Every finding on record at Bear Lake Memorial Skilled Nursing Facility

Based on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods, and use proper hand hygiene when serving food. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 2/17/26 at 10:00 AM, conducted an initial tour of the kitchen area with FSM with the following issues noted. - Outdated spices (Rotisserie chicken seasoning, garlic salt, Italian seasoning) in the dry food storage area and kitchen cooking area with used by dates 2024 and 2025. - In the kitchen grilling area, a squeeze bottle containing a light-yellow liquid later identified by FSM as cooking oil with no dates on the bottle. - In the walk-in freezer – various bags containing breaded fish, tater tots, and French fries without any use by or opened dates. - In the dry food storage area, two opened bags containing breakfast biscuits without any use by dates, teriyaki sauce with used by date of [DATE], and three boxes of chips that were stored on the ground. - The Walk-in refrigerator temperatures on several dates were greater than 40 degrees F. as follows. [DATE] at 6am [DATE] at 6pm [DATE] at 6am [DATE] at 6pm [DATE] at 6am [DATE] at 6pm [DATE] at 6am [DATE] at 6pm [DATE] at 6am [DATE] at 6pm [DATE] at 6am [DATE] at 6am The refrigerator temperature log documented the following: temperatures for the refrigerator are 35 to 41 degrees F. Any unit not at the proper temperature must be reported to the supervisor and maintenance at once and perishable foods removed. Please make a note at the bottom of the sheet when it has been reported. On 2/17/26 at 10:25 AM, observed the lack of any notes at the bottom of the refrigerator temperature log to indicate the higher temperatures had been reported. On 2/17/26 at 10:33 AM, the FSM stated the outdated and non-dated food items should have been addressed and were not. Additionally, the higher refrigerator temperatures should have been reported to the maintenance department but had not been. On 2/18/26 at 1:48 PM, the FSM stated after the cook/server rubbed the resident's shoulder, she should have removed her gloves, washed her hands, and put new gloves on before continuing to serve food to residents and did not. On 2/19/26 at 11:17 AM, observed the following issues in the resident snack refrigerator: - Two small containers of food, one with a resident name but neither had any dates labeled on them. On the resident snack refrigerator door, the following document was visible: Resident Fridge; Please label with a name and date all items placed in it. On 2/19/26 at 11:47 AM, the DNS stated all items in the resident refrigerator should be labeled with a date but were not. On 2/17/26 at 12:12 PM, observed during the lunch meal dietary staff placing a piece of chicken fried steak onto the plate, hold the meat on the plate with a gloved hand and take a pizza cutter and cut into bite-size pieces, once the remaining food items were placed on the plate, the dietary staff delivered the plate to the resident seated at the table, rubbed resident's shoulder. The dietary staff returned to plating food items and holding the meat while cutting without having changed gloves or performing hand hygiene. Dietary staff continued serving multiple residents using same technique. .

Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 1 of 12 residents (Resident #6) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications. Findings include:Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including dementia and diabetes. On 1/21/26, a physician order documented Resident #6 was to start Sertaline (an antipsychotic medication) 25 mg one time a day for depression. On 2/18/26 at 3:16 PM, the Licensed Social Worker (LSW) stated there was no psychotropic medication acknowledgement consent for Resident #6's current use of Sertaline. On 2/18/26 at 3:18 PM, the MDS RN stated, Resident #6 should have signed a psychotropic medication acknowledgement consent prior to administration of Sertaline but had not.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 2 of 12 residents (#30 and #35) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Call System, Residents policy, no date or revision date, documented each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (rapid irregular heart rate) and high blood pressure. On 2/17/26 at 10:27 AM, observed Resident #35 sitting in her recliner which was placed on the left side of her bed and her call light was lying on the nightstand on the right side of her bed and not within her reach. On 2/17/26 at 10:30 AM, LPN #1 stated Resident #35's call light should be within reach and had not been. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease (permanent failure of kidney function), diabetes and repeated falls. On 2/17/26 at 1:25 PM, observed Resident #30 sitting in his recliner which was placed on the right side of his bed, and pinned to the room curtain on the left side of his bed was his call light which was not within his reach. On 2/17/26 at 1:42 PM, LPN #1 stated Resident #30's call light should have been within reach and had not been. On 2/17/26 at 2:52 PM, the Administrator stated resident call lights should be within the resident's reach and had not been.

Based on observation and resident and staff interviews, it was determined the facility failed to ensure residents were provided with a safe and clean, homelike environment that did not pose any safety risks. This was true for 1 of 6 resident room doors (room [ROOM NUMBER]) whose room doors were opened. This deficient practice created the potential for diminished quality of life and psychosocial distress for residents when their room doors do not open correctly or fully to allow entrance or exit of the room. Findings include:Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational paranoia, and auditory hallucinations) and chronic kidney disease.On 2/17/26 at 10:45 AM, when attempting to open resident room [ROOM NUMBER] door, the surveyor observed that the door became jammed when only about halfway open. Resident #23 stated the door has been like that since he was assigned this room.On 2/18/26 at 1:15 PM, the Administrator stated he was unaware room [ROOM NUMBER] door was stuck because maintenance had attempted to repair the stuck door of room [ROOM NUMBER] and the same issue must have occurred again.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 12 residents (Resident #7and Resident #23) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include.Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including chronic pulmonary edema (long-term condition involving gradual buildup of fluid in the lungs) and open right foot wound. On 2/17/26 at 11:07 AM, during interview of Resident #7 he stated he had fallen multiple times and the most recent had been on 2/16/26 when he slid off his recliner onto the floor and the facility had provided him with a different recliner. On 2/17/26 at 12:35 PM, Resident #7's care plan reviewed, and no documented interventions related to the 2/16/26 fall. No documented interventions related to Resident #7's right adaptive shoe use. On 2/17/26 at 12:37 PM, reviewed Resident #7's medical record and a progress note documented resident had a fall on 2/16/26. On 2/18/26 at 1:50 PM, the MDS RN stated Resident #7's care plan should have been revised when the resident had the recent fall and now requires the use of a spacer with the recliner, and the continued use of the right adaptive shoe and had not been. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational paranoia, and auditory hallucinations) and chronic kidney disease. On 2/17/26 at 4:36 PM, observed Resident #23's bed very low to the ground. Resident #23 stated it makes it easier for him to get out of bed. On 2/17/26, Resident #23's care plan had not documented that his bed should be in a low position. On 2/18/26 at 1:24 PM, the MDS RN stated Resident #23's low bed position should have been care-planned and had not been.

Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 12 Residents (#1 and #35) reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when physicians were not contacted regarding residents not having a BM within the last 72 hours. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including psychosis (a mental health symptom, not a specific illness, characterized by a loss of contact with reality) and dementia. On 2/17/26 at 4:40 PM, Resident #1's medical record documented he had a BM on 1/26/26 at 21:59 and not again until 1/30/26 at 21:53, 96 hours later. Resident #1's physician order dated 10/1/25, documented Docusate 100 mg orally 2 times a day for constipation and his MAR documented it was given two times a day throughout the month of January 2026. On 2/18/26, Resident #1's medical record had no documentation that his physician had been contacted 1/26/26 through 1/30/26, regarding no BM for over 72 hours. On 2/18/26 at 1:25 PM, the MDS RN stated nursing staff for Resident #1 should have contacted the physician after 72 hours without a BM and had not. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (rapid irregular heart rate) and high blood pressure. On 2/17/26 at 3:40 PM, Resident #35's medical record documented she had a BM on 2/8/26 at 0029 and not again until 2/12/26 at 1505, 87 hours later. Resident #35's medication administration record documented Resident #35 had the following medication orders; -Milk of Magnesia 30 ml prn QD po for constipation -Bisacodyl 10 mg suppository rectally once daily if needed if Milk of Magnesia not effective – constipation -Docusate 100mg orally twice daily as needed – constipation On 2/17/26 at 4:03 PM, during review of Resident #35's medical record no documented administrations of the ordered bowel care medications between 2/8/26 and 2/12/26.

Based on observation, facility policy review, record review, and interviews, it was determined the facility failed to provide respiratory services consistent with professional standards of practice. This was true for 3 of 3 residents (#4, #11 and #27) whose SpO2 documentation and respiratory equipment was observed. This failure created the potential for residents' oxygen status and health to be affected and respiratory equipment to malfunction and possibly catch fire. Findings include:The facility CPAP/BiPAP Support Level III policy, undated, documented under steps in the procedure #12, connect supplemental oxygen (Note: Connect oxygen after the CPAP machine has been turned on and disconnect before it has been turned off.) and adjust flow rate as prescribed.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including transient cerebral ischemic attack (a temporary blockage of blood flow to the brain that causes stroke-like symptoms) and chronic kidney disease.On 2/17/26 at 3:13 PM, Resident #4's medical record documented on 12/3/25, she had an SpO2 of 82% on room air. No nursing interventions related to the low SpO2 were documented in Resident #4's nursing notes.Resident #4's physician oxygen order dated 10/28/24, documented oxygen 1L/NC to 1.5L /NC at night as needed to maintain oxygen saturation above 90%. On 2/18/26 at 4:00 PM, the MDS RN stated Resident #4's low SpO2 level should have been addressed by nursing staff and had not been.Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and hallucinations.On 2/17/26 at 1:30 PM, observed Resident #11's oxygen was being bled into her PAP device at 3 lpm and the PAP device was not turned on or in use. On 2/17/26 at 2:45 PM, the MDS RN stated Resident #11's oxygen should have been turned off before turning the PAP device off when she was done using the PAP device but had not been.Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including fracture of lower right leg and diabetes.On 2/17/26 at 11:00 AM, observed Resident #27's oxygen was being bled into her PAP device at 2 lpm and the PAP device was not turned on or in use. On 2/17/26 at 2:50 PM, the MDS RN stated Resident #27's oxygen should have been turned off before turning the PAP device off when she was done using the PAP device but had not been.

Based on record review and staff interviews, it was determined the facility failed to have an RN on duty for at least 8 consecutive hours a day. This was true for 1 of 3 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect all residents residing at the facility. Findings include:On 2/18/26 at 12:00 PM, during review of monthly scheduled staffing sheets from January 2025 through January 2026 for licensed nursing hours, 4/11/25, was confirmed as having less than 8 consecutive RN hours coverage.On 2/18/26 at 1:31 PM, the Administrator stated on 4/11/25, the facility only had 4.75 hours of RN coverage. On 2/19/26 at 11:37 AM, the DNS stated she could not find any other RN hours worked on 4/11/25 other than the 4.75 hours earlier reported.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was maintained for 18 months after it had been posted. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 2/17/26 at 9:40 AM, observed the daily nurse staffing documented on a dry erase whiteboard. On 2/17/26 at 4:10 PM, the Administrator provided monthly scheduling staffing sheets for the past 13 months however these did not have the required daily staffing information, for example, the name of the facility, the scheduled vs actual hours worked, and the daily census. On 2/18/26 at 10:10 AM, the Administrator stated the facility had not maintained 18 months of daily staffing sheets due to it being documented on the dry erase whiteboard and should have.On 2/18/26 at 3:35 PM, the MDS RN stated the daily whiteboard information was erased, and new information was added each morning.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication inthe facility. Findings include:On 2/18/26 at 9:40 AM, observed during the South Hall medication cart audit, the narcotic accountability sheet, dated 2/1/26 to 2/18/26, with 1 licensed nurse signature not documented on 2/2/26, 2/4/26, 2/8/26, and 2/17/26. On 2/18/26 at 9:42 AM, LPN #1 stated two nurses should have signed the narcotic accountability sheet and had not. On 2/18/26 at 9:45 AM, observed during the North Hall medication cart audit, the narcotic accountability sheet, dated 2/1/26 to 2/18/26, with 1 licensed nurse signature not documented on 2/16/26. On 2/18/26 at 9:47 AM, LPN #1 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 2/19/26 at 11:07 AM, the DNS stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart and had not.

Based on observation, interviews, and facility policy review, it was determined the facility failed to ensure medications were secured in a locked medication cart, and of expired medications were removed. This was observed in 2 of 2 medication carts. This failure created the potential for residents to obtain prescribed medications used for other residents, presented the risk for cross-contamination of products, and receive expired medications with decreased efficacy. Findings include:On 2/17/26 at 9:35 AM, observed on entry to the facility, the North Hall medication cart unlocked and unattended as LPN #1 walked away from the medication cart and down the hall to a resident room. No other nursing staff present around the medication cart. The following was observed during the medication cart audits. On 2/18/26 at 9:52 AM, the South Hall medication cart was audited with LPN #1 present. Observed the following: - Two bottles of Milk of Magnesia with a manufacturer printed expiration date of 10/25 on the bottle On 2/18/26 at 9:53 AM, LPN #1 stated, the bottles of Milk of Magnesia should have been discarded and had not been. On 2/18/26 at 9:54 AM, observed white colored fine powder debris along the length of the back edge of medication cart drawer 3. On 2/18/26 at 9:56 AM, LPN #1 stated the medication carts are cleaned monthly and should not have had debris in the drawers. On 2/18/26 at 10:25 AM, the MDS RN stated the expired medications should have been removed from the medication cart and had not been. On 2/17/26 at 12:20 PM, observed the north hall medication cart in the nursing station area, unlocked with no licensed nursing staff present. The surveyor had to wait 10 minutes until a CNA walked past and could request to speak to the MDS RN. On 2/17/26 at 12:35 PM, the MDS RN stated the medication carts are to be locked when not in use and when no nursing staff were present but had not been.

Based on observation, policy review, and staff interviews, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not remove dirty gloves, perform hand hygiene, and redon gloves before continuing to serve residents food. This deficient practice had the potential to contaminate served food items and make residents ill. Findings include:The facility Hand Washing policy, undated, documented dietary staff will wash hands before starting work.and at other times hands have been soiled.Based on staff interview and record review, it was determined the facility failed to ensure current infection control standards of practice were implemented by conducting at least an annual review of ICPC policies and procedures. This placed all residents at risk for contamination or infections. Findings include:On 2/18/26 at 3:16 PM during IP interview ICPC policies observed with no review or revision date. The facility could not provide documentation indicating ICPC policies had been reviewed annually. On 2/18/26 at 3:18 PM, the IP stated the IPCP policies had not been reviewed or revised annually and should have been. The IP stated she did not know how many but there were a lot of them. On 2/19/26 at 11:06 AM, the DNS stated the IPCP policies had not been reviewed annually and should have been.

Based on observation and interview, the facility failed to provide a safe and functional environment. This was true for 1 of 2 medication carts whose sharps containers were overfilled. This failure had the potential for injury and infections. Findings include:On 2/17/26 at 11:02 AM and 2/18/26 at 9:40 AM, observed on the South Hall medication cart, the sharps container filled past the full line and the flip top not freely movable.On 2/18/26 at 9:45 AM, LPN #2 stated the sharps container should have been changed when it was full and had not been.On 2/18/26 at 1:08 PM, the Administrator stated the sharps containers should have been changed when full and had not been.

Based on record review, interview, and facility policy review, the facility failed to ensure the physician responded to the Pharmacist's recommendations to review the need for antibiotics ordered prophylactically (to potentially prevent) urinary tract infections (UTIs) for two of five residents (Resident (R) 3 and R4) reviewed for unnecessary medications out of 17 sampled residents. This had the potential for both residents to experience adverse medication reactions. Findings include: Review of the facility's untitled policy titled, Medication Regimen Reviews [MMR], revealed, The Consultant pharmacist reviews the medication regimen of each resident at least monthly .5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication .9. An Irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences .11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the Administrator. 1.Review of R3's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] with a personal history of urinary tract infections (UTIs). Review of R3's Medication Record provided by the facility revealed the resident was ordered Cephalexin (antibiotic) 250 milligrams, once a day for UTI prophylaxis on 02/01/24. The Medication Record revealed the resident was still currently taking the antibiotic and had been administered the antibiotic for over eight months. Review of the facility's Consultant Pharmacist Report, Monthly Drug Regimen Review, dated 06/2024 provided by the facility revealed the physician had been asked to review the prophylactic antibiotic use for R3. There was no evidence a response was made by the physician for the recommendation from the Pharmacist. 2. Review of R4's Face Sheet provided by the facility revealed R4 was admitted to the facility on [DATE] with a personal history of UTIs. Review of R4's Medication Record dated 06/06/24 provided by the facility revealed an order for Cephalexin (antibiotic) 250 mg, once a day for UTI prophylaxis. The Medical Record further revealed the resident had been administered Cephalexin for over four months and continues to be administered the antibiotic. Review of the facility's Consultant Pharmacist Report, Monthly Drug Regimen Review, dated 06/2024 provided by the facility revealed the physician had been asked to review the prophylactic antibiotic use for R4. There was no evidence a response was made by the physician for the recommendation from the Pharmacist. During an interview with the Director of Nursing Services (DNS) on 10/03/24 at 7:00 AM confirmed the physician did not respond to the Pharmacist's recommendations made in June 2024 to review the ordered antibiotics for R3 and R4 that were being used prophylactically without justification. Attempts made to reach the physician who prescribed the antibiotics to R3 and R4 were unsuccessful.

Based on record review, interview, review of the Centers for Disease Control (CDC) guidance on Antibiotic Stewardship, and review of facility's policy, the facility failed to ensure two of five residents (Resident (R) 3 and R4) reviewed for unnecessary medications out of a sample of 17 residents had appropriate clinical indications for the use of an antibiotic. This had the potential for adverse drug reactions for both residents. Findings include: Review of a CDC guidance located at https://www.cdc.gov of a document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Review of the facility's undated policy titled Bear Lake Memorial Skilled Nursing Antibiotic Stewardship revealed, Background: Antibiotics are powerful tools for fighting infections. However, the widespread use of antibiotics has resulted in an alarming increase in antibiotic-resistant infections and a subsequent need to rely on broad-spectrum antibiotics that might be more toxic and expensive. In addition to the development of antibiotic resistance, antibiotic use is associated with an increased risk of Clostridium difficile (C-diff) infection and adverse drug reactions. Since antibiotics are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and reduction of adverse events . viii. Interventions for . antibiotic prophylaxis, the AST [Antibiotic Stewardship Team] will identify actions to directly impact inappropriate antibiotic use for . prophylactic indications. Review of facility' policy titled Urinary Tract Infection/Bacteriuria - Clinical Protocol, revised April 2018 revealed . Treatment/Management .3. The physician should consider stopping antibiotics with uncomplicated UTIs [Urinary Tract Infections] who have been afebrile [absent of fever] and asymptomatic [no symptoms] for 48 hours . Monitoring . 2.a. Physicians should justify continuing or resuming antibiotic treatment beyond an initial course. 1.Review of R3's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] with a personal history of UTIs. Review of R3's Care Plan provided by the facility with a date initiated of 12/13/23 revealed a focus that the resident required assistance with toileting, with interventions to include; monitor for signs/symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Review of R3's Nursing Note provided by the facility dated 02/01/24 revealed the physician had been contacted via text due to the resident saying she was peeing a lot and had a kidney infection. The physician ordered a urinalysis (UA) with culture and sensitivity (CS). The note indicated the resident had no complaints of urinary urgency, frequency, burning, or pain. Review of the facility's Suspected UTI SBAR [situation, background, assessment, recommendation] dated 02/01/24, provided by the facility revealed R3's temperature was 97.8 degrees Fahrenheit (F) with a heart rate of 58 beats per minute. The assessment revealed the criteria was met for a UTI if one of the three situations are met; 1. Acute dysuria (painful urination) alone, or 2. Single temperature of 100 degrees F and at least one new or worsening of the following; urgency, frequency, back or flank pain, suprapubic pain, gross hematuria (blood in urine), and urinary incontinence. The only symptom marked was frequency, or 3. No fever, but two or more of the following symptoms; urgency, frequency, incontinence, suprapubic pain, and gross hematuria. Nothing was marked under the section 3. Review of R3's results of the UA/CS provided by the facility dated 02/08/24 revealed 10,000 colony-forming units per milliliter (CFU/mL) of pseudomonas aeruginosa (a type of bacteria that can cause UTIs). Bacteria greater than 100,000 CFU/mL is suggestive of a UTI. Review of R3's Medication Record provided by the facility revealed the resident was ordered Cephalexin (antibiotic) 250 milligrams, one a day for UTI prophylaxis (attempt to prevent a UTI) on 02/01/24. The Medication Record revealed the resident was still currently taking the antibiotic and has been administered the antibiotic for over eight months. During an interview on 10/02/24 at 3:00 PM, the Director of Nursing Services (DNS) and the Infection Control Preventionist (ICP) confirmed R3 did not meet the criteria of a UTI. The DNS confirmed the last UA/CS was on 02/01/24 and was prescribed an antibiotic prophylactically in order to potentially prevent a UTI. The DNS and ICP confirmed R3 had no signs or symptoms of a UTI. They both further confirmed the SBAR of R3 did not meet the criteria for prescribing an antibiotic. 2. Review of R4's Face Sheet provided by the facility revealed R4 was admitted to the facility on [DATE] with a personal history of UTIs. Review of R4's Progress Note provided by the facility dated 05/28/24 revealed, UA done today, results show UTI. Results to [name of physician] and an order was received for Omnicef (antibiotic) 300 mg, BID [twice a day] for five days. Review of R4's Progress Note provided by the facility dated 05/31/24 revealed, MD [physician] contacted by the DNS regarding current treatment and culture and sensitivity. MD ordered Cipro (antibiotic), 500 mg, BID x 10 doses, MD dc'd (discontinued) prophylactic antibiotic of Omnicef. Review of R4's Progress Note dated 06/05/24 provided by the facility and completed by the physician revealed, resident is having increased back pain. Recently finished antibiotic for UTI. Will order repeat UA/CS. Review of R4's repeat lab results of the UA/CS ordered by the physician provided by the facility dated 06/10/24 revealed the resident was negative for a UTI. Review of R4's Medication Record dated 06/06/24 provided by the facility revealed an order for Cephalexin (antibiotic) 250 mg, once a day for UTI prophylaxis. The Medical Record further revealed the resident had been administered Cephalexin for over four months and continued to be administered the antibiotic. During an interview with the DNS and ICP on 10/02/24 at 3:15 PM confirmed R4's last UTI was on 05/28/24 and the follow up UA/CS completed on 06/10/24 was negative for a UTI. The DNS and IP confirmed R4 continued to be administered Cephalexin without a UTI or any signs or symptoms of a UTI. During a joint interview with the DNS, the ICP, and the Pharmacist on 10/02/24 at 3:30 PM the Pharmacist confirmed she was going to have to have another presentation on the use of prophylaxis antibiotics for UTIs when the criteria was not met. The Pharmacist confirmed administering antibiotics prophylactically was not recommended. Attempts were made to reach the physician who prescribed the antibiotics to R3 and R4 were unsuccessful.

