Every finding on record at Avamere Rehabilitation of Coos Bay

Based on observation, interview, and record review it was determined the facility failed to have an on-hand supply of emergency hypoglycemic medication and administer anti-seizure medications according to provider orders for 2 of 13 residents (#s 5, and 30) reviewed for insulin and medication errors. This placed residents at risk for serious adverse health outcomes and death. Findings include: 1. Resident 5 admitted to the facility in 4/2025 with diagnoses including end stage kidney disease and Type I diabetes. The facility’s 2024 Standing Physician Orders for diabetic management instructed staff to inject 1 gram glucagon when diabetic residents became unresponsive, or capillary blood glucose (CBG) was below 70 mg/dL. The 4/2025 Diabetic Administration Record (DAR) did not include standing orders for glucagon injections. The 4/30/25 admission MDS revealed Resident 5 had a BIMS of 13, which indicated the resident was cognitively intact. A 6/5/25 Summary for Providers Note revealed Resident 5 had a change in mental status, was unresponsive, and was difficult to arouse. Resident 5’s CBG was 34 mg/dL. Resident 5 was sent to the hospital. A 6/5/25 Hospital Provider Note revealed Resident 5 admitted with hypoglycemia and altered mental status. The resident's CBG was 34 mg/dL, and she/he required repeated administrations of intravenous dextrose (D50). A 6/29/25 Progress Note indicated Resident 5 was sent to hospital for low blood glucose of 34 mg/dL. The 6/2025 DAR revealed no standing orders or documentation on 6/5/25 or 6/29/25 staff administered glucagon injections. A 7/6/25 Progress Note revealed Resident 5 was found leaning to the left side, moaning, grinding teeth, and with clammy and sweaty skin. Resident 5’s CBG was 51 mg/dL. The nurse was unable to locate a glucagon injection and called 911. A repeat CBG was 46 mg/dL. About 20 minutes later, paramedics arrived and found the resident’s CBG at 31 mg/dL. The resident was given intravenous glucose, became responsive about 15 minutes later and was transported to the hospital. A 7/6/25 Progress Note revealed Resident 5 was admitted to the hospital for hypoglycemia and hyperkalemia (dangerous level of potassium in the blood which affects the heart and muscles). A 7/24/25 Progress Note revealed Resident 5 was sweaty, lethargic, weak, and had slurred speech. Resident 5’s CBG was 36 mg/dL. Staff notified the physician and reported a glucagon injection or glucagon gel was not available in the facility. The physician instructed staff to send Resident 5 to the hospital if her/his condition did not improve. Resident 5 was transferred to the hospital. A 7/31/25 Physician order instructed staff to maintain glucagon injections in the emergency kit. Staff were to inject 1 mg glucagon every 12 hours PRN for low CBGs related to hypoglycemia. On 8/21/25 at 4:36 PM, Resident 5 reported having multiple hospitalizations due to hypoglycemia. Resident 5 stated she/he was afraid to go to sleep at night because her/his blood sugars dropped and she/he often woke up in the hospital. Resident 5 further stated it was frightening to wake up in the hospital surrounded by unfamiliar people with no memory of the events leading to the hospitalization. On 8/21/25 at 9:06 AM, Staff 18 (LPN) confirmed the facility did not have any glucagon injections available in the emergency kit. On 8/21/25 at 9:10 AM, Staff 11 (Regional Director of Quality Assurance) confirmed the facility did not have any glucagon injections available in the emergency kit. Staff 11 stated the facility had standing orders for all diabetic residents, which should include their own glucagon injections and glucagon gel available on the medication carts. On 8/21/25 at 9:20 AM, Staff 17 (LPN) stated within the past few months, Resident 5 frequently experienced low CBGs, and required hospitalization due to hypoglycemia. Staff 17 further stated nurses were responsible for ordering additional doses however, there were sometimes delays in the pharmacy delivering the injections. On 8/21/25 at 6:56 PM, Staff 22 (LPN) stated Resident 5’s CBGs often went very low. On 8/22/25 at 12:40 PM, Staff 2 (DNS) and Staff 11 (Regional Director of Quality Assurance) confirmed the facility failed to follow standing orders and maintain sufficient supplies of glucagon injections for diabetic residents. Staff 2 confirmed Resident 5 was hospitalized multiple times as a result of the facility not having glucagon injections. 2. Resident 30 admitted to the facility in 8/2023 with diagnoses including quadriplegia (paralysis in all four limbs) and traumatic brain injury. During an observation of medication administration on 8/21/25 at 12:25, the Electronic Medication Administration Record (EMAR) used by Staff 20 (CMA) indicated multiple residents were receiving medications later than ordered. On 8/21/2025 at 12:45 PM, Staff 19 (LPN) stated he noticed medications were running later than ordered, and he was not sure what the policy was for late medications, or when he was supposed to ask for help. A review of Resident 30’s 8/21/25 Medication Administration Audit Report revealed the following: Baclofen 10mg (muscle relaxant) ordered four times a day for muscle spasms: - ordered to be given at 7:00 AM and was administered at 12:24 PM by Staff 19 (LPN). - ordered to be given at 12:00 PM and was administered at 1:26 PM by Staff 19 (LPN). - ordered to be given at 4:00 PM and was administered at 3:07 PM by Staff 20 (CMA). Levetiracetam 500mg (anti-seizure medication) ordered three times a day for Epilepsy (a seizure disorder): - ordered to be given at 7:00 AM and was administered at 12:24 PM by Staff 19 (LPN). - ordered to be given at 12:00 PM and was administered at 1:26 PM by Staff 19 (LPN). - ordered to be given at 4:00 PM and was administered at 3:07 by Staff 20 (CMA). Klonopin 0.5mg (anti-seizure medication) ordered three times a day for Epilepsy: - ordered to be given at 7:00 AM and was administered at 12:24 PM by Staff 19 (LPN). - ordered to be given at 12:00 PM and was administered at 1:26 PM by Staff 19 (LPN). - ordered to be given at 4:00 PM and was administered at 3:07 PM by Staff 20 (CMA). Progress Notes from 8/21/25 through 8/25/25 revealed no documentation the provider was contacted regarding the med errors, and no alert charting was in the resident’s medical chart. On 8/25/2025 at 9:53 AM, Staff 21 (Pharmacist) stated the Baclofen 10mg, Levetiracetam 500mg, and the Klonopin 0.5mg were not advised to be given so close together. She stated the medications are generally spread out over the waking hours for Resident 30, and the provider should be contacted for orders. She stated these medications administered in close proximity could cause increased lethargy and sedation. On 8/25/2025 at 10:21 AM Staff 2 (DNS) stated Staff 19 (LPN) was a new nurse and should not have been administering all the medications by himself. She stated the expectation for staff is to ask for assistance when they need help. On 8/25/2025 at 6:07 PM, Staff 25 (Medical Director/Doctor) stated he was aware of the medication errors on 8/21/25. He stated Resident 30 has had violent shaking episodes in the past when her/his medications were not administered on time, and the current medication administration schedule was currently managing her/his seizures. He stated the expectation was for staff to call him for orders when they were late with medication or if a medication dosage was missed.

Based on observation and interview it was determined the facility failed to ensure an ice machine drain had an airgap to prevent back flow for 1 of 1 kitchen. This placed residents at risk for foodborne illness. Findings include: On 8/20/25 at 11:04 AM and 8/20/25 at 11:20 AM with Staff 29 (Dietary Manager) the ice machine drainpipe was observed to be in a drain hole with no air gap. Staff 29 stated there was no flooding in the kitchen for years. On 8/21/25 at 12:31 PM Staff 30 (Maintenance) stated in 7/2025 the airgap was identified on a work order to be fixed but was not. On 8/25/25 at 10:33 AM Staff 1 (Administrator) stated he was not aware of the lack of airgap for the ice machine prior to survey.

Based on observation, interview, and record review it was determined the facility failed to ensure resident medications were not expired for 1 of 1 medication storage room, 1 of 2 medication carts, and 1 of 1 treatment carts reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include:The facility Medication Labeling and Storage policy, with unknown publication date, stated multi dose vials were to be dated when opened and discarded within 28 days. During an observation of the medication storage room on 8/19/25 at 1:18 PM, the following were found: - Two bottles of Metamucil (a laxative medication) with an expiration date of 4/2025. On 8/19/25 at 1:34 PM, Staff 22 (LPN) stated the expectation for expired medication was for it to be destroyed and replaced. During an observation of the [NAME] Fir Drive medication cart on 8/19/2025 at 2:04 PM, the following was found: - One bottle of acid reducer 20mg (medication used to reduce stomach acid) with an expiration date of 5/2025. On 8/19/2025 at 2:14 PM, Staff 23 (CMA) stated the expectation for expired medication was for it to be removed from the medication cart, destroyed, and replaced. During an observation of the [NAME] Fir Drive treatment cart on 8/19/2025 at 2:17 PM, the following were found: - One vial of Insulin Asparte (medication used for diabetes) with an open date of 7/17/25. - One vial of Insulin Glargine (medication used for diabetes) with an open date of 7/17/25. On 8/19/2025 at 2:22 PM, Staff 22 (LPN) stated the expectation for insulin was for it to be destroyed 28 days after it was opened and replaced with a new vial. On 8/25/2025 at 10:17 AM, Staff 2 (DNS) acknowledged expired medications were found in the medication storage room, on the [NAME] Fir Drive medication cart, and on the [NAME] Fir Drive treatment cart. She stated the expectation for expired medications was for them to be destroyed and replaced. She stated insulin was to be destroyed 28 days after being opened and replaced with a new vial.

Based on observation, interview, and record review, it was determined the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 5 of 10 sampled residents (#s 1, 7, 24, 52, and 61) reviewed for staffing. This placed residents at risk for unmet needs. Findings include:1. Resident 1 was admitted to the facility in 7/2025 with a diagnosis of UTI. Resident 1's 8/4/25 admission MDS revealed she/he had memory loss. On 8/18/25 at 11:53 AM Resident 1 stated, at times, it took approximately 30 minutes for staff to answer her/his call light, and it occurred on all shifts. Resident 1's Past Calls log from 8/14/25 through 8/17/25 revealed her/his call light was activated without a response for more than 30 minutes on 8/15/25 at 7:16 AM, 8/15/25 at 12:22 PM, and 8/16/25 at 7:19 AM. On 8/20/25 at 1:27 PM Staff 14 (CNA) stated Resident 1 often activated her/his call light and was not sure why she was not able to answer it in less than 30 minutes. On 8/20/25 at 2:20 PM Staff 16 (CNA) stated 7:00 AM was a busy time of day when she assisted residents up for breakfast, to bathe, and to get ready for the day. Some days after assisting a resident, there would be eight additional call lights on. Staff 16 stated she had to assist one resident at a time. On 8/21/25 at 2:44 PM and 8/22/25 at 11:57 AM Staff 2 (DNS) stated it was the expectation for resident call lights to be answered within five to ten minutes, and no more than15 minutes during the busy times of the day, such as mealtimes. 2. Resident 7 was admitted to the facility in 6/2024 with diagnoses including fracture of left femur. The care plan dated 3/12/25 identified Resident 7 required assistance with ADLs including repositioning and toilet use. An Annual MDS BIMS assessment dated [DATE] indicated a score of 15 (cognitively intact). A Resident Family Grievance Communication Form dated 8/10/25 revealed Resident 7 activated her/his call light to request assistance with a bedpan. The resident waited one hour before staff entered the room. A few minutes before shift change, Resident 7 was assisted onto the bedpan. After completing use, the resident activated the call light again. No staff responded until shift change was completed. The facility response indicated the call light was activated at 1:31 PM and remained on for 35 minutes. On 8/18/25 at 1:35 PM, Resident 7 stated on 8/10/25 she/he activated her/his call light and was on the bed pan for 20 to 30 minutes. Resident 7 had to wait until the evening shift came on before being assisted off the bed pan. Resident 7 stated she/he completed a grievance. On 8/21/25 at 10:49 AM, Staff 5 (CNA) stated Resident 7 was upset on 8/10/25 and reported she/he waited for assistance for an hour without a response from staff. Staff 5 assisted the resident to complete a grievance form. On 8/22/25 at 12:01 PM, Staff 2 (DNS) stated staff were expected to respond to call lights within five to 10 minutes, and no more than 15 minutes. 3. Resident 24 was admitted to the facility in 7/2024 with diagnoses including respiratory failure and kidney disease The care plan dated 10/4/24 identified Resident 24 as incontinent of bowel and bladder. The resident was encouraged to use the call light for assistance. A Quarterly MDS BIMS assessment dated [DATE] indicated a score of 14 (cognitively intact). A Resident Family Grievance Communication Form dated 8/7/25 revealed Resident 24's call light remained on for one hour and 20 minutes without response. The Past Calls report for call light log 8/12/25 through 8/14/25 and 8/16/25 showed the following: -8/13/25 at 12:45 PM, the call light was on for over 25 minutes without response. -8/16/25 at 9:34 AM the call light was on for over 26 minutes without response. On 8/18/25 at 12:14 PM, Resident 24 stated call light response times were too long. The resident reported one instance took 45 minutes for staff to respond. Resident 24 stated long call light wait times frequently occurred in the afternoons and resulted in multiple episodes of incontinence. On 8/22/25 at 12:01 PM Staff 2 (DNS) stated staff were expected to respond to call lights within five to 10 minutes, and no more than 15 minutes. 4. Resident 52 was admitted to the facility in 7/2025 with diagnoses including fracture of left leg, anxiety, and difficulty in walking. A 7/16/25 admission MDS BIMS assessment indicated a score of 13 (cognitively intact). On 8/20/25 at 8:05 AM, Call light computer time log at the nurses station showed Resident 52 activated the call light at 7:45 AM. Staff 17 (LPN Charge Nurse) entered the room at 8:06 AM-21 minutes later. At 8:30 AM Staff 17 stated he entered Resident 52's room because the call light had been on for a while. At 8:36 AM Resident 52 stated she had been waiting on the bedside commode, and her/his buttocks were getting sore. Resident 52 reported self-transferring back to bed. On 8/21/25 at 10:58 AM, Staff 14 (CNA) stated she assisted Resident 52 onto the bedside commode on 8/20/25. She then informed other staff by radio she needed to complete a shower for another resident. After finishing the shower, she saw Resident 52's call light was on and again informed staff by radio. On 8/22/25 at 12:01 PM, Staff 2 (DNS) stated staff were expected to respond to call lights within five to 10 minutes, and no more than 15 minutes. 5. Resident 61 was admitted to the facility in 8/2025 with diagnoses including diabetes and traumatic subdural hemorrhage (bleeding in the brain caused by trauma). On 8/18/2025 at 4:16 PM, Resident 61 stated she/he had to wait “quite a long time” on 8/17/25 and 8/18/25 to get help from staff. A review of the Call Light Audits for 8/17/25 and 8/18/25 revealed the following call light durations: 8/18/25 at 12:22 AM - 1 hour 7 minutes, 8/18/25 at 6:11 AM - 39 minutes, 8/18/25 at 10:35 AM - 31 minutes, 8/18/25 at 1:23 PM - 28 minutes, and 8/18/25 at 10:51 PM - 25 minutes. On 8/25/2025 at 10:18 AM, Staff 2 (DNS) acknowledged the call light durations and stated her expectation was all staff were responsible for responding to call lights in five to fifteen minutes, no matter what shift, or what was going on in the building.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 15 sampled residents (#s 3, 5, 21, and 59) reviewed for medications, insulin, medication administration, and tube feedings. This placed residents at risk for adverse medication effects. Findings include:1. Resident 3 was re-admitted to the facility in 4/2025 with a diagnosis of heart failure. Resident 3's 6/19/25 clinic physician summary indicated she/he was on a fluid restriction and was seen for a follow-up visit from a recent hospitalization for heart failure. The clinic visit summary revealed a handwritten order which instructed staff to discontinue Resident 3's fluid restriction. If Resident 3 experienced a five pound or greater weight gain in 24 hours, increased swelling in her/his legs, or difficulty breathing with exertion, the fluid restriction was to be reinstated. Resident 3's 6/2025 MAR revealed her/his fluid restriction was discontinued on 6/19/25. Resident 3's 7/2025 and 8/2025 TAR revealed her/his weights were monitored daily unless refused. The daily weights were discontinued on 8/11/25. The TARs did not indicate Resident 3's legs were monitored for edema. Resident 3's Progress Notes dated 6/19/25 through 8/19/25 revealed one note on 6/22/25 which addressed her/his lower extremity edema. On 8/22/25 at 9:35 AM Staff 10 (Regional Reimbursement Resource Nurse) acknowledged Resident 3 was on a fluid restriction which was discontinued on 6/19/25 with instructions to reinstate if she/he had symptoms of fluid retention. Staff 10 stated Resident 3 did not have weight gain and was stable. Staff 2 (DNS) stated Resident 3 had a desired weight loss, her/his daily weights were discontinued, and she/he often refused to be weighed. Staff 2 acknowledged the facility did not clarify with Resident 3's physician if the fluid restriction parameters were still required. On 8/22/25 at 9:48 AM Staff 26 (RNCM) stated Resident 3 refused weights, but the facility did not monitor Resident 3 for symptoms of fluid overload including her/his breathing status, lung assessment, or leg swelling. 2. Resident 5 admitted to the facility in 4/25 with diagnoses including end stage kidney disease and Type I diabetes. The facility’s 2024 Standing Physician Orders for diabetic management instructed staff to inject 1 gram glucagon when diabetic residents became unresponsive, or capillary blood glucose (CBG) was below 70 mg/dL. The 4/30/25 admission MDS revealed Resident 5 had a BIMS of 13, which indicated the resident was cognitively intact. Resident 5’s 6/2025 Diabetic Administration Record (DAR) did not include standing orders for glucagon injections. No documentation was found to indicate staff administered glucagon on 6/5/25 or 6/29/25 when the resident’s CBGs were below 70 mg/dL. Progress notes from 6/5/25, 6/29/25, 7/6/25, and 7/24/25 revealed severe hypoglycemia (blood glucose ranging 31-51mg/dL) and hospital transfers. On 7/6/25 and 7/24/25, staff were unable to locate glucagon injections in the facility, requiring emergency transport to the hospital. A 7/31/25 Physician order instructed staff to maintain glucagon injections in the emergency kit. Staff were to inject 1 mg glucagon every 12 hours PRN for low CBG related to hypoglycemia. On 8/21/25 at 9:06 AM, Staff 18 (LPN) confirmed the emergency kit did not include any glucagon injections. Staff 18 stated all diabetic residents should have standing orders for glucagon injections and gel, available on the medication cart. On 8/21/25 at 9:20 AM, Staff 17 (LPN) stated within the past few months, the facility ran out of glucagon injections on several occasions. During this time, Resident 5 frequently experienced low CBG levels, and required hospitalization due to hypoglycemia. Staff 17 further stated nurses were responsible for ordering additional doses however, there were sometimes delays in the pharmacy delivering the injections. On 8/21/25 at 4:36 PM, Resident 5 reported having multiple hospitalizations in recent months due to hypoglycemia. Resident 5 stated she/he was afraid to go to sleep at night due to frequent drops in her/his CBGs. On 8/22/25 at 12:40 PM, Staff 2 (DNS) and Staff 11 (Regional Director of Quality Assurance) confirmed the facility failed to follow standing orders and maintain sufficient glucagon supplies, contributing to multiple hospitalizations for Resident 5. b. The 6/9/25 Hospital After Visit Summary revealed Resident 5 was seen from 6/5/25 through 6/9/25 for hypoglycemia. A follow-up appointment was scheduled for 6/12/25. The physician referral orders indicated Resident 5 was to be enrolled in a continuous glucose monitoring (CGM) program. A 7/6/25 nephrology referral revealed due to Resident 5’s multiple hospitalizations related to either hyperglycemia or hypoglycemia, the resident was determined to have brittle diabetes (highly unpredictable blood glucose levels). The nephrologist recommended enrollment in a CGM program. The 7/31/25 Hospital After Visit Summary revealed a physician prescribed CGM. Medication changes included Dexcom G7 (blood-glucose) Receiver and Dexcom G7 (blood-glucose) Sensor. No documentation was found to indicate the facility followed through with the physicians’ orders. On 8/22/25 at 9:45 AM, Staff 32 (RCM) stated when residents are admitted or re-admitted with new orders, the facility used its triple check system to ensure orders were accurately entered. Staff 32 was unable to provide documentation Resident 5’s physician orders from 6/12/25, 7/6/25, and 7/31/25 were followed up on. On 8/22/25 at 12:40 PM, Staff 2 and Staff 11 confirmed the facility failed to follow up with physician orders related to Resident 5’s diabetic management. 3. Resident 21 was admitted to the facility in 6/2025 with diagnoses including diabetes and visual loss. An 8/2025 BIMS assessment indicated Resident 21 was cognitively intact. An 8/13/25 Progress Note indicated a provider order was received for Bactrim DS 800-160 mg (an antibiotic medication) to be taken twice a day for seven days. An 8/13/25 Progress Note indicated a provider order to decrease Resident 21’s Lantus insulin (diabetic medication) from ten units twice a day to five units twice a day. A provider order for Lantus insulin five units twice a day was entered into Resident 21’s chart on 8/13/25. An 8/14/25 Progress Note indicated Resident 21 received ten units of Lantus insulin during the morning 7:00 – 10:00 AM administration window. A provider order for Bactrim DS 800-160 mg twice a day for seven days was entered into Resident 21’s chart on 8/14/25. A review of Resident 21’s 8/2025 Diabetic Administration Record revealed the following: On 8/14/25 in the 7:00 - 10:00AM administration window ten units of Lantus insulin were administered, and then the order was discontinued. On 8/20/25 at 12:30 PM, Resident 21 stated she/he was aware of mistakes made with her/his insulin and antibiotic medications earlier in the month. On 8/25/2025 at 10:23 AM, Staff 2 (DNS) acknowledged the medication errors and stated her expectation was for provider orders to be double checked for accuracy by two nurses on different shifts for any new medication, any changes to medications, and prior to any medications being discontinued. 4. Resident 59 was admitted to the facility in 12/2024 with diagnoses including left sided Hemiplegia (paralysis of the left side) and intracerebral hemorrhage (a type of stroke). Review of a 2/12/25 Facility Reported Incident (FRI) indicated Resident 59 missed multiple administrations of Isosource Enteral Feed 1.5 (liquid food given though a tube) 300 ml via G-Tube (a flexible tube inserted into the stomach through the abdomen) from 2/1/25 through 2/5/25. A provider order for Isosource 1.5 300 ml via G-Tube at HS was started on 1/31/25 and was incorrectly discontinued on 2/1/25. A 2/1/25 Progress Note indicated Resident 59 was eating food by mouth and was no longer receiving the Isosource 1.5 300 ml via G-Tube. Another provider order for Isosource 1.5 300 ml via G-Tube at HS was started on 2/6/25. A review of Resident 59’s 2/2025 MAR indicated she/he did not receive the HS administration of Isosource 1.5 300 ml via G-Tube from 2/1/25 through 2/5/25. Alert notes from 2/7/25 through 2/10/25 indicate Resident 59 had no adverse effects from the missed administrations of Isosource 1.5 300 ml via G-Tube at HS. On 8/25/2025 at 10:23 AM, Staff 2 (DNS) acknowledged the medication error and stated her expectation was for provider orders to be double checked for accuracy by two nurses on different shifts for any new medication, any changes to medications, and prior to any medications being discontinued.

Based on interview and record review it was determined the facility failed to ensure a resident had correct sized incontinence products for 1 of 3 sampled residents (#3) reviewed for environment. This placed residents at risk for skin breakdown. Findings include: Resident 3 was admitted to the facility in 9/2023 with a diagnosis of diabetes. Resident 3's Care Plan initiated on 6/12/24 revealed she/he was incontinent of bowel and bladder and wore a three X brief for dignity. Resident 3's 6/18/25 Annual MDS revealed she/he was cognitively intact. On 8/18/25 at 1:39 PM Resident 3 stated the facility often ran out of the incontinence briefs she/he wore, she/he had to wear a smaller size, and it was uncomfortable. On 8/20/25 at 1:19 PM Staff 15 (Central Supplies) stated he ordered residents' incontinence supplies. Resident 3 required a special order. He ordered two boxes every two weeks; however, the shipment did not always arrive because it was back ordered. Staff 15 stated the back order happened regularly. If Resident 3's size did not come in, staff had to use the smaller sized brief. On 8/20/25 at 2:23 PM Staff 16 (CNA) stated approximately every two weeks Resident 3 did not have her/his sized brief for approximately two to three days. On 8/20/25 at 2:39 PM Staff 12 (Social Services) stated Resident 3 reported concerns related to not having the correct sized brief. When she looked into the issue, the supplies were back ordered. On 8/20/25 at 3:01 PM Staff 1 (Administrator) stated if Resident 3 was care planned to have a specific sized brief, the facility needed to ensure there were enough supplies in the facility at all times.

Based on interview and record review it was determined the facility failed to notify a resident's family of a hospitalization for 1 of 2 sampled residents (#3) reviewed for hospitalization. This placed residents at risk for lack of family involvement. Findings include:Resident 3 was admitted to the facility in 9/2023 with a diagnosis of diabetes. Resident 3's clinical record indicated Witness 1 (Family) was listed as her/his first emergency contact. Resident 3's 4/25/25 Progress Note revealed her/his oxygen saturation levels dropped multiple times, a rapid pulse, and five episodes of diarrhea. Despite interventions, Resident 3's oxygen level did not increase, and she/he was transferred to the hospital for evaluation. Resident 3's clinical record did not indicate Witness 1 was notified. Resident 3's 6/18/25 Annual MDS revealed she/he was cognitively intact. On 8/21/25 at 3:05 PM Resident 3 stated she/he had family, including Witness 1, who should be contacted when she/he was hospitalized . On 8/25/25 at 8:38 AM Witness 1 stated she was to be notified when Resident 3 had a change in condition. Witness 1 stated she was not notified in 4/2025 when Resident 3 was hospitalized . Witness 1 stated Resident 3 called her after she/he returned to the facility from the hospital and told Witness 1 she/he had been sick for many days. On 8/21/25 at 2:34 PM Staff 2 (DNS) stated Resident 3 was her/his own responsible party and staff did not have to notify family of hospitalizations.

