her decision to pursue non-medication options for treatment. The DON stated, "If she wasn't on an anti-depressant, I doubt there is a care plan." NOTE: Please see F280 as it pertains to care plan revisions. On 6/6/13 at 4:15 PM, the Administrator was again interviewed about Resident #3's fall. The Administrator stated the facility provided training to all CNAs regarding gait belt use, both at orientation and on an ongoing basis. The Administrator stated there had been re-training to staff on gait belt use after the event. The Administrator stated the facility's expectation was the CNAs would use gait belts with every transfer of a resident, unless the resident had been assessed as independent with transfers by physical therapy. The Administrator stated the CNA involved with Resident #3's fall was an experienced CNA, and had received the training prior to the incident. The Administrator stated Resident #3 had some responsibility for the fall as well, as she had been on her cell phone with her daughter at the time, resulting in unintentional, unexpected actions on both parties' part. The Administrator stated after the event occurred, the facility recognized right away a problem had occurred, followed their process exactly for such an occurrence, and had followed up with their Quality Assurance process. The Administrator stated, "I don't know what more we could have done to prevent it (the fall) from happening." When asked if the transfer had taken place according to facility policy (i.e., using a gait belt, explaining to the resident what was happening, etc.) the fall may have been prevented, the Administrator re-iterated the CNA in question had been trained to do those things prior to the event, but for some reason had not done them at the time. On 6/6/13 at 7:15 PM, the Administrator and DON were informed of the surveyor's findings. On 6/7/13 at 9:30 AM, the Administrator provided documentation of the "Individual Learning History" for the CNA transferring Resident #3 at the time of her fall. The forms documented the CNA received Saf-Lift training on 10/10/12, completed Annual CNA Competencies, including transfers and gait belt use, on 12/11/12, and a "Read & Sign" Gait Belt Review on 2/14/13. The Administrator also provided copies of the mood interviews associated with Resident #3's most recent MDS, and stated, "According to this, she was not depressed." The facility offered no explanation regarding the assessments of depression from Resident #3's physician, or the progress notes indicating mood state changes from the occupational therapist, nutrition services, or the DON. Resident #3 was harmed when she was improperly transferred in the facility, resulting in a fall with a left wrist fracture. Because of that fracture, Resident #3 experienced a decline in her functional status, changes in her mood state, and a delay in her ability to return to her home to live independently. On 6/11/13 BFS received a fax from the facility requesting the citation be re-considered. However, this did not resolve the concern with Resident #3's fall.

Based on observation, record review, and interview it was determined the facility did not ensure a resident who entered the facility with pressure sores received appropriate services to promote healing, and did not ensure new pressure sores did not develop while the resident was in the facility. This was true for 1 of 6 residents reviewed for pressure sores (Resident # 4). The deficient practice caused harm to Resident #4 when the Stage II pressure sore on his left buttock worsened before healing, then re-opened, and he developed a Stage II pressure sore on his right buttock. Findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. decubitus urinary incontinence, and scrotal ulcers. (NOTE: The facility's admission orders [REDACTED].) Documents from (name of acute care hospital) documented: *12/13/12: History and Physical (H&P): "...significant sores and concern for overall worsening of his (Resident #4's) condition...buttocks (with) 2 sores through the skin...area under scrotum red, [DIAGNOSES REDACTED]tosus with lesser breakdown...sores - needs pressure [MEDICAL CONDITION] in above areas..." *Daily Assessment Inquiry Forms -12/13/12. Pressure Ulcer to sacrum. Stage I, butterfly pattern over sacrum. -12/13/12. Pressure Ulcer to left buttock. 