Based on observation, policy review, staff interview, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 2 residents (#3 and #28) reviewed for pressure ulcers. Resident #3 was harmed when she developed a suspected deep tissue injury that worsened to a Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) pressure ulcer to her sacrum (bottom of the spine). Resident #28 was harmed when she developed an unstageable pressure ulcer to her sacrum and suspected deep tissue injuries to her right heel and left calf. Findings include: The facility's policy for Pressure Ulcer Assessment Guidelines, dated 9/5/17, documented: *To ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable; and a resident having pressure ulcers received necessary treatment and services that promoted healing and prevented new ulcers from developing. *All new developing pressure ulcers must be measured and graded according to acceptable definitions of pressure ulcers. The website www.healthline.com, dated 6/15/18, documented, A Kennedy ulcer, also known as a Kennedy terminal ulcer (KTU), is a dark sore that develops rapidly during the final stages of a person's life. Kennedy ulcers grow as skin breaks down as part of the dying process. The National Pressure Ulcer Advisory Panel, dated (MONTH) (YEAR), described a Kennedy pressure ulcer as pear shaped, always on the coccyx or sacrum, red, yellow, and black, sudden onset, and death is imminent. 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, dated 3/6/19, documented Resident #3 was moderately cognitively impaired and required extensive assistance with two staff members for bed mobility, dressing, toileting, and personal hygiene. Resident #3 required limited assistance for eating and was dependent on two staff members for transfers. The MDS assessment documented Resident #3 was at risk for pressure ulcers and had one Stage II (Partial-thickness loss of skin with exposed dermis, presenting a shallow open ulcer) pressure ulcer. A Wound Assessment, dated 8/16/18 at 11:21 AM, documented Resident #3 had an in-house acquired Kennedy pressure ulcer over the sacral/buttock area. The assessment documented the sacral/buttock area did not have drainage, odor, and no tunneling or undermining. The surrounding tissue was normal. The weekly wound summary documented, large purple/maroon area, very slow to blanch, open area still noted to the center of the gluteal fold and measurements are unchanged from last assessment . The treatment was for staff to apply, copious amounts of vaseline several times a day. The assessment did not include measurements of the wound or when the pressure ulcer was first identified. A Wound Assessment, dated 10/26/18 at 12:32 PM, documented Resident #3 had an in-house acquired Kennedy pressure ulcer with an open area in the center above the gluteal fold (where the top of the thigh meets the buttock). The wound edges were defined and flushed, the wound bed was pink and white, no tunneling or undermining, and with minimal clear drainage. The surrounding skin tissue was red. Pressure ulcers are measure by length, width, and depth, in that order. The assessment documented The ulcer in the center of the wound has now divided in half with new [MEDICATION NAME] growth the left side measures 1 cm x 0.5 cm x 2 mm, and the right side measures 3 cm x 1 cm x 2 mm. The additional comments documented, Overall appearance of this areas looks to be a Kennedy (ulcer) as the area about 11 cm x 10 cm is maroon in color, does blanch with open ulcer in the center of the proximal gluteal fold, there is sloughing noted on the right buttock that is very superficial and dry . The assessment documented the wound status had improved. The wound care treatment was for staff to apply Medifil paste (wound healing treatment) in the wound bed and cover with an adhesive dressing. A Wound Assessment, dated 12/11/18 at 2:15 PM, documented Resident #3 had acquired an in-house Kennedy pressure ulcer to her sacrum/buttocks, and the entire reddened area measured 9 cm x 10 cm. Another wound measurement documented on the assessment was 26 x 3 x 2. The measurement did not include how the wound was measured, in centimeters or millimeters. The assessment documented the wound edges were defined and flushed, the wound bed was beefy red, and no tunneling or undermining. There was no drainage or odor and the surrounding skin tissue was normal. The assessment documented the wound continued to improve each week. The additional comments documented the small pressure ulcer to the left was closed, leaving only the ulcer on the right after the one ulcer divided about 2 months ago. The wound care treatment was for staff to apply Medifil paste in the wound bed and cover with an adhesive dressing. A Wound Assessment, dated 2/26/19 at 10:24 AM, documented Resident #3 had an in-house acquired Kennedy pressure ulcer to her sacrum. The measurements were documented 17 x 8 x 5. The measurements did not include how the wounds were measured, in centimeters or millimeters, and did not specify if the measurement was that of the entire reddened area or the open ulcer. The assessment documented the wound edges were defined and the wound bed was pale pink with minimal clear drainage, no tunneling or undermining, and the surrounding skin tissue was normal. The additional comments documented to continue with the treatment for [REDACTED]. A physician's orders [REDACTED].#3's wound bed, to pack the deeper center of the ulcer with sterile gauze lightly soaked in normal saline and covered with Medifil, and to change the dressing every Tuesday, Friday, and as needed. A Physician Visit Note, dated 5/2/19, documented Resident #3 was thin and had a stable sacral wound. A Wound Assessment, dated 5/3/19 at 11:59 AM, documented Resident #3 had an in-house acquired Kennedy pressure ulcer to her sacrum. The wound measurements were 18 x 18 x 5. The measurements did not include how the wounds were measured, in centimeters or millimeters. The assessment documented the wound edges were defined and jagged and the wound bed was pale pink and had about 2 mm of undermining (destruction of tissue or ulceration extending under the skin edges) around entire ulcer, with minimal red drainage, and the surrounding skin tissue was red. The assessment documented the surrounding tissue was 10 cm x 10 cm with red area around the ulcer. The assessment documented the wound status was unchanged. A Wound Assessment, dated 6/7/19 at 12:37 PM, documented Resident #3 had an in-house acquired Kennedy pressure ulcer that presented as a Stage IV pressure ulcer. The wound measurements were 25 x 15 x 10. The measurements did not include how the wounds were measured, in centimeters or millimeters, or indicate if the measurements related to the entire reddened area or the open ulcer. The assessment documented the wound edges were defined and the wound bed was beefy red, no tunneling or undermining with a moderate amount of clear and red drainage. The surrounding skin tissue was red. The assessment documented the wound status was unchanged and to continue with the same wound care treatment of [REDACTED]. Resident #3's Risk for Skin Alterations Related to History of Pressure Ulcers Care Plan, dated 3/10/18 and revised on 6/7/19, documented a decline in skin condition was anticipated related to her failure to thrive and interventions would be in place to help maintain her comfort. The care plan did not identify a current pressure ulcer. The interventions on the care plan directed staff to reposition Resident #3 every 30 minutes during the day and evening, to use an air overlay on the bed, and a pressure relieving mattress. Resident #3's care plan also directed a scoop mattress (mattress with heightened or beveled edges) be placed over the mattress air overlay to keep the air overlay centered and to keep it from sliding off the bed. RN #2 stated a scoop mattress was not in place. An air overlay was in place which she stated had been utilized for residents for [AGE] years. A Physician Visit Note, dated 6/6/19, documented Resident #3 was well-nourished. The pressure ulcer was not addressed in the note. At 11:00 AM on 6/18/19, the Administrator provided the Physician Visit Note, dated 6/6/19, with the following addendum: Pt's (Patient's) nutritional status fluctuates but is generally poor. Staff, including dietician, have exhausted avenues to improve beyond current situation. Pt declines aggressive measures. This in turn will affect the ability for pressure ulcer to heal. It is anticipated that it won't heal but will try to keep it stable. Well-nourished was still checked on the assessment. On 6/17/19 at 10:30 AM, Resident #3 permitted LPN #1 to look at her mattress. An air-overlay mattress was over a pressure relieving mattress. A scoop mattress was not on the bed. On 6/19/19 at 5:00 PM, the DNS stated the wound/skin nurse, RN #2, worked in the adjoining hospital at the [MEDICAL TREATMENT] center. The DNS stated RN #2 completed the dressing changes and obtained and updated wound care orders. The DNS stated RN #2 determined Resident #3's pressure ulcer was a Kennedy ulcer. The DNS was unable to describe a Kennedy ulcer or the characteristics of one. On 6/20/19 at 8:57 AM, RN #2 stated her position at the hospital was the Facility Administrator over [MEDICAL TREATMENT] and [MEDICAL CONDITION]. She stated she also provided wound care to the residents in the skilled nursing facility. RN #2 stated Resident #3's wound started about a year ago. She identified it as a Kennedy ulcer because at that time Resident #3 was not expected to live. RN #2 stated terminal ulcers, though not expected to, could improve. RN #2 stated Resident #3's physician saw the Kennedy pressure ulcer, but it had been a little while, probably a few months. RN #2 stated the physician completed rounds in the facility on Thursdays. Resident #3's bath days were Tuesdays and Fridays, so the wound was usually covered when the physician made rounds. RN #2 stated she told the physician what she saw, and he told her what she should do. RN #2 stated on occasion the facility sent residents to the wound clinic, but the wound clinic was not in the local area and sometimes the health of the residents did not allow that. RN #2 stated the pressure ulcer was almost completely closed, then got worse, and now it was better. RN #2 stated treatment should be changed if the wound did not improve over two weeks. RN #2 reviewed Resident #3's assessments and stated using the same treatment was not the reason the ulcer did not heal over the past year. She stated the lack of healing was not related to Resident #3's positioning. RN #2 said it was the nutritional aspect that determined whether the wound improved or not. RN #2 said the treatment of [REDACTED]. Resident #3's weight records for the past 6 months were documented as follows: *1/29/19 119.5 pounds *3/26/19 117.5 pounds *4/30/19 119 pounds *5/28/19 116 pounds *6/11/19 112.5 pounds Resident #3's weight was relatively stable over 5 of the 6 months, ranging from 119.5 pounds to 116 pounds between 1/29/19 and 5/28/19. Resident #3's 8/16/18 through 6/7/19 (10 months) wound assessments defined her pressure ulcer as a Kennedy terminal ulcer. As previously stated, the National Pressure Ulcer Advisory Panel, dated (MONTH) (YEAR), describes a Kennedy pressure ulcer as pear shaped, always on the coccyx or sacrum, red, yellow, and black, sudden onset, and death is imminent. Resident #3's ulcer was not pear shaped and her death was not imminent (likely to occur at any moment) for 10 months. The facility failed to ensure: *Measurements of Resident #3's open ulcer and surrounding area were consistently and thoroughly documented. *Resident #3's pressure ulcer was monitored by a physician. *Alternate treatment options were considered for Resident #3's pressure ulcer when interventions were not effective. *Resident #3's care plan was updated to address her pressure ulcer and changes in its status. 2. Resident #28 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/3/19, documented Resident #28 had moderately impaired cognition, did not reject care, and required extensive assistance of 2 plus staff for bed mobility, transfers, dressing, and toileting. Resident #28 was frequently incontinent of bowel and bladder. The assessment documented she was not at risk of pressure ulcers. A care plan, dated 1/25/19, documented a focus related to Resident #28's limited physical mobility. The care plan did not describe what the limited physical mobility was. A new intervention, dated 5/7/19, directed staff to ensure Resident #28's brace was in place. The care plan did not direct staff to assess the skin under the brace. A care plan, dated 1/25/19 and revised on 5/24/19, documented Resident was at risk of skin alterations related to incontinence and decreased mobility. The interventions documented Resident #28 repositioned herself independently and staff were to ensure a gel cushion was in her wheelchair and recliner, and an air overlay on her bed. A nursing progress note, dated 4/25/19, at 5:22 PM, documented Resident #28 fell in the bathroom and was diagnosed with [REDACTED]. A nursing progress note, dated 4/25/19 at 7:50 PM, documented the placement of a universal knee immobilizer to Resident #28's left leg. The physician entered orders for non-weight bearing, may transfer to commode, chair, and knee immobilizer on at all times. A follow up 3 view x-ray of left knee was ordered for 5/6/19. A physician's orders [REDACTED].#28 was to wear a knee immobilizer at all times, every day and night shift, dated 4/26/19. The order did not direct staff to check the skin under the brace. A Skin/Wound Note, dated 5/21/19 at 12:51 PM, documented a 5 cm by 6 cm red area on Resident #28's sacrum with 3 small purple non-blanchable areas, and in the center there was an area that looked like it may open but was closed. A gel cushion was to be used in the wheelchair and the recliner, an air overlay was placed on Resident 28's bed, and staff were directed to reposition her every hour. Wound Assessments, dated 5/24/19, documented: *The presence of an in-house acquired pressure ulcer. The assessment documented Resident #28 had an open area to the center of her gluteal fold and the surrounding tissue was red. On the right side there was a 1.3 cm x 0.5 cm area that was fading in color. Resident #28 had an air overlay on her bed and a gel cushion to her wheelchair and recliner. The wound measurements were documented as 15 mm in length x 4 mm in width x 1 mm in depth. *The presence of an in-house acquired pressure ulcer to Resident #28's right heel. The assessment documented there was a 1 cm x 0.5 cm light purple area to the center of the heel that did not blanch and a heel elevator boot was placed on 5/23/19 when staff reported concern. The wound measurements were documented on the assessment to be 17 mm in length x 13 mm in width x 0 mm in depth. A Physician Visit Note, dated 5/28/19, did not address Resident #28's sacral pressure ulcer. A nursing note, dated 6/5/19 at 6:20 PM, documented the immobilizer was to be off while Resident #28 was in bed and when sitting. The note directed staff to use the immobilizer with ambulation for 2 weeks and then it may be removed. A Physician Visit, dated 6/6/19, documented Showed RN #2 a picture of the right heel and she will assess in the morning. Feels as long as it is not open, to leave it for now. Consider a better heel protector and ? dressing. [MEDICATION NAME] with border to left calf. Keep brace off when not walking/transferring. The note did not address the sacral/gluteal pressure ulcer. Resident #28's care plan, dated 6/7/19, documented the focus as (specify name) has a pressure ulcer of the (specify location(s)) r/t. The interventions directed staff to assess, record and monitor the wound healing weekly. If there was no improvement in the wound over a two-week period staff were to notify the physician and consider changing treatments. The second intervention was to provide dietary supplements per the physician's orders [REDACTED].#28's pressure ulcers. A Nutrition/Dietary note, dated 6/12/19 at 5:41 PM, documented acknowledgement of Resident #28's wound to her buttocks (sacral/gluteal), left lower leg, and heel. Wound Assessments, dated 6/7/19, documented: * The assessment described Resident #28's wound bed as a white/grey slough. The note documented the wound was cleansed with wound cleaner, patted dry, dressed using sterile packing and covered with a [MEDICATION NAME] border dressing. The wound measurements were documented on the assessment to be 15 mm in length x 9 mm in width x 3 mm in depth. The assessment documented the wound was declining and was deeper and slightly wider than it was previously. The assessment documented the pressure ulcer as unstageable (full thickness skin and tissue loss in which the extent of the tissue damage cannot be confirmed because the wound bed is obscured with slough or eschar (dead or devitalized tissue).) The assessment did not identify the location of the wound. It was determined the assessment related to Resident #28's sacral/gluteal pressure ulcer as assessments of Resident #28's other two pressures, one on the right heel and another on the back Resident #28's left lower leg, were completed on the same date. *The right heel pressure ulcer measuring larger and was maroon in color, spongy, and had deep purple edges. The assessment documented I talked with MD yesterday about leaving the skin intact for now and using it as a natural band aid. I talked to him about dressing it and advised him that as long as it was not open or draining to leave the dressing off at this time. The wound measurements were documented on the assessment to be 45 mm in length x 45 mm in width x 0 mm in depth. *The assessment documented an in-house acquired pressure ulcer to the back of Resident 28's left lower leg. The assessment documented staff removed the immobilizer a few days ago and noticed discoloration on the left distal calf. The assessment documented the area did not blanch and skin was sloughing in areas causing drainage. The wound measurements were documented on the assessment to be 45 mm in length x 13 mm in width x 0 mm in depth. The immobilizer was assessed, there was a hard metal support that ran down the back of the device, from the top to the bottom and fit right over the ulcer. The assessment documented sheepskin was applied to the brace and [MEDICATION NAME] with border was placed to protect the pressure ulcer. On 6/20/19 at 9:25 AM, RN #2 stated Resident #28's daily skin checks should have been done. The facility was unable to provide documentation of daily skin checks completed for Resident #28. On 6/20/19 at 10:15 AM, RN #1 stated when a resident had a brace, she would check for CMS (Circulation, Motion, Sensation) and document her assessment on the treatment sheets. RN #1 did not specify if she removed the brace to assess the skin under the brace. Resident #28's treatment sheets did not include daily skin checks. The facility failed to ensure Resident #28 was provided the care and services necessary to prevent the development of 3 pressure ulcers, one becoming unstageable.

Based on record review and staff interview, it was determined the facility failed to ensure bowel care interventions were developed and implemented for 3 of 3 residents (#14, #15, and #17) reviewed for bowel care. This deficient practice placed residents at risk of harm related to complications from constipation or impaction. Findings include: a. Resident #14 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A significant change MDS assessment, dated 3/29/19, documented Resident #14 had moderate cognitive impairment, required extensive two person assistance for toileting, and was continent of bowel. Resident #14's (MONTH) 2019 physician's orders [REDACTED].>*Milk of Magnesia (MOM) 473 ml bottle, give 30 ml by mouth QID (four times a day) as needed for constipation ordered on [DATE]. Resident #14's Bowel Movement Records, dated 5/21/19 through 6/19/19, documented he did not have a bowel movement between: *5/24/19 and 5/27/19 (4 days) *6/9/19 and 6/13/19 (5 days) Resident #14's MAR, dated 5/1/19 through 6/18/19, documented he received MOM on 6/12/19 with no results. There was no documentation Resident #14 was offered or received MOM on 6/13/19. Additional bowel care interventions were not documented. b. Resident #17 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 4/7/19, documented Resident #17 had severe cognitive impairment, required extensive one person assistance for toileting, and was continent of bowel. Resident #17's (MONTH) 2019 physician's orders [REDACTED].>*MOM 473 ml bottle, give 30 ml by mouth once daily as needed for constipation ordered on [DATE]. *[MEDICATION NAME] sodium 100 mg, give one capsule by mouth two times a day for constipation, ordered on [DATE]. Resident #17's Bowel Movement Records, dated 5/21/19 through 6/19/19, documented she did not have a bowel movement between 5/26/19 and 5/30/19 (5 days). Resident #17's MAR, dated 5/1/19 through 6/19/19, documented she received MOM on 5/31/19. Medication to treat Resident #17's constipation was provided on day 6 of no bowel movement. c. Resident #15 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 4/5/19, documented Resident #15 was moderately cognitively impaired, required extensive assistance of 2 people for toileting, and was always continent of bowel. Resident #15's physician orders, dated 2/1/19, directed staff to provide Senna Gen 8.6 mg, one tablet 2 times a day for the [DIAGNOSES REDACTED]. The (MONTH) 2019 Bowel Movement Records documented Resident #15 did not have a bowel movement from 5/21/19 through 5/27/19 (6 days). Resident #15's MAR, from 5/1/19 to 5/30/19, did not include documentation that additional bowel care medications were requested from the physician or provided to Resident #15. The (MONTH) Bowel Movement Records documented Resident #15 did not have a bowel movement from 6/5/19 through 6/8/19 (4 days) or from 6/12/19 through 6/15/19 (4 days). A physician's orders [REDACTED]. Resident #15's MARs, from 6/1/19 to 6/20/19, documented MOM 30 mls was provided on 6/16/19. On 6/18/19 at 1:52 PM, LPN #1 said the facility's bowel protocol directed the staff to give MOM if a resident did not have a bowel movement for three days, and to give a suppository if no response with MOM. On 6/18/19 at 1:55 PM, the DNS said the facility did not have a bowel protocol. The DNS said if a resident did not have a bowel movement in 3 days the nurse should give the resident prune juice, and if no response with prune juice the nurse should give the resident MOM. The facility failed to ensure residents were provided bowel care to address constipation and that staff were aware procedures to follow for residents' constipation.

Based on record review and staff interview, it was determined the facility failed to ensure an RN was on duty 8 hours a day 7 day a week to provide care and treatment to the residents. This was true for 4 of the 21 days reviewed. This affected 8 of 8 (#1, #3, #13, #14, #15, #17, #28, and #33) residents residing in the facility and had the potential to affect the other 26 residents residing in the facility. This created the potential for harm if residents' nursing needs went unmet. Findings include: The facility's Three-Week Nursing Schedule from 5/26/19 to 6/15/19, documented there was no RN coverage on 5/27/19 and 6/2/19 and had less than 8 consecutive hours of RN coverageon 6/1/19 and 6/3/19. This created the potential for the routine and emergency nursing needs of Residents #1, #3, #13, #14, #15, #17, #28, and #33, as well as the other 26 residents residing in the facility, to go unmet. On 6/19/19 at 2:30 PM, the Administrator stated the facility did not have RN coverage on 6/2/19 and 6/27/19. The Administrator stated the facility had 2 hours of RN coverage on 6/3/19 and 7.5 hours on 6/1/19. The Administrator stated it is sometimes difficult to get RN coverage.

Based on resident representative and staff interview, policy review, and record review, it was determined the facility failed to provide a financial record, or quarterly statement, to 2 of 2 residents (#3 and #28) whose personal fund accounts were reviewed. This failure created the potential for harm if concerns, including inaccuracies, about the personal fund accounts were not addressed. Findings include: The facility's policy, Deposit of Resident Funds, dated 4/2017, documented the resident is provided a confidential quarterly statement of funds on deposit with the facility, including the activity since the previous statement. a. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/17/19, at 10:06 AM, Resident #3's representative stated she received a financial statement about once a year. b. Resident #28 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/17/19, at 11:16 AM, Resident #28's representative, her daughter, stated she had received receipts but she had not received a financial statement. On 6/18/19, at 11:55 AM, the LSW stated she sent receipts and statements out quarterly, but mostly I have just sent out receipts.

Based on record review, review of billing records, and staff interview, it was determined the facility failed to ensure residents were provided advance notice of the reason their Medicare Coverage A was being terminated during their stay in the SNF and how to appeal the termination process. This deficient practice was true for 2 of 3 residents (#2 & #19) reviewed for notice of Medicare non-coverage (NOMNC). This failure created the potential for residents to experience financial distress and psychological harm when residents were not informed of how to appeal the ending of their Medicare coverage. Findings include: a. Resident #2 admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Physical Therapy Daily Treatment Note, dated 3/1/19, documented Resident #2 was discharged from skilled therapy services on 3/1/19. The facility's billing records documented Resident #2's insurance coverage changed from Medicare Coverage A to another payor source on 3/2/19. A NOMNC was not found in Resident #2's record. b. Resident #19 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Physical Therapy Daily Treatment Note, dated 3/11/19, documented Resident #19 was discharged from skilled therapy services on 3/10/19. The facility's billing records documented Resident #19's insurance coverage changed from Medicare Coverage A to another payor source on 3/11/19. A NOMNC was not found in Resident #19's record. On 6/19/19, at 9:42 AM, the LSW stated the facility did not provide NOMNCs to residents.