Based on observation, interview, and record review it was determined the facility failed to report a bruise of unknown origin for 1 of 3 sampled residents (#41) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 41 admitted to the facility on [DATE] with diagnoses including heart failure and pain. A 6/14/25 physician order instructed staff to complete weekly skin checks on the resident's shower days and document on the Weekly Skin Audit. A 7/14/25 physician order instructed staff to administer apixaban 5 mg (anticoagulant) two times a day for blood clots. Resident 41's Annual MDS completed on 8/7/25 revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The 8/15/25 Alert Note indicated the nurse was notified Resident 41 had a long, dark bruise on the underside of her/his right breast. Resident 41 was unable to explain how the bruising occurred and did not complain of pain. No documentation was found to indicate staff notified the State Agency.On 8/19/25 at 10:53 AM, Resident 41 was unable to recall if she/he had any bruises.On 8/20/25 at 4:04 PM, Staff 17 (LPN) confirmed on 8/14/25 he was notified Resident 41 had a large bruise on her/his right breast. The resident did not recall how the bruise occurred. Staff 17 noted the resident was on anticoagulant medication and bruised easily. Staff 17 initiated a risk management report but did not report the incident to the State agency.On 8/21/25 at 4:42 PM, Staff 2 (DNS) was asked to provide copies of all internal and facility reported incidents (FRIs) that involved alleged abuse. Staff 2 confirmed on 8/14/25 staff identified a bruise on Resident 41, the resident was unable to state how the bruise was acquired, and the incident was not reported to the State agency.

Based on interview and record review it was determined the facility failed to ensure therapy was ordered for a discharged resident for 1 of 2 sampled residents (#22) reviewed for discharge. This placed residents at risk for lack of timely services after discharge. Findings include: Resident 22 was admitted to the facility in 7/2022 with a diagnosis of a stroke. Resident 3's 7/31/25 Discharge Summary and Plan revealed she/he was discharged on 7/31/25 and a Home Health Agency referral was submitted. The expected start of care was 8/4/25. On 8/18/25 at 4:56 PM Witness 4 (Complainant) stated Resident 22 just received orders for therapy on 8/18/25. On 8/20/25 at 2:46 PM Staff 12 (Social Services) stated Resident 22's discharge was resident driven. The facility therapy department recommended two additional weeks of therapy, but Resident 22's family wanted her/him to discharge on [DATE]. Home Health physical therapy and occupational therapy orders were recommended but the orders were not signed before the resident was discharged because the physician was not in the facility. On 8/21/25 at 9:43 AM Witness 2 (Assisted Living Executive Director) stated Resident 22's home health services were delayed. On 8/21/25 at 4:52 PM Witness 3 (Home Health Manager) stated they did not receive therapy orders until Resident 22 went to her/his Primary Care Physician, and that physician's office sent the orders. Witness 3 stated on 8/18/25 Resident 22 was accepted into home health therapy services.

Based on interview and record review it was determined the facility failed to ensure the state Long Term Care Ombudsman's office was notified of facility discharges for 3 of 4 sampled residents (#s 3, 22, and 56) reviewed for discharges and hospitalization. This placed residents at risk for lack of advocacy. Findings include: 1. Resident 3 was admitted to the facility in 9/2023 with a diagnosis of diabetes. Resident 3's Progress Notes revealed she/he was admitted to the hospital on [DATE]. A review of Resident 3's clinical record revealed the state long term care ombudsman (LTCO) was not notified of the resident's facility discharge. On [DATE] at 12:25 PM Staff 11 (Regional Director of Quality Assurance) verified there was no documentation the LTCO was notified of Resident 3's discharge. 2. Resident 22 was admitted to the facility in 7/2022 with a diagnosis of a stroke. Resident 22's Discharge Summary and Plan of Care revealed she/he was discharged on [DATE]. Review of Resident 22's clinical record revealed the state long term care ombudsman (LTCO) was not notified of the resident's facility discharge. The 7/2025 Ombudsman Notice of Residents Discharge form did not include Resident 22. On [DATE] at 12:25 PM Staff 11 (Regional Director of Quality Assurance) verified there was no documentation the LTCO was notified of Resident 22's discharge. 3. Resident 56 was admitted to the facility in 8/2023 with diagnoses including acute respiratory failure with hypercapnia (excess carbon dioxide in the blood) and chronic systolic heart failure (long-term condition where the heart has difficulty pumping blood). Progress Notes indicated Resident 56 was admitted to the hospital on [DATE]. A review of Ombudsman Notice of Residents Discharge forms for 6/2025 and 7/2025 did not include Resident 56's name. On [DATE] at 10:47 AM, Staff 12 (Social Services) stated she sent a monthly fax to the Long-Term Care Ombudsman's (LTCO) office listing all resident discharges. No additional information was provided. On [DATE] at 11:25 AM, an attempt to contact the LTCO office was not successful. On [DATE] at 11:49 AM, Staff 2 (DNS) stated the LTCO office would be expected to be notified monthly if a resident went to the hospital and returned. If a resident died, the LTCO office would be expected to be notified as soon as the facility became aware of the death.

Based on observations, interview, and record review it was determined the facility failed to ensure the resident's care plan was comprehensive for 1 of 3 sampled residents (#41) reviewed for abuse. This placed residents at risk for increased complications related to anticoagulant medication use. Findings include: Resident 41 admitted to the facility on 8/2024 with diagnoses including heart failure and pain. A 6/14/25 physician order instructed staff to complete weekly skin checks on the resident's shower days and document any skin irregularities on the Weekly Skin Audit. A 7/14/25 physician order instructed staff to administer apixaban 5 mg (anticoagulant) two times a day for blood clots. Resident 41's 8/7/25 Annual MDS revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The 8/15/25 Alert Note indicated the nurse was notified Resident 41 had a long, dark bruise on the underside of her/his right breast. Resident 41 was unable to explain how the bruising occurred and did not complain of pain. Resident 41's 8/21/25 care plan indicated the resident was on anticoagulant therapy for blood clots. The goal was for the resident to remain free from adverse reactions related to anticoagulant use. Staff were directed to report abnormalities to the nurse, document, and report bruising.On 8/20/25 at 3:56 PM, Staff 33 (CNA) stated on 8/14/25 she identified a large bruise on Resident 41's right breast and reported the findings to the charge nurse.On 8/20/25 at 4:04 PM, Staff 17 (LPN) confirmed he was notified Resident 41 had a bruise on her/his right breast, the resident did not recall how she/he got the bruise, she/he was on anticoagulant medication, and bruised very easily. Staff 17 initiated a risk management and notified management but did not update the care plan.On 8/21/25 at 4:42 PM, Staff 2 (DNS) confirmed Resident 41 had a physician order for anticoagulant medication and it was not on the care plan.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 9 sampled residents (#52) reviewed for staffing. This placed residents at risk for accidents. Findings include:Resident 52 was admitted to the facility in 7/2025 with diagnoses including fracture of left leg, anxiety, and difficulty in walking. The care plan dated 7/12/25 identified Resident 52 as high risk for falls. Staff were instructed to keep her/his call light within reach at all times and DO NOT leave the resident unsupervised in the bathroom or on the bedside commode. A 7/16/25 admission MDS BIMS assessment indicated a score of 13 (cognitively intact). On 8/20/25 at 8:05 AM, the call light time log showed Resident 52 activated her/his call light at 7:45 AM. Staff 17 (LPN Charge Nurse) entered the room the room at 8:06 AM-21 minutes later. On 8/20/25 at 8:30 AM Staff 17 stated he entered Resident 52's room because the call light had been on for a while. At 8:36 AM Resident 52 stated she had been waiting on the bedside commode, and her/his buttocks were getting sore. Resident 52 reported self-transferring back to bed. Resident 52 was observed in bed with a gait belt around her/his upper waist. Resident 52 stated Staff 17 entered the room after she/he had already self-transferred. On 8/21/25 at 10:58 AM, Staff 14 (CNA) stated she assisted Resident 52 onto the bedside commode on 8/20/25. She then informed other staff by radio she needed to complete a shower for another resident. After finishing the shower, she saw Resident 52's call light was on and again informed staff by radio. Staff 14 stated she did not know Resident 52 was not to be left alone on the bedside commode. On 8/22/25 at 11:57 AM, Staff 2 (DNS) confirmed Resident 52 was care planned to be supervised while on the bedside commode.

Based on interview and record review it was determined the facility failed to ensure residents received timely incontinence care for 2 of 10 residents (#6 and 15) reviewed for staffing. This placed residents at increased risk for skin breakdown and loss of dignity. Findings include:1. Resident 6 was admitted in 7/2025 with diagnoses including kidney failure and muscle weakness. The admission MDS dated [DATE] identified the resident as frequently incontinent of urine and she/he required assistance with toileting. Resident 6 was cognitively intact and did not have any behaviors of rejection of care. The 7/15/25 Urinary Incontinence CAA identified frequent incontinence and dependance on staff for safe completion of toileting hygiene and needs. Resident 6's care plan dated 7/23/25 directed staff to encourage the use of the call light for assistance, offer frequent toileting opportunities, provide frequent check and change throughout each shift, and perform peri care after each incontinent episode.A Documentation Survey Report for bladder from 8/1/25 through 8/18/25 revealed the following for Resident 6:-Day shift: incontinent 11 times, both continent and incontinent five times, continent two times, no documentation one time. No documentation of refusals.-Evening shift: incontinent nine times, both continent and incontinent four times, continent seven times, and no documentation of refusals. On 8/21/25 at 6:08 AM and 8/22/25 at 7:05 AM, Resident 6 stated it was easier to wear a brief than to wait for staff for assistance. Resident 6 confirmed having soaked through her/his wheelchair, leaving urine on the floor on 8/17/25. Resident 6 reported difficulty receiving timely assistance from staff to transfer into bed for incontinence care. On 8/22/25 at 6:45 AM Staff 8 (CNA) stated she was so pissed staff assisted Resident 6 up for lunch, on 8/17/25 and she later assisted with dinner. Between lunch and dinner, Resident 6 remained in her/his wheelchair without receiving incontinence care. Resident 6 urinated all over herself/himself. Staff 8 stated Resident 6 urinated on herself/himself during dinner, leaving a large puddle on the floor. On 8/22/25 at 9:03 AM Staff 4 (CNA) stated she assisted Resident 6 up for lunch and provided incontinence care on 8/17/25. Staff 4 stated she did not provide any incontinence care after lunch. On 8/22/25 at 10:58 AM Staff 5 (CNA) stated he worked the evening shift on 8/17/25 and was assigned to the same hall as Resident 6. He could not recall if he was specifically assigned to Resident 6 but remembered assisting with incontinence care. Staff 5 recalled the evening being very busy and stated Resident 6's urine maybe was on the floor and he helped clean the urine up. On 8/22/25 at 11:44 AM Staff 2 (DNS) stated staff were expected to check on residents every two hours and offer to lay them down in bed. If a resident refused assistance, staff are to notify the nurse. 2. Resident 15 was admitted in 5/2025 with diagnoses including benign prostatic hyperplasia (non-cancerous enlargement of the prostate) with lower urinary symptoms. The admission MDS dated [DATE] identified Resident 15 as cognitively intact and frequently incontinent of both bladder and bowel. Resident 15 also required the assistance of staff for incontinence care. The care plan dated 5/15/24 directed staff to encourage the use of the call light for assistance and to offer frequent toileting opportunities. A Resident Family Grievance Communication Form dated 8/11/25 documented on 8/10/25, Resident 15 requested a brief change at 1:10 PM. At 2:10 PM, Staff 5 entered the room and was informed assistance was still needed. Staff 5 stated he was told Resident 15 had already received incontinence care. A Documentation Survey Report for bladder from 8/1/25 through 8/12/25 revealed the following for Resident 15:-Day shift: incontinence two times, both continent and incontinent 12 times, and continent four times with no documentation of refusals.-Evening shift: incontinent six times, both continent and incontinent four times, and continent two times with no documentation of refusals. On 8/21/25 at 10:49 AM, Staff 5 stated on 8/10/25, Resident 15 reported being soaked through her/his brief and did not receive staff assistance, there was urine on the floor under her/his wheelchair, and Resident 15 requested to file a grievance. On 8/22/25 at 10:27 AM, Resident 15 confirmed timely incontinence care was not provided on 8/10/25. On 8/22/25 at 12:01 PM, Staff 2 (DNS) stated staff were expected to provide timely incontinence care, check on residents every two hours, and offer to lay them down in bed. If a resident refused assistance, staff were to notify the nurse.

Based on observation, interview, and record review, it was determined the facility failed to provide respiratory care and services for 1 of 1 sampled resident (#6) reviewed for medications and respiratory services. This placed residents at risk for unmet respiratory needs. Findings include:Resident 6 was admitted in 7/2025 with diagnoses including sleep apnea and edema (swelling caused by fluid retention).Per the facility's Oxygen Administration policy and procedure, documentation must include:-Date and time of oxygen setup or adjustment-Oxygen flow rate, route, and rationale-Frequency and duration of treatment-Reason for PRN administration-Assessment data before, during, and after the procedure-Resident's tolerance of the procedure The admission MDS dated [DATE] identified Resident 6 was cognitively intact and exhibited no behaviors. Resident 6 was not on oxygen therapy.A physician order dated 8/7/25 instructed staff to administer oxygen at two liters per minute via nasal cannula PRN for shortness of breath. No start date was listed. There was no documentation of oxygen tubing changes or cleaning of the oxygen concentrator filter.An 8/9/25 Physician's Progress Note stated Resident 6 frequently complained of dyspnea (difficulty breathing), although oxygen saturation was good. Oxygen was provided to relieve the sensation.The O2 Saturation Summary Report from 8/7/25 through 8/21/25 revealed oxygen use via nasal cannula on the following dates and times:-8/8/25 at 6:52 AM-8/11/25 at 8:12 AM and 4:07 PM-8/12/25 at 6:34 AM and 2:34 PM-8/13/25 at 6:36 AM-8/14/25 at 6:52 AM-8/20/25 at 10:09 AM, 3:06 PM, and 10:33 PM-8/21/25 at 7:13 AM, 8:44 AM, 2:58 PM, and 6:36 PMReview of Resident 6's 8/2025 MAR and TAR from 8/1/25 through 8/20/25 contained no documentation of Resident 6's PRN oxygen therapy. The care plan dated 8/12/25 identified a risk for ineffective breathing pattern due to edema and positioning. Interventions included:-Administer oxygen as prescribed or per standing order-Encourage coughing, deep breathing, and forced expiratory techniques as ordered-Evaluate pulse oximetry (measurement of oxygen saturation)On 8/21/25 at 6:08 AM, Resident 6 stated she/he used oxygen while sleeping and wore the nasal cannula most of the time. Resident 6 was observed wearing a nasal cannula with oxygen in use.On 8/21/25 at 7:37 AM, Witness 5 stated Resident 6 used oxygen part of the time. On 8/21/25 at 9:20 AM, Staff 7 (CNA) stated Resident 6 always used oxygen during her shifts. On 8/21/25 at 9:37 AM, Staff 9 (Physical Therapist Assistant) stated Resident 6 relied on oxygen. On 8/22/25 Staff 2 (DNS) confirmed there was no documentation on the MAR or TAR of Resident 6's use of oxygen and she would also expect an oxygen tubing and filter cleaning schedule.

Based on interview and record review it was determined the facility failed to ensure a resident's pain medication was available for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for uncontrolled pain. Findings include: Resident 3 was admitted to the facility in 9/2023 with a diagnosis of chronic pain. Resident 3's 6/18/25 Annual MDS revealed she/he was cognitively intact. Resident 3's 6/2025 MAR revealed on 6/12/25 she/he was administered one dose of oxycodone (narcotic pain medication). Resident 3's 4/2025 Order Summary Report revealed she/he was to be administered oxycodone every eight hours PRN for pain. Progress Notes revealed the following:6/12/25 follow up with Resident 3's clinic for an oxycodone refill. Staff were notified they were no longer able to use the emergency supply of oxycodone. 6/13/25 The pharmacy reported Resident 3's oxycodone was on hold pending clarification of which physician was allowed to prescribe refills. Resident 3's 8/2025 Orders Summary Report revealed she/he was to be administered oxycodone every eight hours PRN for pain. Resident 3's 8/2025 MAR revealed she/he was to be administered oxycodone every eight hours PRN for pain. The MAR also indicated oxycodone was to be refilled by one specific physician. As a result, Resident 3 was not administered oxycodone on 8/3/25, 8/4/25, 8/16/25 or 8/17/25. Progress Notes revealed the following:-8/16/25 Resident 3 refused showers and stated she/he would continue to refuse showers until her/his pain medication was re-ordered. -8/17/25 Resident 3's oxycodone was not delivered, the pharmacy reported they needed a new prescription, and Resident 3 did not exhibit signs of pain. -8/18/25 Resident 3's clinic was called for her/his oxycodone refill. -8/19/25 Resident 3's provider was unable to be reached, and a message was left. Resident 3 was administered PRN Tylenol (non-narcotic pain medication) and she/he attended an appointment to have her/his oxycodone prescription refilled. On 8/20/25 at 8:01 AM and 8/21/25 at 7:58 AM Resident 3 stated her/his oxycodone was originally ordered to be administered every eight hours PRN and she/he liked to take the medications three times a day. Resident 3 stated if she/he did not take her/his pain medication, it was difficult to get out of bed in the morning and participate in activities. Resident 3 stated she/he had another appointment with her/his physician in 30 days, and they needed to figure out a system for the facility not to run out of pain medications. On 8/21/25 at 12:24 PM Staff 17 (LPN) stated staff tried to refill Resident 3's prescription at least one week prior to the oxycodone running out. On 8/21/25 at 2:53 PM Staff 2 (DNS) stated the nurses faxed resident 3's oxycodone refill request to the clinic and they were to follow up to ensure they received a response. Staff 2 acknowledged there needed to be a system in place to ensure Resident 3's oxycodone prescriptions were filled timely.

Based on interview and record review it was determined the facility failed to ensure a resident's denture was replaced timely for 1 of 1 sampled resident (#3) reviewed for dental. This placed residents at risk for weight loss. Findings include: Resident 3 was admitted to the facility in 9/2023 with a diagnosis of diabetes. Resident 3's ADL report revealed at times she/he required assistance with oral care. Resident 3's 1/14/15 Care Conference Information form revealed Resident 3 reported the facility lost her/his lower denture. Resident 3 stated she/he set the lower denture on the bedside table and did not place the denture in her/his denture cup. Resident 3 also stated at bedtime she/he requested a snack and at that time she/he could not find her/his lower denture. Resident 3 stated a CNA looked for the denture in the linens, laundry, and dietary department but the denture was not located. Resident 3's 7/9/25 Progress Note revealed Staff 1 (Administrator) notified Staff 12 the facility was to replace Resident 3's lost denture. On 8/20/25 at 8:01 AM Resident 3 stated in 1/2025 she/he was in bed and took her/his dentures out to clean them, put the upper denture in the denture cup, and put the lower denture on the bedside table. Resident 3 stated she/he may have put it in a napkin because she/he was putting adhesive on it. Resident 3 stated later in the evening she/he was going to eat a snack, and she/he could not find the lower denture. The CNAs tried to find the dentures in the bedding, laundry, and garbage and could not find it. Staff 2 (DNS) informed her/him she/he was responsible for the care of her/his dentures. Therefore, she/he would have to pay for the replacement of the dentures. On 8/20/25 at 3:01 PM Staff 1 (Administrator) stated he was not notified of the missing denture in 1/2025. If he would have been aware of Resident 3's missing denture, the replacement process would have been started soon after it was lost.

Based on observation and interview it was determined the facility failed to provide clean and sanitary smoking equipment for 1 of 4 sampled residents (#21) reviewed for smoking. This placed residents at risk for respiratory issues and cross-contamination. Findings include: Resident 21 admitted to the facility in 6/2025 with diagnoses including nicotine dependency and visual loss. The 6/9/25 Smoking Safety Evaluation revealed Resident 21 was alert and oriented, had visual impairment, and required staff supervision while smoking, including the use of a smoking apron.The 8/6/25 Quarterly MDS revealed Resident 21 had a BIMS of 14, which indicated the resident was cognitively intact.On 8/18/2025 at 1:17 PM, Staff 20 (CMA) assisted Resident 21 to the supervised smoking area. Staff 20 and Staff 33 (CNA) stated no clean smoking aprons were available, as the only remaining apron was moldy. Staff 20 stated he would not want to put a moldy apron on himself, nor would he want to put it on any resident.On 8/18/2025 at 1:19 PM, Staff 33 was told by Staff 2 (DNS) they did not have any more smoking aprons in the facility. The remaining smoking apron was covered in black mold stains. Staff 33 attempted to wipe down the moldy smoking apron with an alcohol-based wipe before placing it on Resident 21. After Staff 33 put the smoking apron on Resident 21 she/he stated, yep that smells like mold and alcohol. On 8/18/2025 at 1:22 PM, Staff 33 stated residents should not be wearing moldy smoking aprons. On 8/20/25 at 1:10 PM, Staff 30 (Maintenance Director) stated once he became aware, he replaced all of the smoking aprons. Staff 30 confirmed this was an infection control concern.

Based on observation, interview, and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food borne illness. Findings include: On 5/2/24 at 11:48 AM Staff 26 (Cook/Dietary Aide) was observed to cut a hamburger patty with gloved hands on the cutting board attached to the steam table. Staff 26 placed the hamburger patty on a plate. Staff 26 then grabbed a rag from the red bleach bucket and wiped the cutting board and knife. The cutting board was observed to still be wet when Staff 26 used the same gloved hands to grab a skinned baked potato and cut it on the wet cutting board with the same knife. On 5/2/24 at 11:50 AM when asked about the drying time after wiping a surface, Staff 26 stated she, had no idea. When asked when it was appropriate to change gloves, Staff 26 stated she changed gloves often and had a box of gloves next to her work surface. When asked why she did not change her gloves after using the rag from the bleach bucket and before touching food, Staff 26 stated, I should have changed my gloves, but I forgot. On 5/3/24 at 9:19 AM Staff 27 (Dietary Manager) stated she expected staff to change their gloves and perform hand hygiene whenever they touched a potentially contaminated surface area to minimize risk of food borne illness, and expected staff to use portable cutting boards and to change out the cutting boards when needed.

Based on interview and record review it was determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry. Findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 5/1/24 at 1:17 PM Staff 22 (Housekeeping) stated her shift ended at 2:00 PM and she had the last shift of the day. Staff 22 stated when wet laundry was not completed in the washing machine at the end of her shift, she left the wet laundry in the washing machine overnight. Staff 22 stated the next morning she transferred the wet laundry to the dryer and did not rewash the laundry. On 5/2/24 at 8:52 AM Staff 23 (Housekeeping) stated her shift ended at 2:00 PM and she had the last shift of the day. Staff 23 stated multiple times a week she left wet laundry in the washing machine overnight and transferred the wet laundry to the dryer the next morning. She stated she did not rewash the laundry before it was transferred to the dryer. Staff 23 further stated when the dryer cycle was not completed at the end of her shift, she placed the damp laundry in a basket and covered it. The next morning, she then placed the damp laundry back into the dryer to finish the drying process. On 5/2/24 at 10:15 AM Staff 19 (Housekeeping Manager) was informed of the findings. She acknowledged the staff did not follow standards to produce hygienically clean laundry.

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals, and failed to ensure proper storage temperatures were logged and maintained for 2 of 2 treatment carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and adverse medication side effects. Findings include: 1. On [DATE] at 3:20 PM two vials of tuberculin (used for the testing in the diagnosis of Tuberculosis) were observed to be opened; one was dated October of an illegible year and another was dated [DATE]. The manufacturer's instructions indicated to discard the medication 30 days after opening. On [DATE] at 3:20 PM Staff 12 (LPN) acknowledged the two vials of tuberculin were opened and expired. 2. On [DATE] at 3:20 PM the medication refrigerator temperature logs were observed to be blank on [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 3:20 PM Staff 12 (LPN) acknowledged the temperature logs were blank on [DATE], [DATE] and [DATE] through [DATE]. 3. On [DATE] at 3:28 PM the treatment cart for the 100 hall was observed to have one Admelog insulin vial with an open date of [DATE]. Per manufacturer instructions Admelog insulin was good for 28 days after opening (expired on [DATE]). On [DATE] at 3:28 PM Staff 8 (LPN) acknowledged the Admelog insulin vial was expired. 4. On [DATE] at 3:28 PM the treatment cart for the 100 hall was observed to have one Novolog insulin vial with an open date of ,d+[DATE] (no year was documented). Per manufacturer instructions Novolog insulin was good for 28 days after opening (expired on [DATE]). On [DATE] at 3:28 PM Staff 8 (LPN) acknowledged the Novolog insulin vial was expired.