12/14/12, "Buttocks has sores - largest on right cheek, appears stage 2 possibly, wound care RN has assessed." -12/15/12. Multiple Pressure Ulcers to peri-area and buttock. -12/16/12. Pressure Ulcers to scrotum, groin, and buttock, improving. -12/17/12. Pressure Ulcers to scrotum, groin, and buttock, improving. Resident #4's admission orders [MEDICATION NAME] thin layer topical to Buttock, Penis, Groin BID (twice daily). Resident #4's Admission Skin Inspection, dated 12/17/12, documented: *Bruising to the right wrist and forearm, and to the left forearm and elbow. *Scabs to the right forearm and right outer leg. *Rash to the coccyx. *Stage II pressure ulcers (PU) to the coccyx measuring 1.5 centimeters (cm) long by (x) 1.5 cm wide x 0.3 cm deep, and to the left buttock 2 cm x .05 cm x 0.3 cm. (NOTE: There was no further documentation regarding the pressure ulcer on Resident #4's coccyx.) Resident #4's 12/24/12 Admission MDS assessment coded: *BIMS of 1, indicating severely impaired cognitive skills. *Always incontinent of urine, always continent of bowel. *Needed limited physical assistance from one person for bed mobility and hygiene. *Needed extensive physical assistance from one person for toileting. *Needed cues and supervision for ambulation. *Had 2 Stage II pressure areas present on admission, as well as other open [MEDICAL CONDITION] and Moisture Associated Skin Damage (MASD). *No turning or repositioning program. Resident #4's Pressure Ulcer CAA dated 12/24/12 documented, "Care plan will be developed to address and reduce/eliminate risk factors associated with having pressure areas and assist resident in returning to the highest practicable level of function possible." Resident #4's 3/18/13 Quarterly MDS assessment coded: *BIMS of 2, indicating severely impaired cognitive skills. *Frequently incontinent of urine, continent of bowel. *Needed cues and supervision for bed mobility and transfers. *Needed extensive physical assistance from one person for toileting. *Needed limited physical assistance from one person for hygiene. *Independent with ambulation. *One unhealed Stage II pressure area present. *No other unhealed open [MEDICAL CONDITION], no MASD. *Turning and repositioning program. Resident #4's care plan for impaired skin integrity documented: *"Resident has a open areas (sic) of the L (left) buttock and coccyx will be healed by review date." Initiated 12/27/12. *"Resident needs pressure relieving/reducing mattress to protect the skin while up in chair." Initiated 12/17/12. *"Educate ____/family/caregivers of causative factors and measures to prevent skin injury." Initiated 2/8/13. (NOTE: this item was revised on 2/17/13 with Resident #4's name where the blank space had been.) *"Identify potential causative factors and eliminate where possible." Initiated 2/8/13 *"Keep skin clean and dry. Use lotion on dry skin." Initiated 12/27/12. *"Monitor/document location, size, and treatment of [REDACTED]. to MD." Initiated 12/27/12. *"Apply lotion to BLE (bilateral lower extremities) Q (every) shift." Initiated 3/19/13. *"Wash for NS (normal saline) (sic), apply [MEDICATION NAME] to areas, cover with [MEDICATION NAME] sacral dressing, change Q 3-4 days and prn (as needed)." Initiated 4/29/13. (NOTE: There is no indication on Resident #4's care plan when this approach was discontinued, however, the order for this treatment was discontinued on 5/29/13, and it was not on Resident #4's current care plan at the time of survey.) *"Apply barrier cream to buttocks Q change/toileting and prn." Initiated 6/4/13. (NOTE: There was no addition to Resident #4's care plan to include a turning and repositioning program, as documented in Resident #4's 3/18/13 MDS.) Resident #4's MD progress notes documented: *1/14/13, "Skin, appears good..." signed by Resident #4's MD. *2/18/13, no mention of the condition of Resident #4's skin signed by the PA for Resident #4's physician. *3/12/13, no mention of the condition of Resident #4's skin, signed by Resident #4's physician. *4/8/13, "...rash and redness on his penis...yeast [MEDICAL CONDITION]-fungal cream and barrier cream twice a day...", signed by Resident #4's physician. *6/6/13, a letter signed by Resident #4's physician, addressed "To whom it may concern." The letter documented, "As (Resident #4's) primary care provider during his stay at (facility name), I have been appraised at least every two