Based on record review, resident and staff interview, and review of facility policies and Incident Reports and investigations, it was determined the facility failed to ensure 1 of 8 (#23) sampled residents were free from all forms of abuse, including verbal and mental abuse. Resident #23 sustained psychosocial harm when she was verbally and mentally abused by the LSW, when the LSW coerced Resident #23 to sign a contract stipulating that Resident #23 was responsible for her own falls, and would waive her right to decline a room change if further falls occurred. Following the abuse, Resident #23 and her interested party were afraid she would be discharged from the facility if she did not follow the rules. This deficient practice placed residents residing in the facility at risk of abuse. Findings include: The facility's Abuse Policy and Procedure, revised 9/13/16, defined verbal abuse as use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families . examples include threats of harm, saying things to frighten a resident, such as telling a resident he/she will never be able to see his/her family again. The facility's Abuse Policy and Procedure, revised 9/13/16, defined mental abuse as includes, but is not limited to humiliation, harassment, threats of punishment, or deprivation. Mental abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Resident #23's annual MDS assessment, dated 6/6/17, and quarterly MDS assessments dated 9/6/17 and 12/7/17 documented Resident #23 was cognitively intact. An Incident and Accident Report, dated 9/23/17 at 10:20 AM, documented Resident #23 fell when attempting to ambulate without assistance. Resident #23 obtained a laceration to back of her head and was sent to the emergency room for further evaluation. Resident #23's clinical record had a contract developed by the LSW and signed by Resident #23 and the LSW, dated 10/19/17, documented, I, Resident #23, am entering into a contract of safety with (facility name) as my noncompliance with staff assist transferring has resulted in multiple falls, including a fall with injury. I understand that by continuing to self-transfer, I am putting myself in danger. I, Resident #23, agree to use the call light when I need assistance and wait for the assistance to come. I will not make any attempts to self-transfer. I will not remove my alarms and I understand that the alarms I have in place are related to my noncompliance with transferring and are there for my safety. I understand that my failure to comply with this contract of safety may result in a room change allowing me to be closer to the nurse's station for increased supervision. The LSW's Psychosocial Note, dated 9/19/17 at 1:40 PM, did not document behavioral concerns related to Resident #23 self transferring or falling. The LSW's Psychosocial Note, dated 9/27/17 at 6:30 PM, documented staff reported Resident #23 was depressed. The LSW documented Resident #23 was happy to have the staple removed from the back of her head. The LSW documented she visited with Resident #23 about her tab alarm and Resident #23 stated the tab alarm was a reminder to use the call light for help. The LSW's Psychosocial Note, dated 10/16/17 at 2:59 PM, documented the LSW, DNS, and RN educated Resident #23 on the purpose of the tab alarm and not to remove it to self-transfer. The LSW documented Resident #23 stated after the last fall, she thinks she needs the alarm because she doesn't want to fall again. The LSW validated Resident #23's feelings and encouraged her to use her call light, and not to remove the alarm. The LSW's Psychosocial Note, dated 10/18/17 at 3:24 PM, documented the LSW spent 1:1 time with Resident #23. The LSW documented Resident #23 did not have signs or symptoms of depression. The LSW's Psychosocial Note, dated 10/19/17 at 2:33 PM, documented the LSW provided Resident #23 with a copy of a safety contract. The LSW documented, Res (sic) stated she was okay with interventions being placed and understood it was for her safety. The LSW's Psychosocial Note, dated 10/20/17 at 12:27 PM, documented, LSW followed up res r/t recent fall interventions put in place. Res stated that she thought the seat belt was going to be good. There was no documentation regarding the safety contract that Resident #23 received by the LSW on 10/19/17 and how it made her feel. Resident #23's care plan, dated 1/23/18, documented, Resident #23 is a high risk for falls r/t Gait/balance problems r/t [DIAGNOSES REDACTED]. Interventions included, Has pressure sensitive bed alarm, chair alarm and seat belt alarm to wheelchair as well to alert staff of attempts to stand unassisted. Be aware that alarms will not prevent falls and are only intended to alert staff that she has a need that must be met. Respond promptly to all alarms. The care plan did not document the safety contract. On 1/25/18 at 1:00 PM, Resident #23 stated signing the contract did not make her feel right, but she did not want to lose her private room, so she signed the contract and had been following the rules. Resident #23's interested party stated with the contract, we thought Resident #23 was going to be kicked out of the facility if Resident #23 did not comply with the rules of the contract. On 1/25/18 at 3:15 PM, the Administrator, DNS, and AIT was not aware of the contract in Resident #23's clinical record. The LSW was not available for an interview for the duration of the survey.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received nutritional and hydration interventions to prevent unplanned weight loss and dehydration. This was true for 4 of 5 residents (#s 11, 14, 21, and 22) reviewed for weight loss and hydration concerns. a) Resident #14 was harmed when she experienced a 9.3% weight loss in three months, prior to her being placed on comfort care measures, and she was harmed when she experienced dehydration and multiple UTIs; b) Resident #21 was harmed when she experienced a 15.99% weight loss in five months; and c) Resident #'s 11 and 22 had potential for harm when they were not provided with fluids and/or assistance to consume them, and were observed with dry mouths. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses, including Vitamin D deficiency, [MEDICAL CONDITION], dementia, and [MEDICAL CONDITION] reflux disease (GERD). A quarterly MDS assessment, dated 12/19/17, documented Resident #14 had a severe cognitive impairment, required extensive assistance with eating, lost food and drink from her mouth while eating, and had significant unplanned weight loss. a. Nutrition concerns: Resident #14's January 2018 Physician's Orders documented Resident #14 was on a pureed diet with thickened liquids, dated 2/11/17. Resident #14's Physician's orders did not contain an order for [REDACTED].>The Nutrition Care Plan, initiated 1/29/16, documented the following interventions for Resident #14: * Resident #14 required a pureed diet with honey thick liquids, initiated 7/22/17. * The Dietitian would review Resident #14's weights weekly and report concerns to the physician, initiated 2/1/16. * Resident #14 was dependent on staff for nutritional and fluid intake, initiated 12/20/16. * Resident #14 wore a clothing protector due to excessive loss of foods and fluids during meals, revised 6/27/17. The Nutrition Care Plan's interventions were not updated regarding Resident #14's weight loss. A Weight Flow Sheet, dated 7/20/17 through 9/15/17, documented the following weights for Resident #14: * 7/20/17 - 140 pounds * 7/31/17 - 137.5 pounds * 8/7/17 - 136 pounds * 8/15/17 - 138 pounds * 8/22/17 - 136 pounds * 8/25/17 - 134 pounds * 8/29/17 - 132 pounds * 9/1/17 - 132 pounds * 9/5/17 - 131 pounds * 9/8/17 - 131 pounds * 9/15/17 - 127 pounds A 9/27/17 Physician's order documented Resident #14 was placed on comfort measures. Resident #14 lost 9.3% of her body weight between 7/20/17 and 9/15/17 before comfort measures were initiated. The 6/1/17 through 9/30/17 Activities of Daily Living (ADL) Documentation Survey Report, Nutrition Amount Eaten at meal and Nutritional Supplements, documented Resident #14: * consumed less than 25% of her meals for 80 of 366 opportunities; * refused meals 36 of 366 opportunities; * was not offered a meal 13 of 366 opportunities; * was not offered a supplement 316 of 366 opportunities; * was not offered a meal alternative 129 of 129 opportunities; and * was not offered a snack 366 of 366 opportunities. Resident #14's ADL Documentation Survey Reports, dated 10/1/17 through 1/24/18, documented similar findings in the Nutrition Amount Eaten and Nutritional Supplement sections. Resident #14's Nutritional Risk Assessments (NAR), Weight Change Progress Notes (WCPN), and Nutrition/ Dietary Progress Notes (NDPN) documented the following: * A 3/21/17 WCPN documented Resident #14 had decreased in weight due to problems with swallowing. The note documented the Dietitian would follow up with SLP (Speech Language Pathologist), and suggest that resident have a higher calorie liquids/ nutritional supplements with meals. * A 3/25/17 NDPN documented Resident #14 experienced a significant weight loss in the past 30 days and she required honey thick liquids in a sippy cup. * A 3/25/17 NAR documented Resident #14 was currently receiving a nutritional supplement and the Dietitian recommended nutrition supplements with meals. * A 6/23/17 NAR documented Resident #14 was not receiving supplements and the Dietitian would review her weights weekly. * A 6/27/17 NDPN documented Resident #14 was doing well with her altered texture diet and there were no nutrition related concerns. * A 9/18/17 WCPN documented Resident #14 experienced a 9.3% weight loss over the past 3 months. The WCPN documented Resident #14 had increased difficulty swallowing food, and she required honey thick liquids from a spoon. The WCPN documented Resident #14 did not want tube feeding. * A 9/21/17 NDPN documented Resident #14 experienced weight loss due to problems with swallowing. The note documented comfort measures were initiated. * A 9/26/17 WCPN documented Resident #14 experienced an 8.6% weight loss over the past 3 months. The WCPN documented Resident #14 ate her meals in the dining room, and she was able to take a few bites of her meals. * A 10/1/17 NAR documented Resident #14 choked on thin liquids, and she was not receiving a nutrition supplement. The NAR documented Resident #14 was on comfort measures and tube feeding was not an appropriate intervention. The NAR did not include other nutrition interventions recommended or attempted. A section of the NAR, titled Rate of Unplanned Weight Loss, documented Resident #14 lost less than 7.5% of her body weight over the past 3 months, which was inconsistent with Resident #14's 8.6% weight loss documented in her 9/26/17 WCPN. * A 10/18/17 WCPN documented Resident #14 experienced an 11.8% decrease in her body weight over the past 3 months and related Resident #14's weight loss to her being on comfort measures. Resident #14's clinical record did not contain Nutritional Risk Assessments, Weight Change Progress Notes, or Nutrition/ Dietary Progress Notes between 6/28/17 and 9/17/17 when she experienced a 9.3% weight loss. Resident #14's Nutrition Assessments did not include interventions for the use of fortified foods, snacks, meal alternatives, or consistent use of nutritional supplements. On 1/24/18 at 9:29 AM, Resident #14 was assisted with her breakfast. Resident #14 consumed 3 bites of her pureed eggs and about 1/2 of her cereal. Resident #14 was not offered an alternative or a supplement. On 1/25/18 at 4:11 PM, the Registered Dietitian (RD) stated she did not know what interventions were in place prior to the comfort measure orders. The RD stated Resident #14's orders did not include supplements as snacks, and that Resident #14 did not need them due to her comfort measures order. The RD stated if a resident refused meals or consumed less than 25% of meals, the staff should offer an alternative. The RD stated the facility did not prepare an alternate meal for residents with diet orders of pureed or mechanical soft. The RD stated for these individuals, the facility would provide supplements, such as Ensure, without doctors' orders, when residents refused or consumed less than 25% meals. The RD stated Resident #14 should have received supplements, and did not realize Resident #14 was not consistently provided a supplement, when Resident #14 consumed less than 25% or refused meals. The RD stated Resident #14 should have been offered a snack at night. The RD stated Resident #14's weight loss was gradual did not trigger for weight loss, and when she noticed the weight loss, Resident #14's comfort measures were initiated. The RD stated Resident #14 did not want tube feeding and it did not occur to her to initiate enhanced foods or snacks as interventions. b. Hydration concerns: According to the Nutrition Care Manual Methods for Estimating Fluid Requirements from the Academy of Nutrition and Dietetics, adults within Resident #14's age range should consume 25 ml per kilogram of body weight per day. Using this calculation method, Resident #14 needed a total daily fluid intake of 1397 ml's. Resident #14's clinical record did not include care plans related to dehydration / hydration or Urinary Tract Infections (UTIs). i. Resident #14 experienced multiple UTIs: * Urinalysis (UA) results from 3/28/17, 9/7/17, and 10/27/17 document Resident #14's urine appeared cloudy and contained blood, [MEDICATION NAME], and bacteria. * Resident #14's culture and sensitivity (C&S) results documented the presence of Escherichia Coli (E. coli) (9/7/17 and 10/27/17) and Gram-Negative Rod (3/28/17). Resident #14's UTIs could be signs and symptoms of dehydration. ii. Resident #14 experienced dehydration: *The 1/1/18 through 1/24/18 ADL Documentation Survey Report, Fluid Intake, documented Resident #14's total fluid intake for each day. Resident #14 received the highest total fluid intake of 667 ml on 1/10/18. Resident #14 received the lowest total fluid intake of 100 ml on 1/1/18 and 1/9/18. Resident #14's average fluid intake for the dates above was 339 ml's. Resident #14 refused some fluid offers 7 of 24 days. * Resident #14's ADL Documentation Survey Reports, dated 6/1/17 through 12/31/17, documented similar findings in the Fluid Intake section. *A Basic Metabolic Panel (BMP) result from 9/17/17, documented Resident #14's Sodium (Na) of 155 milliequivalents of solute per liter (mEq/L), Chloride (Cl) of 116 mEq/L, and [MEDICATION NAME] (CO2) of 32 millimoles per liter were elevated. *A BMP result from 1/8/18, documented Resident #14's Na of 149 mEq/L and Cl of 114 mEq/L were elevated. Resident #14's elevated BMP results could be signs and symptoms of dehydration. On 1/23/18 from 9:07 AM to 11:35 AM, Resident #14 was observed in a recliner chair or in her wheelchair in the TV room. Throughout the observation Resident #14 was not offered fluids nor were fluids readily available. On 1/24/18 from 9:04 AM to 11:08 AM, Resident #14 was observed in a recliner chair or in her wheelchair in the TV room, with various staff member contacts. Throughout the observation Resident #14 was not offered fluids nor were fluids readily available. On 1/25/18 at 6:19 PM, the DNS stated Resident #14 had a history of [REDACTED]. The DNS stated the BMP results in Resident #14's record demonstrated signs and symptoms of dehydration. The DNS stated UTIs attributed to E. coli was most likely due to a lack of proper peri-care and / or dehydration. The DNS stated staff should have offered Resident #14 fluids minimally every two hours, and ideally after every resident contact. 2. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses, including arthritis, [MEDICAL CONDITION], and visual impairment. Quarterly MDS assessments, dated 9/4/17 and 12/5/17, documented Resident #21 was cognitively intact, required supervision for eating, and had no weight loss. Resident #21's care plan, dated 6/9/17 and 12/6/17, documented Resident #21 had the potential for weight loss related to arthritis and visual impairment. Resident #21's interventions included, Inform Resident #21 of the location of foods on her plate using the clock method. Provide, serve diet per resident requests and preferences from daily menu . Weights will be reviewed weekly. Dietitian to monitor and report significant wt loss or gain to MD. Resident #21's goals included, Adequate nutrition and fluids to maintain skin integrity, and weight in 150-160 range. A Nutritional Risk Assessment, dated 6/14/17, documented Resident #21's most recent weight was 159 pounds with a nutritional goal to maintain weights between 150-160 pounds. The nutritional interventions documented by the dietitian was to review weights weekly, intakes as needed, and labs when available. Resident #21 was not currently receiving a nutritional supplement. The Weights Summary Report, dated 6/13/17 through 1/23/18, documented Resident #21's weights as follows: * 6/13/17 - 159 pounds * 7/14/17 - 160 pounds * 8/18/17 - 159.5 pounds * 9/8/17 - 149 pounds * 9/19/17 - 151.5 pounds * 10/13/17 - 148.5 pounds * 10/17/17 - 147 pounds * 10/24/17 - 144 pounds * 11/7/17 - 143.5 pounds * 12/8/17 - 143.5 pounds * 12/15/17 - 142 pounds * 12/22/17 - 140 pounds * 12/29/17 - 138 pounds * 1/2/18 - 137 pounds * 1/9/18 - 136 pounds * 1/19/18 - 136 pounds Resident #21 experienced a significant weight loss of 15.00% from 7/14/17 to 1/19/18. There were no Physician Orders for a nutritional supplement for Resident #21 from July 2017 through January 23, 2018. A Nutritional Risk Assessment, dated 9/20/17, documented Resident #21's most recent weight was 151.5 pounds with a nutritional goal to maintain weights between 150-160 pounds. The nutritional interventions documented Resident #21 was receiving [MEDICATION NAME] or Juven supplements to promote wound healing. Resident #21's clinical record did not include Physician Orders for [MEDICATION NAME] or Juven supplements to promote wound healing. Resident #21's care plan did not include interventions for nutritional supplements for wound healing. A Dietitian Progress Note, dated 10/18/17, documented Resident #21's current weight was 147 pounds with a 7.5% weight loss. The Dietitian documented, Resident #21 was ill last month and had some weight loss, she has not had continued weight loss. There was no documentation in Resident #21's clinical record that the physician and family were notified of the weight loss. A Dietitian Progress Note, dated 10/25/17, documented Resident #21's current weight was 147 pounds had some weight loss in the past, will review weights, if weight loss continues, then will notify the physician. A Nutritional Risk Assessment, dated 12/20/17, documented Resident #21's most recent weight was 138 pounds with a nutritional goal to maintain weights between 140-150 pounds. The nutritional interventions documented to review weekly weights, labs and intakes as needed, and weights affected at times by [MEDICAL CONDITION]. The Dietitian documented Resident #21 was receiving Ensure for a nutritional supplement. There was no documentation in Resident #21's clinical record that the physician and family were notified of her significant weight loss. On 1/23/18 at 6:00 PM, Resident #21 was observed eating dinner in her room without a nutritional supplement. On 1/24/18 at 5:52 PM, Resident #21 was observed eating dinner in her room without a nutritional supplement. On 1/24/18 at 2:45 PM, the Dietitian stated Resident #21 had been refusing her dinner meal and her Ensure supplement for the past few months. The Dietitian was unable to provide documentation if Resident #21 was receiving and/or drinking the Ensure supplement. The Dietitian provided a Skilled Nursing Facility (SNF) Resident's Diet Orders Report, dated 1/24/18, from the kitchen that the dietary staff follows. On the Diet Orders Report had a list of seven resident's including Resident #21, who received supplements. Resident #21 was listed to receive a supplement for the pm meal. The Dietitian stated the pm meal was to be served with dinner. The supplement was Ensure, unless it was listed for a specific kind of supplement next to the resident's name. The Dietitian was unable to provide a physician's order or an updated care plan for the Ensure for staff to provide an Ensure supplement with the dinner meal. The Dietitian stated she did not observe Resident #21 receiving the supplement. The Dietitian stated she initiated a high protein jello for Resident #21's 3:00 pm snack on 1/23/18 and will follow up with Resident #21 if she likes on her quarterly nutritional assessment at the end of February or beginning of March. The Dietitian was aware that Resident #21 was a significant weight loss and was unable to provide documentation that she notified the physician and the family. On 1/24/18 at 3:20 PM, Resident #21 stated, she received jello with banana's yesterday and loved it and would eat it everyday. Resident #21 stated she did not receive the Ensure supplement with her dinner meal, unless she asked for it. Resident #21 did not recall when the last time she had an Ensure supplement. On 1/24/18 at 3:30 PM, the Dietitian was notified that Resident #21 enjoyed the jello and banana's. The Dietitian was notified Resident #21 had to request an Ensure and did not recall the last time she had an Ensure. The Dietitian was unable to provide documentation for the staff to offer the high protein jello snack everyday at 3:00 PM. Resident #21's care plan did not include interventions for her significant weight loss. 3. Resident #22 was admitted to the facility on [DATE] with diagnoses, including [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. A quarterly MDS assessment, dated 10/12/17, documented Resident #22 had a severe cognitive impairment, and was dependent upon staff for eating and drinking. The Nutrition Care Plan, dated 1/13/17, documented staff were not to place food or fluids within Resident #22's reach, unless staff were present to supervise. According to the Nutrition Care Manual Methods for Estimating Fluid Requirements from the Academy of Nutrition and Dietetics, adults within Resident #22's age range should consume 25 ml per kilogram of body weight per day. Using this calculation method, Resident #22 needed a total daily fluid intake of 1477 ml's. The 12/27/17 through 1/24/18 ADL Documentation Survey Report, Fluid Intake, documented Resident #22's total fluid intake for each day. Resident #22 received the highest total fluid intake of 1001 ml on 1/4/18. Resident #22 received the lowest total fluid intake of 250 ml on 1/7/18. Resident #22's average fluid intake for the dates above was 605 ml's. Resident #22 refused some fluid offers 12 of 29 days. On 1/23/18 from 9:47 AM to 11:33 AM, Resident #22 was observed in a recliner chair near the nurse's station. Throughout the observation Resident #22 was not offered fluids nor were fluids readily available. On 1/24/18 from 9:14 AM to 11:09 AM, Resident #22 was observed in a recliner chair or in his wheelchair near the nurse's station, with various staff member contacts. Throughout the observation Resident #22 was not offered fluids nor were fluids readily available. On 1/24/18 at 3:06 PM, the DNS stated staff should have offered Resident #22 fluids minimally every two hours, and ideally after every resident contact. 4. Similar findings for Resident #22's hydration concerns were true for Resident #11.

Based on record review and staff interview, it was determined the facility failed to prevent the development of avoidable pressure ulcers, recurring Stage II pressure ulcers, and multiple Stage III pressure ulcers. This was true for 1 of 1 sampled resident (#1) reviewed for pressure ulcers and resulted in harm to Resident #1 when she developed multiple and recurrent Stage II and Stage III pressure ulcers. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including care for an infected surgical wound, diabetes mellitus, dementia, and [MEDICAL CONDITION]. Resident #1 developed a Stage II pressure ulcer to her gluteal fold on 6/13/15; multiple Stage III pressure ulcers to her coccyx and sacrum beginning on 2/3/16; and recurrent pressure ulcers to the coccyx area beginning 5/29/16, as follows: a. Resident #1's Annual MDS assessment, dated 3/3/15, documented the following: * No pressure ulcers present on the prior assessment * At risk of developing pressure ulcers * Extensive assistance of 2 staff required for bed mobility * Total dependence on staff for transfers * Total dependence on 1 staff for locomotion in a wheelchair Resident #1's pressure ulcer care plan, dated 3/4/15, directed staff to: * Inspect the resident's skin during bathing and other personal care * Apply topical treatments per physician order Resident #1's clinical record did not contain physician orders [REDACTED]. Both care plan interventions were discontinued on 9/22/15. A 4/26/15 physician's orders [REDACTED]. No other physician or nursing orders related to preventative skin care were found in Resident #1's record May 2015 through August 2015. When requested, none were provided by the facility. Resident #1's skin care plan, initiated on 6/13/15, when a Stage II pressure ulcer was discovered on the center gluteal fold, directed staff to apply Vaseline to Resident #1's buttocks after each toileting or episode of incontinence, assist with repositioning every 30 minutes during the day and every two hours throughout the night, utilize foam wedges when repositioning, and inspect the resident's skin with each repositioning. Physician Visit Notes, dated 6/4/15 and 6/7/15, addressed alterations in Resident #1's mental status, dehydration concerns, and [MEDICAL CONDITION]. The notes did not include documentation related to Resident #1's skin. A Nursing Note, dated 6/10/15, documented Resident #1 had experienced an 11.1% weight loss. On 6/13/15, a Wound-Weekly Observation Tool documented Resident #1 had a facility acquired Stage II pressure ulcer measuring 2.5 cm x 0.5 cm x 0.2 cm, and described it as a healing, moist wound, with scant amount of serosanguinous drainage. The Observation Tool documented, We looked into a bariatric overlay for bed but Purchasing reported it was too costly and mattress she has is sufficient for needs. A 6/14/15 Nursing Note for Resident #1 documented, Open area noted on center gluteal fold measuring 2.5 cm x 1 cm. Slight bleeding noted coming from area. Also open area noted on left buttock measuring 0.5 cm x 0.5 cm . A 6/23/15 Wound-Weekly Observation Tool documented the Stage II pressure ulcer now measured 2.5 cm x 0.77 cm x 0.2 cm. The Weekly Observation Tool documented there were no changes made to treatment plan, current plan is working, Purchasing unable to get overlay mattress for bed . On 10/6/16 at 8:45 am, RN #1 stated We had a different bed for her after her significant weight loss and her first pressure ulcer in July of 2015. At the time, I would have liked a better bed, but it wasn't feasible. When she was on the bariatric bed I would have liked to have had her on the specialty bed as I was concerned with her Braden (pressure ulcer risk assessment score). I repositioned her every 30 minutes because of her being on the regular bed and she started to have an overall decline. RN #1 also stated the pressure reducing mattress Resident #1 used at that time was the same as those provided to other residents in the facility that were not at risk for pressure ulcers. RN #1 stated, If the pressure ulcer is on the bottom (sacrum, coccyx, gluteal folds), I usually recommend Auqaphor (topical agent), because if a resident is having lots of bowel movements we are constantly taking off the dressing, causing more harm. Resident #1 was not provided with a bed sufficient to meet her skin care needs. Wound-Weekly Observation Tools documented the following: * 6/30/15 - Stage II pressure ulcer to center gluteal fold measuring 2.2 cm x 0.7 cm x 0.2 cm. No changes made to Resident #1's treatment plan this week. * 7/7/15 - Stage II pressure ulcer to center gluteal fold measuring 2.0 cm x 0.6 cm x 0.2 cm. * 7/14/15 - Stage II pressure ulcer to gluteal fold measuring 2.0 cm x 1.6 cm x 0.2 cm. * 7/21/15 - Stage II pressure ulcer to gluteal fold measuring 1.5 cm x 0.3 cm x 0.2 cm. * 7/29/15 - Stage II pressure ulcer to gluteal fold measuring 1.5 c m x 0.4 cm x 0.2 cm. * 8/7/15 - Stage II pressure ulcer to gluteal fold measuring 1.5 cm x 0.3 cm x 0.2 cm. No other Wound-Weekly Observation Tools related to the gluteal fold pressure ulcer were found in Resident #1's record. On 10/6/16 at 8:25 am, the DNS stated there should have been physician orders [REDACTED]. The DNS said a Weekly Wound sheet was to be done for a resident who has a wound and should be done weekly until the wound is resolved. The DNS further said the Skin Observation sheet is to be done weekly. b. Resident #1's Annual MDS assessment, dated 2/2/16, documented the following: * No pressure ulcers present or at time of prior assessment * Severely impaired cognitive skills * Extensive assistance of 2 staff required for transfers, bed mobility, and ambulation * Significant weight loss, not on physician-prescribed weight-loss regimen * At risk of developing pressure ulcers * Pressure reducing devices for chair, bed, and turning/repositioning programs Braden Scale assessments, dated 11/4/15 and 1/30/16, each documented Resident #1 was at high risk of developing pressure ulcers. The facility's Skin Assessment Guidelines documented residents at high risk for pressure ulcers would receive weekly skin checks performed by the facility's skin care team. A 1/27/16 Nurses' Note documented, Dressing to coccyx was changed . A 2/3/16 Nurses' Note documented, Dressing C/D/I to coccyx . A Weekly Skin Observation Tool and Skin/Wound care plan for 11/4/15 through 1/29/16, were not found in Resident #1's record and were not provided by the facility when requested. A Skin Observation Sheet, dated 2/3/16, documented Resident #1 had developed two Stage III pressure ulcers right over the coccyx (#1) and one just to the left of it (#2). Pressure Ulcer #1 measured 2.3 cm x 0.3 cm x 0.2 cm; Pressure Ulcer #2 measured 4.4 cm x 1.4 cm x 0.2 cm. A Wound-Weekly Observation Tool, dated 2/4/16, documented Resident #1 developed a facility acquired Stage III pressure ulcer to the coccyx, and a second Stage III pressure ulcer to the left of the coccyx. Pressure Ulcer #1 was described as moist with a moderate amount of serosanguinous drainage and measuring 4.4 cm x 1.4 cm x 0.2 cm. The treatment plans included, Bed will be moved out and patient will be placed on an air floatation mattress . Pressure Ulcer #2 was described as moist with a moderate amount of serosanguinous drainage, and measured 2.3 cm x 0.3 cm x 0.2 cm. A 2/4/16 physician visit note documented, RN here to eval(uate) coccyx ulcer . coccyx has grade 3 (Stage III) ulcer . A Skin Observation Sheet, dated 2/9/16, documented Pressure Ulcer #1 was healing and measured 3 cm x 0.8 cm x 0.2 cm. Pressure Ulcer #2 was described as healed. A Weekly-Wound Observation Tool, dated 2/9/16, documented Pressure Ulcer #1 measured 3.0 cm x 0.8 cm x 0.2 cm. The Tool documented, (Resident #1) placed on air flotation mattress. We will continue with current treatment plan as it is working and will reassess next week, daily dressing changes done and daily charting per licensed staff. The next Weekly Wound Observation Tool in Resident #1's clinical record was dated 3/15/16, 34 days later. Nurses' Notes documented the dressing to the coccyx wound was changed daily from 2/10/16 through 2/13/16. A Skin Observation Sheet, dated 2/16/16, documented Resident #1's Stage III pressure ulcer now measured 1.3 cm x 0.8 cm x 0.1 cm. A Skin Observation Sheet, dated 3/2/16, documented the coccyx wound measured 0.8 cm x 0.5 cm x 0.1 cm. Notes documented staff applied Normagel with [MEDICATION NAME] to the wound on 3/2/16 and 3/8/16, at which time the coccyx ulcer measured 0.7 cm x 0.5 cm x 0.1 cm. A Weekly-Wound Observation Tool, dated 3/15/16, documented the Stage III sacral wound now measured 0.6 cm x 0.3 cm x 0.1 cm and that staff would continue to monitor weekly and continue with current dressing changes. A Weekly-Wound Observation Tool, dated 3/28/16, stated, PU has healed, [MEDICATION NAME] with border to sacrum has been dc'd. Will continue to monitor . Resident #1's clinical record did not contain physician orders [REDACTED]. Staff performed dressing changes for Resident #1, without physician orders, on: * 2/14/16-2/16/16 * 2/18/16-2/20/16 * 2/28/16 * 3/3/16-3/8/16 * 3/10/16 * 3/13/16-3/16/16 * 3/19/16-3/22/16 * 3/24/16-3/28/16. c. A 4/19/16 Braden Scale assessment documented Resident #1 was at high risk for the development of pressure ulcers. The Facility Skin Assessment Guidelines documented residents at high risk for pressure ulcers would receive weekly skin checks performed by the facility's skin care team. The next Skin Observation Tool for Resident #1, dated 5/29/16, documented a new Stage II pressure ulcer had been identified on her coccyx and measured 1.5 cm x 0.3 cm x 0.1 cm. Residents #1's Nurses' Notes documented the following: * 5/29/16 - 8:31 pm: Stage II PU noted to coccyx where previous PU has been . * 5/31/16 - 10:07 am: Mattress to bed changed to auto-repo(sition) mattress (sic). * 6/1/16 - 4:37 pm: Stage II PU to coccyx healing well . * 6/6/16 - 10:35 am: Stage II PU to coccyx has healed . Resident #1's clinical record did not contain Weekly-Wound Observation Tools from 4/1/16 through 6/6/16 and no Skin Observation Sheets for the period of time after 6/6/16, were provided by the facility. On 10/7/16 at 8:45 am, the DNS provided physician wound care orders, dated 2/1/16 and 3/2/16, and stated no others were found. The facility failed to ensure Resident #1 did not develop avoidable and recurrent Stage II pressure ulcers, or prevent the development of avoidable multiple Stage III pressure ulcers.