Based on interview and record review it was determined the facility failed to ensure Staff 3 (RN) and Staff 4 (LPN) adhered to professional standards of practice related to the provision of CPR (cardiopulmonary resuscitation) on a resident found with no heartbeat and not breathing for 1 of 1 sampled resident (#1) reviewed for Death/CPR. This failure, determined to be an immediate jeopardy situation, resulted from the failure to initiate CPR for the resident according to physician's orders. This failure prevented the possible resuscitation and continued life of Resident 1. Findings include: [NAME] 851 045 0040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. [NAME] 851 045 0050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural, and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall: (C) Selecting appropriate nursing interventions and strategies, (d) Implement the plan of care. [NAME] 851 045 0070 Conduct Derogatory to the Standards of Nursing Defined indicated the following: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (3) Conduct related to communication: (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse co worker) in an ongoing and timely manner. Resident 1 was admitted to the facility in 2022 with diagnoses including Type 2 Diabetes and late onset Alzheimer's disease. Resident 1's care plan dated [DATE] included Advance Directives Full Code (CPR) and the resident's POLST (Portable Orders for Life-Sustaining Treatment) was on file with the facility. Resident 1's POLST dated [DATE] indicated the resident's code status was Full Code (meaning the resident desired intervention such as CPR should her/his heart stop beating or she/he stops breathing) and Full Treatment (use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated). 1. A facility Final Investigation dated [DATE] indicated on [DATE] at 5:50 AM Resident 2 (roommate) of Resident 1 heard the resident coughing and asking for help. Resident 2 went into the hallway and requested help from Staff 6 (CNA). Staff 7 (CNA) also responded. The two CNAs adjusted the resident's position and brought the resident some ice water. Staff 6 said the resident told her she felt better. At 6:20 AM Resident 2 called to Resident 1 but received no response. Resident 2 again went out to the hallway and got assistance from Staff 5 (CNA) who determined the resident had no pulse and called for the nurse. Staff 3 (RN) and Staff 4 (LPN)responded to the room. The resident was pale gray and unresponsive. The investigation noted Staff 3 felt the resident had been expired too long. Staff 4 verified the resident was a Full Code. A Code Blue was not called, the crash cart was not brought to the room, CPR was not initiated, and 911 was not called. Staff 4 left the facility because it was the end of her shift and she was not scheduled for another shift for a few days. Staff 3 was suspended pending an investigation. The facility Final Investigation dated [DATE] also included a written statement from Staff 3 (RN) dated [DATE]. The statement indicated Staff 3 followed Staff 4 (LPN) to Resident 1's room when Staff 5 (CNA) called for assistance. They entered the room and Resident 1 was lying in bed not breathing with no pulse. The resident was pale gray in color, warm to the touch but they were unable to arouse her/him. No other information was included in the statement related to anything which occurred after they found the resident unresponsive. On [DATE] at 10:34 AM Staff 3 (RN) indicated on [DATE] he and Staff 4 responded to Staff 5's (CNA) radio call for a nurse to come to Resident 1's room. They went to the resident's room and the resident was dead. Staff 3 said he had not finished report yet so he was not really prepared for work. Resident 1 was not breathing, had no pulse, and was colorless. Staff 3 then walked back out of the room and did not return to the room. Staff 3 said he did not know the code status of the resident and did not think to look in the code book. Staff 3 stated he should have checked the code status of the resident, called a Code Blue (resident with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert), got the crash cart, started CPR, called the ambulance, and sent the resident to the hospital. Staff 3 also said he did not do what he should have done and did not follow procedure, he messed up. On [DATE] at 11:48 AM Staff 2 (DNS) indicated she was notified by Staff 4 of the resident's death but was unaware at the time that the nurses had not followed all the appropriate procedures for finding a resident unresponsive. She assumed, since both nurses had many years of experience, they had followed standards of practice related to finding the resident unresponsive. It was her expectation that when a resident was found unresponsive, and was a Full Code, staff would call a Code Blue to get assistance, get the crash cart, start CPR, verify the resident's code status, call 911 and send the resident to the hospital if needed. That did not happen for this incident. 2. On [DATE] at 10:06 AM Staff 4 (LPN) said on [DATE] she responded to Staff 5's (CNA) call for a nurse to come to Resident 1's room. She went into the room with Staff 3 (RN). The resident was not breathing and her/his color was grayish. They did not know the resident's code status and left the room to determine the status. The resident was a Full Code. They did not return to the resident's room. They did not call a Code Blue (resident with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert), they did not do CPR, and they did not call 911. Staff 4 said she did not know why she did not start CPR but she should have, even if the RN did not. Staff 4 acknowledged she knew what steps to take when a resident was unresponsive, but failed to follow procedure for the resident who was unresponsive and who's code status was FULL Code which included CPR. A facility Final Investigation dated [DATE] included a written statement from Staff 4 dated [DATE] at 6:20 AM which indicated Staff 5 called Staff 4 to Resident 1's room. Staff 3 went with her and they entered the room. The resident was sitting up in bed with no respirations or pulse. The resident's POLST was verified. Staff 4 called the DNS, the resident's family, and the funeral home. Staff 3 said he would call the doctor. Postmortem care was provided to Resident 1 by CNA staff. No information was contained in the statement related to what steps were taken when they found the resident unresponsive or why CPR was not initiated. On [DATE] at 11:48 AM Staff 2 (DNS) indicated she was notified by Staff 4 of the resident's death but was unaware at the time that the nurses had not followed all the appropriate procedures for finding a resident unresponsive. She assumed, since both nurses (Staff 3 and Staff 4) had many years of experience, they had followed standards of practice related to finding the resident unresponsive. It was her expectation that when a resident was found unresponsive, and was a Full Code, staff would call a Code Blue to get assistance, get the crash cart, start CPR, verify the resident's code status, call 911 and send the resident to the hospital if needed. That did not happen for this incident. On [DATE] at 5:02 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified the incident on [DATE] was an Immediate Jeopardy situation. As the facility identified the deficient practice and instituted corrections, this was determined to qualify for the designation as past non-compliance. On [DATE] at 7:28 AM the facility provided their immediacy removal plan. The facility identified non-compliance on [DATE], initiated training, and education with staff which was completed on [DATE]. The plan included the following: 1. DNS completed immediate huddle with current floor staff on [DATE]. 2. An audit of the facility was completed to determine all residents' code status. 3. DNS (or designee) completed training for direct care staff. Completion date [DATE]. Trainings included the following: a. Expectations of care for unresponsive resident. b. Performance of duties when a code blue is called. c. Policy for Emergency Procedure of CPR. d. Location of POLST Binder related to obtaining Code status information. 4. Completion of mock code blue drills for each shift: Completed [DATE]. 5. Monitoring: Audits for code status initiated beginning [DATE] including: a. POLST Binder b. Electronic Health Record (EHR) for accuracy c. Orders in EHR for change d. Plan of Care in EHR weekly for four weeks, then monthly for four months for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met. 6. DNS (or designee) audited employee status for: a. CPR certification b. Latest training and review of policy & procedure, and implementation of Code Blues. c. Mock Code Blue drill participation weekly for four weeks, then monthly for four months, for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met. On [DATE] at 2:45 PM Survey determined the Past Non-Compliance was corrected on [DATE] when the facility identified deficient practice, initiated corrections, and completed staff education and training. This included: 1. A review of the facility's audit tool used to determine residents' code status. 2. A review of facility In-Service Training Reports regarding the facility policy on code status and emergency CPR, Code Blues, Mock Code Skills, and Emergency Crash Carts with staff signatures for attendance. 3. Interviews with CNA and licensed nurse staff to verify they were provided the in-service trainings and could accurately explain emergency procedures.

Based on interview and record review it was determined the facility failed to perform CPR (Cardiopulmonary Resuscitation) on a resident found with no heartbeat and not breathing for 1 of 1 sampled residents (#1) reviewed for Death/CPR. This failure, determined to be an immediate jeopardy situation, resulted from the facility failing to initiate CPR for Resident 1 according to physician's orders. This failure prevented the possible resuscitation and continued life of Resident 1. Without immediate action to correct the failure the 19 other full code residents at the facility were at risk for not being resuscitated. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including Type 2 Diabetes and late onset Alzheimer's disease. Resident 1's care plan dated [DATE] included Advance Directives Full Code (CPR) and the resident's POLST (Portable Orders for Life-Sustaining Treatment) was on file with the facility. Resident 1's POLST dated [DATE] indicated the resident's code status was Full Code (meaning the resident desired intervention such as CPR should her/his heart stop beating or she/he stops breathing) and Full Treatment (use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated). A review of the facility's Policy Information for Code Blue (resident with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert) initiation dated [DATE] included the following: 1. If a resident was unresponsive, briefly assess and call for help. 2. Begin CPR-instruct staff member to call a Code Blue and initiate call to 911. 3. Verify, or instruct staff member to verify, the resident's POLST for code status. A facility Final Investigation dated [DATE] indicated on [DATE] at 5:50 AM Resident 2 (Roommate) of Resident 1 heard the resident coughing and asking for help. Resident 2 went into the hallway and requested help from Staff 6 (CNA) and Staff 7 (CNA) also responded. The two CNAs adjusted the resident's position and brought the resident some ice water. Staff 6 said the resident told her she felt better. At 6:20 AM Resident 2 called to Resident 1 but received no response. Resident 2 again went out to the hallway and got assistance from Staff 5 (CNA) who determined the resident had no pulse and called for the nurse. Staff 3 (RN) and Staff 4 (LPN) responded to the room. The resident was pale gray and unresponsive. The investigation noted Staff 3 felt the resident had been expired too long. Staff 4 verified the resident was a Full Code. Code Blue status was not called, the crash cart was not brought to the room, CPR was not initiated, and 911 was not called. Staff 4 left the facility because it was the end of her shift and she was not scheduled for another shift for a few days. Staff 3 was suspended pending an investigation. The facility Final Investigation dated [DATE] included a written statement from Staff 3 dated [DATE]. The statement indicated Staff 3 followed Staff 4 to Resident 1's room when the CNA called for assistance. They entered the room and the resident was lying in bed not breathing with no pulse. The resident was pale gray in color, warm to the touch and they were unable to arouse her/him. The facility Final Investigation dated [DATE] included a written statement from Staff 4 dated [DATE] at 6:20 AM which indicated Staff 5 called Staff 4 to Resident 1's room. Staff 3 went with her and they entered the room. The resident was sitting up in bed with no respirations or pulse. The resident's POLST was verified. Staff 4 called the DNS, the resident's family, and the funeral home. Staff 3 said he would call the doctor. Postmortem care was provided to Resident 1 by CNA staff. No information was contained in the statement related to what steps were taken when they found the resident unresponsive or why CPR was not initiated. On [DATE] at 10:06 AM Staff 4 said she responded on [DATE] to Staff 5's radio call for a nurse to Resident 1's room. She went into the room with Staff 3. The resident was not breathing and her/his color was grayish. They did not know the resident's code status and left the room to determine the status. The resident was a Full Code but they did not return to the resident's room. They did not call a Code Blue, start CPR, or call 911. Staff 4 said she did not know why she did not start CPR but she should have, even if the RN did not. Staff 4 acknowledged she knew what steps to take when a resident was unresponsive, but failed to follow procedure for the resident who was unresponsive and who's code status was Full Code which included CPR. On [DATE] at 10:34 AM Staff 3 indicated on [DATE] he and Staff 4 responded to Staff 5's radio call for a nurse to come to Resident 1's room. They went to the resident's room and the resident was dead. Staff 3 said he had not finished report yet so he was not really prepared for work. Resident 1 was not breathing, had no pulse, and was colorless. Staff 3 then walked back out of the room and did not return to the room. Staff 3 said he did not know the code status of the resident and did not think to look in the code book. Staff 3 stated he should have checked the code status of the resident, started CPR, called the ambulance, and sent the resident to the hospital. Staff 3 also said he did not do what he should have done and did not follow procedure, he messed up. On [DATE] at 11:48 AM Staff 2 (DNS) indicated she was notified by Staff 4 of the resident's death but was unaware at the time that the two nurses involved had not followed all the appropriate procedures for finding a resident unresponsive. She assumed, since both nurses had many years of experience, they had followed standards of practice related to finding the resident unresponsive. It was her expectation that when a resident was found unresponsive, and was a Full Code, staff would call a Code Blue to get assistance, get the crash cart, start CPR, verify the resident's code status, call 911 and send the resident to the hospital if needed. That did not happen for this incident. On [DATE] at 5:02 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified the incident on [DATE] was an Immediate Jeopardy situation. As the facility identified the deficient practice and instituted corrections, this was determined to qualify for the designation as past non-compliance. On [DATE] at 7:28 AM the facility provided their immediacy removal plan. The facility identified non-compliance on [DATE], initiated training, and education with staff which was completed on [DATE]. The plan included the following: 1. DNS completed immediate huddle with current floor staff on [DATE]. 2. An audit of the facility was completed to determine all residents' code status. 3. DNS (or designee) completed training for direct care staff. Completion date [DATE]. Trainings included the following: a. Expectations of care for unresponsive resident. b. Performance of duties when a code blue is called. c. Policy for Emergency Procedure of CPR. d. Location of POLST Binder related to obtaining Code status information. 4. Completion of mock code blue drills for each shift: Completed [DATE]. 5. Monitoring: Audits for code status initiated beginning [DATE] including: a. POLST Binder b. Electronic Health Record (EHR) for accuracy c. Orders in EHR for change d. Plan of Care in EHR weekly for four weeks, then monthly for four months for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met. 6. DNS (or designee) audited employee status for: a. CPR certification b. Latest training and review of policy & procedure, and implementation of Code Blues. c. Mock Code Blue drill participation weekly for four weeks, then monthly for four months, for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met. On [DATE] at 2:45 PM Survey determined the Past Non-Compliance was corrected on [DATE] when the facility identified deficient practice, initiated corrections, and completed staff education and training. This included: 1. A review of the facility's audit tool used to determine residents' code status. 2. A review of facility In-Service Training Reports regarding the facility policy on code status and emergency CPR, Code Blues, Mock Code Skills, and Emergency Crash Carts with staff signatures for attendance. 3. Interviews with CNA and licensed nurse staff to verify they were provided the in-service trainings and could accurately explain emergency procedures.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan and ensured a mechanical lift was in safe operating condition for 2 of 5 sampled residents (#s 16 and 22) reviewed for accidents. Resident 16 experienced a fall and sustained bilateral lower leg fractures. Findings include: 1. Resident 16 was admitted to the facility in 11/2020 with diagnoses including stroke, dementia and [CONDITION(S)]. A Significant Change MDS dated [DATE] indicated Resident 16 was rarely understood and had short-and-long term memory issues. Resident 16 required extensive two person assistance with bed mobility and transfers. A comprehensive care plan initiated on 5/7/12 indicated Resident 16's cognitive status varied, some days she/he was able to speak in complete sentences, and other days she/he had a blank stare. A revised care plan dated 11/16/18 indicated Resident 16 was at risk for falls due to poor balance, [CONDITION(S)], contractures and dementia. Staff were directed when Resident 16 was in her/his recliner to place the remote control for the recliner out of her/his reach (per Resident 16's agreement). A Fall Incident Report dated 9/12/20 revealed the following: -Resident 16 was transferred to her/his recliner by two CNAs with a mechanical lift. -Staff 9 (CNA) stated when she placed Resident 16 in the recliner she placed both the call light and remote to the recliner in her/his lap and left the room, Staff 9 returned shortly after putting Resident 16 in the recliner, found Resident 16 on the floor face down and called for help. Staff 5 (LPN) entered the room and indicated the recliner was reclined all the way back and the remote was wedged under Resident 16's arm. Staff 5 indicated Resident 16 possibly activated the remote, the recliner reclined up and forward and Resident 16 fell out of the recliner onto the floor face down. -Resident 16 was assessed by Staff 5 and she/he had a golf size bump to her/his right temple, a large bruise to the back of her/his right hand and bruising to her/his right and left lower shin area. The resident was not taken to the hospital. -On 9/14/20 Resident 16 stated she/he was transferred into the recliner using the mechanical lift, the CNAs left the room and not much longer after the CNAs left the chair started to lift up. Resident 16 stated she/he attempted to yell for help but no one heard her/him yelling. Resident 16 stated the remote was not under her/his arm but thought she/he might have been placed on top of the recliner remote and ultimately fell on to the floor. -On 9/16/20 it was determined after Resident 16 was transferred into her/his recliner Staff 9 placed the call light and remote control to the chair in Resident 16's lap and the resident possibly pushed the recliner button instead of the call light, which caused the chair to lift up and dump the resident out and onto the floor. The fall resulted in multiple injuries including a bruise to her/his forehead and bilateral lower leg fractures. Abuse was ruled out however neglect was unable to be determine because the care plan was not followed at the time of the fall. A progress note dated 9/14/20 revealed Resident 16 had a fall over the weekend and had BLE (bilateral lower extremity) swelling and bruising to both her/his shins and the resident was complaining of increased pain rated nine out of 10. The resident was sent to the hospital and at approximately 3:00 PM the hospital reported Resident 16's imaging results showed she/he had BLE lower leg fractures. The resident returned to the facility and had splints with ace wraps to her/his BLE (from upper thigh to ankle). The resident also had a new pain medication for pain control. On 7/20/21 at 4:21 PM Staff 6 (LPN) stated he remembered the incident on 9/12/20 because I flipped my noodle when he heard Resident 16 had fell out of her/his recliner. Staff 6 stated staff were expected to follow the care plan and additionally he was upset that the resident was not sent out to the hospital until one or two days after the fall, and at the hospital Resident 16 was evaluated with BLE leg fractures. On 7/21/21 at 10:34 AM Staff 5 stated she remembered the 9/12/20 incident because she was called to the room by Staff 9. Staff 5 stated when she walked into the room the resident was on the floor and the recliner was tilted up and forward. Staff 5 indicated she assessed Resident 16 for injuries and she/he had a bump to her/his head and abrasions to her/his shins but was not sent out to the hospital until the next day. Staff 5 further stated while the resident was at the hospital it was discovered she/he had BLE leg fractures. On 7/21/21 at 2:25 PM Staff 9 stated she remembered the 9/12/20 incident with Resident 16. Staff 9 stated she transferred the resident into her/his recliner with another staff person. Staff 9 stated she could not remember if she placed the remote and call light in the resident's lap but somehow the resident got hold of the recliner remote resulting in her/his fall out of the recliner. On 7/26/21 at 12:17 PM Staff 2 (DNS) stated she did not work for the facility when the 9/12/20 fall occurred but would have expected staff to follow the care plan, which was to keep the recliner remote out of reach of Resident 16. 2. Resident 22 was admitted to the facility in 11/2020 with diagnoses including [CONDITION(S)], muscle weakness and obesity. A Quarterly MDS dated [DATE] indicated Resident 22 had a BIMs score of 15 which indicated she/he was cognitively intact. A comprehensive care plan initiated on 2/16/21 indicated Resident 22 was a two-person mechanical lift for transfers from her/his bed to electric wheelchair. A Fall incident report dated 5/29/21 revealed the following: -Staff 16 (LPN) indicated Resident 22 had a witnessed fall from the mechanical lift sling during a transfer when one of the legs strap came undone and the resident fell on to the ground. The resident complained of right shoulder pain and pain to the back of her/his head. The resident had an abrasion to the back of her/his right shoulder approximately four inches long. No injuries were noted to her/his head. Resident 22 was unable to raise her/his right arm above 45 degrees and was sent out to the hospital. -On 6/2/21 Staff 15 (CNA) and Staff 14 (CNA) stated they were laying the resident back down into her/his bed via mechanical lift. While in the air one of the bottom leg straps of the mechanical lift sling came undone and Resident 22 fell out of the sling onto the ground. -On 6/3/21 it was determined abuse and neglect were ruled out as the CNAs transferred the resident appropriately. The mechanical lift was removed from use because a safety guard to prevent the lift sling from becoming unhooked was not in place. Staff were educated not to utilize the mechanical lift if the guards were missing. The resident was sent out to the hospital on 5/29/21 and returned the same afternoon with no new diagnoses but had a large bruise to her/his right posterior shoulder. On 7/22/21 at 3:18 PM Resident 22 stated she/he had a fall during a mechanical lift transfer in 5/2021. Two CNAs were transferring her/him back to bed and the mechanical sling came undone and I fell to the floor, hit my head, and was pretty shook up. Resident 22 stated she/he was sent out to the hospital and came back the same day. Resident 22 stated she/he had a large purple bruise to her/his right shoulder and staff monitored the bruise. The resident stated the bruise was no longer on her/his right shoulder. On 7/22/21 at 4:54 PM Staff 14 stated Resident 22 was alert and oriented, and was a two-person transfer with the mechanical lift. Staff 14 stated on 5/29/21 she and Staff 15 transferred the resident from her/his electric wheelchair to the bed. Staff 14 stated they hooked Resident 22 up to the lift via the sling and started to move her/him towards the bed. Then one of the straps by her/his leg came unhooked and the resident slid feet first down onto the floor. Staff 14 stated the resident was scared and crying when she/he initially fell to the ground, and Resident 22 was sent out to the hospital and came back later that afternoon. Staff 14 stated she did not recall seeing anything missing on the lift when they transferred her/him that day. Staff 14 stated the lift was removed from service. On 7/22/21 at 5:33 PM Staff 15 stated on 5/29/21 Resident 22 needed to be transferred back into bed. Staff 15 stated she and Staff 14 utilized the mechanical lift, hooked the resident up to the lift via the sling and did not see any safety features were missing or out of place. Staff 15 stated once they got Resident 22 in the air and started to move her/him one of the leg straps came unhooked and the resident slipped out of the sling feet first and hit her/his back and then the right shoulder. Staff 15 stated the resident was in shock but did not appear painful. Staff 16 assessed the resident and the resident was sent out to the hospital. Staff 15 stated the facility had three mechanical lifts, and two were newer, and the one they used on the resident on 5/29/21 was the oldest (third) but she did not see anything that looked unsafe when they hooked the sling up for the transfer. On 7/22/21 at 5:52 PM Staff 16 stated she was called into Resident 22's room on 5/29/21 due to a fall. Staff 16 entered the room and the resident was pretty shaken up and had significant pain to her/his right shoulder and decreased mobility. Staff 16 stated the resident hit her/his head on the floor and she initiated neurological checks. Staff 16 stated they got Resident 22 back into bed and then sent her/him out to the hospital. The resident returned from the hospital the same afternoon with no new diagnoses. On 7/26/21 at 10:01 AM Staff 21 (Maintenance Director) stated he recalled the incident with the mechanical lift on 5/29/21 because he removed the lift from the service because it was missing a safety clip. Staff 21 stated the lift that was removed from service, was an older model with safety clips to keep the sling in place. Staff 21 stated he ordered new parts for the lift. On 7/26/21 at 12:35 PM Staff 2 (DNS) stated they discovered the lift was missing a metal clip which prevented the sling from coming unhooked. Staff 2 stated they were not sure how long the clip was missing.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse and neglect for 3 of 5 sampled residents (#s 1, 2 and 3) reviewed for abuse and neglect. Due to the neglect of care related to incontinence Resident 2 developed moisture related skin breakdown and worsening of a Stage 3 (full thickness tissue loss without visible muscle, tendon or bone) pressure ulcer. Findings include: 1. Resident 2 was admitted to the facility in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 1/4/21 Admission MDS indicated Resident 2 was cognitively intact. Resident 2's CAA for Pressure Ulcers and Urinary Incontinence dated 1/4/21 included the following: - Resident 2 was always incontinent of bladder. Resident 2 had a Stage 3 pressure ulcer to the sacrum (bony structure at the bottom of the spine). Resident 2 was to be toileted frequently and provided good peri-care. Resident 2's Care Plan dated 12/31/20 indicated Resident 2 would be clean, dry and odor free and use adult briefs. Resident 2 had impairment to her/his skin which included a Stage 3 pressure ulcer to the sacrum. On 1/5/21 a Physical Therapy Treatment Encounter note indicated Staff 7 (PT) noticed Resident 2 had an open wound to her/his lumbar spine and she reported the skin injury to the nursing staff. On 1/7/21 a Physical Therapy Treatment Encounter note indicated Resident 2 stated her/his lower back was itching. Staff 7 proceeded to lift Resident 2's shirt but the shirt was stuck to Resident 2's skin due to dried urine. Resident 2's brief and bed linens were malodorous and saturated with urine. Staff 7 indicated she assisted Resident 2 with incontinence care and found two additional red areas on Resident 2's lower spine. Staff 7 reported the skin condition to Staff 20 (Resident Care Manager) and Staff 2 (DNS). Staff 7 indicated she discussed with nursing staff that Resident 2 would benefit from more frequent checks as the soiled brief and moisture could exacerbate her/his sacrum wound. An Incident Report and investigation dated 1/7/21 indicated that on 1/4/21 and 1/7/21 Staff 7 found Resident 2 with a saturated brief and an open wound on Resident 2's lower spine. The report further indicated Staff 12 (CNA) had left Resident 2 in a wet brief for an extended period on both dates: -The report indicated Staff 7 was in Resident 2's room to observe a wound dressing change. Staff 7 assisted to roll the resident to change the sacrum wound dressing. While turning the resident an obvious strong [MEDICATION(S)]/urine smell was present. Resident 2's brief was completely saturated and had partially soaked into the disposable incontinence pad. Staff 7 noted an open wound on Resident 2's lower spine near the top of the saturated brief. -Staff 7 and Staff 9 (LPN) indicated the resident stated her/his back felt itchy. They checked Resident 2's back and the red wound area looked 25% bigger than on 1/4/21. They noted a new dime size red spot on Resident 2's spine. Resident 2's brief was completely saturated, the urine was an orange color and the brief was beginning to separate due to the saturation. Staff 7 and Staff 9 reported the incident immediately to Staff 20 and Staff 2. -On 1/12/21 Staff 15 (LPN) indicated Resident 2 was found on 1/4/21 around 2:30 PM by her and Staff 11 (CNA) to be very wet with dark, foul smelling urine in her/his brief as well as her/his bed linens. Staff 15 stated when assisting with the dressing change on 1/5/21 they found Resident 2 again with a saturated brief with foul smelling dark brown urine. Resident 2 stated she/he had not been changed all afternoon. Staff 15 assessed Resident 2's urine on 1/6/21 to find the actual characteristics of the urine and it was light yellow in color, had no brown tinge and was not odorous. The brown color and odor were a result of being left in the brief for extended periods of time. -On 1/12/21 Staff 12 (CNA) indicated after she returned from lunch the resident's brief was saturated with urine. Staff 12 stated she forgot to change Resident 2. On 3/25/21 at 12:17 PM Staff 8 (CNA) stated she worked on the same hall as Staff 12 and on 1/7/21 Staff 12 left the resident in a saturated brief. Staff 8 stated she often had to take care of Staff 12's residents. Staff 8 stated she and Staff 7 notified Staff 2 at the time. On 3/25/21 at 12:39 PM Staff 2 stated the red spot on the resident's back and the open wound on the resident's spine was moisture related [CONDITION(S)] (damage occurring to the skin when urine or stool is left on the skin) and occurred as a result of Resident 2 being left in saturated briefs multiple times. Staff 2 acknowledged being left in a saturated brief would likely cause additional damage to a pressure ulcer like the one on the resident's sacrum which worsened. Further interviews following the interview with Staff 2 on 3/25/21 indicated the resident continued to be left in saturated briefs: On 4/23/21 at 3:09 PM Staff 15 (LPN) stated she had found Resident 2 wet many times and had reported this to Staff 1 (Administrator) and Staff 2 but it kept happening. On 5/2/21 at 3:35 PM Staff 16 (CNA) stated when she would follow Staff 12's shift and Resident 2 was always more saturated than normal. 2. Resident 3 was admitted to the facility in 2/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4 was admitted to the facility in 4/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A complaint intake dated 11/27/20 revealed Resident 4 threw a rock at Resident 3's head and grabbed her/his hand and squeezed which caused Resident 3's right index finger to bleed. The 12/2/20 Incident Document information provided by the facility indicated the rocks were at the nursing station on display after another resident painted them. Resident 4 was interviewed by the facility but was unable to say why she/he threw the rock and injured Resident 3's hand. An Incident Description dated 11/27/20 indicated Resident 4 was aggressive towards Resident 3, threw a rock at Resident 3's head and caused a cut on her/his finger. An Incident Description indicated Staff 26 (CNA) notified a nurse who assessed Resident 3 and noted a cut with a bruise surrounding it on her/his right index finger. Resident 3 was frazzled at the time and was not able to appropriately describe the incident. Resident 3 was asked if she/he was okay, Resident 3 stated yes, she/he cut my finger and threw a rock at my head. The Incident Report Notes dated 11/27/20 indicated due to the mental capacity of Resident 4 a validation of purposeful maliciousness or abuse could not be verified. On 3/24/21 at 1:00 PM Resident 3 stated she/he had a resident hurt her/his head and her/his hand. On 3/24/21 at 1:38 PM Staff 2 (DNS) indicated Resident 3 was hit with a rock thrown by Resident 4 which struck the side of her/his head and her/his finger was bruised and cut when Resident 4 grabbed her/his hand. 3. Resident 1 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident Report dated 1/20/21 at 2:15 PM indicated there was a physical and verbal altercation between Staff 3 (CNA) and Resident 1. Staff 4 (CNA) was a witness to the incident. Staff 3 was terminated for suspected verbal and physical abuse. On 3/24/21 at 2:00 PM Staff 6 (RA/CNA) stated Staff 4 told him that a couple of days prior Resident 1 and Staff 3 were joking around and they started to argue and swear and Staff 3 threw a package of wipes at the resident which hit the resident in the face. Staff 6 asked if Staff 4 reported the incident and Staff 4 replied no. Staff 6 immediately reported the incident to the DNS. On 3/24/21 at 3:10 PM Staff 2 (DNS) indicated on 1/20/21 she initiated a FRI for an allegation of abuse involving Staff 3 and Resident 1. Staff 4 was a witness to the incident. Staff 2 immediately began an investigation into the abuse allegation. Staff 4 revealed Staff 3 and Resident 1 had a heated exchange and they both swore at each other. Resident 1 told Staff 3 to get out of the room. Staff 3 was near the foot of the bed and when exiting the room Staff 3 threw a package of wipes. Staff 4 stated the wipes hit the resident in the face. Staff 2 indicated Staff 3 initially denied the allegations but later revealed he was angry and threw the wipes in the direction of the resident. Staff 2 indicated she could not rule out abuse upon completion of her investigation and Staff 3 was terminated. On 3/24/21 at 4:05 PM Staff 5 (Agency CNA) stated she was at the nurse's station when she heard Resident 1 and Staff 3 yelling from Resident 1's room. Staff 5 said she saw Staff 3 throw the package of wipes toward the resident's bed. Staff 5 also stated, you are never supposed to throw wipes at any time. Staff 5 said she did not hear the details of what was said during the verbal altercation but she heard Staff 3 in the hallway say, Are you [OBSCENITY] ing kidding me? On 3/25/21 at 11:56 AM Staff 3 indicated he and Staff 4 went to Resident 1's room together to provide incontinence care. Resident 1 was not being cooperative. Staff 3 stated he said something to Resident 1 about needing to hurry and the resident got upset. They argued and the resident told him to, get the [OBSCENITY] out. Staff 3 stated he was mad and as he left the room, he threw a package of wipes toward the resident's head and they landed next to the resident's head on the pillow but did not hit the resident. Staff 3 said the resident may have thought he was throwing the wipes at him because his head was on the pillow. Staff 3 acknowledged he should not have thrown the wipes; it was a bad decision and he regretted throwing them. Staff 3 stated he never cussed at the resident or any other resident. Staff 3 also said Staff 5 (Agency CNA) saw him throw the wipes. On 3/26/21 at 5:02 PM Staff 4 (CNA) said he believed the incident occurred on a Saturday and during last rounds with Staff 3. Staff 3 and the resident got to joking, in sort of an insulting type of banter. Staff 4 indicated Resident 1 and Staff 3 were both a little hotheaded and both liked to have the last word. They offended each other and started having words. They both swore at each other, but Staff 4 could not remember the exact words they used. Staff 3 had a package of wipes in his hands, and he was standing near the foot of the bed. Staff 3 threw the wipes as he walked toward the door and they hit the resident's face. Staff 4 said he was standing near the doorway with his back to the door and he did not see any other staff near the room. Staff 4 reiterated he saw Staff 3 toss the wipes which hit the left side of the resident's face. Staff 4 said Staff 3 threw the wipes because he was mad. Staff 4 said he did not report the incident. Staff 4 also said he did not think Staff 3 was actually aiming for the resident's head or that he meant to hurt the resident. On 3/25/21 at 1:15 PM Resident 1 revealed he was unable to remember much of the incident. Resident 1 said she/he and Staff 3 argued but her/his memory was fuzzy ever since her/his stroke. On 4/3/21 at 10:30 AM Staff 2 acknowledged she had not ruled out verbal and physical abuse of Resident 1 by Staff 3 and Staff 3 was terminated.