weeks of his condition, particularly regarding the wounds in his gluteal area. I and the nursing staff have all regarded these wounds to be non-pressure wounds. All assessments have lead (sic) us to a [DIAGNOSES REDACTED]." Resident #4's Weekly Pressure Ulcer reports for the left buttock documented: *12/17/12: 2 cm x 0.5 cm wide x 0.5 cm deep, Stage II. *12/29/12: 1 cm x 1 cm x 0.2 cm, Stage II. *1/1/13 : 1 cm x 1 cm x 0 cm, Stage II. *1/13/13: 1 cm x 1 cm x 0 cm, Stage II. *1/20/13 : 1 cm x 1 cm x 0 cm, Stage II. (NOTE: There was no improvement in Resident #4's PU documented between 1/1/13 and 1/20/13.) *1/27/13: 1 cm x 1 cm x 0.2 cm, Stage II. (NOTE: The PU had been previously documented as having no depth, indicating it was worsening at this point.) *2/13/13: 0.3 cm x 0.4 cm x 0 cm, Stage I. (NOTE: There was no Weekly Pressure Ulcer report for this wound documented between 1/27/13 and 2/13/13. On 2/13/13, the wound was documented to have improved from a Stage II to a Stage I.) *2/20/13: 1 cm x 0.5 cm x 0.1 cm, Stage II. (NOTE: Increased in size and depth from the previous week. The PU was documented to have deteriorated from a Stage I the previous week to a Stage II. No new orders were received until 2/26/13, which were to apply Baza anti-fungal cream to buttock each shift.) *2/27/13: 1 cm x 0.5 cm x 0.1 cm, Stage II. *3/5/13: 0.5 cm x 0.5 cm x 0.1 cm, Stage II. * 3/12/13: 1.2 cm x 0.5 cm x 1 cm, Stage II. (NOTE: Increased in size and depth from the previous week.) *3/22/13: 1 cm long x 1 cm wide. The area for "Depth" was blank. Stage II. *3/26/13: 0.5 cm x 0.5 cm x u-4, Unstageable. (NOTE: There was no documentation as to what "u-4" indicated.) *4/9/13: 6 cm x 4 cm x 0.1 cm, Stage II. (NOTE: The wound was documented to have grown by 5.5 cm in length and 3.5 cm in width between 3/26/13 and 4/9/13. The only new order received for skin care during this timeframe was to apply barrier and anti-fungal cream to Resident #4's penis.) *4/16/13: 6 cm x 4 cm x 0.1 cm, Stage II. The form further documented for that week, "Area is excoriated and has deteriorated as has his other buttock due to incontinence." (NOTE: This was the date Resident #4's MAR began to include documentation from the nurse once per shift Resident #4 had been toileted.) *5/1/13: 3 cm x 2 cm x 0.2 cm, Stage II. (NOTE: There was no Weekly Pressure Ulcer report for this wound documented between 4/16/13 and 5/1/13. There were, however, new orders for wound treatment received on 4/24/13.) *5/14/13: 0.2 cm x 0.3 cm x 0.2 cm, Stage II. (NOTE: There was no Weekly Pressure Ulcer report for this wound documented between 5/1/13 and 5/14/13.) *5/21/13: 0 cm x 0 cm x 0 cm, no stage. Shape specified as, "Healed area." *5/28/13: 0.3 cm x 0.2 cm x .02 cm, Stage II. (NOTE: This wound was documented as healed the previous week, but was now documented to be open again.) *6/4/13. 1.0 cm x 0.5 cm x 0.1 cm. Stage II. On 2/3/13, a facility Weekly Pressure Ulcer report documented a Stage II pressure ulcer to the right gluteal fold, measuring 1.2 cm x 1 cm x 0.1 cm. The report documented the date of initial observation of this wound was 12/17/12. On 2/10/13, it was documented as 1.0 cm x 1.0 cm x 0.1 cm. There was no documentation of PUs to Resident #4's right gluteal fold before 2/3/13 or after 2/10/13. On 4/23/13, a facility Weekly Pressure Ulcer report documented a Stage II PU to Resident #4's right buttock, measuring 1.3 cm x 2 cm x .01 cm. The date of initial observation of this wound was documented as 12/20/12. (NOTE: There was no facility documentation at the time of admission of PUs or other skin issues to Resident #4's right buttock. There was no facility documentation of a PU to Resident #4's right buttock between his admission on 12/17/12, and the Weekly Pressure Ulcer report on 4/23/13.) The Weekly Pressure Ulcer reports for the PU on Resident #4's right buttock documented: *5/7/13: 0.3 cm x 0.6 cm x 0.2 cm, Stage II. *5/15/13: 0.1 cm x 0.2 cm x 0.2 cm, Stage II. *5/22/13: 0.5 cm x 0.2 cm x 0.2 cm, Stage II. *5/29/13: 0.3 cm x 0.1 cm x 0.2 cm, Stage II. *6/4/13: 0 cm x 0 cm x 0 cm, "Wound has healed." Resident #4's Physician's Telephone Orders documented: *2/26/13: "Baza anti-fungal cream to buttock Q shift." *4/8/13: "Apply barrier - anti-fungal cream to penis BID (twice daily) topical until inflammation resolved. Dx fungal infection." *4/16/13: "Place