Based on record review and staff interview, it was determined the facility failed to ensure residents were provided with adequate nutritional support to avoid severe weight loss. This was true for 1 of 2 residents (#1) sampled for weight loss and resulted in harm when Resident #1 lost 23-pounds in 20 days, 14.5 pounds in in 28 days, and a total of 109.5 pounds, or 37.1% of her body weight, in six months. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including care of an infected wound, [MEDICAL CONDITION], diabetes, dementia, GERD, [MEDICAL CONDITION], and depression. Resident #1's Annual MDS assessment, dated [DATE], documented the following: * Intact cognition * No dental issues * No swallowing disorder * No weight loss * Weight = 288 pounds, height =5-foot, 2 inches * Set-up assistance only required by staff for eating Resident #1's nutritional care plan, dated [DATE], documented staff were to promote healthy food choices, but recognize (Resident #1's) right to have foods of her choosing. No additional nutritional care plans, in effect for [DATE] to [DATE], were contained in Resident #1's clinical record. Resident #1's Weights and Vitals Summary documented the following weights: * [DATE] = 295.5 pounds * [DATE] = 296.5 pounds * [DATE] = 294 pounds * [DATE] = 261.5 pounds (An 11% loss of body weight, in 28 days.) Resident #1's Nutritional Review, dated [DATE], documented a 1500-calorie ADA diet with average food intake less than 75%, average fluid intake at 75%, independent with eating, weight of 294 pounds, and that Resident #1's weight would be reviewed weekly. A Weight Change Note for Resident #1, dated [DATE], documented, Weight warning: 11.1% (32.5 lbs) weight loss in last 1 month, 11.5% (34 lbs) in last 3 months . (Resident #1) has been more depressed and asleep during the day and meals are often refused . A Weights and Vitals Summary documented Resident #1 weighed 267 pounds on [DATE]. A Weight Change Note for Resident #1, dated [DATE], recorded her weight at 258 pounds and documented, Weight warning: 9.6% (28.5 lbs) weight loss in last 3 months . significant weight loss this past month . weight loss would be beneficial, but goal was for gradual weight loss to occur . allow gradual weight loss of ,[DATE] pounds per month. A Weights and Vitals Summary documented Resident #1 weighed 258 pounds on [DATE]. A Nutrition/Dietary Note, dated [DATE], recorded Resident #1's weight as 247.5 pounds and documented, Will continue with goal for gradual weight loss . A Weights and Vitals Summary documented Resident #1 weighed 247.5 pounds on [DATE]. A Weight Change Note for Resident #1, dated [DATE], documented, Weight warning: 5.4% (14 lbs) weight loss in last month, 16.5% (49 lbs) weight loss in last 3 months, 13.2% (37.5 lbs) in last 6 months . A Nutrition/Dietary Note, dated [DATE], documented Resident #1 was on comfort measures .She needs softer foods as she does not chew well . A Nutritional Review, dated [DATE], documented Resident #1 received a mechanical soft diet, her average food intake was less than 75%, her fluid intake was 75%, she was independent with eating, her weight was not documented, and she remained on comfort measures. A Nutritional Review, dated [DATE], documented Resident #1 received an ADA diet, average food intake was 50%, average fluid intake was 50%, she was independent with eating, a current weight was not provided, and she remained on comfort measures. An undated nutritional care plan, printed on [DATE], documented, (Resident #1) is on comfort measures . Encourage monthly weights . A Weights and Vitals Summary documented the following weights for Resident #1: * [DATE] = 281 pounds * [DATE] 5 = 284 pounds * [DATE] = 269 pounds * [DATE] = 254 pounds * [DATE] = 249 pounds Resident #1's nutritional care pan, dated [DATE], documented, Recent weight loss related to poor oral intake . Resident on comfort measures, Comfort measures for Resident #1 were discontinued on [DATE]. A Weight Change Note for Resident #1, dated [DATE], documented, Weight warning .Will order [MEDICATION NAME] or Jeven supplements . Weights and Vitals Summary documented the following for Resident #1: * [DATE] = 228.5 pounds * [DATE] = 221.5 pounds * [DATE] = 216.5 pounds Resident #1's Weight Change Note, dated [DATE], documented, Weight warning .13.1% (32.5 lbs) weight loss in last month, 26.6% (78.5 lbs) weight loss in last 3 months, 22.8% (weight loss) (64 lbs) in last 6 months . A Nutritional Assessment Form, dated [DATE], documented Resident #1 had experienced a weight change of 13% in 30 days. Interventions included, Patient has been on comfort measures . continue to review weights . Resident #1's clinical record did not contain additional Nutritional Assessment forms, but Weights and Vitals summaries documented the following: * [DATE] = 225.5 pounds * [DATE] = 206.5 pounds * [DATE] = 203.5 pounds A Weight Change Note for Resident #1, dated [DATE], documented, Weight warning .significant weight loss of 5.8% over last 1 month, 24.3% last 3 months, 31% last 6 months. A Weights and Vitals Summary documented Resident #1 weighed 202 pounds on [DATE] and noted, 31.5% (93 lbs) weight loss since [DATE] . 20.5% (52 lbs) weight loss since [DATE] . Weights and Vitals summaries for Resident #1 documented the following: * [DATE] = 195 pounds * [DATE] = 198 pounds * [DATE] = 198 pounds * [DATE] = 187.5 pounds * [DATE] = 187 pounds A Weights and Vitals Summary for Resident #1, dated [DATE], documented, 36.6% (108 lbs) weight loss since [DATE] .15.6% (34.5 lbs) weight loss since [DATE] . A Weights and Vitals Summary for Resident #1, dated [DATE], documented a weight of 185 pounds and noted, 37.3% (110 lbs) weight loss since [DATE] .16.5% (36.5 lbs) weight loss since [DATE] . A Quarterly MDS Assessment, dated [DATE], documented Resident #1 was feeling down, had little interest in doing things, felt tired, had little energy, required limited assistance of 1 staff for eating, experienced no issues with swallowing, did not receive antidepressant medications, and weighed 187 pounds. A [DATE] Weights and Vitals Summary, dated [DATE], documented Resident #1 weighed 183.5 pounds, which represented a 37.8% (111.5 lbs) weight loss since [DATE] .15.2% (33 lbs) weight loss since [DATE] . A Weights and Vitals Summary, dated [DATE], documented Resident #1 weighed 185.5 pounds and noted, 37.1% (109.5 lbs) weight loss since [DATE] .14.1% (30.5 lbs)weight loss since [DATE] . Weights and Vitals summaries documented Resident #1 weighed 186 pounds on [DATE] and 182 pounds on [DATE]. Resident #1's Nutritional Review, dated [DATE], documented a weight of 186 pounds, she continued to receive an ADA diet, average food intake was ,[DATE]%, average fluid intake of 50%, she now required assistance to eat. The nutritional care plan documented, No changes needed, she is still comfort cares . Weights and Vitals Summaries for Resident #1 documented the following: * [DATE] = 186.5 pounds * [DATE] = 184 pounds * [DATE] = 182 pounds * [DATE] = 181 pounds * [DATE] = 178 pounds * [DATE] = 176.5 pounds A physician order, dated [DATE], documented staff were to administer [MEDICATION NAME] to Resident #1 for a [DIAGNOSES REDACTED].#1 daily. A Weight Change Note for Resident #1, dated [DATE], documented, Weight Warning .she continues to decline, she refuses meals, and help with meals often. Failure to thrive due to desire to give up on living. Weights and Vitals summaries documented Resident #1 weighed 175.5 pounds on [DATE] and 178 pounds on [DATE]. A physician order, dated [DATE], discontinued the use of [MEDICATION NAME] for anorexia. A Weights and Vitals Summary documented Resident #1 weighed 171 pounds on [DATE]. Resident #1's Nutritional Review, dated [DATE], documented a weight of 171 pounds, ADA diet, average food intake of 25%, and an average fluid intake of 50%. The review documented Resident #1 continues to have weight loss . Weights and Vitals summaries documented Resident #1 weighed 164 pounds on [DATE] and 162.5 pounds on [DATE]. A physician order, dated [DATE], documented staff were to provide Resident #1 with [MEDICATION NAME] 4 mg, for [DIAGNOSES REDACTED]. Weights and Vitals summaries for Resident #1 documented the following: * [DATE] = 158.5 pounds * [DATE] = 164 pounds * [DATE] = 171.5 pounds * [DATE] = 171 pounds * [DATE] = 171 pounds * [DATE] = 178 pounds * [DATE] = 181 pounds * [DATE] = 186 pounds On [DATE] at 11:00 am, when asked to provide documentation of efforts the facility made to curb Resident #1's severe weight loss from [DATE] through [DATE], the facility's RD stated Resident #1's family did not want the facility to make her eat while depressed over the loss of a deceased child and, more recently, the death of a spouse. The RD noted Resident #1 desired to lose some weight and had been placed on comfort measures from [DATE] through [DATE]. When asked to provide evidence of the facility's efforts to address the severe rate of weight loss experienced by Resident #1, the RD stated, I have all my records at home; I don't have an office here anymore. I wasn't concerned about the rate of weight loss as Resident #1 wanted to lose weight. When asked about regular scheduled meetings with the Interdisciplinary Team to discuss weight loss and pressure ulcer prevention, the RD stated, I'm not really part of the skin treatment team. I'm not notified usually of pressure ulcers except at Monthly CQI and family conferences.

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure residents received the appropriate care and services, including adequate supervision, to prevent falls with injuries. This was true for 3 of 8 sample residents (#s 6, 9, and 10) reviewed for falls. Resident #6 was harmed when he fell in the shower and sustained a fracture to his left hip which required surgical intervention. Resident #10 was harmed when she sustained a C2 (second cervical vertebrae) fracture, a laceration to the forehead, pain, and died 4 days after a fall from the bed. And, Resident #9 had four falls in 28 days which created the potential for harm to the resident. Findings included: 1. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE] and [DATE]. The resident had multiple [DIAGNOSES REDACTED]. Additionally, the resident was diagnosed with [REDACTED]. Note: Review of an Incident/Accident (I/A) Report dated [DATE], documented Resident #6 fell on a "slippery" shower floor when a shower mat was not in place. The conclusion of the Fall Scene Investigation Report (FSI), documented, "Res(ident) (transferred) to acute care for ORIF (Open Reduction Internal Fixation) r/t (related to) (left) nondisplaced lower femoral neck fracture. Resident #6's annual MDS assessment, dated [DATE], prior to the [DATE] fall, included: * Impaired cognition with a BIMS score of 10; * Extensive assistance of 1 person for bed mobility, transfers,and bathing; * Limited assistance of 1 person for dressing, toileting, and hygiene; * Scheduled and PRN (as needed) pain medications; * Occasional pain at "8" on a scale from ,[DATE]; and, * No falls since admission or the prior MDS assessment. Resident #6's admission MDS assessment, dated [DATE], after the [DATE] fall, included: * Severely impaired cognition with a BIMS score of 6; * Extensive assistance of 1 person for bed mobility, transfers, ambulation in room/hallways/on unit, dressing, toileting, hygiene, and bathing; * PRN pain medication; * Frequent pain at "8" on a scale from ,[DATE]; * Pain limited day to day activity; * One fall with significant injury; * Two days of Occupational Therapy; and, * Six days of Physical Therapy. An operative report documented resident underwent [REDACTED]. On [DATE] at 10:00 a.m., when asked about Resident #6's fall on [DATE], the DNS confirmed that a shower mat was not in place when the resident fell . The DNS stated, "A mat should have been on the floor." The facility failed to ensure a mat was in place on the shower room floor. This resulted in harm when Resident #6 fell and required surgical intervention for a non-displaced intertrochanteric hip fracture. On [DATE] at 6:00 p.m., the Administrator was informed of the issue. No other information or documentation was received from the facility that resolved the issue. 2. Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Additionally, the resident died in the facility on [DATE], four days after a fall on [DATE]. Resident #10's last quarterly MDS, dated [DATE], coded in part: * Short and Long-term memory problems; * Minimal hearing difficulty and impaired vision; * Able to understand others and make self understood; * Moderately impaired cognition - decisions poor, cues/supervision required; * Extensive assist of 2 people for bed mobility, transfers, and toileting; and * No falls. The Resident's Care Plan, modified [DATE], included the following problems and their interventions: * ADLS - "...Needs extensive two person assistance for bed mobility...Needs extensive, two person assistance for transfers...Needs extensive two person assistance for toileting. She is unable to maintain balance..." * Injury Risk, at risk for injury from falls - "...Needs two person assistance for transfers... Assure proper foot placement and that she is well balanced before beginning transfer...(Resident's name) does not typically attempt to stand unassisted but beware that increased confusion and delirium increase her risk for falls..." The Resident's Care Plan, reviewed and updated on [DATE], included the following problems and their interventions: * ADLS "Functioning/Structural", and, in handwriting, was "(Secondary) to fall (with) fx (fracture)of neck." - Handwritten interventions included, "[DATE] bed rest only...Provide repositioning hourly throughout the day using log roll technique using caution to stabilize head/neck during movement...Provide comfort bath using ,[DATE] person assist for repositioning [DATE]." Additional interventions included, "...Needs extensive ,[DATE] person assistance for bed mobility... She is non-ambulatory at this time...Needs extensive two-3 person assistance with dressing...Assess for pain before beginning cares. Notify nurse if noted for medication to minimize pain during cares." * Injury, fall with fx on [DATE] - "[DATE] Report anxiousness to nurse if observed. Do not leave unattended if she is anxious or restless. Resident #10's Incident/Accident Report, dated [DATE] at 6:30 a.m., documented, in part: * "Fall from bed to floor, landed on head/L (Left) shoulder/L hip." * Describe exactly what happened - "I (CNA #10's name) on [DATE] was doin (sic) (Resident #10's name) AM cares and getting her dressed for the day. I sat her up on the bed in sitting position with her feet hanging over the edge, the same way I have done for a year straight prior to today. I had just finished changing her shirt and turned to grab her comb...when I turned back she had leaned toward the head of the bed and then fell forward. I tried to catch her as soon as I saw her falling but I couldn't stop her from falling. She landed on the floor and hit her head. I immediately pushed the help button and the nurses and a few of the other aides came running in..." Below this, LN #2, documented, "She (the resident) was on floor (with) copious amount of blood pooling on floor from head injury. Calling for help. Assisted (by) 4 to W/C (wheel chair) (and) taken immediately to ER (emergency room )..." * Type of Injury, indicate on diagram location of injury - A front body diagram noted a laceration at the left forehead and "Pain" with a line drawn to the left shoulder and left hip. A Fall Scene Investigation Report (FSI), dated [DATE], documented in part: * CNA #10 witnessed the fall. * Factors at the time of the fall - "Resident lost their balance" and "Lost strength/appeared to get weak." * What appears to be the root cause of the fall? - "Res(ident) being assisted (with) 1 asst (assist) (at time) of fall-CP (Care Plan) requires 2 asst for bed mobility (and transfers). Bed elevated to unsafe height. Res left unattended while CNA went to get comb. Res unable to maintain balance, fell forward striking head on floor. Resulting in C1-C2 spine Fx - ST (skin tear) to (right) hand, Laceration (left) forehead. Possible Fx of (right) hip." * "Conclusion: Fall d/t (due to) non-adherence to Plan of Care, resulting in physical harm to res. BFS (Bureau of Facility Standards) notified..." * Multiple staff interview statements were attached to the FSI. Three of the statements indicated the resident's bed was raised higher than it should have been. A statement by a CNA student documented the resident said, "I hurt, my neck, head." A statement by LN #11 documented, "Res ashen colored face - Crying in pain, Shaking, stated was going to throw up." Physical Assessment Patient Progress Notes (PAPNP) documentation included: * [DATE] at 2:13 p.m. - "Amended: [DATE] (at 2:22 p.m.) Note: Resident back to facility at 1100 this AM. Resident has stitches to forehead and neck brace to keep C-spine in place. Orders for bedrest and comfort measures with C-spine support with rolling, and IV (intravenous) morphine 2 mg (milligrams) (every) 1 H (hour)...administered 2 doses since returning to SNF..." * [DATE] at 11:43 p.m. - "Amended: [DATE] (6:55 a.m.) Note: MD (physician's initials) in to assess. Orders received for morphine PCA at 1 mg/hr (milligrams per hour)...now hooked up..." * [DATE] at 5:52 a.m. - "...C/o (complained of) pain once..." * [DATE] at 11:35 a.m. - "Note: 2 mg PRN IV push MSO4 giver per PCA (2 milligrams morphine sulfate given IV push per PCA pump as needed for pain). Resident restless, pulling at neck collar, trying to set (sic) up, and screaming. Tried...repositioning, 1 on 1, offering fluids, no decrease in behavior..." * [DATE] at 1:45 p.m., "Note: Res awake...in pain, MD (physician) notified...increased morphine..." * [DATE] at 3:26 p.m. - "Sleeping, (resident's name) was getting kind of agitated so i (sic) sat...with her...tried to massage her legs...but she did not like that. I tried to swab her mouth out but she grabbed it from me." * [DATE] at 10:40 p.m. - "Note: Res...mostly unresponsive... When cares done, often wakes up and resists cares. She stated over and over 'Kill me.' 2 mg morphine bolus around 1725 (5:25 p.m.), which appeared to help her calm down and cares were done..." * [DATE] at 6:00 a.m. - "Rested majority of night. Will awaken briefly...anxious X2 (times two) and called out. Easily calmed... * [DATE] at 2:49 p.m. - "Amended: [DATE] (3:01 p.m.) Note: Res agitated this AM, calling out, trying to remove neck brace. Crying out while repositioned, morphine bolus of 2 mg...(at 6:46 a.m.) with noted pain relief. Additional morphine bolus of 2 mg given (at 7:50 a.m. and 11:15 a.m.). Continuous morphine infusing at 1 mg/ml... Dressing to forehead C/D/I (clean, dry, and intact). Bruising noted to face (and) left shoulder..." * [DATE] at 8:32 p.m. - "Amended: [DATE] (8:38 p.m.) Note: Pt (patient) repositioned with 4 assist every hour... Pt has had episodes of agitation, pulling at bed linen, taking off gown, pushing neck brace up over chin and onto face. Facial grimace and crying out also noted with movement. Pt pulled PICC (peripherally inserted central catheter) out at approximately (6:00 p.m.). MD notified. IV peripheral line started...X2 attempts. MD increased drip rate (IV morphine) to 1.5 mg/hour. Pt given bolus of morphine X2 thus far... This appears to help with relaxation and comfort." * [DATE] at 10:30 p.m. - "...log rolled with four staff at (10:00 p.m.). Supported head and neck brace on. Restless... Pulled gown off... PCA morphine infusion at 1.5 mg per hour..." * [DATE] at 12:30 a.m. - ""Checked on resident. No response. No respiratory effort... Vital signs absent. Pupils fixed and dilated. Color pale. Cyanotic mucous membranes." A letter from the facility to the BFS, dated [DATE], regarding the investigation of Resident #10's fall on [DATE], documented in part, "The bed was measured and was determined to be elevated to (a) height of 27 (inches) from the top of the mattress to the floor. At this height the resident was unable to properly position her feet on the floor. (CNA #10) indicated that she had positioned the resident at the side of the bed to complete AM cares and turned to get her comb, leaving her unattended briefly." On [DATE] at 1:35 p.m., the DNS was interviewed about Resident #10's [DATE] fall. When asked if the resident had previous falls or orthostatic hypotension, the DNS answered "No" to both questions. The DNS stated CNA #10 did know the resident was care planned for 2 person assist with bed mobility and transfer, "But she did not do that." The DNS added, "I have let the staff know before how important it is to follow the care plans." The DNS stated that in early 2013, before the resident's fall, the facility recognized a trend in falls and implemented multiple corrective measures. She stated the corrective measures included a communication board for staff on which to share and/or reinforce information about residents' care plans; Kardex notes for CNAs; placed a White Board in the staff break room regarding changes for residents; and, a weekly interdisciplinary team (IDT), meeting about falls, which the physician attended. The DNS stated that since the resident's fall, a plan for fall reduction for 2013 was initiated. The DNS said the fall reduction plan included the aforementioned corrective measures and the following: a weekly newsletter about current issues, including falls, and staff must sign each newsletter to document they read them; the shift-to-shift report policy was updated; staff were in-serviced about care plans and rounding sheets were reinforced; and, the Nurses' Station was remodeled to improve the line of site to residents and to reduce the amount of time needed to exit the Nurses' Station. Resident #10 was harmed when she fell on [DATE] and sustained a laceration to the head, a C2 fracture, pain that required IV morphine, and died 4 days after the fall. The facility failed to ensure the resident's care planned interventions for 2 person assistance with bed mobility and transfers and proper foot placement were followed. The facility also failed to ensure staff did not leave the resident alone when she was seated on the side of the bed. On [DATE] at 6:00 p.m., the Administrator and the DNS were informed of the finding of harm to Resident #10 related to the [DATE] fall. However, no other information or documentation was received from the facility. 3. Resident #9 was admitted to the facility on [DATE]. The Resident had multiple [DIAGNOSES REDACTED]. An annual MDS assessment, dated [DATE], prior to Resident #9's first fall on [DATE], coded in part: * Severely impaired cognition with a BIMS score of 5; * Extensive assistance of 2 or more people for bed mobility, transfers, walking in room, and walking in corridor; * Extensive assistance of 1 person for locomotion on and off the unit, dressing, and toilet use; * Limited assistance of 1 person for personal hygiene; and, * No falls since admission or the prior MDS assessment. A quarterly MDS assessment, dated [DATE], after Resident #9's falls on [DATE], [DATE], [DATE], and [DATE], coded in part: *Impaired cognition with a BIMS score of 10; * Extensive assistance of 2 or more person for bed mobility, transfers, walking in room, and walking in corridor; * Extensive assistance of 2 or more person for locomotion on and off the unit; * Extensive assistance with 1 person for dressing and toilet use; * Extensive assistance with 1 person for personal hygiene; and, * Falls after admit/previous MDS assessment. Resident #9's Long Term Care Plan, dated [DATE], documented interventions for limited physical mobility, in part: * Needs ,[DATE] person assistance for transfers. She is able to transfer from her bed to the bedside commode (BC) with one person assisting; * Needs ,[DATE] person assistance for ambulation. Two person assistance for ambulation and a third person to push wheelchair behind to allow for breaks as needed; * Needs one person assistance for use of BC during the day and bed pan at night; and, * Bed alarm in bed to alert staff to attempts to stand unassisted. On [DATE], Resident #9's care plan was revised and documented in part: * Needs 2 person assistance for transfers. She is able to transfer from her bed to the BC with 2 person assisting; and, * Needs ,[DATE] person assistance for ambulation. One person assistance for ambulation and a second person to push wheelchair behind to allow for breaks as needed. Incident/Accident Reports (I/A) documented Resident #9 had four falls in a 28 day period as follows: * On [DATE] - "Res. (resident) was found laying on floor on back...Res. states, 'Trying to reach for pillow on ground (and) slid on butt.'" * On [DATE] - "She used the restroom and we were walking back out and got right to the doorway and (resident's name) started to wobble. I had my right hand on the gait belt so I grabbed hold with both hands and she fell backwards into me and I held on to her with the belt and slowly lowered her to the floor as I was helping her slide down the front of me." * On [DATE] - "Bed alarm noted to be going off. Staff in to assess. Resident found on left side of bed laying on right side...Resident stated, 'I rolled off trying to get comfortable.'" * On [DATE] - "CNA stated, 'Resident lost balance while I was cleaning her up after using BC (bedside commode).' Resident stated, 'My helper was cleaning me up when I lost balance and she helped me sit on the floor.'" FSI -- Fall Scene Investigation Report documented Resident #9's aforementioned falls as follows: * On [DATE] - The root cause, "Bed alarm not plugged in to box. Wearing normal sox (socks)." Intervention by facility: "Bed alarm placed (and) plugged in correctly." * On [DATE] - The root cause, "Res (resident) being amb (ambulated) (with) 1 asst (assist)- Legs became weak et (and) res lowered to floor to prevent injury. CP (care plan) states needs ,[DATE] asst for (transfers) et amb." Intervention by the facility: "CNA received disciplinary action for failure to adhere to care plan." * On [DATE] - The root cause, "Resident trying to get comfortable." Intervention by facility: "Considered (changing) to high-low bed to prevent injuries if res falls. Family desires to maintain current bed." * On [DATE] - The root cause, "Resident lost balance." Intervention by facility: "Use 2 person assist AAT (at all times)." Note: Resident #9's first and second falls were due to the facility's failure to adhere to the care plan related to the use of the bed alarm and ,[DATE] person assist for ambulation, respectively. On [DATE] at 1:40 p.m., the DON acknowledged that Resident #9 had 4 falls in less than a month, and indicated the resident's care plan had been updated. No other information was received from the facility that resolved the issue.