Based on interview and record review it was determined the facility failed to provide appropriate pressure ulcer care, moisture management and [MEDICATION(S)] for 1 of 3 sampled residents (#2) reviewed for abuse and neglect. This failure resulted in Resident 2 experiencing worsening of a pressure ulcer and severe pain. Findings include: Resident 2 was admitted to the facility in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/4/21 Pressure Ulcer and Urinary Incontinence CAAs indicated Resident 2 was frequently incontinent of bowel, always incontinent of bladder and was more prone to pressure ulcers. Resident 2 had a Stage 3 (full thickness tissue loss without visible muscle, tendon or bone) pressure ulcer to her/his sacrum (end of spine). Facility Wound Evaluations noted the following: - On 12/30/20 Resident 2 had a Stage 3 pressure ulcer to the sacrum which measured 1.48 cm by 1.21 cm by 0.2 cm deep. The wound was present upon the resident's admission to the facility and the age of the wound was unknown. -On 1/12/21 the Stage 3 sacrum wound measured 2.55 cm by 2.15 cm by 1.67 cm and was getting bigger. -On 1/19/21 had no measurements but indicated the Stage 3 sacrum wound had remained the same. -On 1/26/21 the pressure ulcer measured 4.22 cm by 2.82 cm by 2.02 cm and remained a Stage 3 but the wound had increased in size and contained slough and eschar (dead tissue). -On 2/9/21 the pressure ulcer measured 5.68 cm by 3.4 cm by 2.2 cm. The Wound Evaluation progress note indicated the sacrum wound had declined over the past week and there was slough and eschar in the wound. The slough and eschar made it hard to view the entire wound. -On 2/23/21 the pressure ulcer measured 5.89 cm by 4.6 cm and no depth was indicated. The Wound Evaluation progress note indicated Resident 2 was sent to the ER (emergency room ) due to severe wound decline and increased pain. -On 3/2/21 the pressure ulcer measured 6.6 cm by 5.62 cm with no depth noted. The Wound Evaluation progress note indicated the sacrum wound had made some improvement but the progress notes indicated new tunneling (a wound that has progressed to form passageways underneath the skin). Wound Clinic Progress Notes included the following: -On 3/4/21 the sacrum wound had worsened to a Stage 4 (full thickness, tissue loss with exposed muscle, tendon or bone). There was a large amount of foul smelling purulent (thick or thin opaque drainage) from the pressure ulcer. The wound also had undermining (pocket beneath the skin). Resident 2 stated her/his pain was an 8 on a scale of 0 to 10 (pain which is 8 and above is considered severe). The pressure ulcer base had slough and eschar. -On 3/8/21 Staff 2 (DNS) called and stated the family was unable to afford a stretcher for transport at this time. Staff 2 indicated she wanted to put the resident's wound clinic visits on hold until such time as Resident 2 discharged from the facility. -On 3/15/21 Resident 2's pressure ulcer was much worse, foul-smelling and full of new necrotic (dead) skin and debris. The wound clinic physician indicated Resident 2 was in dire straights. Resident 2 was transported to the ER and the prognosis was poor. A 3/16/21 facility Progress Note indicated the facility received a call from the hospital which indicated Resident 2 was put on comfort care, was expected to expire in less than 48 hours and they would keep her/him in the hospital until she/he passed. On 4/22/21 at 1:37 PM Staff 8 (CNA) stated when he worked with resident 2 he would change her/him every one to two hours or more frequently due to her/his bottom being so painful. On 5/2/21 at 3:59 PM Staff 20 (RN/Wound Nurse) stated she assessed Resident 2 every week. Staff 20 stated she would do a conference call with the resident's physician and the physician decided the best treatment. She added there was a lot of infection in the wound in addition to Resident 2's incontinence. Staff 20 was asked about the use of a catheter to manage Resident 2's incontinence and she indicated it was never discussed but agreed it would have helped with wound healing. On 5/2/21 at 4:35 PM Staff 20 (Resident Care Manager) stated Resident 2 was sent to the ER for pain and progression of the wound. Staff 20 indicated a catheter may have helped to heal the wound by keeping the urine out of the wound and off the skin. On 5/5/21 at 11:38 AM the wound clinic nurse stated when Resident 2 came to the clinic on 3/4/21 her/his wound was 7 cm long, 6 cm wide and 2.5 cm deep. On 3/15/21 the wound had worsened to 10.5 cm long, 9 cm wide and 3 cm deep. The wound clinic nurse stated she was concerned with the size of the wound due to the rapid progression. On 5/5/21 at 1:55 PM Staff 18 (Resident Care Manager) stated when Resident 2 was admitted to the facility she/he had wounds to her/his legs and a pressure ulcer on her/his sacrum. Staff 18 stated Resident 2 should have gone to the would clinic at least a month or two before she/he passed away. In an interview on 5/12/21 at 10:18 AM with Staff 2 and Staff 24 (Nurse Consultant), Staff 2 acknowledged she was aware the resident's wound had worsened and of the extreme pain Resident 2 had experienced. No additional information was provided.

Based on interview and record review it was determined the facility failed to provide adequate pain management for 1 of 3 sampled residents (#2) reviewed for neglect and abuse. As a result Resident 2 experienced uncontrolled pain for a prolonged period and diminished participation in therapy. Findings include: Resident 2 admitted to the facility in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A revised care plan dated 1/15/21 indicated Resident 2 had acute/chronic pain related to polyneuropathy, [CONDITION(S)] and multiple wounds. Staff were to administer pain medication per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A Progress Note dated 2/20/21 by Staff 20 (Resident Care Manager) indicated Resident 2's sacral wound was extremely painful and foul smelling. Staff 20 indicated a call was received from Staff 2 (DNS) stating to send Resident 2 to the hospital for an evaluation. The ER (emergency room ) physician provided new treatment orders for the wound. The physician did not address Resident 2's pain. A Progress Note dated 2/20/21 by Staff 18 (RN/wound nurse) indicated she called the facility Medical Director and explained the concerns related to Resident 2's increased pain. The Medical Director passed the call to the on-call physician who ordered stronger pain medications. A Progress Note dated 2/21/21 indicated Staff 20 premedicated Resident 2 prior to a dressing change but Resident 2 still experienced increased pain. A Progress Note dated 2/23/21 indicated Resident 2 stated she/he was too painful to sit on her/his sacrum. Wound Clinic Progress Notes dated 3/4/21 indicated Resident 2 stated her/his pain was an 8 on a scale of 0 to 10 (pain which is 8 and above is considered severe). A Progress Note dated 3/5/21 indicated Resident 2 was very painful during care and repositioning. A Progress Note dated 3/13/21 indicated Resident 2 had severe pain during wound care. A Progress Note dated 3/15/21 indicated Staff 19 (RN) spoke with the nurse at the wound clinic before Resident 2's appointment and explained her/his pain was excruciating. Staff 19 indicated she received a call back from the wound clinic nurse who stated they were sending Resident 2 to the ER for pain management. On 4/14/21 at 12:24 PM Staff 11 (CNA) stated Resident 2 needed stronger pain medication. Staff 11 added when Resident 2 was repositioned she/he would scream out in pain. On 4/23/21 at 12:49 PM Staff 7 (PT) and Staff 10 (OT Assistant) stated they tried to work with Resident 2 but the resident was too painful. Staff 7 stated she reported Resident 2's pain to nursing staff and nursing staff stated they had medicated her/him but it was not helpful. Staff 7 stated Resident 2 could have continued therapy if she/he had better pain control. On 5/2/21 at 3:59 PM Staff 18 stated Resident 2's pain level increased significantly. On 5/5/21 at 10:04 AM Staff 15 (LPN) stated Resident 2 had a lot of pain due to a large pressure ulcer to her/his sacrum. Staff 15 stated Resident 2 screamed out in pain. Staff 15 stated since the middle of 2/2021 and in 3/2021 Resident 2 was frequently screaming in pain. In an interview on 5/12/21 at 10:18 AM with Staff 2 and Staff 24 (Nurse Consultant), Staff 2 acknowledged she was aware of the extreme pain Resident 2 had experienced. No further information was provided.

Based on interview and record review it was determined the facility failed to provide adequate care to prevent the development of a pressure ulcer and failed to provide adequate oral care for 2 of 4 sampled residents (#'s 8 and 11) reviewed for pressure ulcers and oral care. This placed resident 11 at risk for poor dentition and resulted in Resident 8 developing an Unstageable (obscured full-thickness skin and tissue loss) pressure ulcer with pain. Findings include: 1. Resident 8 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. Resident 8's care plan initiated on 3/14/19 indicated Resident 8 was at risk for skin breakdown due to reduced mobility from a fall with compression fractures to the spine. A Progress Note dated 3/29/19 revealed a CNA reported at 9:45 AM drainage to the incontinent pad of the resident with possible blood behind the back-brace. An Unstageable pressure ulcer was found on the spine under the brace. The top of the wound bed had eschar (slough (dead) tissue) tissue, slough found to the rest of the wound bed, wound was odiferous with redness to the surrounding skin. A Progress Note dated 3/29/19 revealed staff were able to visualize the severity of the spinal pressure ulcer and the pain evidenced when the resident was moved, turned or repositioned. On 3/29/19 Resident 8 was sent to the physician's office for the wound on her/his back related to the back-brace use. A Wound Care Certified RN discussed repositioning with the resident who stated she/he didn't like to reposition because it was not comfortable and it hurt to be repositioned. An Incident Report dated 3/28/19 at 9:45 PM revealed the resident had a facility acquired Unstageable pressure ulcer on her mid spine. The admission paperwork was reviewed and there was no note found regarding orders for the back-brace the resident had worn since admission. The report further revealed a review of the facility progress notes, tasks, hospital records, care plans and staff interviews indicated the following internal facility issues had been identified: there was no order for the back-brace, there was no follow-up for instruction on managing the back-brace, the back-brace was not care planned, the back-brace was not monitored and skin checks were not on the TAR. The hospital history and physical indicated the resident had an abrasion on the spine, the admission nursing data base stated the resident had a bruise on the spine but there was no monitoring for either skin issue on the TAR or clarification if there was a bruise or abrasion. Additionally, although staff alleged the resident had refused to reposition, monitoring of the resident's behaviors for refusals of care was not in place and there was no follow-up as to why the resident was refusing care or the pain the resident expressed with the repositioning. A review of the admission Kardex (care plan used by CNAs) initiated on 3/14/19 found no instructions for back-brace care or behavior monitoring for refusals of care for Resident 8. On 7/17/19 at 4:15 PM Witness 8 (Home Health & Hospice Nurse) indicated she had called in a complaint to the state related to concerns she had regarding the handling and reporting of the facility acquired pressure injury to Resident 8's spine. Witness 8 stated the pressure ulcer on the resident's spine was a huge, significant wound and it was at least a Stage III (devitalized tissue when soft tissue is compressed between a bony prominence). Witness 8 stated she believed Resident 8 did not receive adequate wound care while in the facility. The wound required the agency to contact a Wound Specialist because the wound was so bad. Witness 8 also believed the facility did not report the wound and felt they should have. On 7/11/19 at 12:15 PM Staff 1 (Administrator) acknowledged the items outlined in the facility's investigation of the facility acquired pressure ulcer developed by Resident 8 on her/his spine under the back brace included the following items: there was no physician order for [REDACTED]. Additionally, there was no care plan for the resident's refusals to reposition to offload pressure on her/his spine or why she refused to reposition and no information related to the pain resident was experiencing with repositioning. The facility did not report the facility acquired wound because abuse and neglect of care were initially ruled out in their investigation because there was documentation of skin checks completed. However, the facility's own investigation included multiple issues the facility failed to do to prevent Resident 8 from developing the pressure wound. 2. Resident 11 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. A Physician's Visit Progress Note from Resident 11's dental office dated 7/24/19 stated the following: Patient oral care unacceptable. Patient requires better assistance with oral hygiene. Patient is being neglected. Doctor concerned with oral infection affecting systemic health. Patient has oral thrush (an infection in which the fungus [MEDICAL CONDITION][MEDICATION NAME] accumulates in the mouth). On 7/29/19 at 3:35 PM Witness 9 (Dentist office staff) stated their office had contacted the facility twice recently regarding Resident 11's oral care on 5/29/19 and 7/24/19. Their office notified the facility if the oral care did not change, they would report it as neglect of care to the State. They reported it to the State because there was no improvement. On 7/29/19 at 3:45 PM Witness 10 (Dentist) indicated they had found a lot of debris in the resident's mouth which had accumulated over time and was not from one meal. There was white cheesy debris under the denture because they were not cleaning the dentures. The resident also had one tooth in a super bad state. Witness 10 stated it would be better to prevent needing oral surgery than for her/him to have surgery at her/his age. If you don't provide care for the teeth an infection could develop especially when there is a compromised immune system, such as for this resident. The resident also had oral thrush which could affect other parts of the body as well. A facility Investigation regarding the resident's oral care dated 7/29/19 substantiated an allegation of neglect for Resident 11's oral care. The investigation included a review from the dentist progress notes on 5/29/19 and 7/24/19 which indicated poor oral hygiene. The progress note from 5/29/19 indicated a thick moderate plaque/food packed which has irritated the tissues. The 7/24/19 progress note had concerns related to the resident's overall health and need for oral thrush treatment. Additionally, issues of oral care were identified for two of six sampled residents. The investigation concluded although oral care was charted to be completed, the quality of care was not satisfactory. On 7/29/19 Staff 2 (Administrator In Training) provided a copy of the facility investigation and acknowledged neglect of care was substantiated.