on Q round toileting on MAR for nurse to document completion excoriation per (Nursing Order)." *4/16/13: "(Change) tx (treatment) to: Apply anti-fungal cream, put [MEDICATION NAME] powder, cover (with) barrier cream topical TID (three times daily). D/C (discontinue) [MEDICATION NAME]." *4/24/13: physician's orders [REDACTED]. Now we are using the [MEDICATION NAME] and [MEDICATION NAME]." Signed by Resident #4's physician. *4/24/13: physician's orders [REDACTED]. Cleanse (with) normal saline, apply [MEDICATION NAME] to areas, cover (with) sacral dressing. (Change) Q 3 days and prn." Signed by Resident #4's physician. *5/21/13: "(Change) tx to buttock to Baza clear. Topical TID" *5/29/13: "D/C [MEDICATION NAME] (and) sacral (dressing) to buttock/ Apply barrier cream top(ical) TID to Buttock (Baza clear). Dx Pressure Sore." On 6/3/13 at approximately 2:30 PM, during the initial tour of the facility, Resident #4 was noted to be sitting in a stationary chair in his room. On 6/4/13 at 8:10 AM, Resident # 4 was observed sitting in the same stationary chair in his room, in the same position, until 10:00 AM. At 10:00 AM, he was not in his room or in the bathroom. A blue gel pad was observed in the stationary chair. Resident #4 was observed again in the stationary chair from 10:50 AM until 3:15 PM. On 6/5/13 at 1:30 PM, the surveyor observed Resident #4's wound to his buttocks along with the ADON. The surveyor noted a Stage II pressure ulcer to the medial aspect of the left buttock, half moon shaped with granulation, no drainage. The ADON stated it was measured the day before at 1.0 cm x 0.5 cm. The surveyor also observed 2 healed areas to Resident #4's right buttock. On 6/5/13 at 1:45 PM, the ADON was interviewed about Resident #4's skin breakdown. While looking at the computerized skin records with the surveyor, the ADON reported Resident #4 was admitted with his skin issues. She clarified Resident #4 had been admitted with 2 pressure areas, and stated, "but his daughter thinks they are incontinence related." The ADON could not recall exactly where Resident #4's PUs were on admission, but upon reviewing the computerized record stated, "It looks like they were on his coccyx and his left buttock." The ADON stated Resident #4 currently had 1 open pressure area and 1 scabbed over area. She described the open area as "getting semi-closed, then open again." During the interview on 6/5/13 at 1:45 PM, the ADON was asked what measures were in place to reduce skin problems, the ADON stated, "Frequent toileting." When asked what frequent toileting meant, the ADON stated, "Before and after meals, and as of yesterday a 2 hour toileting plan." The ADON was asked what toileting plan had been in place before that. The ADON stated, "He took himself." The ADON was asked what prompted the change in Resident #4's toileting plan the day before. She stated, "During wound rounds yesterday the DON and I were wondering what could make it (Resident #4's wound) better." The ADON was asked about pressure relief for Resident #4 while sitting in his chair. The ADON stated, "We have a pad in his chair." When asked how long the pad had been in Resident #4's chair, the ADON stated, "I'm not sure. Maybe a month or so." (NOTE: There had been no care plan changes for the cushion in Resident #4's chair since 12/27/12.) The ADON was asked what other treatments or pressure relief had been tried or were in place. The ADON stated the facility had tried a "[MEDICATION NAME]" dressing, but it wouldn't stay in place. The ADON reported other dressings had been tried as well, but they would not stay in place either. The ADON was asked if the facility had requested a wound consultation for Resident #4. The ADON stated, "No. He came with orders from the hospital." The ADON was asked how often staff prompted Resident #4 to get up, so as to provide pressure relief. The ADON stated, "He gets up on his own a lot." The ADON stated there was no schedule for staff to ensure Resident #4 had been up. During the ADON interview on 6/5/13 at 1:45 PM, while reviewing Resident #4's computerized record with the surveyor, the ADON stated she was unsure about the documentation indicating PUs had developed on Resident #4's right gluteal fold and Resident #4's right buttock. On 6/6/13 at 11:15 AM, Resident #4's physician was interviewed about Resident #4's PUs, with the