Based on observation, staff interview, record review and review of facility policies, it was determined the facility failed to provide care planned interventions and rechecks for [DIAGNOSES REDACTED] and [MEDICAL CONDITION], and failed to ensure that a resident at risk of aspiration had the head of bed maintained during assisted feeding as care planned. This was true for 3 of 9 residents sampled for blood glucose (BG) monitoring and interventions (Residents #1, 2, and 6) and 1 of 6 residents sampled for meal assistance and [MEDICAL CONDITION] (Resident #2), and had the potential that residents could develop complications related to [DIAGNOSES REDACTED], [MEDICAL CONDITION], or aspiration. Findings included: NOTE: The facility's [DATE] [DIAGNOSES REDACTED] policy documented, "[DIAGNOSES REDACTED] is an abnormally low level of glucose in the blood, often associated with neurological side effects and arousal of the sympathetic nervous system. Medication induced [DIAGNOSES REDACTED] is a common occurrence during the treatment of [REDACTED]. The charge nurse is then responsible to reassess the resident's blood glucose within 1 hour after the initial assessment.... When [DIAGNOSES REDACTED] is noted, the following should also be documented in the resident's chart: initial blood glucose reading, condition of resident at time of hypoglycemic episode (e.g. symptoms), type of snack or meal provided, repeat blood glucose reading, physician notified and current condition of resident." 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident expired [DATE] from complications of diabetes. The [DATE] Quarterly and [DATE] Discharge MDS assessments both coded that the resident received daily insulin injections. The [DATE] Long Term Care Plan documented interventions which included: "Monitor blood glucose (BG) levels and administer sliding scale insulin per MD order. If BG (less than) 70, provide substantial snack and reassess within 30 minutes. If continues to be (less than) 70, notify MD." The resident's [DATE] Physician order [REDACTED]. * Accu checks 1 hour before every meal and bedtime every day * Humalog insulin subcutaneously, sliding scale based on BG levels * [MEDICATION NAME] 10 units subcutaneously every bedtime The resident's [DATE]-[DATE] Diabetic Chart documented BG levels below 70, without any interventions or rechecks: * ,[DATE] - 66; ,[DATE] - 67 * ,[DATE] - 57; undated, between ,[DATE] and ,[DATE] - 54; ,[DATE] - 67; ,[DATE] - 68; ,[DATE] - 67 * ,[DATE] - 68; ,[DATE] - 66; ,[DATE] - 65; ,[DATE] - 58; ,[DATE] - 62; ,[DATE] - 69 * ,[DATE] - 69; ,[DATE] - 60; ,[DATE] - 67 * ,[DATE] - 38; ,[DATE] - 58 * ,[DATE] - 65; ,[DATE] - 69; ,[DATE] - 66 Additionally, there were numerous BG levels below 70 in which juice, snacks or significant meals were documented to be provided, but there was no documented recheck of the BG level. The DON and Administrator were informed of the findings on [DATE] at 1:45 PM. No further information was received from the facility related to Resident #1's hypoglycemic episodes. 2. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The [DATE] Annual and [DATE] Quarterly MDS assessments both coded that the resident received daily insulin injections. The [DATE] Long Term Care Plan, printed [DATE] and reviewed [DATE], documented interventions which included: "Monitor blood glucose (BG) levels per MD order. If BG (less than) 70, provide substantial snack and reassess BG level within 30 minutes. If continues to be (less than) 70, notify MD." A Physician's Nursing Orders Report printed on [DATE] documented orders for [MEDICATION NAME],[DATE], 50 units subcutaneously every morning and 15 units subcutaneously at 5:30 PM. The resident's Diabetic Flow Sheet, printed [DATE], documented BG levels between [DATE] and [DATE]. Results below 70 were documented on ,[DATE] (64), ,[DATE] (63), and ,[DATE] (54). No interventions or rechecks were documented. The DON and Administrator were informed of the findings on [DATE] at 1:45 PM. No further information was received from the facility related to Resident #6's hypoglycemic episodes. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent significant change MDS assessment, dated [DATE], documented that the resident required extensive assistance one person physical assistance with eating. a. Resident #2's Care Plan, dated [DATE], documented the problem, "Alteration in Nutrition, Recent weight loss r/t (related to) increased nutritional needs d/t (due to) [MEDICAL CONDITION], fluid loss and refusal of meals." Included in the interventions for this problem were: * "Needs assistance with eating, * Eats meals in bed, * Assure his head is elevated to nearly 90 degrees to minimize risk of aspiration." On [DATE] at 8:45 am, Resident #2 was observed in his room being fed by a CNA. His head of bed (HOB) was measured and found to be approximately 45 degrees. LN #2 was asked to observe the HOB and she verified the HOB was not at the care planned 90 degrees and that it appeared to be 45 degrees. The CNA present stated she had tried to increase the HOB but that the resident shook his head "no." On [DATE] at 4:00 pm, the Administrator and DON were informed of this issue. The DON stated she was going to change the resident's Care Plan to document the HOB at 45 degrees because the resident was unable to tolerate a greater angle. No further information was received from the facility. b. The surveyor requested and received a copy of the facility policy, Vital Signs Monitoring. This policy stated, "If abnormal or out of range values are noted, reassess and report to licensed nurse immediately. The licensed nurse should reassess the abnormal value immediately after notification from the CNA. It is the responsibility of the licensed nurse to assess the resident for changes in condition which may warrant notification of the MD such as: 1. Cyanosis 2. Respiratory distress 3. Distention of neck veins 4. [MEDICAL CONDITION] 5. Congestion 6. Dizziness 7. Change in level of consciousness 8. [MEDICAL CONDITION] 9. Headache 10. Diaphoresis 11. Other changes in the resident condition CNA Guidelines for reporting: Blood pressure ,[DATE] Report less than ,[DATE] or greater than ,[DATE] Pulse: 60 to 90 Report less than 50 or greater than 90 Respirations: ,[DATE] Report less than 10 or greater than 24 Temperature 98.6 Report greater than 100.1 O2 (oxygen) Sat (saturation) greater than 90% Report less than 90%" A review of blood pressure measurements taken for Resident #2 from [DATE] to [DATE] documented the following low blood pressures: [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]). On [DATE] at 3:30 pm, the DON was asked for documentation that the abnormal blood pressures were communicated to the LN and subsequently the physician, per the policy. She stated she did not have documentation for this communication. A review of the Nursing Notes and Patient Progress Notes for this period of time did not indicate this communication as well. The Administrator and DON were informed of this issue on [DATE] at 4:00 pm. No further information regarding this issue was received from the facility.