Based on interview and record review it was determined the facility failed to provide adequate pressure ulcer prevention care and failed to follow the care plan for repositioning for 2 of 5 sampled residents (#s 3 and 8) reviewed for pressure ulcers. This placed residents at risk for unmet care needs and resulted in the development of an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer for Resident 8 with accompanying pain. Findings include: 1. Resident 8 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. Resident care plan initiated on 3/14/19 indicated Resident 8 was at risk for skin breakdown due to reduced mobility from a fall with compression fractures. The resident was admitted with some bruising on the back. An intervention in the care plan stated to monitor bruise initiated on 3/14/19. No monitoring of the bruise was found in the medical record. A review of the admission Kardex (care plan used by CNAs) initiated on 3/14/19 found no instructions for back brace care or behavior monitoring for refusals of care for Resident 8. The 3/25/19 MDS CAA for pressure ulcers revealed the resident was at risk for skin breakdown due to reduced mobility and bowel and bladder incontinence. The resident was admitted with an abrasion on her/his back from a fall. Resident was working with the therapy department to manage bed mobility, transfers and personal care within restrictions related to the back injury. The resident required extensive assist for the back brace and personal care due to pain and limited mobility. An Incident Report dated 3/28/19 at 9:45 PM revealed the resident had a facility acquired Unstageable pressure wound. The admission paperwork was reviewed and there was no note regarding orders for a back brace. Documentation was found indicating the resident was wearing the brace at the hospital. The hospital history and physical indicated the resident had an abrasion on her/his back upon discharge. The admitting nurse at the facility indicated the resident had a bruise on her/his back upon admission but did not mention an abrasion. The last skin check for resident was on 3/24/19 and no issues were noted. On 3/24/19 the resident started refusing turning and repositioning. On 3/28/19 it was discovered the resident had developed an Unstageable pressure ulcer next to the spine. The report further went on to reveal after review of the progress notes, tasks, hospital history and physical, care plans and staff interviews the following internal facility issues were identified: there was no order for the back brace, there was no follow-up for instruction on managing the back brace, the back brace was not care planned, the back brace was not monitored and skin checks were not on the TAR. The hospital history and physical indicated the resident had an abrasion on the spine, the admission nursing data base stated the resident had a bruise on the spine but there was no monitoring on the TAR. Additionally, monitoring of the resident's behaviors for refusal of care was not in place and there was no follow-up as to why the resident was refusing care. A Progress Note dated 3/29/19 revealed a CNA reported at 9:45 AM drainage to the incontinent pad of resident with possible blood behind the brace. An Unstageable wound was found on the spine. The top of the wound bed had eschar (slough (dead) tissue) tissue, slough found to the rest of the wound bed, wound was odiferous with redness to the surrounding skin. A Progress Note dated 3/29/19 revealed staff were able to visualize the severity of the back wound and pain evidenced when the resident was moved, turned or repositioned. On 3/29/19 Resident 8 was sent to the physician's office for the wound on her/his back related to back brace use. A Wound Care Certified RN discussed repositioning with the resident who stated she/he didn't like to reposition because it was not comfortable and hurt to be repositioned. On 4/2/19 at 2:47 PM a Skin and Wound Evaluation revealed the type of wound as pressure, the wound Stage was Unstageable due to obscured full-thickness skin and tissue loss. The wound measured 24.8 cm 2 (area) x 10.7 cm (length) x 3.5 cm (width). The wound was 10% filled with Slough and 90% eschar. An additional Skin and Wound Evaluation on the same 4/2/19 at 2:50 PM (3 minutes later) stated the wound was facility acquired and measured 14.1 cm 2 (area) x 11.6 cm (length) x 3.5 cm (width). The wound bed was 100% filled with eschar. On 7/17/19 at 4:15 PM Witness 8 (Home Health & Hospice Nurse) indicated she had called in the complaint related to concerns she had regarding the handling and reporting of the facility acquired pressure injury to Resident 8. Witness 8 stated the pressure ulcer was a huge, significant wound and it was at least a Stage III (devitalized tissue when soft tissue is compressed between a bony prominence). Witness 8 stated she believed Resident 8 did not receive adequate wound care while in the facility. The wound required the agency to contact a Wound Specialist because the wound was so bad. Witness 8 also believed the facility did not report the wound and felt they should have. On 7/11/19 at 12:15 PM Staff 1 (Administrator) acknowledged the items outlined in the facility's investigation of the facility acquired pressure ulcer developed by Resident 8 included the following items: there was no physician order for [REDACTED]. Additionally there was no care plan for the resident's refusal of cares or why she refused care. A Performance Improvement Action Plan was initiated on 4/2/19. 2. Resident 3 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] indicated Resident 3 with a BIMs score of 3/15 which indicated the resident had significant cognitive impairment. The resident was totally dependent with all ADLs. The Admission MDS indicated the resident received hospice services. The current comprehensive care plan and kardex (a tool used by CNAs to provide care) indicated the resident was totally dependent on staff for repositioning and turning in bed. Staff were directed to reposition the resident with two staff members in bed every two hours. An investigation completed by the facility on 11/25/18 revealed Resident 3 was not repositioned for approximately 6 hours during day shift by Staff 34 (CNA). The resident was discovered to acquire multiple Kennedy ulcers (a dark sore or sores that develop rapidly during the final stages of a person's life. The ulcer or ulcers grow as skin breaks down as part of the dying process) to her/his shoulders, several sores on the spinal processes and on the resident's rib cage. The irregular borders and deep discoloration was determined to be Kennedy terminal ulcers which were part of Resident 3's dying process. The investigation determined the Kennedy terminal ulcers were not preventable, however it was determined Staff 34 failed to meet the standards of care for the resident. Staff 34 was counseled and offered their resignation. On 7/10/19 at 7:30 AM Staff 11 (LPN) stated she recalled the incident on 11/25/18 and Staff 34 had not repositioned or checked on Resident 3 most of her shift. The nurse on day shift encouraged Staff 34 to tend to the resident and then asked two other CNA's to care for Resident 3. This was when the wounds were discovered on the resident's back and shoulders. On 7/23/19 at 4:47 PM Staff 29 (CNA) indicated she remembered the resident and she/he was on hospice, dependent on staff for repositioning and was to be repositioned every two hours. She indicated she worked the day shift on 11/25/18 but was not assigned to the resident. She stated Staff 34 was assigned to Resident 3, however she did not reposition the resident the entire shift. Staff 29 stated she was asked to reposition the resident with another CNA and the sores were discovered. She reported the wounds to the nurse. On 7/10/19 at 3:35 PM Staff 9 (RN-Regional Nurse Consultant) and Staff 10 (DNS) stated they were aware of the incident which occurred on 11/25/18 and the investigation which was completed on 11/25/18 with Resident 3 acquiring a Kennedy pressure ulcers during the resident's dying process. Staff 9 and Staff 10 acknowledged Staff 34 failed to follow the care plan and Staff 34 should have repositioned the resident every two hours.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 2 sampled residents (#1) reviewed for abuse. Resident 1 experienced psychosocial harm as a result of verbal abuse and neglect. Findings include: Review of a facility policy and definition of abuse revised (MONTH) 2010 indicated each resident had the right to be free from abuse which included freedom from physical and verbal abuse. The policy defined abuse as the willful infliction of injury and verbal abuse defined as use of oral, written or gestured language that willfully includes disparaging and derogatory remarks. Resident 1 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 5/1/19 Admission MDS revealed Resident 1's Brief Interview of Mental Status score was 14 which indicated Resident 1 was cognitively intact. A comprehensive care plan revised 4/19/19 indicated Resident 1 had an ADL self care deficit with limited mobility related to left leg fracture and left shoulder fracture. The resident required moderate assistance with one staff person to transfer from the bed to the wheelchair. The resident required one staff person assist to utilize the commode over the toilet. The resident could bear weight to the left hip as tolerated, but was non-weight bearing to the left shoulder. A 5/5/19 Incident Investigation Report revealed the following: -Staff 1 (Interim DNS) interviewed Resident 1 who indicated she/he turned on the call light and Staff 10 entered the room and stated What do you want? The resident indicated she/he needed to use the bathroom and Staff 10 started to transfer the resident from the bed to wheelchair without using a gait belt. The resident stated we need a gait belt but Staff 10 stated it was okay and lifted the resident under her/his arms. This caused discomfort to the resident's shoulder, which was fractured. The resident started to slip during the transfer because Staff 10 did not apply non-skid socks on the resident's feet. The resident reminded Staff 10 to apply the non-skid socks and Staff 10 stopped and placed the non-skid socks to the resident's feet as indicated by the care plan. Staff 10 transferred the resident, again, to the wheelchair. When in the bathroom Staff 10 again transferred the resident without a gait belt to the commode and while doing so the resident felt unsafe. The resident refused to be transferred off the commode by Staff 10 and Staff 10 started to argue with the resident and raised her voice yelling at Resident 1. The resident told Staff 10 to leave and Staff 8 (CNA) came and assisted her/him. Staff 1 suspended Staff 10 immediately. -An interview was completed with Staff 10 who transferred the resident without a gait belt to the bathroom. Staff 10 indicated she grabbed Resident 1 around the waist when transferring the resident and indicated the resident kept telling her she was doing the transfer wrong. Staff 10 got the resident in the wheelchair and into the bathroom, where again the resident continued to report to Staff 10 she was not transferring her/him correctly. Staff 10 indicated once she got the resident on the commode in the bathroom she told the resident she was going to get some help, placed the wheelchair in front of the resident and reported to the nurse the resident wanted something for pain and was yelling at her. - On 5/8/19 Staff 1 and Staff 2 (Administrator) determined verbal abuse occurred by Staff 10 for speaking harshly enough to the resident to incite emotional response. Neglect also occurred due to Staff 10 consciously choosing to not use the gait belt to transfer the resident and not following the care plan. During the investigation it was determined the gait belt was not used and the transfer was not done appropriately which caused the resident discomfort. Staff 10 did not listen to the resident's direction or desire. Additionally, Staff 10 failed to get another staff person before the situation escalated causing the resident tearfulness and despair. A revision to the Incident Investigation Report dated 5/10/19 indicated Staff 8 (CNA) completed a Grievance Communication Form which indicated on 5/5/19 before breakfast Staff 10 approached her and indicated Resident 1 yelled at her and Staff 10 couldn't take it. Staff 8 entered the resident's room and the resident was in the bathroom sitting on the commode and had tears running down her cheeks. Staff 8 asked the resident what was wrong and the resident indicated (Staff 10) was yelling at me to do things. The resident indicated Staff 10 attempted to transfer her/him without non-skid socks on. Staff 10 did not use a gait belt and when Staff 10 stood the resident up Staff 10 pulled on her/his injured shoulder and it hurt. I do not want Staff 10 to care for me anymore. I am afraid of Staff 10 and her yelling. Staff 8 assured the resident she would care for her/him the remainder of the day. On 6/13/19 at 4:16 PM Resident 1 stated on 5/5/19 she/he needed to use the bathroom and Staff 10 came to assist the resident to the bathroom. Staff 10 attempted to transfer the resident without non-skid socks, a gait belt and placed her hands under the resident's armpits pulling on the resident's injured shoulder. The resident stated you can't lift me like that, but Staff 10 insisted and got the resident to a standing position. The resident's feet started sliding and Staff 10 sat the resident back on the bed. Staff 10 reattempted the transfer, but again placed her hands under the resident's arms and the resident stated you can't lift me that way, so Staff 10 put her arms around the resident's waist with no gait belt and transferred the resident to the wheelchair. Staff 10 got the resident into the bathroom and kept telling the resident you have to get up, I am in a hurry. The resident asked Staff 10 to grab the back of her/his pants to help her/him up onto the commode, which Staff 10 did. The resident indicated Staff 10 was yelling at her/him and the resident asked Staff 10 not to yell at her/him. The resident stated by that time she/he was in tears and very upset. Then Staff 8 entered the room and assisted the resident. Resident 1 stated Staff 8 did things the right way. The resident indicated her/his left arm and shoulder were sore after the transfer and her/his left hip started locking up after the incident. X-rays were obtained and the left hip was okay. On 6/13/19 at 3:32 PM Staff 8 stated on 5/5/19 Staff 10 approached her around breakfast time and stated I can't handle (Resident 1) today, she is yelling and cursing at me. Staff 10 asked Staff 8 if she would attend to Resident 1. When Staff 8 entered the resident room the resident was in tears sitting on the commode. The resident stated (Staff 10) was hurting me . (Staff 10) was pulling on my arms and was not using a gait belt or non-skid socks. The resident stated I am afraid of her. The resident was very upset, crying and stated a couple of times (Staff 10) hurt my left shoulder. Staff 8 spoke to the resident for approximately 10 minutes to calm her/him down before using a gait belt and transferring the resident back to her/his wheelchair. Staff 8 stated she reported the incident immediately to Staff 1 (Interim DNS). She further stated she worked with the resident then next few days and the resident seemed more anxious with any ADL care and thought staff would forget to put her/his non-skid socks on and not utilize the gait belt. On 6/14/19 at 7:46 AM Staff 5 (Occupational Therapy Assistant) stated she was not present when the incident occurred on 5/5/19 but indicated she worked with Resident 1 a couple times after the incident and the resident reported her/his left hip hurt more and the resident was more fearful after the incident when working with her on transfers. She stated the resident needed a little more assistance and coaching after the incident. She further stated all staff were expected to use gait belts and especially for a resident with a broken hip and left shoulder fracture. Staff 5 further stated failure to use one was a recipe for disaster. On 6/14/19 at 8:39 AM Staff 7 (Physical Therapy Assistant) stated prior to the incident the resident complained of pain. She worked on transfers from the bed to wheel chair and toileting. A gait belt was recommended to always be used for safety precaution. She stated she worked with the resident on 5/6/19 and the resident indicated her/his left hip was stiff and painful and rated between an eight or nine out of 10 during the session. She indicated the resident was more particular after the incident with her/his sessions. On 6/14/19 at 9:37 AM Staff 1 (Interim DNS) confirmed the facility determined abuse occurred by Staff 10 to Resident 1 on 5/5/19. On 6/14/19 at 11:36 AM Staff 2 (Administrator) stated Staff 1 was physically in the building when the event occurred on 5/5/19. They concluded in a day or two of the investigation to terminate Staff 10.

Based on observation and interview it was determined the facility failed to ensure the environment was free of accident hazards for 6 of 31 resident areas (rooms 107, 111, 201, 305, 307, 310 and the activity office) reviewed for accident hazards. Surface temperatures of readily accessible in-wall heaters operational throughout the facility in resident areas measured in excess of 200 degrees Fahrenheit up to and including 302 degrees Fahrenheit. This placed residents at immediate risk of serious harm. Findings include: On 1/18/18 between 4:22 PM and 5:00 PM the surface temperatures of in-wall heaters located throughout the facility were checked. Resident rooms 107, 111, 201, 305, 307, 310 and the activity office had in-wall heaters which were hot to the touch. Staff 7 (Maintenance) was observed by surveyors to measure the temperature of each of the heaters in the above-stated rooms with a thermometer. The following heater surface temperatures were recorded: room [ROOM NUMBER]: 207 degrees Fahrenheit room [ROOM NUMBER]: 282 degrees Fahrenheit room [ROOM NUMBER]: 233 degrees Fahrenheit room [ROOM NUMBER]: 242 degrees Fahrenheit room [ROOM NUMBER]: 264 degrees Fahrenheit room [ROOM NUMBER]: 302 degrees Fahrenheit Activity Office: 280 degrees Fahrenheit According to medical records, four of the ten residents in the above rooms had a [DIAGNOSES REDACTED]. On 1/18/18 at 4:22 PM Staff 7 (Maintenance) stated staff turned the temperatures on the wall heaters all the way up when they just needed to turn the thermostat until it clicked. On 1/18/18 at 4:50 PM Staff 7 (Maintenance) was observed to tell Resident 1 in resident room [ROOM NUMBER] to not touch the the heaters because they were too hot. The resident stated she/he knew they were too hot to touch. On 1/18/18 at 4:55 PM Staff 7 (Maintenance) acknowledged the surface temperatures of the heaters were too high. On 1/18/18 at 5:37 PM Staff 1 (Administrator) was informed of immediate jeopardy situation due to the surface temperatures of the above-listed heaters. Staff 1 was asked for an immediate plan of correction. On 1/18/18 at 5:42 PM Staff 7 stated there was no audit plan for testing the wall heater surface temperatures but he cleaned the units and checked the room temperatures every three months. On 1/18/18 at 7:15 PM an acceptable immediate plan of correction was received which included the following corrective measures: Staff members to do Q15 minute room checks to ensure no combustible items are in close proximity and to ensure resident safety until issues is permanently resolved. Call electrician to either install thermostats which will regulate heater temps or protective mesh covers will be installed in order to prevent direct surface contact with heated area. Staff on current shift will be immediately notified via walkie (wireless radio) of safety concern and room check requirement and will be individually in-serviced by management staff. Charge nurses at shift change will in-service staff regarding safety concern and Q15 check protocol. On 1/18/18 at 7:16 pm all elements of the final accepted immediate plan of correction were verified. On 1/22/18 at 1:28 PM Staff 6 (Regional RN) acknowledged the wall heaters were a hazard to residents' safety.

Based on interview and record review it was determined the facility failed to safely transfer a resident with a mechanical lift for 1 of 3 sampled residents (#1) who were reviewed for accidents. Resident 1 fell from a mechanical lift during a transfer and suffered a fractured pelvis. Findings include: Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The facility's policy and procedure titled Lifting Machine, Using a Portable dated October 2010 indicated two staff were required unless the resident was able to participate in the lifting procedure. Resident 1's Care Plan revised 3/31/16 indicated the resident was transferred using a Hoyer (a mechanical lift which cradled the resident in a fabric sling) and two staff. A Progress Note dated 6/22/16 at 7:36 pm by Staff 4 (LPN) indicated CNAs were transferring Resident 1 with a Hoyer from the resident's bed to a chair when the left lower sling strap came off the Hoyer which caused the resident to fall approximately four feet to the floor. The resident landed on her/his coccyx and left buttock. When Staff 4 entered the resident's room, the resident was laying on the floor with her/his back across the Hoyer legs. The resident was assessed and shook her/his head no when asked if she/he was okay. The resident was sent to the hospital for evaluation. A Progress Note dated 6/22/16 at 7:37 pm by Staff 4 (LPN) indicated the hospital reported Resident 1 had a non-operable pelvis fracture. A fall Incident Report investigation dated 6/22/16 indicated Staff 3 (former CNA) went to Resident 1's room to assist Staff 5 (CNA) with transferring the resident. Staff 5 was assisting another resident in the room with her back to Resident 1 and Staff 3. When Staff 5 turned around she witnessed the left lower Hoyer sling strap give way and the resident fell to the floor. Staff 3 had applied the Hoyer sling to Resident 1 and was transferring the resident by herself. The investigation indicated Staff 3 stated she placed the sling under the resident and used the Hoyer to lift the resident. Staff 3 stated she knew Resident 1 was supposed to be transferred with two staff and acknowledged Staff 5 was not directly assisting with the transfer when Resident 1 fell . Staff 3 stated it was her understanding that as long as a second staff was in the room it was okay to do a Hoyer lift transfer. The investigation indicated Staff 1 (Administrator) and Staff 2 (DNS) told Staff 3 it was not a standard of practice and the facility did not instruct staff a Hoyer transfer could be done by one staff with hands-on and a second staff just being present in the room. Staff 3 was suspended from work. On 8/29/16 at 2:36 pm Staff 4 stated she was called to Resident 1's room because the resident was on the floor. She saw the resident was on the floor laying across the feet of the Hoyer. The Hoyer was elevated and the lower left strap was hanging down. Neither the strap nor the hook on the lift were broken. Staff 3 told her the resident slid out of the lift. Staff 5 told her she was assisting another resident in the room with her back to Resident 1 and Staff 3. When she turned around she was Resident 1 sliding out of the lift. Staff 5 stated she thought Staff 3 was just getting Resident 1 ready for the transfer and did not know Staff 3 had already lifted the resident. Staff 4 stated all residents who required a Hoyer for transfers needed two staff for the transfer. Staff 4 was not aware of Staff 3 or any other staff member transferring residents without the use of two staff. On 9/1/16 at 8:48 am Staff 5 stated she was assisting Resident 1's roommate with transferring to a wheelchair while she waited for Staff 3 to come and assist her with transferring Resident 1 with the Hoyer. While she was engaged with Resident 1's roommate, Staff 3 entered the room and began assisting Resident 1 with personal hygiene. Staff 5 stated she heard Staff 3 say oh my gosh and gasp. Staff 5 stated when she turned around she saw Resident 1 hit the floor landing on her/his left hip and buttock. She said she was not aware Staff 3 was in the process of lifting Resident 1 without her assistance. When she rushed over to the resident she saw the left lower sling strap was not connected to the lift. Staff 5 stated she would not have condoned starting a lift without a second aide. Staff 5 stated they inspected the sling and the Hoyer and found nothing wrong with them. She said apparently it was user error. Staff 3 stated it was the facility policy and, prior to the accident with Resident 1, was reiterated throughout the facility that two staff were required for using a Hoyer lift. A hospital Emergency Department Note dated 6/22/16 indicated Resident 1 went to the hospital after she/he was dropped from a Hoyer. The note indicated Resident 1 had fractures to the left superior and inferior rami (part of the pelvis). On 9/15/16 at 10:44 am Staff 1 (Administrator) acknowledged Resident 1 was care planned for a two person assist Hoyer lift for transfers and Staff 3 attempted to transfer the resident herself without assistance. Staff 1 verified a strap on the Hoyer came off and the resident fell to the floor and fractured her/his pelvis.

Based on interview and record review it was determined staff failed to follow standards of practice for transferring a resident with a mechanical lift for 1 of 3 sampled residents (#1) who were reviewed for accidents. Resident 1 fell from a mechanical lift during a transfer and suffered a fractured pelvis. Findings include: The Oregon State Board of Nursing OAR [PHONE NUMBER] indicated Conduct Unbecoming a Nursing Assistant included the following: A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established. Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities. Failing to implement the plan of care developed by the registered nurse. Jeopardizing the safety of a person under the CNA's care. Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The facility's policy and procedure titled Lifting Machine, Using a Portable dated October 2010 indicated two staff were required unless the resident was able to participate in the lifting procedure. Resident 1's Care Plan revised 3/31/16 indicated the resident was transferred using a Hoyer (a mechanical lift which cradled the resident in a fabric sling) and two staff. A Progress Note dated 6/22/16 at 7:36 pm by Staff 4 (LPN) indicated CNAs were transferring Resident 1 with a Hoyer from the resident's bed to a chair when the left lower sling strap came off the Hoyer which caused the resident to fall approximately four feet to the floor. The resident landed on her/his coccyx and left buttock. A fall Incident Report investigation dated 6/22/16 indicated Staff 3 (former CNA) went to Resident 1's room to assist Staff 5 (CNA) with transferring the resident. Staff 5 was assisting another resident in the room with her back to Resident 1 and Staff 3. When Staff 5 turned around she witnessed the left lower Hoyer sling strap give way and the resident fell to the floor. Staff 3 had applied the Hoyer sling to Resident 1 and was transferring the resident by herself. The investigation indicated Staff 3 stated she placed the sling under the resident and used the Hoyer to lift the resident. Staff 3 stated she knew Resident 1 was supposed to be transferred with two staff and acknowledged Staff 5 was not directly assisting with the transfer when Resident 1 fell . Staff 3 stated it was her understanding that as long as a second staff was in the room it was okay to do a Hoyer lift transfer. The investigation indicated Staff 1 (Administrator) and Staff 2 (DNS) told Staff 3 it was not a standard of practice and the facility did not instruct staff a Hoyer transfer could be done by one staff with hands-on and a second staff just being present in the room. Staff 3 was suspended from work. On 9/1/16 at 8:48 am Staff 5 stated she was assisting Resident 1's roommate with transferring to a wheelchair while she waited for Staff 3 to come and assist her with transferring Resident 1 with the Hoyer. While she was engaged with Resident 1's roommate, Staff 3 entered the room and began assisting Resident 1 with personal hygiene. Staff 5 stated she heard Staff 3 say oh my gosh and gasp. Staff 5 stated when she turned around she saw Resident 1 hit the floor landing on her/his left hip and buttock. She said she was not aware Staff 3 was in the process of lifting Resident 1 without her assistance. When she rushed over to the resident she saw the left lower sling strap was not connected to the lift. Staff 5 stated she would not have condoned starting a lift without a second aide. Staff 5 stated they inspected the sling and the Hoyer and found nothing wrong with them. She said apparently it was user error. Staff 3 stated it was the facility policy and, prior to the accident with Resident 1, was reiterated throughout the facility that two staff were required for using a Hoyer lift. A hospital Emergency Department Note dated 6/22/16 indicated Resident 1 went to the hospital after she/he was dropped from a Hoyer. The note indicated Resident 1 had fractures to the left superior and inferior rami (part of the pelvis). On 9/15/16 at 10:44 am Staff 1 (Administrator) acknowledged Resident 1 was care planned for a two person assist Hoyer lift for transfers and Staff 3 attempted to transfer the resident herself without assistance. Staff 1 verified a strap on the Hoyer came off and the resident fell to the floor and fractured her/his pelvis. Refer to F-323

Based on interview and record review it was determined the facility failed to follow physician orders to discontinue a medication for 1 of 3 sampled residents (#4) reviewed for medications. Resident 4 had an adverse medication reaction and was admitted to the ICU (intensive care unit). Findings include: Resident 4 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. An 8/3/16 Wound Clinic Physician's Visit Progress Note indicated Resident 4's heart rate was very low and to hold the resident's beta-blockers and call the residents physician. A Physician's Visit Progress Note dated 8/4/16 MD ordered Resident 4's [MEDICATION NAME] (classified as a beta-blocker and used to treat high blood pressure) discontinued. A Progress Note dated 8/4/16 at 4:05 pm by Staff 7 (RN) indicated the resident went out to see her/his physician and her/his heart rate was low. The physician discontinued the resident's [MEDICATION NAME]. Resident 4's August 2016 MAR indicated [REDACTED]. A review of Resident 4's clinical record revealed no physician's order to hold the resident's [MEDICATION NAME] on the morning of 8/4/16 and no progress note was found to indicate why the medication was held. A Progress Note dated 8/5/16 at 8:15 am indicated Resident 4's heart rate was down to 30 (normal is 60 to 100) and the resident was lethargic, nauseated and had radiating left arm pain. The resident stated she/he wanted to go to the emergency department. The resident was assisted to bed with oxygen on while waiting for the ambulance to arrive. A Progress Note dated 8/5/16 at 10:46 am by Staff 7 indicated Resident 4 was admitted to the hospital for beta-blocker toxicity. A hospital Discharge Summary dated 8/8/16 indicated the physician ordered Resident 4's [MEDICATION NAME] held and then ordered the [MEDICATION NAME] discontinued the day before the resident was admitted to the hospital. The summary indicated the resident received two additional doses of [MEDICATION NAME] after it was discontinued. The resident's heart rate fell to the 30's and the resident nearly passed out. The resident was transported to the hospital where it was felt the resident likely had beta-blocker induced severe [MEDICAL CONDITION] (low heart rate). The resident received [MEDICATION NAME] in the field (an injected medication indicated for temporary blockade of severe or life threatening conditions including [MEDICAL CONDITION] marked by an extremely slow pulse; [MEDICATION NAME] can lead to complete [MEDICAL CONDITION] in patients with an enlarged prostate), and was admitted to the ICU overnight. The resident had [MEDICAL CONDITION] and a urinary catheter was placed for 24 hours. A facility incident investigation dated 8/4/16 indicated Resident 4 returned from a physician appointment with orders to discontinue the resident's [MEDICATION NAME]. Two progress notes and an alert note were made but the [MEDICATION NAME] was not discontinued from the resident's orders. The resident received an evening dose on 8/4/16 and a morning dose on 8/5/16. The resident was slumped at breakfast and complained of chest pain and radiating left arm pain. The resident stated she/he knew something was up and knew it was related to her/his medications. EMS (emergency medical services) was called to transport the resident to the hospital. The resident's pulse was documented as 30 and 32. The report indicated Staff 7 (RNCM) made a progress note the resident's [MEDICATION NAME] was discontinued but accidentally did not remove the order from the MAR (medication administration record). The report indicated the resident received two doses of [MEDICATION NAME] after it was discontinued. On 9/15/16 at 9:01 am Staff 7 (RN) stated Resident 4 went to the physician (on 8/4/16) who discontinued the resident's [MEDICATION NAME]. She stated she put the resident on alert charting and wrote a nurses note. Staff 7 stated there was a data entry error on the computer. She thought she discontinued the medication from the MAR but it was not. She stated the resident received one or two doses of the [MEDICATION NAME] after it was discontinued. The resident was woozy at breakfast (on 8/5/16) and the resident was sent to the hospital by ambulance.