DON present. The physician reported he had cared for Resident #4 prior to his admission to the facility. The physician reported prior to admission, Resident #4 had dependent [MEDICAL CONDITION] and PUs, and overall had improved in the SNF environment. The physician was asked about the facility documentation indicating the PU on Resident #4's left buttock had worsened, then healed, then re-opened. The physician stated, "I think that's a given." The physician stated he had observed the resident to be quite mobile during his visits, unless there were other concerns. The surveyor informed the physician of the observations from 6/4/13, where Resident #4 sat for almost 2 hours in the morning without moving, and again in the afternoon for 4 1/2 hours without moving. The physician did not respond to the observation. On 6/6/13 at 11:30 AM, the DON was interviewed about Resident #4's PUs documented by the facility on the left buttock, right gluteal fold, and right buttock, as follows: *The DON stated she was not sure the wound to the right gluteal fold had actually been a PU. She reported she was new to the facility at that time, and no wound team was yet in place. The DON referred to the MD dictation dated 6/6/13 which documented the wounds on the gluteal area were non-pressure wounds. *The DON was asked about the worsening of Resident #4's PU to his left buttock, documented by the facility, between 3/26/13 and 4/9/13. The DON stated, "He was more incontinent at that time." When asked how the facility had responded to Resident #4's increased incontinence, the DON stated, "We had the nurse document on the MAR indicated (NOTE: There was no documentation from the facility that this measure had been implemented until 4/16/13, at least a week after the wound was noted to have worsened. Resident #4's MAR indicated [REDACTED].) *The DON reported on 4/24/13 the facility tried covering Resident #4's wounds, but the resident "started tearing them off", so treatments involving covering the wounds were discontinued. *When asked about Resident #4's wound to his right buttock developing, and the wound to his left buttock healing then re-opening, the DON stated, "It was fungal. But once it was documented as pressure, it stays pressure." The DON further stated, "The physician insists it (the PU's) are related to incontinence. When asked if the physician had documented that assessment while treating the wounds, the DON stated, "No." The DON was asked, even if the wounds were related to incontinence, if the facility could show what they had done to improve the wound to the left buttock, to prevent the wound to the right buttock, or to keep the wound to the left buttock from re-opening. The DON answered by referring to the nursing order from 4/16/13 for the licensed nurse to document each shift Resident #4 had been toileted. *The DON also stated the wound to the right buttock was documented by the acute care hospital to have been present prior to admission, therefore could be presumed to have been present when Resident #4 was admitted to the nursing facility. The DON was asked to provide documentation of that wound's presence on the facility admission skin assessment. That documentation could not be ascertained, beyond the DON's supposition the Stage II PU to Resident #4's coccyx noted on the admission assessment may have actually been on his right buttock. The DON was asked for facility documentation monitoring the wound between the time of Resident #4's admission on 12/17/12 and the first notation of a wound to the right buttock noted on a facility Weekly PU report on 4/23/13. The DON stated, "There were clearly 2 PUs present at admission." The surveyor referred again to the facility admission skin assessment, which documented Stage II PU's to Resident #4's coccyx and left buttock at the time of admission, but continued documentation on only the wound to the left buttock. The DON stated it was likely an error in knowledge of the person assessing the wounds during that time on how wounds should be measured, and the facility has since implemented a wound team. However, no other explanations were offered. On 6/6/13 at 7:15 PM, the administrator and DON were informed of the findings. On 6/11/13 BFS received a fax re-iterating the facility's explanation of Resident #4's wounds. However, this information did not resolve the concerns.