Based on record review, staff interviews, and review of the facility's [DIAGNOSES REDACTED] policy, it was determined the facility failed to notify the resident's physician when residents with diabetes receiving hypoglycemic agents, blood glucose (BG) levels fell below acceptable standards, according to it's own [DIAGNOSES REDACTED] policy and accepted standards of professional practice. These residents were determined to be at risk for serious injury, harm, impairment, or death and that constituted an Immediate Jeopardy (IJ) to residents' health and safety. This situation was brought to the attention of the facility on 6/5/12 at 6:10 pm at which time the facility was provided specific examples of residents who were experiencing or had experienced [DIAGNOSES REDACTED] and whose physician's had not been informed of the hypoglycemic episodes. In addition, the facility's [DIAGNOSES REDACTED] policy failed to meet standards of practice outlined by the American Diabetes Association (ADA) regarding when to recheck low BG levels after interventions to raise the BG levels were implemented. The facility provided an Immediate Plan of Correction (POC) dated 6/5/12. Diabetic residents in the facility had an immediate BG check on 6/5/12 (one resident was checked on 6/6/12). Residents with BG levels lower than 70 mg/dL (milligrams/deciliter) would be provided with a high glucose snack. The residents' BG levels would be reassessed with [REDACTED]. If BG levels continued to be below 70 mg/dl, the resident's physician would be notified immediately day or night. If the residents' providers were unavailable, the emergency room physician would be notified. Documentation of interventions, reactions and follow-up care would be entered into the residents' charts immediately. Inservices, which started on 6/5/12, were given by the DNS to all staff prior to the next worked shift. The inservices addressed the new Interim Hypoglycemic Policy, which included the immediate POC interventions and documentation requirements. Standing orders for [MEDICATION NAME] for diabetic residents would be added to the MAR and emergency [MEDICATION NAME] kits would be added to the medication carts on 6/6/12. Additionally, by 6/8/12, a new section would be added to the EMR which would address nursing interventions provided for [DIAGNOSES REDACTED] and the dietician would provide a recommended list of carbohydrate-containing foods to be given to residents during a hypoglycemic episode. Inservices, conducted by the dietician and/or certified diabetic educator, were scheduled on 6/14/12 for all staff. The facility took immediate steps to remove the jeopardy as evidenced by their POC and Interim [DIAGNOSES REDACTED] Policy, and the IJ was abated on 6/6/12 at 1:15 pm. This applied specifically to 5 of 15 sampled residents with diabetes (#s 6, 11, 15, 16, & 21). Also, the facility failed to recheck and report to the physician a resident's heart rate that was outside the normal parameters identified in the facility's Vital Sign Policy and standards of practice. This was true for 1 of 4 resident's reviewed for vital signs (#11). Findings included: 1. PROFESSIONAL GUIDANCE/STANDARDS OF PRACTICE Lippencott Manual of Nursing Practice, 8th edition, documented on page 921 in the table Standards of Care Guidelines: Caring for Patients With Diabetes Mellitus, "...Get help immediately for signs of [DIAGNOSES REDACTED] that do not respond to usual glucose replacement..." The ADA documented in the "Standards of Medical Care in Diabetes-2012," on page S27, "...Prevention of [DIAGNOSES REDACTED] is a critical component of diabetes management. ...The stress of illness...frequently aggravates glycemic control... Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose..." The ADA defined [DIAGNOSES REDACTED] as a glucose level less than 70 mg/dL. The ADA recommended 15-20 grams of glucose in the treatment of [REDACTED]. If the BG level showed continued [DIAGNOSES REDACTED], the treatment and BG rechecks should be repeated until the BG level was normal. The ADA further recommended that, "[MEDICATION NAME] should be prescribed for all individuals at significant risk of severe [DIAGNOSES REDACTED]..." Diabetes Spectrum, Volume 18, Number 1, 2005 stated in Table 4 titled, Age-Specific Considerations Regarding [DIAGNOSES REDACTED], under the heading, Geriatric, on page 43, "Elderly individuals may have [DIAGNOSES REDACTED] unawareness (i.e., they do not experience the early symptoms of [DIAGNOSES REDACTED]). This is particularly concerning because the blood glucose level continues to drop and may reach very serious levels (< 40 mg/dl) before [DIAGNOSES REDACTED] is recognized and treated." THE FACILITY'S POLICY FOR HYPOGLYCEMIC MANAGEMENT The facility's policy for [DIAGNOSES REDACTED], dated 11/2/2009, documented, in part, "...If at any time a resident's blood glucose level is < 70 mg/dl (less than 70 mg per deciliter), the charge nurse will be notified immediately and the resident provided with a substantial snack or regular meal. The charge nurse is then responsible to reassess the resident's blood glucose within 1 hour after the initial assessment. If blood glucose levels continue to be below therapeutic range, the physician should be notified..." The policy did not contain any references from which the policy was derived. a. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's May and June 2012, physician's orders [REDACTED]. The physician ordered the following diabetic medications: * Glimepiride, 4 milligram (mg) tablet by mouth every day * Glimepiride, 2 mg tablet by mouth every evening * [MEDICATION NAME], 50 mg tablet by mouth every day Resident #11's Long Term Care Plan documented the problem, dated 5/23/12, "Alteration in Nutrition Potential for episodes of hypo/[MEDICAL CONDITION] r/t DM (related to diabetes mellitus)." Interventions included, in part, "Monitor blood glucose levels per MD (physician) order. If BG is < 70, provide substantial snack and reassess within 30 minutes. If continues to be <70 notify MD..." Resident #11's Diabetic Flow Sheet, Medication Record and Progress Notes documented the following, in part: 5/30/12 - 6:30 am: Given [MEDICATION NAME] 50 mg and Glimepiride 4 mg - 6:42 am: "...had diarrhea. c/o (complains of) nausea. emesis of undigested food... Given Diet 7-up to sip... - 9:44 am: "...resident not feeling well today..." - 12:10 pm: BG 134 - 12:33 pm: "...breakfast: refused alternative meal... lunch: refused alternate meal, refused supplement drink..." - 2:31 pm: "...to (sic) sick to get dressed." - 2:41 pm: "...large diarrhea..." - 3:11 pm: "...still complains of nausea..." - 5:24 pm: BG = 52 "carb count 26" (Note: "Carb count" indicated a carbohydrate food intervention for the low blood sugar was given to the resident, but did not specify if the carbohydrate given to the resident contained glucose.) - 6:00 pm: BG = 51 - 7:00 pm: BG = 64 - 7:07 pm: Given Glimepiride 2 mg tablet - 7:36 pm: "...refused dinner...refused supplement drink NOTE: There was no documentation that the low blood sugars were rechecked in 15 minutes. There was no documentation that quick acting glucose was administered to the resident when his blood sugar was 51 and 64. There was no documentation that the physician was called regarding the BG's < 70. The resident continued to receive his diabetic medication even though he was nauseated/vomiting and refusing breakfast, lunch, dinner and his snacks. 5/31/12 - 2:28 am: BG = 71 - 6:14 am: "...reports still feeling nauseated...given regular 7-up and took sips - 6:52 am: Given [MEDICATION NAME] 50 mg and Glimepiride 4 mg - 7:30 am: BG = 62 "carbcount 23" - 8:00 am: BG = 87 - 11:30 am: BG = 48 "carbcount 38" - 12:15 pm: BG = 38 - 12:16 pm: "carbcount 26" - 1:00 pm: BG = 60 "carbcount 38" - 1:22 pm: "Note: Resident has struggled throughout the day to regulate BS (blood sugar). Checked Q 30 min (every 30 minutes) to 2 hours depending on how high last test was. Has been nauseated and had diarrhea also. Will cont(inue) to monitor and maintain BS above 70...." - 1:37 pm: breakfast..."refused meal...refused supplement drink...10 AM snack taken 100%...refused lunch." - 2:05 pm: BG = 51 "carbcount 20" - 2:27 pm: "...medium diarrhea..." - 3:00 pm: BG = 49 - 4:00 pm: BG = 74 - 4:36 pm: "...refused snack..." - Resident #11's blood sugars were rechecked hourly from 5:00 pm to 10:00 pm with results documented as 75, 73, 105, 243, 95, and 72. - 10:30 pm: "Accu checks (BG checks) performed every hour due to unstable blood sugars. Snacks provided for low blood sugars. Encouraged resident to drink juice throughout shift...Resident had diarrhea throughout shift. Resident n/v (nauseated with vomiting) at 2130 (9:30 pm)..." NOTE: There was no consistent documentation that the resident received 15-20 grams of glucose for the low blood sugars. The resident's BG's were rechecked every hour and not every 15 minutes after receiving oral glucose according to standards of practice. There was no documentation that the physician was called regarding the BG's < 70. 6/1/12 The progress notes documented the resident refused breakfast and dinner and most of his between meal snacks and was given 7-up to sip on. The progress notes also recorded BG's below 70, diabetic medication administration and progress notes as follows: - 1:15 am: BG = 55 - 6:59 am: Given [MEDICATION NAME] 50 mg and Glimepiride 4 mg - 11:30 am: BG = 69 - 1:30 pm: BG = 58 - 2:00 pm: BG = 52 - 3:00 pm: BG = 49 - 4:00 pm: BG = 55 - 5:00 pm: BG = 56 - 7:00 pm: BG = 50 - 7:00 pm: Given Glimepiride 2 mg - 8:00 pm: BG = 46 - 8:00 pm: "...Resident has had low blood sugars throughout shift. Accu checks performed every hour from 11:30 (am). MD notified. No new orders..." - 9:00 pm: BG = 46 - 9:00 pm: "...Note: CNA reported BS of 46. Resident is alert and oriented, no s/s (signs or symptoms) of [DIAGNOSES REDACTED] noted. stated that he was 'too full' and felt like he could not eat any more." - 9:30 pm: BG = 37 - 9:30 pm: "Note: BS checked again per myself (LN)...BS reading of 37 rechecked with BS of 43..." - 9:33 pm: BG = 43 - 9:45 pm: "...Note: MD was notified of concerns and down to assess resident. New orders written..." - 11:30 pm BG = 40 A physician progress notes [REDACTED]. 60's, although he clinically does not appear to be hypoglycemic... Plan: ..verifying his glucose readings. If he truly has a low blood sugar, we will need to adjust his diabetic agents..." A lab report, dated 6/1/12 at 10:25 pm, documented Resident #11's blood glucose level as 42 mg/dL. The physician ordered "[MEDICATION NAME] Emergency Kit, 1ml/mg (milliliter per milligram), 1 ml" subcutaneous (SQ). The LN documented in the Progress Notes that the [MEDICATION NAME] was administered at 11:37 pm on 6/1/12 "...for BS of 40..." The physician also discontinued the daily Glimepiride 4 mg and 2 mg tablets on 6/1/12 at 11:32 pm. NOTE: The resident continued to experience low blood sugars. There was no documentation that the resident received 15-20 grams of glucose for the low blood sugars. The resident continued to receive his diabetic medication despite his low blood sugars. The resident's physician was not notified of low blood sugars until 8:00 pm. 6/2/12 - 2:45 am: BG = 59 "...Note: Blood Sugar 59, Strawberry ensure given. - 3:45 am: BG = 41 "...Peanut butter sandwich and ensure given for BS of 41. Resident c/o being dizzy." - 4:15 am: BG = 47 "...Note: BS 47, c/o fell ing dizzy. MD notified. [MEDICATION NAME] ordered SQ x 1 (one time). Will continue to monitor." The LN documented the [MEDICATION NAME] was administered to the resident on 6/2/12 at 4:23 am. Resident #11 experienced low blood sugars for 3 days. The facility failed to notify the physician of the low blood sugars until the end of the third day. The resident continued to receive his diabetic medication despite his low blood sugars, nausea/vomiting, diarrhea and refusal to eat his meals which could have contributed to the low blood sugars. The resident received snacks after some of the low blood sugars but it was unclear if the resident received 15-20 grams of glucose as recommended by the ADA. The resident's low blood sugars were not rechecked 15 minutes after the snack was given and the snack repeated if the blood sugar was still low as recommended by the ADA. The physician documented the resident was not showing signs/symptoms of [DIAGNOSES REDACTED] even when the resident's laboratory blood sugar was 42 on 6/1/12 at 10:25 pm, which could indicate the resident was experiencing [DIAGNOSES REDACTED] unawareness. b. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #21's May and June 2012 physician's orders [REDACTED]." The physician ordered the following diabetic medication: * [MEDICATION NAME] 10 mg orally every morning * [MEDICATION NAME] 5 mg orally at bedtime (HS) The resident's Long Term Care Plan documented the problem, dated 5/23/12, "Alteration in Nutrition Potential for episodes of hypo/[MEDICAL CONDITION] r/t DM." Interventions included, in part, "Monitor blood glucose levels per MD order. If BG is <70 provide substantial snack and reassess within 30 minutes." Resident #21's Diabetic Flow Sheet, Medication Record and Progress Notes documented the following, in part: 6/2/12 - 1:07 pm: "...Note: ...thoughts are more connected today...she is still more confused now than what is normal...states that she still does not feel well, stayed in room all shift." - 2:23 pm: "...stayed in bed all day and did not get up. Her bllod (sic-blood) sugar was low. she was given ensure and juice..." (NOTE: There was no documentation of the BG value nor the time the BG was checked.) - 2:34 pm: "...BS recheck 72, 1/2 sandwich and juice were taken, reporting that she would finish it." - The resident refused breakfast, lunch and a supplement drink. 6/3/12 The Diabetic Flow Sheet, Progress Notes and Medication Record recorded BG's below 70, diabetic medication administration and assessments as follows: - 3:24 am: BG = 63 - 4:39 am: BG = 74 - 6:29 am: "...BS at 0324 (3:24 am -63) given vanilla ensure. BS at 0439 (4:39) -74. Given remainder of vanilla ensure..." - 9:19 am: Given [MEDICATION NAME] 10 mg - 10:11 am: "...Resident is very confused this morning..." - 12:20 pm: BG = 62 - 12:21 pm: "...BS at 1130 (11:30 am) was 62. Pt is alert, no s/s of [DIAGNOSES REDACTED]..." - 1:20 pm: BG = 68 "...resident just barely finished with lunch tray...will continue to monitor..." - 3:09 pm: "...BS reassessed 49...orange juice and yogurt given...pt (patient) is still confused..." - 3:21 pm: BG = 49 - 4:05 pm: BG = 65 "...ham and cheese sandwich, apple juice and gold fish (cracker) taken into resident. state that she would eat it, will continue to monitor." - 6:00 pm: BG = 64 "...BS is 64 despite eating snacks, supper tray taken into resident, resident stated she would try it." - 7:00 pm: BG = 68 - 7:07 pm: MAR documented the resident refused the [MEDICATION NAME] 5 mg tablet at bedtime. NOTE: There was no documentation that the physician was notified the resident had low blood sugars on 6/2/12 and 6/3/12. The resident was not provided snacks consistently when her BG's were low and her blood sugar was not rechecked in 15 minutes after the snack was given to determine if further interventions would be needed. c. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's June 2012 physician's orders [REDACTED]." The physician ordered the diabetes medications: * Insulin: [MEDICATION NAME] Mix 70/30, SQ, 65 units every morning and 15 units every evening. Resident #6's Diabetic Flow Sheet, Medication Record and Progress Notes documented the following, in part: 6/5/12 - 5:13 am: "...She is sick, nurse knows keeping and (sic) eye on her and checking on her..." - 5:56 am: "...had medium liquid green emesis..." - 7:56 am: Given [MEDICATION NAME] Mix Insulin 70/30, 65 units, SQ (Note: There was no documentation that a BG was checked before the insulin was administered.) - 12:00 pm: BG = 54 - 1:05 pm: BG = 54 - 1:55 pm: BG = 72 - From 11:01 am to 2:15 pm, the Progress Notes documented the resident was nauseated with vomiting and had diarrhea, "(Resident #6) was in bed all day with the flu. Emisis (sic) x 6 and bm x 2 (bowel movement times 2)." The resident refused breakfast, lunch and her supplemental drink. - 5:00 pm: BG = 73 - 5:20 pm: "...physician notified of pt low blood sugars. Order given to hold current insulin and only give partial dose in am - see order..." NOTE: There was no documentation the resident received a snack after the low blood sugars at 12:00 pm and 1:05 pm and with her nausea/vomiting, and refusals of breakfast, lunch and snacks, she may not have been able to eat a snack. The resident had received her morning dose of insulin and was now unable to eat. There was no documentation the physician was notified until 5:20 pm that the resident was experiencing low BG levels. On 6/5/12 at 5:05 pm, the DNS was interviewed and stated that Resident #6 "is now experiencing low blood sugars." At 6:55 pm, the DNS stated the resident's physician was notified at 5:20 pm that the resident's BG's were low only because the survey team directed her to do so and that she would not have called the physician regarding the low BG's had the survey team not directed her to do so. According to the Progress Notes on 6/5/12 at 5:20 pm, the physician ordered the resident's insulin to be held that evening and reduced the morning dose of insulin to be administered on 6/6/12. d. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15's May and June 2012 physician's orders [REDACTED]." The physician ordered the following diabetic medications: * Insulin: [MEDICATION NAME] Mix 70/30, SQ, 60 units every morning and 40 units at bedtime. The medication was discontinued on 6/1/12. * Insulin: Humalog 100 units per milliliter, SQ, per sliding scale protocol. Resident #15's Long Term Care Plan documented the problem, dated 3/22/12, "Alteration in Nutrition at risk for injury r/t hypo/[MEDICAL CONDITION] d/t (due to) diabetes." Interventions included, in part, "...(Resident #15) is able to monitor her blood glucose levels and report results to nursing staff. Administer insulin as ordered as per sliding scale. Notify MD if BG level >350 (greater than 350). If BG level <70, provide substantial snack and reassess within 30 minutes. If continues to be <70, notify MD for further orders and interventions..." Resident #15's Diabetic Flow Sheet, Medication Record and Progress Notes documented the following, in part: 5/30/12 - The resident's Progress Notes documented the resident was nauseated with 4 episodes of emesis of green and yellow liquid. The resident had 5 episodes of diarrhea and was refusing breakfast, lunch, dinner and her between meal snacks. The resident was "more confused than normal" and "less responsive." The resident was also described as "weak." The physician was called and intravenous normal saline was started and antibiotics were given. - The resident's BG's were documented at 5:30 pm, 8:05 pm, 10:04 pm and 11:00 pm as 227, 177, 160, and 100 respectively. - 7:47 pm: Insulin, [MEDICATION NAME] Mix 70/30, 40 units given SQ 5/31/12 - 1:56 am: BG = 74 - 2:27 am: BG = 74 - 6:21 am: "...Accucheck at 0200 74. Continues to take sips of regular coke and eat string cheese. Refused other po (oral intake) offered..." - 7:30 am: BG = 124 - 8:22 am: Insulin, [MEDICATION NAME] Mix 70/30, 60 units given SQ - 10:30 am: BG = 50 - 11:30 am: BG = 45 - 12:42 pm: BG = 237 - 2:00 pm: BG = 84 - 2:30 pm: Resident refused alternate breakfast, lunch and snacks. "...MD notified of unstable blood sugars...cont(inue) to monitor BS. If unable to keep stabilized orally call MD for interventions...monitor d/t sudden drops in BS..." - 3:00 pm: BG = 50 - Resident #15's blood sugars were taken every hour from 4:00 pm to 10:00 pm with results documented as 82, 230, 245, 223, 196, and 94. At 10:30 pm, the physician came in to see the resident and decreased the resident's insulin to [MEDICATION NAME] Mix 70/30, 30 units every morning and 20 units at bedtime. NOTE: There was no documentation that the facility notified the physician at the time the resident's BG's dropped to 50 and 45. There was no documentation that the BG's were rechecked 15 minutes after a 15-20 gram glucose snack was given. e. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16's May and June 2012 physician's orders [REDACTED]." The physician ordered the following diabetic medications: * [MEDICATION NAME] 50 mg tablet by mouth once daily * Glimepiride 4 mg tablet orally twice daily The resident's Long Term Care Plan documented the problem, dated 5/3/12, "Alteration in Nutrition..." Interventions included, in part, "2. Blood glucose monitoring as ordered. If BG is <70 provide substantial snack and reassess within 30 minutes. If continues to be <70 notify MD..." Resident #16's Diabetic Flow Sheet, Medication Record and Progress Notes documented the following, in part: 5/17/12 - 6:32 am: BG = 66 - 6:33 am: "...juice given. Will recheck in 1 hour..." - 7:14 am: BG = 104 5/19/12 - 6:45 am: BG = 47 - 7:16 am: BG = 153 - 7:17 am: "...given two orange juices with 20 grams of carbs each. Rechecked within one hour and blood sugar noted to be 153..." 5/26/12 - 8:35 am: BG = 69 NOTE: There was no documentation a snack was given or the BG was rechecked. 5/29/12 - 7:33 am: BG = 66 "carb count 23" - 7:55 am: BG = 111 6/2/12 - 6:43 am: BG = 66 - 6:44 am: "...Juice given will recheck (BG)..." - 8:44 am: BG = 84 - 9:01 am: Given [MEDICATION NAME] 50 mg tablet but refused the Glimepiride 4 mg due to nausea. - Resident #16's Progress Notes documented she refused breakfast, lunch, dinner and all between meal snacks. 6/4/12 - 11:03 pm: BG = 59 "...requested blood sugar checked...orange juice with sugar and sandwich taken..." -12:06 pm: BG = 94 6/5/12 - 12:08 am: BG = 94 NOTE: There was no documentation that the resident's physician was notified when any of her BG's were below 70. The resident's low blood sugars were not rechecked within 15 minutes after a snack was given. 2. THE FACILITY'S POLICY FOR VITAL SIGN MANAGEMENT The facility's policy, dated 5/7/12, titled, "Vital Sign Management," documented, "Each resident...will have vital signs monitored routinely to establish a 'baseline.' " If abnormal or out of range values are noted, reassess and report to licensed nurse immediately... It is the responsibility of the licensed nurse to assess the resident for changes in condition which may warrant notification of the MD such as...2. Respiratory Distress, 6. Dizziness, 8. [MEDICAL CONDITION]" Normal pulse rate (heart rate) was identified as 60-90 beats per minute (bpm). Facility staff were inserviced on this policy on 5/10/12. Resident #11 was admitted to the facility on [DATE] and placed on medication for [MEDICAL CONDITION] on 2/1/12. On the morning of 5/22/12, an ER Note documented that Resident #11 was admitted to the Emergency Department, after a visit to his physician, with a heart rate of 160 bpm. An EKG was done which showed [MEDICAL CONDITION]. The resident received [MEDICATION NAME] IV which reduced his heart rate to 87 bpm. The resident was returned to the facility with an order for [REDACTED]. The resident's heart rate was recorded on the Vital Signs Bar Graph or on the Progress Notes for 2012 as: 5/23 (161), 5/24 (113) (101) (72), 5/25 (150) (83) (124), 5/26 (89), 5/27 (140), 5/28 (110), 5/29 (95), 5/30 (125), 5/31 (51), 6/1 (52), 6/2 (119). Resident #11's Progress Notes documented, in part: 5/23/12 - 1:12 pm: "...Notified Dr. (name) office around 1130 about...pulse of 120 and very irregular. Resident is very gray and sweating profusely. ...PA into (sic) see resident..." - 3:32 pm: "...Received call from PA...Continue to monitor resident. Will continue to monitor and assess..." - 3:59 pm: "...Reviewed vitals, pulse 161, will continue to monitor and assess patient..." 5/25/12 - 5:38 am: "...assisted to wheelchair...apical pulse at this time 150...c/o not being able to catch his breath...rest for 30 minutes...apical pulse retaken-irregular 89..." 5/27/12 - 4:58 am: "...reported that when he got out of bed he felt 'woozy' Resident SOB (short of breath) upon exertion...apical pulse 140 after exertion, will continue to monitor. Resident reports no pain, just the discomfort of being SOB..." - 12:34 pm: "...states that he feels SOB at times. HR (heart rate) irregular ranging from 65 - 80 bpm..." 5/28/12 - 11:12 am: "...had and (sic) episode during breakfast when he reported that he felt dizzy and light headed. O2 was not on, O2 placed on...stated that he felt better and was no longer dizzy...vs (vital signs) taken by CNA..." Pulse rate: 110. There was no documentation after 5/23/12 and until 6/1/12 at 9:41 pm, that the physician was notified when the resident's heart rate went above 100 or below 60 or when the resident experienced symptoms of shortness of breath, dizziness and increased heart rate. On a 6/1/12 physician progress notes [REDACTED]." There was no further documentation regarding the heart rate. On 6/5/12 at 2:30 pm, LN #1, who was the Charge Nurse, was interviewed regarding the fluctuations in Resident #11's heart rate, the resident's known [MEDICAL CONDITION], the vital sign policy and the lack of notification of the physician. She stated there were no parameters documented in the EMR of when to notify the physician regarding the resident's heart rate. She stated that information would be on the resident's care plan. The care plan was reviewed and there was no documentation regarding the resident's [MEDICAL CONDITION], shortness of breath, irregular heart rates, or dizziness. On 6/5/12 at 3:50 pm, the DNS was asked about Resident #11's irregular heart rate. She stated, "125 is too fast for him and 51-52 is too low for him. They should have reported this (to the physician)." On 6/6/12 at 5:25 pm, the Acting Administrator and DNS were informed of the issue. The facility provided no other information or documentation that resolved the concern.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents who were admitted without pressure ulcers (PU) did not develop them after admission. This was true for 2 of 5 (#s 2 and 4) sampled residents. Resident #2 developed 5 PU after admission - a Stage IV to his left foot, a Stage II to his left scapula, a suspected deep tissue injury (SDTI) to his right great toe, a Stage II to his right mid calf, and a Stage II to his lower left mid back. Resident #4 developed 4 PU - a Stage II to his left anterior medial thigh caused by his catheter tubing, a Stage II to his right anterior thigh caused by his catheter tubing, a Stage II to his right lateral hip, a Stage II to his right lateral thigh, and a Stage II to his right buttock crease. These PUs resulted in harm to both residents. The facility failed to recognize risk factors, design and consistently implement personalized care plan interventions to prevent PU from developing and promote healing, or to document wound assessments at regular intervals to track wound progress. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent significant change MDS assessment, dated 2/28/12, documented that the resident required extensive 1 person physical assistance with eating and bed mobility, and total dependence requiring 1 person physical assistance for personal hygiene. This assessment also documented 1 Stage IV PU present. NOTE: The resident's admission MDS assessment, dated 7/10/11, documented 4 Stage I PU. Nursing notes documented these 4 PU were not in the same location as those PU cited here, and these 4 Stage I PU did heal after admission. Resident #2's 7/11/11 Long Term Care Plan (LTCP) documented the problem, "Skin Breakdown." A handwritten entry, not dated or initialed, documented, "r/t (related to) hx (history) of PU's, decrease (sic) nutritional intake, decreased mobility and extensive (assist) with ADL's and urinary/fecal incontinence, and stasis ulcers." Interventions included: * Reposition and check for incontience (sic) according to repostioning (sic) schedule. Handwritten note with no date or initials above this documented "Q 30 minutes." Change and provide good peri care after each episode of incontience (sic). * [MEDICATION NAME] (protein supplement) BID (twice daily). Handwritten note with no date or initials documented, "or juice with added protein." Encourage fluids throughout the day. Weigh on bath days. * Assess skin weekly. Handwritten entry with no date or initials documented, skin assess 2 x week (twice weekly) per LN. 7. Supplements with meals. Handwritten note with no date or initials documented "[MEDICATION NAME] for wound healing (mix with diet coke). 8. Handwritten note dated and initialed 7/12/11 documented, "Q 30 minute repositioning." 9. Handwritten note with no initials or date documented, "Dressing changes per order (wound vac)." On 4/11/12 at 8:00 am, the DON was asked for information as to when each PU developed, its treatment and progress, and any interventions implemented. Nursing Notes and photographs were supplied to the surveyor. The DON stated that protective boots for the resident's lower extremities were considered, but the particular brand the facility utilized came up to the mid calf and they decided these would rub against the stasis ulcer on the left calf and were not used; the facility did not consider purchasing any other type of protective boots. The Braden Scale for Predicting Pressure Sore Risk form for Resident #2 documented the following scores: * 9/6/11 - Score 13 - Moderate risk * 10/5/11 - Score 12 - High risk * 11/1/11 - Score 12 - High risk * 1/3/12 - Score 13 - Moderate risk NN and PPN (Patient Progress Notes) documented: * 11/6/11 - "On the medial side of L(left) foot where big toe attaches to the foot there is a 1 cm (centimeter) Stage I (PU). CNAs reminded to keep pillow or blanket between feet after repositioning. Foot cradle is in place and it has been for a month or better with sheets over it and not feet each time I have entered room, will continue to monitor." (NOTE: The resident's care plan did not address a foot cradle as an intervention, and NN documented its application occasionally but not consistently.) In addition, discrepancies were found in the NN; some staff documented repositioning every 2 hours and other staff documented repositioning every 30 minutes to 1 hour. * 11/15/11 - Wound on medial left side of foot was SDTI with a "blue egg crate piece in place at end of bed, pillow placed between feet to keep them from touching each other, foot cradle is in place, no dressing placed on this area at this time." NOTE: If this wound had progressed to a SDTI, interventions to protect the skin would be necessary but the wound could be expected to open and progress. According to the National Pressure Ulcer Advisory Panel's staging system, SDTI PU "May further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." * 11/23/11 - "Spot on L great toe has scabbed area (eschar) with redness surrounding. Reported to skin nurse." * 11/29/11 - "(SDTI) L medial toe is now hard to the touch, eschar is noted in the middle, pale skin around that and the very edges are red, skin is intact, no drainage... Instructions given to nurse to also have MD assess SDTI to L medial toe as well as instructions on how to place new dressing on after MD assessment." * 12/10/11 - "I talked with (physician) about area on L medial toe/foot, as long as area does not drain or look infected, we are just going to monitor the area, no dressing is in place, hard black eschar noted, unchanged in size, no drainage, well adhered." * 12/13/11 - "Spot on L scapula open 1 cm round. Reddness (sic) around edges. No blanching." NOTE: Second PU. * 12/15/11 - "Found an open area in the center 1 cm in diameter this appears to be a Stage II (PU). I also noted that right across this maroon/non blanchable area and the open sore is an impressed quarter circle that looks like the resident had been lying on a cord or O2 (oxygen) tubing, Normagel was applied to sore and covered with address. DNS was notified, resident is on a 30 (minute) repositioning schedule, will have nurses follow up on repositioning throughout shifts." NOTE: This note appeared to reference the pressure ulcer on the left scapula. * 12/20/11 - "Skin was assessed this AM, light purple bruise noted on top of right great toe, (SDTI) with eschar noted, unchanged in size and appearance from previous assessments." NOTE: Third PU. Previous assessments not found. * 12/27/11 - "Light purple bruise noted on anterior R (right) great toe... Stage II (PU) to L back is healing and measures 3 mm (millimeters) x 3 mm." * 1/2/11 (error, should have been 1/2/12) - "Dressing to Stage II on back was (discontinued) as area has healed." * 1/5/12 - "Has abrasion on left lower back just to left of backbone." NOTE: Fourth PU. * 1/9/12 - "On resident's lower back there is a small 1/2 cm open area, blanches, unsure of how this occurred (sic), no s/s (signs or symptoms) of infection, scant amount of serous drainage, new Alldress applied.... (Resident) has 1 cm size shearing type abrasion with (small amount) of (drainage) (bloody) on (dressing)." * 1/15/12 - "No dressing on back seen, wound appeared to be closed." NOTE: This indicated that both PU on the resident's back had healed and the remaining PU were the Stage IV on his left medial great toe and a SDTI to his right anterior great toe. * 1/16/12 - "CNA from midnight shift reported that eschar to L medial toe/foot was starting to drain some fluid... (eschar) was very soft and surrounding 4 to 5 cm around the eschar was soft, red and warm... this wound was covered with [MEDICATION NAME] and [MEDICATION NAME] while in whirlpool bath... (Physician) called, orders given to start [MEDICATION NAME] (for) infected wound. Orders given to culture wound as well." NOTE: Order was changed on 1/19/12 to [MEDICATION NAME] based on culture results [MEDICAL CONDITIONS]. * 1/22/12 - "Eschar is gone." * 2/3/12 - "1/2 cm area of exposed bone noted, surounding (sic) tissue is dry and light brown in color, slight reddness (sic) noted around light brown area, no drainage, on the posterior side of foot next to the light brown area there is a lighter pink area that looks like it may break down in the future, [MEDICATION NAME] with border applied, secured with kerlix. MD's office was notified of findings. No new orders at this time." NOTE: The Stage IV PU to the left medial first metatarsal did not receive evaluation by the podiatrist until 2/9/12, 12 weeks after its discovery, infection [MEDICAL CONDITION], and deterioration. Physician order [REDACTED].' basis. Primary physician will be notified if more complicated issues are noted." * 2/4/12 - "Tissue around to the back of foot is deteriorating and is a light pink/yellow color, no soft areas noted, no warmth noted. Area is very dry... MD was called... in reguards (sic) to concerns about this area, orders to have podiatrist consult on Thursday when (physician) comes were given, concerns about lack of reserves and reduced options for (treatment) were discussed with MD." * 2/9/12 - "(Podiatrist) into (sic) assess Stage IV (PU) to left medial toe/foot. There is a nickel sized area with exposed bone, tunneling noted around the edges of the open sore at least 2 mm, tissue was obtained from site and sent to pathology, orders given to start wound vac therapy to this site as well... (Resident) stated that it is painful to the touch, pain medication was given prior to dressing change." * 2/14/12 - "Very light purple bruise noted on medial right great toe." NOTE: This was the next chronological documentation found for the SDTI on the resident's right great toe. The resident's LTCP was updated on 3/9/12, and the following problem area was noted: "Skin Conditions: Skin Integrity, impaired r/t stage IV (PU) to left great toe and stasis ulcer to left calf secondary to impaired circulation and poor nutritional status." Interventions included: * "Reposition every 30 minutes throughout the day and every 2 hours throughout the night using the repositioning kit. * Skin assessment twice weekly per (LN). Current (PU) risk is 13 (moderate) per Braden scale. * Wound vac with Y connector to both ulcers per MD order. * [MEDICATION NAME] mixed with Diet Coke for wound healing twice per day. * Podiatry assessments/interventions monthly or as ordered. * Bed cradle to bed to keep pressure off of toes. * Air overly mattress to bed. Check daily to assure sufficient air to minimize pressure to bony promininces (sic). * (Resident) has poor nutritional status. Encourage increased protein in diet to help promote wound healing. * Monitor for increase in drainage, increased warmth or redness around wound sites, discoloration of wound beds, fever or other signs of infection immediately (sic). * Inspect skin each time he is repositioned, during bathing and when performing personal care. Report non-blanching reddened areas, bruising, rashes or other breaks in skin integrity." PPN after the updated LTCP documented: * 3/15/12 - "New Stage I (PU) noted on the posterior side of right leg mid calf, resident will be turned side to side and calf will be elevated off of bed as much as possible." NOTE: Fifth PU. * 3/17/12 - "New dressing applied to Stage II (PU) right posterior calf." PPN continued through 4/11/12 with documentation of the wound care for the Stage II PU to the right calf and the Stage IV PU to the left great toe. There was no further mention of the SDTI to the right great toe. Various entries documented the resident was turned every 30 minutes, every hour, or every 2 hours. The use of a foot cradle was not consistently documented. On 4/12/12 at 11:00 am, the surveyor observed LN #2 perform wound care on Resident #2. Wound care was observed to the stasis ulcer on the resident's left calf and to the Stage IV pressure sore on the resident's left first metatarsal. The Stage IV pressure sore appeared to have no exposed bone and was beefy red in the center. LN #2 reinforced the edge of the dressing with tape, and LN #2 stated she needed to do this because the resident rubbed his feet on his bedding which caused the dressing to curl up. Although the facility was observed to utilize a foot cradle on the resident's bed, this would not preclude the resident's feet from being subjected to friction and shearing if the resident rubbed his feet against the bed surface. The facility was aware, based on LN #2's statements, that the resident routinely did this - but there was no intervention documented. Federal guidelines at 42 CFR 483.25(c) state, "When assessing the ulcer itself, it is important to: Differentiate the type of ulcer (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of ulcer; Determine the ulcer's stage; Describe and monitor the ulcer's characteristics; Monitor the progress toward healing & for potential complications; Determine if infection is present; Assess, treat and monitor pain, if present; and Monitor dressings and treatments. Ulcer Characteristics - It is important that the facility have a system in place to assure that the protocols for daily monitoring & for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility." On 4/12/12 at 8:30 am, all PU documentation, including any skin sheets and NN, were requested from the DON. The DON stated they did not use any type of skin form or anatomical diagrams, only the notes referenced above. The lack of consistent documentation and anatomical diagrams made it very difficult to track numerous PU. None of the newly developed PU were coded on the resident's quarterly MDS assessments. The facility failed to consistently assess, develop interventions, evaluate the effectiveness of interventions, monitor each PU's progress, or to consistently document on all PU. 2. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 2/28/12, documented the resident required extensive assistance by 1 person for bed mobility, dressing, and personal hygiene; was cognitively intact; had a Foley catheter; was occasionally incontinent of bowel; and did not have any PU. The resident's 10/25/10 LTCP documented, "Skin; (PU), potential for skin breakdown due to decreased physical mobility." Interventions included: * Assist resident with repositioning at least every hour. Handwritten notes with no initials or dates changed this to "every two hours." * Pressure relieving mattress, air overlay, to bed. Assure sufficient air to decrease pressure to bony prominences. * Encourage resident to be up in recliner for all meals. * Assure catheter tubing is not placed underneath resident's legs. * Handwritten note dated and initialed 9/13/11: Leave Attends open at all times. The resident's Braden Scale for Predicting Pressure Sore Risk form, documented mild risk with a score of 15 on 9/13/11, 10/11/11, 11/1/11, and 12/6/11. NN and PPN documented: * 6/2/11 - "Skin has blister to (upper) thigh from f/c (foley catheter) possibly. F/C changed to other leg when found and Aquafor (sic) applied." NOTE: Location not identified as to L or R leg. * 7/6/11 - "Resident has a dime sized water blister on L anterior thigh, it is intact with no s/s of infection." NOTE: First Stage II PU, not identified as a PU. * 7/23/11 - "Blister on L thigh larger than (7/21/11) - (approximately) quarter sized (and) fluid filled." Later in the day the blister had burst: "Moderate amount of thin clear yellow drainage on Alldress." NOTE: Second Stage II PU, on the posterior L ischial tuberosity (IT), as identified in the photograph supplied by the facility. * 8/16/11 - "On R lateral hip there is a small scab, it is intact, no s/s of infection. [MEDICATION NAME] applied. Attends are still being left undone at (night)." NOTE: Third Stage II PU, not identified as a PU. * 8/23/11 - "Skin was reassessed this am. L proximal medial thigh is healing well. Dressing to this area was (discontinued) as it is closed and no drainage. [MEDICATION NAME] applied... Scab on R lateral thigh is intact." NOTE: Fourth Stage II PU; entry also referenced the third PU, documented via photograph, which was identified by surveyors to be on the L ischial tuberosity/buttock. On 9/27/11 the LTCP was updated to include interventions: * Assist with repositioning at least every two hours. Encourage him to be up in recliner for all meals. * Assure catheter tubing is not placed under his legs. Secure tubing to opposite leg each day to minimize risk of breakdown caused by catheter tubing. * Likes sheepskin to cover entire bed. Assure it is in place and wrinkle free to minimize pressure. * Handwritten note dated 2/28/12: Use Depends (Attends) on him at all times. * Skin assessment weekly per LN. Report any observed irritation, redness or odor to charge nurse for further assessment and intervention. * Bed cradle to bed to minimize pressure to toes. NN and PPN after the updated LTCP documented: * 10/25/11 - "Blister noted on R posterior hip with reddness (sic) surrounding. Blister is approximately 1 cm round, intact. Area around blanches. Blister also noted to anterior R leg. Resident states it is from catheter. Catheter moved to L leg. Resident encouraged to lay on L side." * 11/15/11 - "No blisters noted on hips or thighs from Attend(s), they are being left open, no other areas of concern." * 12/27/11 - "Skin was assessed, there is an open blister noted in the crease of the right thigh/buttock... (Resident) is on (every 2 hour) repositioning schedule, air overlay mattress and gel pad in recliner." NOTE: Fifth Stage II PU. Monthly Documentation for High Risk Skin/Pressure Ulcer forms documented: * 7/26/11 - "(PU) risk assess score is 20, unchanged from May, note made in resident's chart about open sore L proximal medial thigh, picture taken of this area... no other issues noted at this time... air overlay mattress on bed and gel pad in (wheelchair)." NOTE: The photograph of this wound documented this wound was on the resident's L posterior IT, not the "proximal medial thigh". * 8/9/11 - "Resident did have small blister on R lateral hip, it has popped and has healed over, I feel that these blisters are d/t the Attends and is having (sic) the aides roll resident to reposition Attend(s) rather than pull Attends and having them leave Attends undone while in bed." NOTE: This documented facility staff believed Attends caused friction/shearing. * 9/13/11 - "(PU) risk assess score is 15/mild per Braden scale... no blister noted on (R) hip." NOTE: This documentation indicated the R lateral hip PU had healed. * 11/1/11 - "On R lateral leg there is a small 1/2 cm open blister." The 9/17/11 LTCP was modified on 3/7/12, but contained only 1 intervention change: "Leave Attends open to air when he is in bed to minimize moisture and sweating." On 4/12/12 at 8:30 am, all PU documentation, including any skin sheets and NN were requested from the DON. The DON stated they did not use any type of skin form or anatomical diagrams, only the notes referenced above. The lack of consistent documentation and anatomical diagrams made it very difficult to track the numerous PU. None of these PU were coded on the resident's quarterly MDS assessments. The facility failed to consistently assess, develop interventions, evaluate the effectiveness of interventions, monitor each PU's progress, or to consistently document on all PU.