Based on interview and record review it was determined the facility failed to properly fit and position an orthotic device and routinely evaluate for pressure areas for 1 of 4 sampled residents (#3) reviewed for immobilizer use and risk of pressure ulcers. Resident 3 developed a Stage IV pressure ulcer on the left Achilles tendon related to the immobilizer. Resident 3 was reviewed as a closed record. Findings include: Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Physical Therapy Evaluation and Plan of Treatment dated 1/8/14 included precautions of non-weight bearing on the left lower extremity with a knee immobilizer on the left leg. The resident received skilled therapy from 1/8/14 to 1/30/14. A comprehensive MDS assessment dated [DATE] indicated the CAA for Pressure Ulcers was triggered. The CAA for Pressure Ulcers dated 1/15/14 did not identify the use of an immobilizer as an increased risk to skin integrity. The resident's care plan had no information related to the immobilizer until 2/3/14 when a Care Plan History indicated a "Knee immobilizer at all times". There was no information included in the care plan related to the provision of personal care, proper fit and application of the immobilizer or how to clean the immobilizer. There were no instructions of how to complete personal care for the resident with the immobilizer in place. A C.N.A. Skin Inspection Sheet dated 2/3/14 included an open sore on the resident's left heel/ankle area. It was signed by Staff 4 (CNA). The licensed nurse who received and signed the skin sheet was Staff 9 (LPN). Progress Notes dated 2/3/14 signed by Staff 9 (LPN) did not include information about the open sore reported on 2/3/14 per the C.N.A. Skin Inspection Sheet. Progress Notes dated 2/5/14 included "CNA skin inspection sheet received from (Staff 4, CNA) from shower on 2/3. The note was signed by Staff 9 (LPN). There was no indication Staff 9 observed the left heel at that time. Progress Notes dated 2/6/14 included a skin audit completed by Staff 10 (LPN) who noted non-[MEDICAL CONDITION] in bilateral feet/ankles, but did not identify any open sore on the left heel. Nine days after discharge from skilled therapy, a Progress Note dated 2/8/14, indicated a wound to the left Achilles tendon with tendons visible (Stage IV) was discovered. The Progress Note indicated the pressure ulcer was "created" by the immobilizer rubbing on the resident's Achilles area. The physician was faxed regarding the immobilizer that "created" the wound. Weekly Wound Progress Notes dated 2/8/14 indicated there was a stage IV pressure area on the left Achilles tendon with tendons exposed which measured in centimeters: 1.5 length x 2.5 width x 0.4 depth. Interventions included to elevate and keep pressure off of affected area, frequent skin checks, and low flow alternating pressure airbed. The wound was caused by the immobilizer rubbing on the resident's heel. A Weekly Wound Progress Note of the left Achilles tendon ulcer dated 2/14/14 included measurements in centimeters: 3.5 length x 3.5 width x 0.4 depth which reflected a rapid increase in size in six days time from the previous wound progress note. Interventions included to elevate and keep pressure off of heels. Conditions which would affect healing were "Infection, pressure, immobilizer rubbing on area." The wound treatment was to cleanse and apply petroleum gauze to the wound and cover with 3 layers of ABD pad, then wrap with kerlix and secure. There was no assessment and care plan related to how to elevate the heels without applying pressure to the Achilles heel and no assessment related to using 3 layers of ABD pad which could cause increased pressure under the edge of the immobilizer. There was no assessment of the rapid increase in size of the pressure ulcer and no reassessment or change of interventions. On 4/9/14 at 10:35 am Staff 8 ( PT/DOR Director of Rehabilitation) stated Resident 3 was admitted with the immobilizer on the left leg and received therapy until 1/30/14, when the resident was referred to the restorative aide. Staff 8 stated the immobilizer fit correctly while in therapy. On 4/9/14 at 11:55 am Staff 14 (CNA/RA, Restorative Aide) stated the immobilizer did not fit right. After an adjustment which was to bend metal bars/pieces away from the ankle, the metal pieces/bars slipped out the end of the immobilizer near the ankle. The aides would push them back up and try to pad the end of the brace with a folded pillow case. Staff 14 stated she recalled seeing some redness on Resident 3's ankle area from the end of the brace (prior to discovery of the open sore on the Achilles tendon) but was told by another CNA that nursing was aware of it and did not report it. On 4/16/14 at 10:00 am Staff 4 (CNA) stated the aides were told to always keep the immobilizer on Resident 3's leg, which included during personal care, transfers and bed mobility. They were not provided specific instructions regarding the brace application or fit. The immobilizer was placed next to the skin and they put pants on over the brace many times. On 4/18/14 at 11:30 am Staff 12 (CNA) stated on 2/8/14 she took the brace off in order to put slacks on the resident. She noticed the brace was wet at the ankle and the brace fabric was rolled out away from the area above the back of the ankle. The brace was next to the resident's skin. She looked at the back of the ankle and saw the open wound. The resident was in pain and moaned whenever she/he was moved. Staff 12 stated there was a foam wedge pillow which was used to float the resident's heels. When the head of the bed was raised the heels would slip over the edge of the foam wedge and rest on the end of the immobilizer which would put pressure over the Achilles area. On 4/22/14 at 10:50 am Staff 9 (LPN) stated she remembered receiving a CNA skin sheet but believed Staff 4 (CNA) had reversed the left and right heels and meant to circle the right heel where a pressure ulcer was already present. On 4/22/14 at 11:05 am Staff 10 (LPN) stated she completed the skin audit on 2/6/14 and saw bilateral extremities [MEDICAL CONDITION], but the only wound on the feet/ankles was on the right heel. On 4/22/14 at 3:00 pm Staff 4 (CNA) stated she gave the resident a bed bath on 2/3/14, and had to remove the immobilizer brace to bathe the resident. She found a new sore on the left heel/ankle which was"nothing like I had ever seen before". She stated it was about a quarter sized sore and she could see string-like tissue that might have been tendon. She gave the skin sheet to the nurse who told her she couldn't look at the sore right then, but to remind her later. On 4/23/14 at 8:15 am Witness 14 (Wound Consultant, RN) stated on 2/14/14 and 2/25/14 she discussed the Achilles wound and treatment with facility staff. She did not see the wound. She was concerned when staff told her they were putting 3-4 layers of ABD dressings over the wound and under the edge of the brace. Her concern was whether staff did an assessment for increased pressure related to the ABD dressing. On 4/23/14 at 11:08 am Staff 1 (DNS) confirmed there were no instructions in the care plan related to the proper fit and application of the immobilizer, or provision of bathing, dressing and personal care with the immobilizer in place. On 4/29/14 at 10:15 am Witness 11 (MD) confirmed Resident 3 was admitted to the nursing facility with the knee immobilizer on the left leg. He stated X-rays taken on 2/3/14 at his office indicated the surgical repair of the fractured femur had failed and the resident would always need to use the immobilizer to stabilize the left femur. Witness 11 further stated during two office visits (on 2/3/14 and 2/12/14), the immobilizer was not properly positioned and tightened on the resident's leg which allowed it to slide down to the left Achilles heel and caused the pressure ulcer. Witness 11 stated even though the immobilizer was initially to be worn at all times, that did not preclude it from being moved, loosened and removed carefully to provide bathing and personal care. On 4/29/14 at 3:30 pm Witness 9 (Orthotic Specialist assistant in Witness 11's office) stated when the resident was seen in the physician's office, on 2/3/14 and 2/12/14 the immobilizer was not applied correctly. The immobilizer was not too long, but was not positioned high up on the thigh and was not properly secured. This allowed the immobilizer to slide down towards the ankle. Witness 9 indicated that improper application of the immobilizer could have contributed to the failed surgical repair of femur fracture in Resident 3. Witness 9 indicated he spoke at length with two different staff members that accompanied the resident from the facility and demonstrated the proper application and snug fit required for the brace to provide the support needed for the healing fracture. The metal stays needed to be placed in the correct position; one posterior and one centered on each side of the knee. The witness indicated the brace was dirty, had dried feces on the top inside and exterior of the brace and that attempts to clean the brace had only rubbed the feces deeper into the foam. He indicated the foam padding needed to be properly washed in a sink. He indicated the brace was dirty enough that he felt the need to wear gloves to handle it. Following one visit he called to speak to the charge nurse to provide information regarding fit and cleaning of the brace and to suggest checking it now that it was properly adjusted. Witness 9 indicated he was at the facility twice in February and noted the brace was not properly fitted on Resident 3 (it was not positioned high enough on the leg and was down too low by the ankle). He offered to provide a free staff in-service on the proper application and fit of the immobilizer and the offer was declined. On 4/30/14 and 5/6/14 the facility provided information related to the resident's co-morbidities which might have contributed to the development of the left Achilles tendon pressure ulcer. However, they were unable to provide documentation of a comprehensive assessment related to the risk of pressure ulcers or a reassessment of interventions after the pressure ulcer worsened. Resident 3 developed an Achilles tendon Stage IV pressure ulcer within 9 days of discharge from skilled therapy.

Based on interview and record review it was determined the facility failed to complete a comprehensive assessment related to the increased risk of pressure ulcers for 1 of 4 sampled residents (#3) who had braces/immobilizers. Resident 3 had a pressure ulcer discovered at a Stage IV (with tendons visible) related to pressure from an immobilizer. Resident 3 was reviewed as a closed record. Findings include: 1. Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A comprehensive MDS assessment dated [DATE] indicated the CAA for Pressure Ulcers was triggered. The CAA for Pressure Ulcers dated 1/15/14 under Treatments and other factors that cause complications or increase risk documented newly admitted resident with functional limitation in range of motion. The check box for Devices that can cause pressure, such as... casts, splints, etc was not marked as in use. On 2/8/14 a NN indicated a wound to the left Achilles tendon with tendons visible (Stage IV) was discovered. It was "created" by the immobilizer rubbing on the resident's Achilles area. On 4/9/14 at 10:35 am Staff 8, (PT/DOR, Director of Rehabilitation) and on 4/16/14 at 12:02 pm Staff 9 (LPN) stated Resident 3 was admitted with the immobilizer brace on the left leg. On 4/21/14 a written response to requests for assessments related to the immobilizer pressure ulcer risk was received from Staff 13, Administrator. It included: "Initial assessment of leg brace fitted by ortho on 2/3" and "Braces are fitted and placed by the professionals implementing (sic) the braces....". On 4/30/14 at 10:30 am the lack of a comprehensive admission assessment related to the immobilizer brace and the increased risk of pressure ulcers related was discussed with Staff 1 (DNS). There was no further information provided.

1. Based on interview and record review it was determined the facility failed to ensure an immobilizer brace was properly applied, securely fit and cleaned adequately for 1 of 4 sampled residents (#3) reviewed for use of immobilizer devices. Resident 3 developed a Stage IV pressure ulcer on the left Achilles Tendon related to the immobilizer. Resident 3 was reviewed as a closed record. Findings include: Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Physical Therapy Evaluation and Plan of Treatment dated 1/8/14 included precautions of non-weight bearing on the left lower extremity with a knee immobilizer on the left leg. The resident received skilled therapy from 1/8/14 to 1/30/14. The resident's care plan had no information related to the immobilizer until 2/3/14 when a Care Plan History indicated a "Knee immobilizer at all times". There was no information included in the care plan related to the provision of personal care, proper fit and application of the immobilizer or how to clean the immobilizer. There were no instructions of how to complete personal care for the resident with the immobilizer in place. A C.N.A. Skin Inspection Sheet dated 2/3/14 indicated an open sore on the resident's left heel/ankle area. It was signed by Staff 4 (CNA). There was no evidence the LNs checked for the open sore on 2/3/14. Nine days after discharge from skilled therapy, a Progress Note dated 2/8/14, indicated a wound to the left Achilles tendon with tendons visible (Stage IV) was discovered. The Progress Note indicated pressure ulcer was "created" by the immobilizer rubbing on the resident's Achilles area. On 4/9/14 at 10:35 am Staff 8 (PT/DOR,Director of Rehabilitation) stated Resident 3 was admitted with the immobilizer on the left leg and received therapy until 1/30/14, when the resident was referred to the restorative aide. Staff 8 stated the immobilizer fit correctly while in therapy. On 4/9/14 at 11:55 am Staff 14 (CNA/RA, Restorative Aide) indicated she removed the immobilizer when she followed up with the resident after discharge from skilled therapy. The immobilizer did not fit right and an adjustment of bending the metal bars/pieces away from the ankle was done by orthotics. The metal pieces/bars would slip out the end of the immobilizer near the ankle and the aides would push them back up and try to pad the end of the brace with a folded pillow case. There were no written instructions related to how to place the immobilizer on the leg, and how to protect the ankle. Staff 14 stated she recalled seeing some redness on Resident 3's ankle area from the end of the brace (prior to discovery of the open sore on the Achilles tendon) but was told nursing was aware of it and did not report it. On 4/11/14 a written statement from Staff 9 (LPN) indicated Resident 3 was admitted with a knee immobilizer which she believed was too long for the resident. She indicated it would constantly slip down and need to be pulled up. She reported after the brace was adjusted at the orthopedic office on 2/12/14 she found the metal supports were protruding slightly from the end of the foam padding and repositioned them back into the brace. The bars were secured with tape and she did not see them against the resident's skin. On 4/16/14 at 10:00 am Staff 4 (CNA) stated the aides were told to always keep the immobilizer on Resident 3's leg, which included during personal care, transfers and bed mobility. They were not provided specific instructions regarding the brace application or fit. Staff 4 stated when doing brief changes and incontinent care she would pull the pants down over the top of the brace just far enough to provide space to remove the brief and clean the resident. Staff 4 stated at first they could not take the brace off and just cleaned around it. The immobilizer was placed next to the skin and they put pants on over the brace many times. On 4/22/14 at 3:00 pm Staff 4 (CNA) stated she gave the resident a bed bath on 2/3/14, and had to remove the immobilizer brace to bathe the resident. She found a new sore on the left heel/ankle which was like nothing she had ever seen before. She stated it was about a quarter sized sore and she could see tissue or tendons. She gave the skin sheet to the nurse who told her she couldn't look at the sore right then, but to remind her later. On 4/23/14 at 11:08 am Staff 1 confirmed there were no instructions in the care plan related to provision of bathing, dressing and personal care with the immobilizer in place. There were no instructions of how to apply and secure the immobilizer or to clean the immobilizer. On 4/29/14 at 10:15 am Witness 11 (MD) confirmed Resident 3 was admitted to the nursing facility with the knee immobilizer on the left leg. He stated X-rays taken on 2/3/14, indicated the surgical repair of the fractured femur had failed and the resident would always need to use the immobilizer to stabilize the left femur. Witness 11 stated that although the immobilizer was to be worn constantly at first, it could have been moved, loosened and removed carefully to provide bathing and personal care. Witness 11 observed twice during office visits in February 2013, the immobilizer was not properly positioned on the resident's leg which allowed it to slide down to the left Achilles heel and caused the pressure ulcer. On 4/29/14 at 3:30 pm Witness 9 (Orthotic Specialist assistant in Witness 11's office) stated when the resident was seen in the physician's office, on 2/3/14 and 2/12/14 the immobilizer was not applied correctly. The immobilizer was not too long, but was not positioned high up on the thigh and was not properly secured. This allowed the immobilizer to slide down towards the ankle. Witness 9 indicated that improper application of the immobilizer could have contributed to the failed surgical repair of femur fracture in Resident 3. Witness 9 further stated the resident was fitted with a standard universal knee splint/immobilizer. The manufacturer's instructions for the immobilizer (provided by Witness 9) indicated a complete and careful review of the instructions was vital to the proper functioning of the device. Instruction for applying the brace included wrapping the foam padding around the affected leg while centering the metal stay on the back of the leg. The other metal stays could than be placed in the fabric sleeve and centered on the sides of the leg (sleeve attached with Velcro to foam padding). The Velcro straps were then tightened in alternating directions, with the strap closest to the knee tightened first then the calf strap and then the thigh strap. Instructions to hand wash the foam padding, rinse thoroughly and air dry prior to reapplication were included. Witness 9 indicated he spoke at length with two different staff members that accompanied the resident from the facility and demonstrated the proper application and snug fit required for the brace to provide the support needed for the healing fracture. The metal stays needed to be placed in the correct position; one posterior and one centered on each side of the knee. The witness indicated the brace was dirty, had dried feces on the top inside and exterior of the brace and that attempts to clean the brace had only rubbed the feces deeper into the foam. He indicated the foam padding needed to be properly washed in a sink. He indicated the brace was dirty enough that he felt the need to wear gloves to handle it. Following one visit he called to speak to the charge nurse to provide information regarding fit and cleaning of the brace and to suggest checking it now that it was properly adjusted. Witness 9 indicated he was at the facility twice in February and noted the brace was not properly fitted on Resident 3 (it was not positioned high enough on the leg and was down too low by the ankle). He offered to provide a free staff in-service on the proper application and fit of the immobilizer and the offer was declined. On 4/30/14 and 5/6/14 the facility provided information related to the resident's co-morbidities which might have contributed to the development of the left Achilles tendon pressure ulcer. However, they were unable to provide evidence of a comprehensive assessment of the risk of pressure ulcers related to the immobilizer use. There was no evidence in the resident's record that staff were instructed in the application, fit and care of the immobilizer. Resident 3 developed an Achilles tendon Stage IV pressure ulcer within 9 days of discharge from skilled therapy. 2. Based on interview and record review the facility failed to provided adequate assessment, monitoring and placement of Foley (urinary) catheter tubing, for 1 of 1 sampled resident (#1) reviewed as a newly admitted resident with a Foley catheter. The resident developed necrosis and erosion around the penile meatus where the catheter tube was inserted. Resident 1 was reviewed as a closed record. Findings include: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing Data Base dated 2/18/14 did not include information about the urethral tear specifying whether the tear was internal or external, and whether the resident exhibited symptoms of external or internal bleeding related to the urethral tear. The Admission Care Plan dated 2/18/14 included the use of a Foley catheter. The care plan was not individualized and included generic instructions to remind resident to wipe front to back, check and change every 2-3 hours and to change soiled clothing PRN. The urethral tear related to Foley catheter use was not identified and there were no instructions to monitor for tubing placement and bleeding around the catheter or sign/symptoms of further urethral trauma. A Treatment Administration Record dated 2/18/14 - 2/27/14 included catheter checks every shift. There were no instructions to monitor for urethral trauma/bleeding and to alternate/change the placement of the tubing on the resident's body. Progress Notes dated 2/19/14 indicated the resident wanted the Foley catheter out. It was noted the Foley catheter was placed due to a urethral tear caused by the resident pulling the Foley catheter out (prior to admission to the nursing facility). It was to stay in place until the urethra healed. On 2/22/14 and 2/24/14 there "continued" to be bleeding around the catheter. The Nursing Note did not include an assessment regarding the frequency, amount, or identify location of the bleeding. On 2/27/14, the resident was admitted to the hospital for [MEDICAL CONDITION] and pneumonia. A hospital Emergency Department Note dated 2/27/14 indicated ER staff found the resident's catheter tube taped to the leg. The penis was held down to the leg in a way which caused a large area of necrotic breakdown of the ventral aspect of the penis at the meatus. The necrosis was caused by "excessive persistent pressure" from the catheter tube. A physician's (urologist) hospital Progress Note dated 3/2/14 indicated the penile meatus showed some sloughing, necrotic mucosa, and some clot within the meatus. The ventral portion of the meatus was eroded. The Impression included "Most likely bleeding from the urethral injury distally... if ... discharged ... to a skilled nursing facility, it is important that the catheter be taped up to (her/his) belly." On 3/6/14 an Admission Nursing Data Base indicated the resident was (re)admitted on [DATE]. Problematic conditions did not include the urethral trauma with post hemorrhagic [MEDICAL CONDITION], and there was no evidence staff were aware of the necrotic area on the penis, or the need to position the catheter tubing to the resident's belly. On 4/10/14 at 1:40 pm Staff 7 (RNCM) stated the facility did not use tape to secure catheter tubing to the leg. The facility used a Velcro strap which could be adjusted around the thigh to hold the catheter tubing in place. Staff 7 was unable to provide an assessment or description of the urethral tear and condition of the penis around the catheter when the resident was admitted on [DATE]. Staff 7 was unaware of the penile necrosis discovered at the hospital on [DATE]. On 4/29/14 at 12:30 pm Witness 13, Medical Assistant to Resident 1's physician/urologist (Witness 12) relayed the following: Had nursing staff assessed the area of bleeding, checked and changed the placement of the catheter tubing on a daily basis, the breakdown and necrosis that resulted from catheter tubing pressure could have been prevented. The physician did not believe the necrosis and breakdown occurred during the time period between discharge from the facility on 2/27/14 and when emergency room staff found it. The physician confirmed on return to the facility on [DATE], the catheter tubing was to be taped to the belly to prevent further breakdown. On 4/30/14 at 10:30 am the lack of assessment and individualized care plan related to the urethral trauma and placement of the catheter tubing was brought to the attention of Staff 1, DNS. No further information was provided.

Based on interviews and record review, it was determined the facility failed to provide dressing changes according to standards of practice for 1 of 4 sampled residents (#1). The resident's dressing for the abscess of the right groin wound was not changed daily and the condition of the wound was not assessed. The resident was admitted directly to the local hospital from a wound clinic appointment. Findings include: Scope of Practice Standards for All Licensed Nurses 851-045-0040 (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; (d) Communicates client's choices, concerns and special needs to other members of the healthcare team; and (6) Standards related to the licensed nurse's responsibility to accept and implement orders for client care and treatment. The licensed nurse: (f) Has the authority and responsibility to question any order or recommendation which is not clear, perceived as unsafe, contraindicated for the client or inconsistent with the plan of care. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/28/12, the physician ordered dressing changes for the resident's right knee and foot. There were no physician's orders for a wound dressing of the resident's right groin area. The 6/28/12 Admission Nursing Data Base completed by the facility assessed the resident's right upper thigh to have "an area of redness measuring 8 by 3 cm along 'old' suture line." The 7/6/12 Aftercare instructions from the local hospital emergency department indicated the resident had been treated for [REDACTED]. The orders indicated wet to dry dressing changes were to be started on Monday 7/9/12. There was no directive from the physician how often the dressing changes were to be done. The 7/7/12 Wound or Pressure Sore Identification and Progress Record indicated the resident had a thigh abscess of "old" incision measuring 2.1 cm in length, width was 0.6 cm and depth was 3.0 cm. The wound was assessed to be red, serosangeous drainage, intact and pink. There was no odor assessed with [REDACTED]. The July 2012 Treatment Administration Record (TAR) indicated the order date for the daily wet to dry dressing changes to the right upper thigh began on 7/8/12. The documentation indicated the dressing change had been completed on 7/8/12. There was no documentation the dressing was changed during the three shifts of 7/9/12 and the documentation revealed the resident refused the dressing change on 7/10/12 at 5:00 pm. A 7/9/12 Interdisciplinary Progress Notes (IPN) written at 2:35 am by Staff 11 (LPN) indicated the resident was asleep most of shift and dressing to abscess on right upper thigh was clean, dry and intact. A 7/9/12 IPN written at 8:00 am (as a late entry for 7/9/12) by Staff 3 (LPN) indicated the resident was "up and refused to lay back down to allow me to change her/his dressings, I explained to her/him how important it was that the doctor had ordered daily dressing changes to her/his leg. She/he continued to refuse all day while I was working." There was no documentation for the evening and night shift of 7/9/12 to indicate the resident was approached about a dressing change. There was no documentation for the day shift of 7/10/12 to indicate the resident was approached about a dressing change. The 7/10/12 IPN written at 5:00 pm by Staff 3( LPN) indicated Resident 1 "refused to lay down so I could change her/his dressing even after I explained to her/him the need." A 7/10/12 IPN written at 7:15 pm indicated the resident's dressing was clean, dry and intact. There was no documentation for the night shift of 7/10/12 to indicate the resident was approached about a dressing change. There was no documentation to indicate the resident's physician had been advised of the resident's multiple refusals to lie down to change her/his dressings. The resident was admitted to the local hospital after a wound clinic appointment on 7/11/12. The 7/11/12 local hospital wound clinic evaluation written by Witness 1 (local hospital wound specialist) indicated the resident's right groin wound dressing was dated 7/8/12. The documentation indicated the resident's right 1st and 5th metatarsal wounds had black necrotic tissue and purulent exudate. Right groin wound with yeast infection at periwound and purulent exudate. The resident was directly admitted to the hospital and resident and family member were informed Resident 1 "may need a BKA ([MEDICAL CONDITION]) of RLE (right lower extremity) 2nd (secondary) to severe necrosis...." An interview on 8/1/12 at 11:20 am with Staff 3 (LPN) revealed Staff 2 (DNS) assessed the resident's right upper thigh wound because the wound had an odor and was hard to the touch. Staff 3 stated the resident had been seen at the local hospital wound clinic for treatment. Staff 3 was asked about no dressing changes on 7/9/12 and 7/10/12. Staff 3 stated the resident refused to lie down when she approached her/him about the dressing changes. Staff 3 could not remember if the nurse for the next shift and the physician had been informed of the resident's refusals. An interview on 8/1/12 at 12:40 pm with Staff 4 (RN) revealed Staff 4 conducted dressing changes of the resident's heel and toes wounds on 7/11/12. Staff 4 stated she did not change dressing for the resident's upper thigh wound on 7/11/12. On 8/1/12 at 1:30 pm Staff 5 (RNCM) reviewed the resident's record and determined there were no physician's orders regarding the frequency of the wet to dry dressing for the resident's upper thigh abscess. Staff 5 stated the nursing standard of practice was for the dressing to be changed every day unless there was a specific physician's order for the frequency of the dressing changes. Staff 5 indicated there had been no clarification of the physician's order. An interview on 8/1/12 at 3:00 pm with Staff 1 (Administrator) and Staff 2 (DNS) revealed the physician's orders did not indicate the frequency of the wet to dry dressing for the resident's upper thigh abscess. Staff 1 and Staff 2 were asked to provide the facility's policy and procedure regarding wound care, expectations of the nursing staff to continue to attempt to change the dressings and standards of nursing care regarding the frequency of the dressing changes. On 8/7/12 at 4:00 pm Staff 1 and Staff 2 were asked to provide the physician's orders for the wound dressing changes for the right upper thigh wound and the facility policy and procedure regarding wound care. Staff 2 was asked about the need to clarify with the physician about the provision of wound care. Staff 1 and Staff 2 were going to provide additional information regarding the resident's right groin wound care. On 8/10/12 Staff 2 (DNS) provided a written statement regarding the wet to dry dressing changes. Staff 2's statement indicated "regarding the wet to dry dressing ordered by the ER (emergency room ) physician. It is a normal standard of practice that a wet to dry dressing is changed every day. More often than this would disturb the wound bed and not allow it to advance healing. (Facility Corporation) does not have a written policy in regard to wet to dry dressings. Wet to dry dressings are not generally used in wound care on a regular basis in current practice. I spoke with Witness 1 (local hospital wound specialist) to see if they had a written policy for their practice. She also stated that wet to dry dressings are currently not often used in wound care but when they do it is normal practice to change them on a once a day basis. She stated they do not have a written policy stating such. Next I spoke with Witness 2 (RN at local hospital emergency department). I asked her what their standard practice is regarding wet to dry dressing orders written by their in house ER physicians. She stated that unless otherwise written it is a daily dressing change." An interview on 8/15/12 at 9:07 am with Witness 1 (local hospital wound specialist) revealed the standard of practice was for the wet to dry dressings to be changed daily unless specified by the physician. It was expected if the dressings were not able to be accomplished during the day shift the next shift would conduct the dressing changes. The physician needed to be contacted if there were problems in accomplishing the dressing changes. Witness 1 stated she observed the resident's thigh wound the afternoon of 7/11/12 and there was an odor and a large amount of drainage. On 8/21/12 written documentation was provided from Staff 10 (LPN). Staff 10 indicated on 7/9/12 she had been informed by Staff 3 (LPN) Resident 1 refused to lie down to have her/his dressings changed. Staff 10 documented the resident refused to have the dressings changed because she/he was sitting in the wheelchair. On 8/29/12 at 3:40 pm Witness 1 (Wound Care Nurse) was asked what precipitated the resident's admission to the local hospital from the wound clinic appointment. Witness 1 stated the resident's right groin dressing was saturated with drainage and had an odor. Witness 1 stated the resident was hospitalized because of the condition of both the resident's groin and right foot. On 9/13/12 at 9:40 am Witness 5 (surgeon) was asked what precipitated the resident's admission to the hospital from the wound clinic. Witness 5 stated the resident was admitted to the hospital because of the condition of both the groin and right foot. On 9/21/12 the facility provided a written statement from Staff 11 (LPN) regarding the night shift of 7/9/12 and 7/10/12. The statement indicated Resident 1 was assisted into bed at 11:30 pm on 7/9/12 and 7/10/12 when Staff 11 checked the resident's right upper thigh dressing. Staff 11 documented she asked Resident 1 about changing the dressing and the resident stated she/he did not want the dressing changed because the dressing "looked fine." Staff 11 indicated the dressing was intact with no visible drainage. Staff 11 indicated at 5:30 am on 7/10/12 and 7/11/12 she checked the dressing and the resident refused to have the dressing changed. Refer to F-309.

Based on interviews and record review, it was determined the facility failed to provide dressing changes as needed for 1 of 4 sampled residents (#1). The resident's dressing for the right groin wound was not changed daily so the condition of the wound was not assessed. The resident was admitted directly to the local hospital from a wound clinic appointment. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/25/12 local hospital history and physical examination [REDACTED]. Resident 1 had "just undergone amputation of toes of the right foot with the right first and fifth toes amputated with the metatarsal heads. This had been done for gangrene. The resident had some recent revascularization of her/his legs as well, but flow status was apparently not good enough to heal ...." On 6/28/12, the physician ordered dressing changes for the resident's right knee and foot. There were no physician's orders for a wound dressing of the resident's right groin area. The 6/28/12 Admission Nursing Data Base completed by the facility assessed the resident's right upper thigh to have "an area of redness measuring 8 by 3 cm along 'old' suture line." A 7/6/12 urgent fax to the physician indicated Resident 1 developed a large red area on the resident's right upper medial thigh. It measured "approximately 8 cm by 13 cm and was described as red, warm, with a white area approximately 3.5 cm by 1.5 cm." The skin surrounding the white area was assessed to be hard to the touch. The facility obtained physician's orders for the resident to be evaluated at the local hospital emergency department. The 7/6/12 Aftercare instructions from the local hospital emergency department indicated the resident had been treated for [REDACTED]. The facility was to change the thigh dressing every two hours the night of 7/6/12 for drainage. The orders indicated wet to dry dressing changes were to be started on Monday 7/9/12. There was no directive from the physician how often the dressing changes were to be done. The 7/7/12 Wound or Pressure Sore Identification and Progress Record indicated the resident had an abscess of "old "incision measuring 2.1 cm in length, width was 0.6 and depth was 3.0. The wound was assessed to be red, serosangeous drainage, intact and pink. There was no odor assessed with [REDACTED]. The July 2012 Treatment Administration Record (TAR) indicated the order date for the daily wet to dry dressing changes to the right upper thigh began on 7/8/12. The documentation indicated the dressing change had been completed on 7/8/12. There was no documentation the dressing was changed on 7/9/12 and the documentation revealed the resident refused the dressing change on 7/10/12 at 5:00 pm. A 7/9/12 Interdisciplinary Progress Note (IPN) written at 2:35 am by Staff 11 (LPN) indicated the resident was asleep most of the shift and the dressing to the right upper thigh was clean, dry and intact. A 7/9/12 IPN written at 8:00 am as a late entry for 7/9/12 by Staff 3 (LPN) indicated the resident was "up and refused to lay back down to allow me to change her/his dressings, I explained to her/him how important it was that the doctor had ordered daily dressing changes to her/his leg. She/he continued to refuse all day while I was working." There was no documentation during the evening and night shift of 7/9/12 to indicate the resident was approached about a dressing change. On 7/9/12 there was a fax from the facility to indicate a local hospital wound clinic appointment had been made for 7/11/12 at 3:00 pm. The 7/10/12 IPN written at 5:00 pm by Staff 3 indicated Resident 1 "refused to lay down so I could change her/his dressing even after I explained to her/him the need." A 7/10/12 IPN written at 7:15 pm indicated the resident's dressing was clean, dry and intact. There was no documentation for the night shift of 7/10/12 to indicate the resident was approached about a dressing change. There was no documentation to indicate the resident's physician had been advised of the resident's multiple refusals to lie down and dressing changes. The resident was admitted to the local hospital after a wound clinic appointment on 7/11/12. The 7/11/12 local hospital wound clinic evaluation written by Witness 1 (local hospital wound specialist) indicated the resident's right groin wound dressing was dated 7/8/12. The documentation indicated the resident's right 1st and 5th metatarsal wounds had black necrotic tissue and purulent exudate. Right groin wound with yeast infection at periwound and purulent exudate. The resident was directly admitted to the hospital and resident and family member were informed Resident 1 "may need a BKA ([MEDICAL CONDITION]) of RLE (right lower extremity) 2nd (secondary) to severe necrosis...." The 7/16/12 local hospital discharge summary indicated the resident had [MEDICAL CONDITION] in her/his right leg with E.coli. An interview on 8/1/12 at 11:20 am with Staff 3 (LPN) revealed Staff 2 (DNS) assessed the resident's right upper thigh wound because the wound had an odor and was hard to the touch. Staff 3 stated the resident had been seen at the local hospital wound clinic for treatment. Staff 3 was asked about no dressing changes on 7/9/12 and 7/10/12. Staff 3 stated the resident refused to lie down when she approached her/him about the dressing changes. Staff 3 could not remember if the nurse for the next shift and the physician had been informed of the resident's refusals. An interview on 8/1/12 at 12:40 pm with Staff 4 (RN) revealed Staff 4 conducted dressing changes of the resident's heel and toes wounds on 7/11/12. Staff 4 stated she did not change dressing for the resident's upper thigh wound on 7/11/12. On 8/1/12 at 1:30 pm Staff 5 (RNCM) reviewed the resident's record and determined there were no physician's orders regarding the frequency of the wet to dry dressing for the resident's upper thigh abscess. Staff 5 stated the nursing standard of practice was for the dressing to be changed every day unless there was a specific physician's order for the frequency of the dressing changes. Staff 5 indicated there had been no clarification of the physician's order. An interview on 8/1/12 at 3:00 pm with Staff 1 (Administrator) and Staff 2 (DNS) revealed the physician's orders did not indicate the frequency of the wet to dry dressing for the resident's upper thigh abscess. Staff 1 and Staff 2 were asked to provide the facility's policy and procedure regarding wound care, expectations of the nursing staff to continue to attempt to change the dressings and standards of nursing care regarding the frequency of the dressing changes. On 8/7/12 at 4:00 pm Staff 1 and Staff 2 were asked to provide the physician's orders for the wound dressing changes for the right upper thigh wound, the facility policy and procedure regarding wound care. Staff 2 was asked about the need to clarify with the physician about the provision of wound care. Staff 1 and Staff 2 were going to provide additional information regarding the resident's right groin wound care. On 8/10/12 Staff 2 (DNS) provided a written statement regarding the wet to dry dressing changes. Staff 2's statement indicated "regarding the wet to dry dressing ordered by the ER (emergency room ) physician. It is a normal standard of practice that a wet to dry dressing is changed every day. More often than this would disturb the wound bed and not allow it to advance healing. (Facility Corporation) does not have a written policy in regard to wet to dry dressings. Wet to dry dressings are not generally used in wound care on a regular basis in current practice. I spoke with Witness 1 (local hospital wound specialist) to see if they had a written policy for their practice. She also stated that wet to dry dressings are currently not often used in wound care but when they do it is normal practice to change them on a once a day basis. She stated they do not have a written policy stating such. Next I spoke with Witness 2 (RN at local hospital emergency department). I asked her what their standard practice is regarding wet to dry dressing orders written by their in house ER physicians. She stated that unless otherwise written it is a daily dressing change." An interview on 8/15/12 at 9:07 am with Witness 1 (local hospital wound specialist) revealed the standard of practice was for the wet to dry dressings to be changed daily unless specified by the physician. It was expected if the dressings were not able to be accomplished during the day shift the next shift would conduct the dressing changes. The physician needed to be contacted if there were problems in accomplishing the dressing changes. Witness 1 stated she observed the resident's thigh wound the afternoon of 7/11/12 and there was an odor and a large amount of drainage. On 8/21/12 written documentation was provided from Staff 10 (LPN). Staff 10 indicated she had been informed on 7/9/12 by Staff 3 (LPN) Resident 1 refused to lie down to have her/his dressings changed. Staff 10 documented the resident refused to have the dressings changed because she/he was sitting in the wheelchair. On 8/29/12 at 3:40 pm Witness 1 (Wound Care Nurse) was asked what precipitated the resident's admission to the local hospital from the wound clinic appointment. Witness 1 stated the resident's right groin dressing was saturated with drainage and had an odor. Witness 1 stated the resident was hospitalized because of the condition of both the resident's groin and right foot. On 9/13/12 at 9:40 am Witness 5 (surgeon) was asked what precipitated the resident's admission to the hospital from the wound clinic. Witness 5 indicated the resident was admitted to the hospital because of the condition of both the resident's groin and right foot. On 9/21/12 the facility provided a written statement from Staff 11 (LPN) regarding the night shift of 7/9/12 and 7/10/12. The statement indicated Resident 1 was assisted into bed at 11:30 pm on 7/9/12 and 7/10/12 when Staff 11 checked the resident's right upper thigh dressing. Staff 11 documented she asked Resident 1 about changing the dressing and the resident stated she/he did not want the dressing changed because the dressing "looked fine." Staff 11 indicated the dressing was intact with no visible drainage. Staff 11 indicated at 5:30 am on 7/10/12 and 7/11/12 she checked the dressing and the resident refused to have the dressing changed.

Based on interviews and record review, it was determined the facility failed to provide discharge planning for 1 of 2 sampled residents (#2) to ensure the resident had appropriate care and services to treat her/his pressure ulcers. Resident 2 discharged from the facility, required hospitalization and treatment for [REDACTED]. Findings include: Resident 2 was admitted to the facility on [DATE] after decompressive cervical laminectomy (back of neck/spine) surgery. There was a Skin Impairment form completed on 12/26/11 by Staff 5 (RN) to indicate the resident had a pressure ulcer and shearing present at admission. The documentation indicated the resident's skin impairment measured 17 cm by 14 cm with a depth of 0.1 cm with scant drainage; wound color was pink/red, no odor or tunneling. The area was assessed to be nonstageable (full thickness tissue loss in which the base of the ulcer is covered in slough-yellow, tan,gray, green or brown and/or eschar-tan,brown or black in wound bed; until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore stage, cannot be determined). The documentation indicated the resident had two areas of necrosis (dead skin) measuring 2 cm by 2.5 cm by 0.1 cm with a yellow wound bed and an area measuring 2 cm by 1.8 cm by 0.1 cm with a yellow wound bed. The 12/27/11 Interdisciplinary Progress Note (IPN) written at 11:15 am Staff 3 (RN) indicated the resident presented with increased slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft and moist) to one open area, the left buttock had increased necrosis on left upper buttock and right lower buttock with 5 cm by 6 cm open area. The note indicated the resident was aware of the condition of the ulcers. On 12/27/11 Staff 3 sent a fax to the physician to describe the resident's pressure ulcers. The fax asked the physician for approval to try a topical debriding agent such as Santyl with dry dressing every day to necrosis and slough with wound gel at other open areas every day and PRN. Witness 5 (physician's nurse practitioner) responded with a "yes" and indicated the facility "may refer to wound care specialist at the local hospital if needed for further evaluation and treatment if needed." A 12/27/11 fax was sent to the physician to indicate the resident requested to be discharged to her/his home. The resident was identified as doing well with therapy. Caregivers were ready to help her/him when she/he was to return home. Witness 5 (physician's nurse practitioner) responded on 12/27/11 "will see tonight to d/c (discharge)." There was no documentation Witness 5 (nurse practitioner) made a facility visit to talk with Resident 2 before her/his discharge home on 12/27/11. The 12/27/11 IPN written at 5:20 pm by Staff 1 (DNS) documented the review of the discharge instructions with resident. There was no documentation of physician's orders for the treatment of [REDACTED]. A complaint received on 1/3/12 indicated Resident 2 was discharged from the facility on 12/27/11 with a large ulcer on her/his coccyx. The ulcer measured 16 cm by 12 cm. Witness 2 (Complainant) indicated the resident's ulcer was "uncovered at the time of discharge from the facility." The resident was admitted to the local hospital on [DATE] secondary to ulcer infection. Witness 2 (Complainant) indicated from reports received the local hospital, the resident was in intensive care and the hospital assessed the ulcer as a Stage IV. An interview on 1/5/12 at 1:30 pm with Witness 2 (Complainant) revealed Witness 3 (home care provider) assisted the resident daily for two hours of care daily for bowel and bladder care. Witness 2 stated the resident was hospitalized , transferred to the facility and then discharged to her/his home. Witness 2 indicated when the resident was discharged from the facility; the facility did not send instructions on how to care for the resident's pressure ulcer. Witness 2 stated the facility did not inform Witness 2 of the resident's condition prior to discharge from the facility. Witness 2 stated the first time she was aware of the resident's pressure ulcer was when Witness 3 (home care provider) made a home visit to care for the resident a day after Resident 2 discharged from the facility. Witness 3 called Witness 2 to inform Witness 2 of the resident's skin condition and the need for a nurse to assess the resident. Witness 2 stated the facility did not fax any instructions regarding the resident's skin care. Witness 2 stated the facility was contacted and the facility was unable to fax additional information. Witness 2 stated Witness 4 (In-home care RN) went to the facility to obtain the skin care orders. Witness 4 was unable to obtain orders regarding the resident's skin care. An interview on 1/5/12 at 1:45 pm with Witness 3 (home care provider) revealed Witness 3 provided assistance with bowel and bladder care for Resident 2. Witness 3 stated Resident 2 was in the facility for a few weeks and she made a home visit the day after Resident 2 discharged from the facility (12/28/11). Witness 3 stated she turned the resident onto her/his side and saw the resident's coccyx area. Witness 3 stated she was not able to describe the resident's ulcer though stated "it was awful." Witness 3 asked the resident if the facility had told her/him about the pressure ulcer and the resident said "no." Witness 3 stated Resident 2 was not aware she/he had skin breakdown. Witness 3 stated she called Witness 2 (Complainant) immediately and asked for an RN to assess the resident. Witness 3 stated she was not aware of the resident's condition and there were no instructions from the facility on how to clean the ulcer. An interview on 1/5/12 at 4:00 pm with Witness 4 (Contract RN for in home care provider) revealed she conducted a skin assessment for Resident 2 on 12/29/11. Witness 4 stated the resident's coccyx/buttock ulcer measured 16 cm by 12 cm with a large amount of slough. Witness 4 stated she was unable to stage the ulcer due to slough though Witness 4 determined there was undermining when she touched the area with a Q-tip. Witness 4 stated there was an odor and the resident had brown discharge on the disposable sheet under the resident. Witness 4 indicated there were no discharge orders from the facility regarding pressure ulcer care. Witness 4 stated Resident 2 was a paraplegic and was unable to feel pain from the pressure ulcers. Witness 4 stated she went to the facility to obtain orders for the treatment of [REDACTED]. Witness 4 stated both Witness 4 and Witness 2 (Complainant) were in contact with the local home health RN to describe the resident's condition. Witness 4 was concerned because there would be no assessment of the resident over the holiday weekend. Witness 4 stated Witness 2 was able to obtain the authority from the local home care provider to send the resident to the local hospital emergency department. An interview on 1/5/12 at 4:20 pm with Witness 1 (local hospital RN discharge planner) revealed the resident's pressure ulcer was quite large and would require a long time to heal. Witness 1 stated Resident 2 was depressed on 1/5/12 to learn the length of time for the healing of the pressure ulcer. Witness 1 stated the resident did not have a history of pressure ulcers and had been independent in her/his home with minimal assistance with bowel and bladder care. Witness 1 provided a copy of the 12/30/11 hospital consultation report to indicate the resident had discharged from the facility a few days prior to 12/30/11 after a rehabilitation stay following a cervical laminectomy. The report indicated the resident's caregiver noticed a sacral decubitus ulcer and brought her/him back for further evaluation. The consultation report indicated the resident did not have any prior history of sacral decubitus ulcers. The ulcer measured 15 cm by 15 cm with some mild surrounding [DIAGNOSES REDACTED] (redness) and no fluctuance noted. The assessment indicated the resident would benefit from some sharp debridement with IV sedation. The resident then received debridement of the ulcer with the use of enzymes. On 12/31/11, the pressure ulcer was described as a Stage IV, black in appearance with an odor before cleansing. The resident required hospitalization until her/his discharge to another local facility on 1/7/12. An interview on 1/10/12 at 12:13 pm with facility Staff 5 (RN) revealed she observed the resident's pressure ulcer on 12/26/11 and described the ulcer as "large." Staff 5 stated she was concerned about the ulcer and asked Staff 4 (RNCM) to observe the ulcer. Staff 5 stated Staff 4 instructed her to use a Duoderm dressing (opague dressing used to provide a moist wound-healing environment while protecting from contamination, nonbreathable and adheres to the skin) on the ulcer to keep the dressing in place. Staff 5 stated there had been no specific physician's order to treat the pressure ulcer prior to 12/26/11. Staff 5 stated she could not remember if she contacted the physician on 12/26/11 for pressure ulcer treatment orders. Staff 5 stated she didn't know why she would not have contacted the physician as it was a "very horrible ulcer." An interview on 1/10/12 at 8:30 am with Staff 3 (RN) revealed she observed the resident's pressure ulcers on 12/27/11 and the Duoderm dressing was rolled up and there were areas of black/necrotic (dead) skin under the dressing. Staff 3 stated she removed the Duoderm and placed a foam dressing on the ulcer and contacted the physician for orders to treat the ulcer. Staff 3 stated she informed Staff 1 (DNS) of the condition of the resident's pressure ulcer on 12/27/11. Staff 3 stated she did not work for a few days after 12/27/11. Staff 3 stated she returned to work and learned the resident discharged to her/his home with the pressure ulcers. Staff 3 stated she was concerned the resident was discharged to her/his home with the pressure ulcers and questioned the resident's discharge. An interview on 1/10/12 at 10:00 am with Staff 4 (RNCM) revealed she observed the resident's pressure ulcer on 12/26/11 though could not provide any documentation of the observation. Staff 4 stated she was not working at the facility on 12/27/11. Staff 4 reviewed the resident's chart and the physician's orders sent with the resident upon discharge. Staff 4 indicated there were no physician's orders for treatment of [REDACTED]. Staff 4 stated it was the facility practice to provide hand-written instructions on the physician's order sheet. Staff 4 stated the fax to the physician may not have arrived when the resident discharged . Staff 4 stated the resident's pressure ulcer would have needed the services of a home health RN in order for it to be treated. An interview on 1/10/12 at 11:50 am with Staff 6 (Social Services Director) revealed the facility could not locate the discharge plan established for Resident 2 with the facility when the resident was discharged on [DATE]. Staff 6 stated the resident requested to return to her/his home. Staff 6 stated she sent a faxed request to the resident's physician and informed the nursing staff of the resident's request. Staff 6 stated the nursing staff would inform Staff 6 of the need for referrals to be made. Staff 6 stated she was not aware the resident had a pressure ulcer and need for a home health care nurse or wound care nurse referral. An interview on 1/10/12 at 11:59 am with Witness 5 (nurse practitioner) indicated there was no record Witness 5 visited the resident prior to her/his discharge on 12/27/11. Witness 5 stated the resident left the building before she was able to assess the resident. Witness 5 was asked would there need to be nurse involvement and an order to treat the resident's pressure ulcer upon discharge. Witness 5 stated "yes." An interview on 1/12/12 at 7:45 am with Staff 1 (DNS) revealed she assisted with the resident's discharge from the facility on 12/27/11. Staff 1 stated the resident's air mattress was delivered to the facility on [DATE] at the time the resident was being discharged to her/his home. Staff 1 stated she had not reviewed the resident's record prior to her/his discharge home. Staff 1 stated she had not arranged for a home health nurse to be involved in the resident's care when he was at home. Staff 1 confirmed there were no physician's orders regarding the care of the resident's pressure ulcer when she/he was discharged home. Staff 1 stated the resident did not return home against medical advice. Staff 1 stated she assumed Witness 5 (nurse practitioner) saw the resident prior to her/his return home. Staff 1 stated she learned later that Witness 5 did not see the resident prior to her/his discharge home. Staff 1 stated she was at the facility when Witness 4 (Contract RN for in-home care agency) came to the facility to obtain physician's order for treatment of [REDACTED]. An interview on 1/11/12 at 2:15 pm with Resident 2 revealed she/he was about to be discharged from the facility on 12/27/11 when the air mattress was delivered to her/his room. Resident 2 stated no one at the facility indicated the resident needed an air mattress and the air mattress was not delivered to her/his home. Resident 2 stated she/he returned home and Witness 3 (home care provider) came to her/his home on 12/28/11 to provide bowel and bladder care. Witness 3 stated she/he had a large pressure ulcer and Witness 3 needed to call Witness 4 (Contract RN for in-home care agency). Witness 4 assessed the resident and obtained authorization to have the resident sent to the local hospital on [DATE]. Resident 2 stated she/he was hospitalized for [REDACTED]. Refer to F-281 and F-314.