Based on staff interview and record review, it was determined the facility failed to provide increased supervision and assistive devices to keep residents safe from accidents and injury. This was true for 3 of 6 residents sampled for falls and fractures (Residents #1, 3, and 10), and resulted in fractures for 2 residents (#s 1 and 3). Resident #1 was harmed when she fell from a mechanical transfer device when the wrong size sling was used, and Resident #3 was harmed when increased supervision was not provided after she was administered a psychotropic medication, even though she was care planned to have increased supervision when psychotropic medication had been administered. Resident #10 had multiple falls out of bed and while self-transferring or ambulating, but adequate changes to the care plan, including increased supervision, were not provided. Findings included: 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident expired [DATE] from complications of diabetes, after surgery to repair a fractured femur. The [DATE] Quarterly and [DATE] Discharge MDS assessments both coded that the resident: * Was cognitively intact * Required extensive assistance by 2 or more staff for bed mobility * Was dependent on assistance by 2 or more staff for transfers and toilet use * Had bilaterally impaired lower limb range of motion CAA worksheets from [DATE] and [DATE] documented that the resident was and had been non-ambulatory, and required a ,[DATE] person assist with mechanical lift for transfers. The [DATE] Long Term Care Plan documented interventions which included: * She is unable to position herself up in the bed. * Use a mechanical lift for all transfers. * She is assisted to the bedside commode with the standing lift. * Extensive assist for transfers. Interdisciplinary Care Plan Conference Records documented: * [DATE] - "(No) falls." * [DATE] - "(No) falls past 6 (months)." * [DATE] - "Mechanical lift - (no) falls in last 6 month (sic)." An [DATE] Nursing Note documented, "Resident taken to ER (emergency room ) (due to) fall from lift transfer failure. X-Ray (sic) (and) found (left) leg broken in femur - upper end." The Incident/Accident Report and investigation report related to the [DATE] fall with fracture documented: * "(Two staff) stated the lift failed on one end (and) resident fell out of sling onto floor. Was (up) in air (due to) removal from bed. Unclear as to accident (sic) mechanical lift failure or human error." * "Staff failed to assure proper sling fit and to assure safety straps were properly secured prior to beginning (transfer)." * "The sling strap supporting (Resident #1)'s right shoulder slipped off of the hook, immediately causing her to fall backward from the sling onto the legs of the lift... buttocks were approximately 37 inches from the floor when she fell ." * "The lift appears in good working condition... A thorough investigation into the incident revealed that two factors appear to have contributed to the fall: 1. The sling was very large and not the proper size for (Resident #1). The size of the sling likely contributed to the fall. If the sling were the proper size, (Resident #1) may not have slid from it so easily when the strap became disengaged from the hook. 2. The strap could not have been properly secured to the hook by the clips. The CNA reports hearing the 'click' from the clip as the straps were placed on the hooks but when the straps were placed on the hook only partially (during the investigation), a click was also heard. No visual inspection was made to assure proper placement of the straps." An [DATE] History and Physical documented the resident had renal osteodystrophy, and "The patient fell and sustained a left subtrochanteric femur fracture. The patient has been non-ambulatory for over 1-,[DATE] years. She transfers only. She has very osteoporotic bone.... On postoperative day #1, she had trouble with confusion and was taken off dialysis early. She was given Narcan and started on Toradol. With better pain control, she was returned to dialysis. She gradually improved with vital signs remaining stable, but still having difficulty with pain control and requiring IV (intravenous) medications." A [DATE] Death Summary documented, "Symptoms improved, however she became frustrated with her quality of life. She chose to stop dialysis on [DATE]. She passed away peacefully on [DATE] with cause of death... end stage renal disease... diabetes... other contributing factors: left femur fracture post open reduction and internal fixation, cellulitis, emesis, hypoxia, and sacral decubitus skin lesion." The [DATE] investigation report documented, "Interventions have been put into place to assure no further incidents of this type occur: 1. Prior to using a mechanical lift for transfers, all residents (who require a mechanical lift for transfer) will be assessed for proper sling fit by the restorative nursing director or (DON). 2. Each resident who requires the mechanical lift for transfer shall have 2 properly fitting slings personally assigned to him/her to be kept in his/her room. This will enable one sling to be used while the other sling is being laundered. 3. Each staff member will be required to demonstrate competency with the use of the mechanical lift prior to being allowed to transfer residents using this technique. The skill will be taught upon hire and a refresher will be offered at least twice yearly at inservice trainings. 4. The facility's mechanical lift policy has been revised and updated... all staff members will be required to review and sign the policy, acknowledging that they understand and agree to adhere to it." The DON was interviewed about the resident's history of falls, and the events surrounding the resident's [DATE] fall with fracture and subsequent death. The DON stated the resident had no other falls in the year prior to her fall with fracture. The DON and Administrator were informed of the findings on [DATE] at 1:45 PM. No further information was received from the facility related to Resident #1's fall with fracture. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Admission MDS assessment coded that the resident required: * Required limited assistance by 2 or more staff for bed mobility * Required extensive assistance by 2 or more staff for transfers, and walking in the room or corridor * Was dependent on staff for locomotion on and off the unit * Had fallen within the month, and ,[DATE] months, prior to admission to the facility The [DATE] Long Term Care Plan documented interventions which included: * Needs extensive 2 person assistance with transfers, ambulation, and toilet use. * Use gait belt and walker. * "fell OOB (out of bed) on [DATE]. She states she rolled out of bed onto the floor. She sustained a laceration to her right calf. She reports the fall was due to the size of her bed. States she is not used to sleeping in a twin sized bed. Remind her to sleep in the center of the bed." * "States she has sudden 'spasms' in her legs and her knees buckle without warning during ambulation. Assure a wheelchair is close by to assist her if needed during ambulation." * A hand written entry dated [DATE] - "fell OOB on [DATE] - states (due to) air overlay... removed (and) egg crate placed." * A hand written entry dated [DATE] - "fell OOB - assure bed in lowest position when (resident) sleeping." The [DATE] History and Physical documented the resident's chief complaint as, "Weakness and falling down." Additionally, the physician documented: "She has had three episodes of syncope and numerous falls, and is complaining of paresthesias and not being able to feel her legs or feet. This has gotten progressively worse over the last three months." The [DATE] Discharge Plan/Discharge Plan Review, completed when the resident was admitted to the facility, documented a history of weakness, fatigue, and falls; that the resident required 2 person assistance for transfers and an attendant for ambulation, and "Family can no longer take care of (resident at) home due to weakness (and) falling. She can no longer be left alone." A [DATE] RSD (Resident Service Director) Assessment documented: "She has frequent pain in her legs, but says the left leg is worse. She has grabbing pain that makes her (right) leg spasm... She needs... 2 assist to transfer... She walks (with) 2 assist." A [DATE] Interdisciplinary Care Plan Conference Record documented that the team discussed ADLs and falls, and included the following comments: "Ambulates by (wheelchair with) 1 assist - ambulated (with) front wheel walker/2 assist - (Physical Therapy and Restorative Nursing Aide) working (with) her... (history) of falls - has fallen here [DATE]... Room close to (nursing) station, monitor/assist when ambulating - likes (wheelchair) follow behind for frequent rests. Air overlay to bed." A [DATE] physician progress notes [REDACTED]. Physical Therapy has indicated that she is walking quite well but it seems that her knees occasionally 'give out' when she is ambulating in her room... She typically either forgets to call for staff or does not feel that she needs them, and she feels that the walker is too bulky and large to use in her room... Physical Therapy states she has reached her maximum rehab potential. The nurses will arrange for her four-point cane to be brought in that she can prop next to her and use in the room, and the patient has been asked to please call for nursing assistance when she is moving to help avoid any type of falls." Facility Incident/Accident Reports documented the following falls: * [DATE] at 4:00 AM - "Resident reports she rolled out of bed during sleep. Deep abrasion approximately 10 (centimeters) in length... and ,[DATE] (centimeter) in width noted to (right) shin... States she fell OOB (and) cut leg on bedside table... States she is (not) used to small bed. States she will sleep in center of bed from now on." * [DATE] at 3:20 AM - "States her air overlay mattress causes her to roll OOB (due to) uneven distribution... Air overlay mattress removed from bed... Egg crate placed." * [DATE] at 10:30 PM - "She was leaning against bedside table (and) lost balance (table slid away from her) causing her to slide from bed to floor... States she will try to remember to (not) lean on bedside table." * [DATE] at 5:55 AM - "Found sitting on floor beside bed - states 'I just slid out. I was asleep and the next thing I knew was on the floor...' States she is used to sleeping in king sized bed. States, 'I just need to get used to smaller bed...' (Family) wondering about side rails. Educated on risk of entrapment (with side rails). Decision to (continue) to monitor (and) place bed in low position when (resident) sleeping." * [DATE] at 10:10 AM - "Was trying to go from chair to bed. Slippers went out from under her. She fell right next to bed... bed in low position... Nightgown (and) slippers on, fit well. Trying to do transfer alone. (A staff member) was in room making beds... States she thought she could (transfer) short distance from chair to bed. Call light was in reach but she 'didn't want to be a bother.' Instructed (resident) in need to call for (assistance with transfers due to) weakness. She verbalizes understanding... No (changes) to (care plan at) this time." The DON was interviewed on [DATE] at 11:10 AM about the resident's history of falls at the facility, and whether the facility had implemented any interventions such as a lipped mattress or body pillow to help the resident be aware of the perimeter of the mattress, or to stay in bed. She stated, "We talked to her a lot about a scoop mattress and body pillow." She was asked to provide documentation of those conversations and considerations, but none was provided. No further information was received from the facility related to Resident #10's falls. 3. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated [DATE], documented the following: * Severe cognitive impairment - NOTE: Resident coded the same for the past year. * Delusions * Rejection of care * Extensive assistance requiring two persons for bed mobility and transfers * Extensive assistance requiring one person for dressing * Total dependence requiring two persons for personal hygiene and bathing * Falls since admission The resident's Care Plan (CP), dated [DATE], documented the following handwritten problem: Risk for falls/injury from falls r/t (related to) hx (history) of falls, dated [DATE]. Added under this problem was, "(Had fall on [DATE], [DATE], [DATE], slid from chair when reaching for item dropped on floor) (NOTE: This was initialed but not dated.) Interventions included: * Remind res (resident) to call for asst (assistance) for items out of reach. * Remind res to avoid lifting chair too high-can cause res to slide to floor. (see CP for injury r/t vision) * Attach tabs alarm when res given prn (as needed) psychotropics d/t (due to) (increased) fall risk. NOTE: According to the DON on [DATE] at 9:30 am, the tab alarms were to be used for the resident's wheelchair, and the recliner was added [DATE], although this was not dated in the Care Plan, and the bed alarm was a pressure alarm. * Provide assistance with x-fers (transfers)/amb (ambulation) when res has been given prn psychotropics.(Dated [DATE]) Physician order [REDACTED]. A review of the facility Incident/Accident Report forms for Resident #3 documented the following: * [DATE] at 1:00 pm- "...heard scream et (and) then a thump. Looked into res rm (room) et seen her laying on the floor (sic), walker near res. Res was holding can of juice in hand... [DATE] Res assessed per MD immediately following incident. No injuries noted. MD orders to monitor for (increased) unsteadiness r/t (increased) use of psychotropic med r/t agitation/anxiety...Staff instructed to (increase) monitoring/supervision from safe distance when res upset. Medication to be used as last intervention for anxiety." * [DATE] at 8:05 am-"Resident received (sic) am (morning) medications as ordered, as well as .25 mg (milligrams) Xanax for extreme agitation at (6:45 am). Resident then assisted with ADL's as needed, ambulated to BR (bathroom) per self et walker at (8:05 am), and (staff name) notified LPN that resident had fallen immediately in room...MD in to assess res., meds (medications) adjusted. CP (care plan) updated. Res to have tabs alarm attached when given PRN psychotropics. No other orders at this time. Monitor for cont (continued) or (increased) pain in R (right) hip. Notify MD if noted." NOTE: Mosby's Nursing Drug Reference 2010 documented the following for Xanax: Onset: 30 minutes, peak: ,[DATE] hours, duration: ,[DATE] hours, half life: ,[DATE] hours. * [DATE] at 3:25 pm Resident's condition before incident/accident: "Calm, resting in recliner in room." "DNS et RN were at nurses station. Heard 'thump' from (Room number). Observed res lying on floor in entrance to BR and head facing bed and legs inside BR. Res (complains of) pain in R hip/pelvic area when hip palpated. (vital signs) taken per RN...MD notified et ordered to (transport) to (emergency room ) per gurney...X-ray obtained in ER et stable pelvic (fracture) identified... Noted severe pain upon weight bearing. Pain meds (administered) per (LN).." "Bed alarm placed to bed to alert staff to attempts to rise unassisted. Q 1 hour (every hour) repositioning schedule initiated. (Increased) monitoring et assist with x-fers et amb until further notice." NOTE: The Care Plan was revised to include a bed alarm on [DATE]. NOTE: The [DATE] MAR documented the resident received Xanax 0.25 mg at 11:50 am for "yelling, anxious, agitated." This fall occurred approximately 3.5 hours after the resident had been given Xanax, a prn psychotropic. The Incident/Accident Report from [DATE] stated the resident was to have a tabs alarm attached when prn psychotropic medications were given but it was not documented as being attached or sounding at the time of the fall. In addition, increased monitoring and supervision had been ordered in the prior Incident/Accident Report conclusions, but was not documented in the chart. The resident was harmed when she fell after receiving Xanax and suffered a right superior ramus fracture. This caused pain and affected her ability to bear weight and ambulate after the injury. In addition, the resident fell on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The [DATE] and [DATE] falls documented no bed alarm sounding, and the [DATE] and [DATE] falls documented no tab alarms sounding. The facility failed to implement and revise interventions to prevent Resident #3 from falling, even after a fall which resulted in a fracture. The Administrator and DON were informed of these issues on [DATE] at 4:00 pm. No further information regarding this issue was received from the facility.

Based on a review of the facility's Fall Scene Investigation Reports (FSIR), Incident/Accident Reports (I/A), record review and staff interview, it was determined the facility failed to ensure that: * Resident #10 was re-assessed for side rail safety after a fall involving the side rails. * Resident #8 was not left unattended in bed during perineal care. These failed practices involved 2 of 6 residents (#s 8, & 10) reviewed for incidents and/or falls. This failed practice had the potential to place residents at risk for future falls, pain and injury. Findings included: The facility's Plan of Correction, with the compliance date of 5/12/12, for the recertification survey conducted on 4/12/12 for F323 documented in part: "...A fall risk assessment will be complete on admission (,) quarterly and with any change in condition..." 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 3/5/12, coded a BIMS score of 15 and her 14-day MDS assessment, dated 3/11/12, coded a BIMS score of 14. The resident's most recent quarterly MDS, dated [DATE], coded the resident had a BIMS score of 13 and required physical assistance of two or more persons for bed mobility, transfers and toilet use. She had one fall since her admission to the facility. Resident #10's Physician order [REDACTED]." The resident's Long Term Care Plan documented the problem, dated 3/12/12, "Injury Risk At risk for injury from falls r/t (related to) weakness and sciatic nerve pain aeb (as evidenced by) recent history of falls." An intervention, dated 4/30/12, was, "Fall OOB (out of bed). Family req(uests) 3 SR (3 side rails up) (2 (up) on R(ight) side-facing window 1 (up) on L(eft) side-toward door). SR eval(uation) complete-order received from MD (physician)." Resident #10's most recent Side Rail Evaluation Screen form, dated 5/1/12, documented the side rails "fit the mattress well" and that the resident "is observed using them safely/effectively." An Incident/Accident Report, dated 5/17/12 at 6:10 pm, documented, in part, "Resident found lying on bed on back with legs hanging off bed. L(eft) thigh wedged between bed and bed railing...Repositioned resident back into bed. Alert et (and) oriented. When asked what she was trying to do resident reports 'I don't know. I was just trying to do it myself.' No bruising or injury noted. Resident had c/o pain in back (all over) and legs bilaterally. Norco given....side rails in place...encouraged to call for help. DNS notified - 2000 (8:00 pm.)" The ADNS wrote the following: "Resident reported that she was attempting to get up per self. Tabs alarms were on Resident did not fall. She was lying on bed with feet on floor. Continue with plan care (sic) at this time. Remind resident to use call light. Encourage her to allow staff to assist her when she wants up. Continue (with) tabs alarm." A Fall/Incident Review form documented Resident #10 fell in her room, "all but feet were in bed." The "plan to prevent future occurrences" area on the form documented, "continue with care plan." On 6/5/12 at 3:00 pm, the DNS was asked if Resident #10 was reassessed for the use of side rails after the fall on 5/17/12 described above. The DNS said, "Probably not." She did agree that Resident #10 should have been reassessed for side rail safety after the 5/17/12 fall involving the side rails. The DNS stated a Care Conference was held 6/5/12 and the family agreed that the 3 side rails should remain in place. The Interdisciplinary Care Plan Conference Record recorded, "...3. family is okay (with) interventions for falls. 'Rails up are good - better her leg gets caught - than falling out of bed.' " The DNS said Resident #10 would be reassessed for the use of side rails. 2. Resident #8 was admitted to the facility on [DATE]. Her most recent quarterly MDS, dated [DATE], identified active [DIAGNOSES REDACTED]. Her BIMS score was "15." She required two+ persons physical assist for bed mobility, transfers, and toilet use. The MDS described "toilet use" as, "How resident uses the toilet room, commode, bedpan or urinal..." A FSIR, dated 5/17/12 at 6:50 am, documented the following in part: "Res(ident) rolled to L(eft) sided for peri-care (perineal) care. CNA stepped to sink for more wipes et (and) res rolled OOB (out of bed) ..." NOTE: Resident #8 did not require emergent care following the incident. The report also contained a handwritten statement by the CNA, dated 5/17/12, which documented in part: "...I grabbed a wipe & rolled her to her left side as she grabbed side rail w/ (with) her right hand...told (Resident #8) I needed another one (wipe), went into the bathroom to get it...heard her say something I ran out of bathroom found her on the other side of bed on the floor her body laying on her right side. Top rail of bed was up on left side..." Resident #8's care plan, with the review date of 4/3/12, directed in part: * "Needs 3 person physical assistance for transfers to and from BSC (bedside commode)..." * "Needs extensive assistance with bed mobility. Encourage her to use the small top handrail to assist with repositioning from side to side in bed. She rolls to the left easier than the right..." NOTE: The care plan did not identify what "extensive assistance" for bed mobility meant for the staff and did not specify if the extensive assistance was required during bedpan toileting. Resident #8's care plan was revised on 5/17/12 following her fall out of bed to include: * "Needs 2 person asst to et (assistance to and) from BSC." * "Needs 2 person assistance with bed mobility" * "2 person asst (with) bed mobility/bed pan." Resident #8's PPNs documented that after the 5/17/12 incident staff continued to perform bedpan assistance with only one staff on the following dates/times: 5/17/12, 2:40 pm and 9:29 pm; 5/18, 6:14 am; 5/20, 2:32 am; 5/22, 1:44 am; and 5/25, 2:36 am. The following PPNs did not include any documentation on how many staff provided assistance during bedpan toileting: 5/21/12, 12:52 am, and 8:56 pm; 5/22, 9:09 pm; and 5/23, 12:59 am. During an interview with the DNS on 6/6/12 at 2:20 pm, she stated the following: Prior to the incident, Resident #8's care plan directed 1 to 2 staff assist for bedpan toileting; The resident could roll side to side with one aide; Resident #8's care plan was updated to ensure two staff assisted the resident during bedpan toileting. The DNS was informed that review of the PPNs revealed at least six times when a CNA documented only one person assist during bedpan toileting. The DNS stated, "No, that shouldn't have been...It was put on the EMR "white board screen" that she needed two assist with bedpan use."