Based on interviews and record review, it was determined the facility failed to comprehensively assess a pressure ulcer, obtain or clarify physician's orders for pressure ulcer treatment and provide physician's orders for pressure ulcer treatment upon discharge for 1 of 2 sampled residents (#2). Resident 2's pressure ulcer increased in size, the resident discharged home and required hospitalization to debride (Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process) a Stage IV pressure ulcer (Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle bone or supporting structures). Findings include: The facility's October 2009 Skin Program Guidelines were to prevent avoidable pressure ulcers and to facilitate the healing of ulcers in accordance with current standards of practice. Upon admission, the admitting nurse or designee was to evaluate any new impaired skin integrity and document the findings in the resident's record. The physician was to be notified to obtain orders to include: area to be treated, frequency of treatment, treatment type (i.e. cleanses with sterile normal saline, pat dry, cover with 4 by 4 gauze and secure), nutritional needs as indicated, update medication and treatment record as indicated. Skin documentation of wounds or pressure ulcer identification was to be completed on the Wound or Pressure Ulcer Identification and Progress Record. There was to be one form for each area of skin breakdown/pressure ulcer. Resident 2 was admitted to the facility on [DATE] after decompressive cervical laminectomy (back of neck/spine) surgery. The hospital's 12/19/11 Nursing Transfer Summary indicated the resident had a Stage II (Stage II is a partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer on her/his coccyx. The information indicated the resident denied she/he had a pressure ulcer before the hospital admission. There were no physician's orders from the hospital to the facility for the treatment of [REDACTED]. The 12/19/11 Interdisciplinary Progress Note (IPN) and Admission Nursing Data Base completed by Staff 8 (LPN) indicated the resident was admitted to the facility with skin breakdown on her/his coccyx (tailbone). It was described as a large area with three intact blisters and three opened blisters. Staff 8 indicated an [MEDICATION NAME] (non-adhesive foam) dressing was applied and the resident was instructed not to lay on her/his back. There was no documentation to indicate a Skin Impairment sheet was initiated to indicate the date of onset, the location, length/width; depth; drainage; color, odor; the stage of the ulcer; evidence of pain and related comments. Staff 8 completed an Ulcer Risk Evaluation Form on 12/19/11 to indicate the resident was a High Risk for pressure ulcer development. The form did not indicate the resident had a current pressure ulcer. The form contained a second page where the Licensed Nurse was to identify the risk factors and identified care plan approaches. This section of the form was blank. There was no documentation to indicate the physician was contacted to obtain pressure ulcer treatment orders. The December 2011 TAR contained no documentation the resident received an [MEDICATION NAME] dressing on 12/19/11. The 12/20/11 physician's progress note indicated Witness 5 (physician's nurse practitioner) saw Resident 2 during a facility visit. The progress note contained no documentation of an assessment of the pressure ulcers and physician's orders for the treatment. The 12/21/11 chart care plan indicated the resident was at a high risk for potential skin impairment and did not identify the resident had pressure ulcer. The care plan goal was for the resident to maintain skin integrity. The 12/21/11 the physician's telephone orders indicated the resident had a sacral (large triangular bone at the base of the spine) skin breakdown- pressure ulcers-blisters. There was an order for [REDACTED]." There were no specific physician's orders regarding the treatment of [REDACTED]. The 12/22/11 IPN written at 11:00 pm by Staff 9 (LPN) indicated the resident's pressure ulcer dressing was changed and the resident was to have her/his position changed every two hours. The December 2011 TAR indicated on 12/23/11 the resident's coccyx dressing was changed. There was an undated hand-written note of a "foam dressing to coccyx." There was a line drawn through the note with no date as to when the foam dressing was discontinued. The 12/24/11 IPN written at 6:00 pm by Staff 8 (LPN) indicated the resident's blisters were now open, the wound bed was pink, was healing with a small amount of serosanguineous (containing blood and serum) drainage, the ulcer was cleaned and a foam dressing was applied. There was a Skin Impairment form completed on 12/26/11 by Staff 5 (RN) to indicate the resident had a pressure ulcer on the coccyx and shearing present at admission. The documentation indicated the resident's skin impairment measured 17 cm by 14 cm with a depth of 0.1 cm with scant drainage; wound color was pink/red, no odor or tunneling. The area was assessed to be nonstageable (full thickness tissue loss in which the base of the ulcer is covered in slough-yellow, tan, gray, green or brown and/or eschar-tan, brown or black in wound bed; until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore stage, cannot be determined). The documentation indicated the resident had areas of skin torn with skin intact; two areas of necrosis (dead skin) measuring 2 cm by 2.5 cm by 0.1 cm with a yellow wound bed and an area measuring 2 cm by 1.8 cm by 0.1 cm with a yellow wound bed. The December 2011 TAR had a hand-written note dated 12/26/11 for the resident's [MEDICATION NAME]/[MEDICATION NAME] (opague dressing used to provide a moist wound-healing environment while protecting from contamination, nonbreathable and adheres to the skin) dressing was to be changed every five days or as needed for cleaning or if the dressing came off. The area was to be covered with a clear film bandage. There was also a directive "Do not change per RNCM-Do not use if will not stay on or will strip skin." There was no documentation the physician was contacted about an order for [REDACTED]. The 12/26/11 IPN written at 7:00 pm by Staff 8 (LPN) indicated the resident had a [MEDICATION NAME] dressing on buttock wound. The 12/27/11 Skin Impairment form completed by Staff 3 indicated the date of onset was 12/27/11. One page indicated the resident had a nonstageable pressure ulcer on the left buttock measuring 5.5 cm by 2 cm, unable to determine depth, opaque drainage, eschar in color and a foam dressing was applied pending a physician's order. Another Skin Impairment form indicated there was a nonstageable pressure ulcer on the resident's right upper buttock measuring 5 cm by 6 cm with moderate amount of serosanguineous drainage and a 4 cm by 4.5 cm necrotic area; a foam dressing was placed on the ulcer pending new physician's orders. Another Skin Impairment form indicated a nonstageable pressure ulcer on the resident's upper left buttock measuring 3 cm by 3 cm and Staff 3 was unable to measure the depth of the ulcer due to slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft and moist). The slough measured 2 cm by 1 cm and a foam dressing was applied pending physician's orders. The 12/27/11 IPN written at 11:15 am Staff 3 (RN) described the resident's pressure ulcer and stated the resident was aware of the condition of the pressure ulcers. Staff 3 also sent a fax to the physician to request a topical debridement agent and informed the physician that a foam dressing was applied pending physician's orders. Witness 5 (physician's nurse practitioner) responded with a "yes" and indicated the facility "may refer to wound care specialist at the local hospital if needed for further evaluation and treatment if needed." A 12/27/11 fax was sent to the physician to indicate the resident requested to discharge home. The resident was identified as doing well with therapy. Caregivers were ready to help her/him when she/he was to return home. Witness 5 (physician's nurse practitioner) responded on 12/27/11 "will see tonight to d/c (discharge)." There was no documentation Witness 5 (nurse practitioner) made a facility visit to assess Resident 2's pressure ulcers before her/his discharge home on 12/27/11. The 12/27/11 IPN written at 5:20 pm by Staff 1 (DNS) documented the review of the discharge instructions with resident. There was no documentation of physician's orders for the treatment of [REDACTED]. There was no documentation the resident received an air mattress until 12/27/11, the date of discharge. A public complaint received on 1/3/12 indicated Resident 2 was discharged from the facility on 12/27/11 with a large pressure ulcer (16 by 12 cm) on her/his coccyx. Witness 2 (Complainant) indicated the resident's ulcer was "uncovered at the time of discharge" and there were no physician's orders for the treatment of [REDACTED]. An interview on 1/5/12 at 1:30 pm with Witness 2 (Complainant) revealed Witness 2 knew the resident prior to her/his surgery early December 2011. Witness 2 stated Witness 3 (home care provider) assisted the resident daily for two hours of care daily for bowel and bladder care. Witness 2 stated after the hospitalization , the resident was transferred to the facility and then discharged to her/his home. Witness 2 indicated when the resident was discharged from the facility; the facility did not send instructions on how to care for the resident's pressure ulcer. Witness 2 stated the facility did not inform Witness 2 of the resident's condition prior to discharge from the facility. Witness 2 stated the first time she was aware of the resident's pressure ulcer was when Witness 3 (home care provider) made a home visit to care for the resident a day after she/he discharged from the facility. Witness 3 (home care aide) called Witness 2 (Complainant) to inform Witness 2 of the resident's skin condition and the need for a nurse to assess the resident. Witness 2 stated the facility did not fax any instructions regarding the resident's skin care. Witness 2 stated the facility was contacted and the facility was unable to fax additional information. Witness 2 stated Witness 4 (in-home care agency RN) went to the facility to obtain the skin care orders and was unable to obtain orders regarding the resident's skin care. The 12/30/11 local hospital history and physical indicated after the resident was discharged from the facility, the caregiver observed a sacral decubitus ulcer and the resident was admitted to the hospital for further evaluation. The hospital record indicated the resident's sacral decubitus ulcer measured 15 cm by 15 cm with some very mild surround [DIAGNOSES REDACTED]. The hospital documentation indicated the resident had been wheelchair-bound for [AGE] years and had no prior history of a decubitus ulcer. The resident received sharp debridement (refers to removal of foreign material or devitalized tissue by a surgical instrument) of a Stage IV pressure ulcer. The resident required hospitalization until her/his discharge to another local facility on 1/7/12. An interview on 1/10/12 at 10:00 am with facility Staff 4 (RNCM) revealed the facility process and standard of practice was for the nurse to treat the pressure ulcer and then contact the physician to obtain orders to treat the pressure ulcers. Staff 4 reviewed the resident's record and confirmed there were no physician's orders to treat the resident's pressure ulcer until a fax was sent on 12/27/11. Staff 4 stated she assessed the resident's pressure ulcer on 12/26/11 with Staff 5 (RN). Staff 4 stated she did not document the observation. An interview on 1/10/12 at 11:59 am with Witness 5 (nurse practitioner) indicated there was no record Witness 5 visited the resident prior to her/his discharge on 12/27/11. Witness 5 stated the resident left the building before she was able to assess the resident. An interview on 1/10/12 at 12:13 pm with Staff 5 (RN) revealed she observed the resident's pressure ulcer on 12/26/11 and described the ulcer as "large." Staff 5 stated she was concerned about the ulcer and asked Staff 4 (RNCM) to observe the ulcer. Staff 5 stated Staff 4 instructed her to use a [MEDICATION NAME] dressing on the ulcer to keep it in place. Staff 5 stated there had been no specific physician's order to treat the pressure ulcer prior to 12/26/11. Staff 5 stated she could not remember if she contacted the physician on 12/26/11 for pressure ulcer treatment orders. Staff 5 stated she didn't know why she would not have contacted the physician as it was a "very horrible ulcer." An interview on 1/11/12 at 2:15 pm with Resident 2 revealed she/he was about to be discharged from the facility on 12/27/11 when the air mattress was delivered to her/his room. Resident 2 stated no one at the facility indicated the resident needed an air mattress and the air mattress was not delivered to her/his home. Resident 2 stated she/he returned home and Witness 3 (home care provider) came to her/his home on 12/28/11 to provide bowel and bladder care. Resident 2 stated Witness 3 stated she/he had a large pressure ulcer and Witness 3 needed to call Witness 4 (in-home care agency RN). Witness 4 assessed the resident and obtained authorization to have the resident sent to the local hospital on [DATE]. Resident 2 stated she/he was hospitalized for [REDACTED]. An interview on 1/10/12 at 8:30 am and on 1/12/11 at 8:45 am with Staff 3 (RN) revealed she observed the resident's pressure ulcers on 12/27/11 and the [MEDICATION NAME] dressing was rolled up and there were areas of black/necrotic (dead) skin under the dressing. Staff 3 stated she removed the [MEDICATION NAME] and placed a foam dressing on the ulcer and contacted the physician for orders to treat the ulcer. Staff 3 stated she informed Staff 1 (DNS) of the condition of the resident's pressure ulcer on 12/27/11. Staff 3 stated she did not work at the facility for a few days after 12/27/11 and she returned to work and learned the resident discharged to her/his home with the pressure ulcers. Staff 3 stated she was concerned the resident was discharged to her/his home with the pressure ulcers. Staff 3 (RN) was asked about the specific pressure ulcer instructions at the nurse's station. Staff 3 stated there were no specific instructions for the nurses to use. Staff 3 provided a copy of the fax that would be sent to the physician for the care and treatment orders for Stage 1 pressure ulcers. Staff 3 was shown Resident 2's 12/21/11 physician's order of "wound care-routine; measure and monitor." Staff 3 indicated the order was not specific and the nurse receiving the order needed to contact the physician to clarify the order. An interview on 1/12/12 at 7:45 am with Staff 1 (DNS) revealed she assisted with the resident's discharge on 12/27/11. Staff 1 stated the resident's air mattress was delivered to the facility on [DATE] at the time the resident was being discharged to her/his home. Staff 1 stated she had not reviewed the resident's record prior to her/his discharge home and was not aware of Staff 3's fax to the physician on 12/27/11. Staff 1 stated she had not arranged for a home health nurse to be involved in the resident's care upon discharge. Staff 1 confirmed there were no physician's orders regarding the care of the resident's pressure ulcer when she/he was discharged home. Staff 1 stated the resident did not discharge against medical advice. Staff 1 stated she assumed Witness 5 (nurse practitioner) saw the resident prior to her/his return home. Staff 1 stated she learned later that Witness 5 did not see the resident prior to her/his discharge home. Staff 1 stated she was at the facility when Witness 4 (in-home care agency RN) came to the facility to obtain physician's order for treatment of [REDACTED]. Staff 1 was asked about the physician's order on 12/21/11 to indicate "routine wound care." Staff 1 stated there were specific instructions at the nurse's station for the routine treatment of [REDACTED]. An interview on 1/26/12 at 5:30 pm with Staff 8 (LPN) revealed she remembered when the resident was admitted on [DATE] and the local hospital called to inform the facility the resident was being admitted with a pressure ulcer. Staff 8 stated she documented a Skin Impairment sheet with the measurements of the resident's pressure ulcer though the documentation could not be located at the facility. Staff 8 could not remember why she did not indicate the resident had a pressure ulcer on the Ulcer Risk Evaluation Form and if the physician was contacted for treatment orders. Staff 8 stated it was a very busy evening/night and she worked with the resident's physician on medication orders. Staff 8 was asked what she would provide with a physician's order for routine wound care. Staff 8 stated a clarification would be needed from the physician though with Resident 2 she stated the use of a wound cleaner and then the application of an [MEDICATION NAME] dressing would have been routine.

Based on interviews and record review, it was determined the facility staff failed to provide care and service according to professional standards of care for 1 of 4 sampled residents (#2). Resident 2 discharged from the facility and required hospitalization and treatment for [REDACTED]. Findings include: Scope of Practice Standards for All Licensed Nurses 851-045-0040 (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (a) Advocates for the client's right to receive appropriate care, including person-centered care and end-of-life care, considerate of the client's needs, choices and dignity; (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; (c) Advocates for the client's right to receive appropriate and accurate information; (d) Communicates client's choices, concerns and special needs to other members of the healthcare team... (2) Standards related to the licensed nurse's responsibilities for the environment of care. The licensed nurse: (a) Promotes an environment conducive to safety and comfort for all levels of care, including self-care and end-of-life care; and (b) Identifies client safety and environment concerns; takes action to correct those concerns and report as needed. Scope of Practice Standards for Registered Nurses 851-045-0060 (3) Standards related to the Registered nurse's responsibility for collaboration with an interdisciplinary team. The Registered Nurse: (a) Functions as a member of the healthcare team to collaborate in the development, implementation and evaluation of integrated client-centered plans of care; (b) Demonstrates knowledge of roles of members of the interdisciplinary team; (c) Communicates with other relevant personnel regarding integrated client-centered plans of care; and (d) Makes referrals as necessary and ensures follow-up on those referrals... Resident 2 was admitted to the facility on [DATE] after decompressive cervical laminectomy (back of neck/spine) surgery. The hospital's 12/19/11 Nursing Transfer Summary indicated the resident had a Stage II (Stage II is a partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer on her/his coccyx. The information indicated the resident denied she/he had a pressure ulcer before the hospital admission. There were no physician's orders from the hospital to the facility for the treatment of [REDACTED]. There was a Skin Impairment form completed on 12/26/11 by Staff 5 (RN) to indicate the resident had a pressure ulcer and shearing present at admission. The documentation indicated the resident's skin impairment measured 17 cm by 14 cm with a depth of 0.1 cm with scant drainage; wound color was pink/red, no odor or tunneling. The area was assessed to be nonstageable. The documentation indicated the resident had two areas of necrosis (dead skin) measuring 2 cm by 2.5 cm by 0.1 cm with a yellow wound bed and an area measuring 2 cm by 1.8 cm by 0.1 cm with a yellow wound bed. The 12/27/11 Interdisciplinary Progress Note (IPN) written at 11:15 am Staff 3 (RN) indicated the resident presented with increased slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft and moist) to one open area, the left buttock had increased necrosis on left upper buttock and right lower buttock with 5 cm by 6 cm open area. The note indicated the resident was aware of the condition of the ulcers. On 12/27/11 Staff 3 sent a fax to the physician to describe the resident's pressure ulcers. The fax asked the physician for approval to try a topical [MEDICATION NAME] agent such as Santyl with dry dressing every day to necrosis and slough with wound gel at other open areas every day and PRN. Witness 5 (physician's nurse practitioner) responded with a "yes" and indicated the facility "may refer to wound care specialist at the local hospital if needed for further evaluation and treatment if needed." A 12/27/11 fax was sent to the physician to indicate the resident requested to be discharged to her/his home. The resident was identified as doing well with therapy. Caregivers were ready to help her/him when she/he was to return home. Witness 5 (physician's nurse practitioner) responded on 12/27/11 "will see tonight to d/c (discharge)." There was no documentation Witness 5 (nurse practitioner) made a facility visit to talk with Resident 2 before her/his discharge home. The 12/27/11 IPN written at 5:20 pm by Staff 1 (DNS) documented the review of the discharge instructions with resident. There was no documentation of physician's orders for the treatment of [REDACTED]. A complaint received on 1/3/12 indicated Resident 2 was discharged from the facility on 12/27/11 with a large ulcer on her/his coccyx. The ulcer measured 16 cm by 12 cm. Witness 2 (Complainant) indicated the resident's "uncovered at the time of discharge from the facility." The resident was admitted to the local hospital on [DATE] secondary to ulcer infection. Witness 2 (Complainant) indicated from reports received from the local hospital, the resident was in intensive care and the hospital assessed the ulcer as a Stage IV. An interview on 1/5/12 at 1:30 pm with Witness 2 (Complainant) revealed Witness 3 (home care provider) assisted the resident daily for two hours of care daily for bowel and bladder care. Witness 2 stated the resident was hospitalized , transferred to the facility and then discharged to her/his home. Witness 2 indicated when the resident was discharged from the facility; the facility did not send instructions on how to care for the resident's pressure ulcer. Witness 2 stated the facility did not inform Witness 2 of the resident's condition prior to discharge from the facility. Witness 2 stated the first time she was aware of the resident's pressure ulcer was when Witness 3 (home care provider) made a home visit to care for the resident a day after Resident 2 discharged from the facility. Witness 3 called Witness 2 to inform Witness 2 of the resident's skin condition and the need for a nurse to assess the resident. Witness 2 stated the facility did not fax any instructions regarding the resident's skin care. Witness 2 stated the facility was contacted and the facility was unable to fax additional information. Witness 2 stated Witness 4 (in-home care agency RN) went to the facility to obtain the skin care orders. Witness 4 was unable to obtain orders regarding the resident's skin care. An interview on 1/5/12 at 1:45 pm with Witness 3 (home care provider) revealed Witness 3 provided assistance with bowel and bladder care for Resident 2. Witness 3 stated Resident 2 was in the facility for a few weeks and she made a home visit the day after she/he discharged from the facility (12/28/11). Witness 3 stated she turned the resident onto her/his side and saw the resident's coccyx area. Witness 3 stated she was not able to describe the resident's ulcer though stated "it was awful." Witness 3 asked the resident if the facility had told her/him about the pressure ulcer and the resident said "no." Witness 3 stated Resident 2 was not aware she/he had skin breakdown. Witness 3 stated she called Witness 2 (Complainant) immediately and asked for an RN to assess the resident. Witness 3 stated she was not aware of the resident's condition and there were no instructions on how to clean the ulcer. An interview on 1/5/12 at 4:00 pm with Witness 4 (in-home care agency RN) revealed she conducted a skin assessment for Resident 2 on 12/29/11. Witness 4 stated the resident's coccyx/buttock ulcer measured 16 cm by 12 cm with a large amount of slough. Witness 4 stated she was unable to stage the ulcer due to slough though Witness 4 determined there was undermining when she touched the area with a Q-tip. Witness 4 stated there was an odor and the resident had brown discharge on the disposable sheet under the resident. Witness 4 indicated there were no discharge orders from the facility regarding pressure ulcer care. Witness 4 stated Resident 2 was a paraplegic and was unable to feel pain from the pressure ulcers. Witness 4 stated she went to the facility to obtain orders for the treatment of [REDACTED]. Witness 4 stated both Witness 4 and Witness 2 (Complainant) were in contact with the local home health RN to describe the resident's condition. Witness 4 was concerned because there would be no assessment of the resident over the holiday weekend. Witness 4 stated Witness 2 was able to obtain the authority from the local home care provider to send the resident to the local hospital emergency department. An interview on 1/5/12 at 4:20 pm with Witness 1 (local hospital RN discharge planner) revealed the resident's pressure ulcer was quite large and would require a long time to heal. Witness 1 stated Resident 2 was depressed on 1/5/12 to learn the length of time for the healing of the pressure ulcer. Witness 1 stated the resident did not have a history of pressure ulcers and had been independent in her/his home with minimal assistance with bowel and bladder care. Witness 1 provided a copy of the 12/30/11 hospital consultation report to indicate the resident had discharged from the facility a couple of days ago after a rehabilitation stay following a cervical laminectomy. The report indicated the resident's caregiver noticed a sacral decubitus ulcer and brought her/him back for further evaluation. The consultation report indicated the resident did not have any prior history of sacral decubitus ulcers. The ulcer measured 15 by 15 cm with some mild surround [DIAGNOSES REDACTED]. No fluctuance noted. The assessment indicated the resident would benefit from some sharp debridement with IV sedation. The resident then received debridement of the ulcer with the use of enzymes. On 12/31/11, the pressure ulcer was described as a Stage IV, black in appearance with an odor before cleansing. The resident required hospitalization until her/his discharge to another local facility on 1/7/12. An interview on 1/10/12 at 12:13 pm with Staff 5 (RN) revealed she observed the resident's pressure ulcer on 12/26/11 and described the ulcer as "large." Staff 5 stated she was concerned about the ulcer and asked Staff 4 (RNCM) to observe the ulcer. Staff 5 stated Staff 4 instructed her to use a [MEDICATION NAME] dressing (opague dressing used to provide a moist wound-healing environment while protecting from contamination, nonbreathable and adheres to the skin) on the ulcer to keep it in place. Staff 5 stated there had been no specific physician's order to treat the pressure ulcer prior to 12/26/11. Staff 5 stated she could not remember if she contacted the physician on 12/26/11 for pressure ulcer treatment orders. Staff 5 stated she didn't know why she would not have contacted the physician as it was a "very horrible ulcer." An interview on 1/10/12 at 8:30 am with Staff 3 (RN) revealed she observed the resident's pressure ulcers on 12/27/11 and the [MEDICATION NAME] dressing was rolled up and there were areas of black/necrotic (dead) skin under the dressing. Staff 3 stated she removed the [MEDICATION NAME] and placed a foam dressing on the ulcer and contacted the physician for orders to treat the ulcer. Staff 3 stated she informed Staff 1 (DNS) of the condition of the resident's pressure ulcer on 12/27/11. Staff 3 stated she did not work for a few days after 12/27/11. Staff 3 stated she returned to work and learned the resident discharged to her/his home with the pressure ulcers. Staff 3 stated she was concerned the resident was discharged to her/his home with the pressure ulcers. An interview on 1/10/12 at 10:00 am with Staff 4 (RNCM) revealed she observed the resident's pressure ulcer on 12/26/11 though could not provide any documentation of the observation. Staff 4 stated she was not working at the facility on 12/27/11. Staff 4 reviewed the resident's chart and the physician's orders sent with the resident upon discharge. Staff 4 indicated there were no physician's orders for treatment of [REDACTED]. Staff 4 stated it was the facility practice to provide hand-written instructions on the physician's order sheet. Staff 4 stated the fax to the physician may not have arrived when the resident discharged . Staff 4 stated the resident's pressure ulcer would have needed the services of a home health RN in order for it to be treated. An interview on 1/10/12 at 11:50 am with Staff 6 (Social Services Director) revealed the facility could not locate the discharge plan established for Resident 2 with the facility when the resident was discharged on [DATE]. Staff 6 stated the resident requested to return to her/his home. Staff 6 stated she sent a faxed request to the resident's physician and informed the nursing staff of the resident's request. Staff 6 stated the nursing staff would inform Staff 6 of the need for referrals to be made. Staff 6 stated she was not aware the resident had a pressure ulcer and need for a home health care nurse or wound care nurse referral. An interview on 1/10/12 at 11:59 am with Witness 5 (nurse practitioner) indicated there was no record Witness 5 visited the resident prior to her/his discharge on 12/27/11. Witness 5 stated the resident left the building before she was able to assess the resident. Witness 5 was asked would there need to be nurse involvement and an order to treat the resident's pressure ulcer upon discharge. Witness 5 stated "yes." An interview on 1/12/12 at 7:45 am with Staff 1 (DNS) revealed she assisted with the resident's discharge from the facility on 12/27/11. Staff 1 stated the resident's air mattress was delivered to the facility on [DATE] at the time the resident was being discharged to her/his home. Staff 1 stated she had not reviewed the resident's record prior to her/his discharge home. Staff 1 stated she had not arranged for a home health nurse to be involved in the resident's care when he was at home. Staff 1 confirmed there were no physician's orders regarding the care of the resident's pressure ulcer when she/he was discharged home. Staff 1 stated the resident did not return home against medical advice. Staff 1 stated she assumed Witness 5 (nurse practitioner) saw the resident prior to her/his return home. Staff 1 stated she learned later that Witness 5 did not see the resident prior to her/his discharge home. Staff 1 stated she was at the facility when Witness 4 came to the facility to obtain physician's order for treatment of [REDACTED]. An interview on 1/11/12 at 2:15 pm with Resident 2 revealed she/he was about to be discharged from the facility on 12/27/11 when the air mattress was delivered to her/his room. Resident 2 stated no one at the facility indicated the resident needed an air mattress and the air mattress was not delivered to her/his home. Resident 2 stated she/he returned home and Witness 3 (home care provider) came to her/his home on 12/28/11 to provide bowel and bladder care. Resident 2 stated Witness 3 stated she/he had a large pressure ulcer and Witness 3 needed to call Witness 4 (in-home care agency RN). Witness 4 assessed the resident and obtained authorization to have the resident sent to the local hospital on [DATE]. Resident 2 stated she/he was hospitalized for [REDACTED]. Refer to F-250 and F-314.

Based on observation, interview, and record review it was determined the facility failed to use an assistance device which resulted in a fall for 1 of 4 sampled residents (#1) who had experienced falls. Resident 1 experienced an avoidable fall, sustained a fractured leg and experienced pain. Findings include: Resident 1 was admitted to the facility in June, 2009. [DIAGNOSES REDACTED]. The comprehensive care plan dated September 2010, indicated the resident had a potential for falls related to unsteady gait and poor safety awareness. Interventions were to remind the resident to allow staff to assist with transfers and encourage the resident to participate with the restorative program. A tab alarm was to be used when the resident was in a wheelchair or recliner and not to leave the resident in the bathroom unattended. The quarterly MDS dated [DATE] indicated the resident had both short and long term memory loss, required extensive assistance from staff for transfers, dressing and bathing. Resident 1 was dependent for toileting and was incontinent. The resident was essentially bedfast or chairfast by choice. According to the facility's Incident/Accident report dated 11/5/10, Resident 1 had been in the bathroom with Staff 9 (CNA) present. The CNA reported she assisted the resident to stand. While holding onto the grab bar the resident stated s/he was to weak to stand any longer, the CNA "reportedly" lowered the resident to the floor. The CNA had not placed a gait belt around the resident, per facility policy. On 11/5/10 at 7:45 am the CNA was told by another CNA to summon the nurse. The charge nurse assessed Resident 1's leg which was "distorted at an irregular angle." The resident was sent to the hospital and a fracture was confirmed. According to the Surgeon's statement the fracture was due to a "velocity fall." Further investigation completed by the facility, revealed the resident had fallen to the floor. The Interdisciplinary Progress Notes, dated 11/5/10 at 7:45 am, indicated the resident was found lying on her/his back in the bathroom. Resident 1's left leg was extended toward the toilet and the right leg was distorted at an angle. The resident was in pain and deep bruising was noted on the back side of the right knee. The Paramedics were called and the resident was transferred to the hospital. On 12/1/10 at 1:15 pm, Staff 1 (Administrator) stated their investigation took about a week to complete. Staff 1 stated there were some discrepancies with the CNAs story. It was determined the CNA had not used a gait belt as was the facility's policy. On 12/1/10 at 2:20 pm, Staff 3 (CNA) stated the resident returned to the facility and now required a mechanical lift for transfers due to a leg brace. Staff 3 stated before the resident had the fall, the resident was able to be transferred using a gait belt and walker. Staff 3 stated "we are always to use a gait belt when transferring any resident." On 12/1/10 at 3:00 pm, Staff 2 (acting DNS) stated the resident's care plan indicated the resident was a one person transfer and was able to help. Staff 2 added, the information that was reported by the CNA after the fall happened did not add up. Staff 2 stated the "CNA later acknowledged s/he had not used a gait belt on Resident 1 and the CNA no longer worked there." Staff 2 stated they have always had a "no lift" policy, a gait belt was always to be used with a transfer unless the care plan called for a mechanical lift. On 12/1/10 at 3:40 pm, Staff 4 (RN) stated she was the nurse who assessed the resident after the fall occurred on 11/5/10. Staff 4 stated she had last seen the resident about 7:00 am when she went to check the resident's blood sugar. The resident was in a wheelchair wanting to go to the bathroom. Staff 4 asked the CNA to take the resident to the bathroom. Staff 4 stated "the next thing she knew at 7:45 am the CNA came to the nurses station and said she had to ease the resident to the floor, in the bathroom." Staff 4 asked the CNA where the gait belt was, the CNA stated s/he did not have one. Staff 4 stated after she assessed the resident she called the doctor and the paramedics "the resident's leg was so distorted I knew it was fractured." On 12/1/10 at 4:30 pm, Staff 6 (CNA) stated she always used a gait belt when transferring a resident unless the care plan indicates they are to be a lift. Staff 6 confirmed that information was located on the CNA pocket care plan. On 12/1/10 at 4:55 pm, Staff 7 (CNA) stated she had frequently cared for Resident 1 before the fall. Staff 7 stated the resident would use the wheelchair to the bathroom door, a gait belt would be used and the resident would stand and hold onto the grab bar. Staff 7 stated the resident would sometimes tell her s/he "felt to weak to stand so she would then help her, but that was rare." The Resident returned to the facility on [DATE]. The CNA pocket care plan dated 11/15/10 indicated the resident was non-weight bearing on the right leg and was to be transferred using a mechanical lift at all times.