Based on observation, staff interview and record review, it was determined the facility failed to prevent pressure sores from occurring in their residents. The facility harmed two (#s 4 & 5) residents as a result of failed practice. * The facility failed to prevent, care plan and provide timely treatment for [REDACTED]. * The facility failed to prevent two Stage II pressure sores from developing after it healed a Stage I pressure sore for Resident #5. The facility failed to care plan for prevention and integration of pressure sore cares with Hospice services. The facility had 3 of 9 (#s 2, 4, and 5) sampled residents with pressure sore problems. Findings include: 1. Resident #4 was admitted to the facility 10/18/10 with [DIAGNOSES REDACTED]. The most recent significant change MDS assessment, dated 1/18/11, documented the resident: * Had short and long term memory problems, * Had severe cognitive impairment, * Had behaviors of: inattention, altered level of consciousness and psychomotor [MEDICAL CONDITION] that fluctuated on a daily basis, * Was moderately depressed, * Required total assistance of one to two staff for transfers, dressing, eating, personal hygiene and bathing, * Was occasionally incontinent of bowel and frequently incontinent of bladder, and * Had a Stage IV pressure sore. The admission MDS assessment, dated 10/24/10, documented that the resident did not have a pressure sore (M0210 = no) The residents' medical record documented a physician's orders [REDACTED]." The facility nursing notes, "Hourly Rounding Log," documented that the resident had the lap buddy in place to keep the resident in the wheelchair. The lapbuddy was noted on the logs starting, 11/27/10, 11/29/10 to 12/16/10 and 12/26/10. The resident's medical record contained two areas of documentation. All nursing documentation was completed on the "Nursing Notes" form. There was day to day nursing documentation in the medical record and the skin nurse had separate documentation in a skin notebook. The chronological events were extracted from both areas. The "Nursing Notes" documented the following: * 11/23/10 - "Pressure ulcer risk assess ... @ (at) this time, no other skin issues... egg crate on bed, foam gel in w/c(wheelchair), repositioned q(every) 2 (hours) and toileted q 2 (hours)." (Of Note: "egg crate" mattress is no longer a standard of practice for pressure relief.) *12/9/10 (6-2) (6:00 am to 2:00 p.m.) - "Resident has 2 small blisters over the coccyx in the crack of buttocks. Blisters are red, not open or draining at this time. Blisters are aprox (approximately) 2 mm (millimeters) in size, Alldress dressing placed over blisters, surrounding skin blanchable, red [MEDICATION NAME] applied to surrounding skin." *12/11/10 (10-6) (10:00 p.m. to 6:00 a.m.) - "Resident has 2 blisters on coccyx open et (and) red...." * 12/11/10 - "Resident slept in the recliner all shift...Dressing is C/D/I (clean/dry/intact)...Resident not responding appropriately, had to use lift to get resident out of chair and into bed...." * 12/12/10 (6-2) - "...Dressing to coccyx C/D/I.... Tabs alarms on along (with) lap buddy for safety. Able to 'ambulate' about the facility in w/c per self." * 12/13/10 (2-10) - "Dressing to coccyx is dry + (and) intact, repositioned q 2 (hours), off of coccyx in bed...." * 12/15/10 (6-2) - "Dressing to coccyx was changed long 2 cm (centimeter) x 1 cm dark purple area noted in crack of buttocks it was reported resident had a couple of Stage II pressure sores that were tunneled together, this area does appear to (be) one ulcer now that has no superficial skin covering, bed is purple in color as well + does not blanch, on right buttock just above anal opening there is another open area 1 cm in diameter + 1 mm deep, base is pink, both areas were cleaned (with) NS (normal saline)...." * 12/15/10 (2-10) - (7:00 p.m.) "CNA's reported to nurse 2 open areas on scrotum. Assessed per RN et DNS [MEDICATION NAME] applied...." * 12/17/10 (10-6) - "...Repositioned q 2 (hours) Applied new [MEDICATION NAME] border sacrum dressing, (after) cleaning (with NS + applying normalgel. Large open area in crack of buttock also breakdown on R (right) buttock...." * 12/18/10 (6-2) - "Dressing to coccyx changed x 3, incontinent of stool every hour, repositioned q 1 (hour) from side to side, breakdown to coccyx has increased a lot over past couple of days. Stage II ulcer to coccyx is open 3 1/2 cm in length x 2 cm width yellow wound bed with possible tunneling, there is another red area several small open areas that extends from open coccyx down to 1 cm above anus + around to R butt cheek, area was cleansed... education about the cause of pressure ulcer formation, prevention + repositioning was taught to both the 6-2 CNA's + the 2-10 CNA's, will continue to monitor." * 12/20/10 (10-6) - "Dressing on coccyx (changed), large amt (amount) of foul odor discharge noted...." * 12/21/10 - "Coccyx is much worse today see skin assess notes...." * 12/21/10 - "Pressure ulcer risk assess score 23 this month (increase) from 18 the previous month. This is d/t (due to) the development of a 7 1/2 cm x 2 cm x 1/2 cm Stage II pressure ulcer affecting the coccyx and right buttock, tissue inside ulcer is yellow and slough is present...." * 12/22/10 (6-2) - "Dressing to coccyx was changed using sterile technique, cleaned wound with wound cleanse, applied Hypergel, packed with mepital (with) border ulcer is 7 1/2 cm x 2 cm x 1/2 cm, yellow slough noted in wound bed with pink granulation around outer edge...." * 12/25/10 - "Coccyx dressing was changed this AM, granulation tissue noted on distal tip of ulcer, the superior portion of the ulcer looks as if it (is) starting to tunnel under the skin on the lateral edges...." * 12/27/10 (6-2) - "...dressing (changed) first thing this AM. Odor foul...Skin team to assess for wound vac use later today...." * 12/27/10 - "Wound assessed per DNS. Presents as stage III mod(erate) amt greenish colored drainage noted - foul odor, res(ident) winces in pain when dressing (changed) or repositioning occurs. Musculature tissue noted, yellow slough present despite debridement (with) Hypergel...." * 12/28/10 (6-2) - "Resident drsg(dressing) (changed) drainage/ moderate amount; yellow/brown/noted. Eschar noted. (No) tunneling noted. Foul odor noted. Sloughing noted... wound is 8 1/2 cm long; 3 cm wide; et 1 1/ cm deep. Resident is very tender in area... repositioned off coccyx q 1 (hour) et prn...." * 12/29/10 (6-2) - "...Kept in bed other than meals to offload Stage III pressure ulcer...." * 12/29/10 (2-10) - "...Small amount of bleeding noted on lower end of ulcer. Foul odor noted, pink tinged sanguinous drainage from wound, moderate amount, wound bed black eschar with yellow slough noted. Peri wound reddened, slow to blanch, painful noted...." * 1/1/11 1:00 p.m. - "Dressing for wound vac was changed d/t soiling under the distal border, wound underneath appears to (be) healing, distal border is pink with new granulation noted in center of ulcer it has begun to tunnel 2 cm deep up towards 12 o'clock superior, 1/2 of ulcer is grey in color with granulation noted around edges of wound bed, area was cleaned...." * 1/3/11 (3:00 p.m.) - "Dr (name) office called with orders to start [MEDICATION NAME] 500 mg(milligram) one orally q day x 10 days...." * 1/5/11 (11:30 a.m.) - "Wound Vac was removed + resident was given tub bath... wound was measured 8 cm x 3 cm x 2 cm deep, undermining noted 3 o'clock to 9 o'clock, measuring width of 3 1/2 cm. RN reported just prior to getting into the tub they had removed a black eschar about 4 cm in diameter from center of wound bed, RN reported the eschar was free floating over wound held on by small piece of slough, distal tip of ulcer which wraps around the right buttock is pink, very superficial @ this point + is healing area is about 2 cm x 1 cm the base of the ulcer is over the coccyx, 2 cm of muscle noted on L (left) internal wall, small amount of slough noted in center of ulcer, no bone or other underlying tissue is seen or felt @ this time. There is no tunneling noted @ this time pink granular tissue noted in wound bed + around outer edges,... Pictures were taken see skin book. Tissue surrounding pressure ulcer is dark pink in color + blanches, drainage is brown/tan in color with foul odor, will continue to monitor changes." * 1/10/11 - "Pressure ulcer risk assess score is 28 this month d/t development from Stage II to a healing Stage IV, Wound Vac dressing was changed... measures 7 1/2 x 3 1/2 x 2 1/2... no slough is noted in center of ulcer, good beefy red tissue is noted through out the ulcer... no bone or muscle noted in wound bed... no s/s (sign or symptom) of infection, ulcer is currently staged @ a healing Stage IV, strict repositioning q 1 (hour) side to side...." The nursing wound documentation continued on a Monday, Wednesday and Saturday schedule with a description of the Stage IV pressure ulcer and treatments provided. On 3/16/11 at 10:45 a.m., the pressure sore was observed and measured 3 cm long by 1.8 cm wide by 1.8 cm deep. The tissue was pink and there was no s/s of infection noted. The Wound Vac dressing was changed at the time. During the survey the resident was on bed rest, and staff were observed to reposition the resident about every hour. The resident's "Long Term Care Plan" dated 1/20/11 documented a problem of: "Breakdown pressure ulcer to coccyx." The goal was: "Pressure ulcer to coccyx will heal by 4/12/11." The documented interventions were: "1. Assist with repositioning at least every hour and prn avoiding pressure to coccyx. Reposition 15 - 30 minutes in wheelchair. Avoid prolonged sitting in wheelchair. 2. Skin assessment weekly. Report any new issues to MD promptly. 3. Weekly measurements and photos of pressure ulcer. Wound Vac as ordered. Dressing changes Mon., Wed., and Sat. PRN as needed. 4. Good peri care after toileting and episodes of incontinence. 5. Foam cushion to wheelchair. 6. [MEDICATION NAME] with meals and snacks. 7. Nutritional consult as needed. 8. Feed resident meals. 9. Air overlay to bed 1/26/11." During the morning cares of Resident #5 on 3/15/11 at 8:05 a.m. two CNAs were observed to transfer the resident into a wheelchair. The wheelchair had a hard seat and did not have a "foam cushion" as care planned. On 3/17/11 at 11:00 a.m. the DON and wound nurse were interviewed about the events that resulted in a Stage IV pressure sore. The wound nurse indicated that the resident was, "incontinent of urine and sometimes was combative when he was in the recliner." The wound nurse worked at both the nursing home and the hospital. She indicated that she did not see the sore from 12/9/10 until 12/13/10. The wound nurse said that there were, "two blisters on the 9th (12/9/10) then real bad on the 21st (12/21/10).... I had to crack down with staff." The resident's spouse and son were interviewed on 3/16/11 at 2:00 p.m. They were asked why they thought the resident had a pressure sore. The spouse responded, the resident "spent too much time in the wheelchair" after the lap buddy was ordered. The family had requested that staff take him out of the wheelchair and put him in the recliner more often; this was what they used to do at home before he was admitted . 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 2/1/11, documented that the resident: * Had short and long term memory issues, * Was moderately impaired for decision making, * Required extensive assistance of two staff for transfers, ambulation, dressing, * Required total assistance of one staff for eating, personal hygiene and bathing, * Was continent of bowel and frequently incontinent of bladder, * Had daily fluctuations in behaviors of inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION], * Had nearly daily moods of; little interest or pleasure doing things, feeling tired or having little energy, poor appetite, trouble concentrating on things, and being short tempered and easily annoyed, * Had a trunk restraint in place, and * Had a Stage II pressure sore that was acquired on 1/10/11. The resident's medical record contained two areas of documentation. All nursing documentation was completed on the "Nursing Notes" form. There was day to day nursing documentation in the medical record. The skin nurse had separate documentation in a skin notebook. In addition, the Hospice nurse documented in a separate area in the medical record. The chronological events were extracted from all three areas. * 8/14/10 - "...previous spot on coccyx clear and blanching well...." * 8/30/10 - "... Pt (patient) has redness on inner L buttocks...." * 9/8/10 - "... Noticed buttocks et coccyx area is very red. Staff stated they are applying aqua 4 to area...." * 9/21/10 - "Skin assessment complete. Buttock area (with) some redness to coccyx. Areas blanch easily. No open areas noted...." * 9/28/10 - "redness on buttocks is better today...." * 9/28/10 - "Pressure ulcer risk score of 23 red rashy blotches noted on face... (no) other skin issues noted, air overlay mattress in place, gel foam in w/c repositioned q 2 (hours)...." * 10/19/10 - "Dressing applied to coccyx - area red, not open still blanchable...." * 10/26/10 - "Pressure ulcer risk score of 34 this is up since score of 23 last month d/t resident developing 3 red areas on coccyx that are 1 1/2 cm x 2 cm, they do not blanch, dressing to coccyx was changed, no open areas noted...." * 10/28/10 (6-2) - "Resident dressing to coccyx off the am. CNA's came to report it. Dressing placed to protect skin until such time as Hospice comes to treat as ordered." * 11/4/10 (6:30 a.m.) - "Skin assessment not completed @ this time d/t resident resting comfortably on 10-6 shift. Annaphor (sic) applied to coccyx d/t redness and risk of breakdown...." * 11/23/10 - "... Coccyx this month is pink with no unblanchable red areas, no open areas noted...." *12/21/10 - "... Coccyx is red but blanches with no open or unblanchable areas heels are slightly spongy + elevated off of surfaces... [MEDICATION NAME] applied to coccyx buttock area...." * 1/9/11 - (3:15 p.m.) - "... Report received from previous shift skin nurse ... that res(ident) has a Stage II pressure ulcer on coccyx et drsg (dressing) was (changed)... C/D/I (no) drainage...." * 1/10/11 - "Pressure ulcer risk assess score #37 up from 32 last month d/t development of 2 Stage II pressure ulcers. 1 is directly over coccyx + measures 1 cm in diameter the second is @ 1 o'clock from coccyx and measures 1/2 cm, the skin around both areas blanch well + is pink, no s/s of infection are noted, dressing of [MEDICATION NAME] (with) border was applied, heels are not spongy this month...." * 1/10/11 (6-2) - "... (family member) in to see, upset because she wasn't told about her mom's coccyx wound, Dressing on coccyx C/D/I...." * 1/10/11 - "... Pt (patient) has dressing on coccyx for superficial wounds, still applied barrier cream...." (Hospice CNA) * 1/11/11 - "...Drsg to coccyx C,D,I no drainage noted." (Hospice RN) * 1/11/11 (10-6) - "... Dressing to coccyx is dry + intact...." * 1/13/11 (6-2) - "... Hospice aide here to bath resident, reports drsg C/D/I et denies further areas of breakdown...." * 1/14/11 (10-6) - "... Dressing on coccyx Dry + intact...." * 1/17/11 - "... (changed) dressing on coccyx, sure looks better (no) redness seems to be healing well, not open...." (Hospice CNA) * 1/20/11 - "... Drsg to coccyx clean, dry, intact...." (Hospice RN) * 1/25/11 - "... (checked) pt coccxy (sic) wound. It's closed + drsg taken off...."(Hospice RN) * 2/8/11 - "Pressure ulcer risk assess score 32 this month (decrease) from 37 last month d/t healed stage II pressure ulcer on coccyx, butt cheeks and coccyx are pink, blanch easily (with) no other signs of breakdown...." The residents' care plan, dated 11/19/10 and reviewed 2/2/11, documented, "LTC Problem: At risk for skin breakdown R/T frequent incontinence - functional and cognitive impairment AEB (as evidenced by) resident is incontinent qd but does have some control at times. and history of pressure ulcers." The interventions were: "1. Resident wears depends and liners. 2. Toilet resident first thing in AM: (after) breakfast.... 3. 2 assist with toileting - resident is dependent on staff for all toileting and peri care. 4. Reposition resident every 1-2 hours in bed, every 30 to 60 minutes in recliner and every 15 - 30 minutes in wheelchair. 5. Monitor skin for any redness, irritation, or odor. Report promptly to nurse if noted. * Use term 'rest room' rather than bathroom to assess need for toileting. * Barrier cream to buttocks, coccyx (after) toileting. * Apply lotion to dry, fragile skin daily and (after) bathing." On 3/16/11 the resident was observed to be seated in the recliner during the day except when she was transferred to a wheelchair for meals and to use the bathroom. The resident was under constant observation from 9:00 a.m. until 10:30 a.m. seated in a recliner. The resident was not repositioned as care planned. At 10:30 a.m., two CNA's transferred the resident to a wheelchair and she was taken to the bathroom which took the staff about 10 minutes to complete. On 3/16/11 at 11:10 a.m. the DON and wound nurse were interviewed about the resident's pressure sore. The wound nurse indicated the Hospice staff cared for the pressure sore. She also indicated that they used [MEDICATION NAME] as a treatment, which was not her dressing of choice. The Hospice failed to have a care plan available and failed to have descriptive characteristics of the wound and surrounding skin. The description's available for review were from the monthly wound rounds that the wound nurse did. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 12/29/10, documented the following: * Severely impaired cognitive skills for daily decision making * Extensive assistance requiring at least one person physical assistance for bed mobility, transfers, toilet use, and personal hygiene * Limited assistance requiring at least one person for physical assist for walking in the room or corridor, and locomotion on the unit. * Indwelling catheter * Two Stage 2 pressure ulcers * Trunk restraint used daily a. A physician's progress note, dated 9/30/10, documented the resident had a non-palpable dorsalis pedis and posterior tibial pulse in her left foot. The physician further stated this (left great toe ulcer) may be a vascular insufficiency issue. This ulcer was coded on the most recent quarterly MDS assessment, dated 12/29/10, as a Stage 2 pressure ulcer. On 3/16/11 at 9:20 am, LN #4, identified as the facility wound nurse, reported the doctor had later stated the ulcer on the left great toe was an arterial ulcer due to vascular insufficiency and not pressure related. When asked if any arterial studies had been performed, she stated they had not. The only documentation was the physician assessment of absent pedal pulses for the resident. The facility's Daily Skilled Nurse's Note, dated 3/15/11, documented in the section titled, "Skin," a handwritten note, "arterio ulcer L (left) gr (great) toe." The left great toe was observed during a dressing change on 3/16/11 at 10:00 am. The surveyor observed a superficial scab which came off when cleaned with normal saline. Iodosorb was applied to the wound and a bandaid applied. LN #4 was asked if the resident was wearing shoes at the time the wound occurred and she replied the resident had been wearing shoes but after the discovery of the wound, the resident was placed in slippers and a bed cradle used when the resident was in bed, to reduce any friction or pressure on the feet. b. Resident #2 developed a Stage 2 pressure ulcer to her left thigh from the leg bag straps to her indwelling foley catheter. Nurse's notes, dated 12/25/10, documented, "...There is a blister on L thigh from leg bag straps. An alldress (dressing) was applied for protection..." On 1/21/11, a Daily Skilled Nurse's Note documented, "Drsg (dressing) to L thigh DC'd (discontinued). blister is gone (with no) scab, just red area where blister was...." On 3/17/11 at 3:00 pm, the MDS Coordinator was interviewed with regards to the coding of the two Stage 2 pressure ulcers on the most recent quarterly MDS assessment. She verified she had coded the left great toe ulcer as a Stage 2 pressure ulcer as that had been the information at the time, and also the left thigh blister as a Stage 2 pressure ulcer. The Interdisciplinary Care Plan Conference Record (ICPCR), dated 1/5/11, documented under Care Areas Reviewed, "#16 Pressure Ulcer," with comments, "Risk Assessment score 25. L great toe improved 1/2 cm (centimeter) x 3/4 cm scab. Bed cradle. No socks at this time." Other concerns listed were, "Reposition her to prevent pressure ulcers." Under Action Plan was documented, "No socks at this time. Keep pressure off toes - Bed craddle (sic) to bed." There was no specific care plan for pressure ulcers other than the ICPCR. The DON and MDS Coordinator were informed of these issues on 3/17/11 at 5:30 pm. No further information was received from the facility.

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents received adequate supervision and care planned interventions to prevent falls, or to consistently implement interventions necessary to prevent further falls. This related specifically to Resident #1, who fell twice in a 24 hour period and suffered a fracture requiring emergency hospital evaluation, and resulted in harm to the resident. Resident #6 sustained 2 falls where the care planned intervention which required three people for transfers was not followed. This affected 2 of 8 (#10 and #6) sampled residents reviewed for falls. Findings included: 1. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated [DATE], documented the following: * Short and long-term memory problems * Moderately impaired cognitive skills for daily decision making * Easily distracted * Periods of altered perception or awareness of surroundings * Mental function varies over the course of the day * Usually understood and usually understands others * Limited assistance requiring one person for physical assistance with bed mobility, dressing, and toilet use * Independent requiring no set up or physical assistance from staff with transfers or walking in the room * Supervision requiring one person for physical assistance for walking in the corridor and eating * Not able to attempt test for balance while standing without physical help * Maintained position to test balance while sitting * Continent of bowel and bladder * fell in past ,[DATE] days The resident's Plan of Care, dated [DATE], documented the following: * [DATE] Problems/Strengths: Potential for injuries from falls due to recent history of falls and confusion secondary to Alzheimer's. Interventions included some of the following: - Monitor (resident) for steadiness and balance. - Chair alarm in room. Provide (2 person) assist as needed when resident (is) up and ambulating. NOTE: Bracketed information was handwritten on care plan. The Plan of Care, dated [DATE], also documented the following Problem/Strength: * [DATE] Problems/Strengths: At risk for deterioration in ADL function and stability due to confusion related to Alzheimer's. Interventions included: - (Resident ambulates in room independently) (NOTE: This bracketed entry had a line drawn through it with no date or initials when it was discontinued.) She requires (supervision from staff) (NOTE: This bracketed entry had a line drawn through it with no date or initials when it was changed or discontinued.) often with assistance at times of confusion or unsteadiness, and to locate were (sic) she is going throughout the facility. (Handwritten note in the margin, with no date or initials when it was added to the care plan) 2 person asst (assist) (with) amb (ambulation), 1 person asst (with) xfe (transfers). NOTE: These care plan interventions were different than the documentation on the MDS assessment which stated the resident was independent and required no set up or physical assistance for transfers or walking in her room. The DON stated in a fax received on [DATE] at 6:00 pm, that the Interdisciplinary Team reviewed the resident's decline in condition on [DATE], and made the decision to move the resident to a private room located directly across from the nurse's station for closer observation. They also added a chair alarm to be used when she was in her room, with one person for physical assistance for transfers during times of unsteadiness and confusion. A facility Incident and Accident Report for Resident #10, dated [DATE], documented the resident fell on that date at 4:40 pm. The report documented, "What was the resident doing when staff member last saw him/her? Bending over getting stuff out of cubboard (sic) under TV." In the section titled, "Please describe below exactly what happened," the following was documented: "LPN was sitting (at) desk and looked up et (and) saw res (resident) bent over et then loose (sic) her balance et fall to floor landing on R (right) arm et R leg, head never appeared to have touched the ground. LPN et RN ran into rm (room) et sat Res (up) on floor-took VS WNL (vital signs within normal limits) BP (blood pressure) ,[DATE] O2 (oxygen saturation) 93 (percent) HR (heart rate) 84. R (resident) c/o (complains of) R arm pain-LPN assessed et found sm (small) old scab bleeding-(no) swelling, bruising or abrasions noted. Res denies pain in R leg... [DATE] Res fell again this AM. Repts (reports) pain in R hip et difficulty with amb. Call in to MD et family for f/u (follow up). No pain throughout noc (night) but difficulty with amb et reports of pain this AM prior to 2nd fall. No bruises to arms, legs, hips, buttocks or back. See rept (report) for [DATE](signed by DON)." A facility Incident and Accident Report for the resident, dated [DATE], documented the resident fell on that date at 11:50 am. The report documented, "What was the resident doing when staff member last saw him/her? Sitting on floor in front of door (door was closed) with her underwear down around ankles, garbage can at her side." In the section titled, "Please describe below exactly what happened," the following was documented: "Resident was found on the floor in front of her door to the room. Her underwear was (sic) down around her ankles. She was a bit fearful, et tearful, confused, stated "it wouldn't stay up-kept moving around." Assumption made that resident was confused and thought garbage can was her toilet. VS taken on ground et up in chair. Stable...c/o R hip hurting this AM-report by (staff CNA) et c/o lower back and general all over pain at this time. Able to ambulate with one assist. MD notified. No new orders at this time-wait et watch-call if change in condition (need x-ray? etc.)..XXX[DATE] Res assessed per DNS-no bruising to arms, legs, hips, buttocks or back. Does c/o R hip pain. Call placed to MD et family for f/u." In the section titled, "Conclusion," the following was documented: "X-ray revealed pelvic fx (fracture). Res treated in ER (emergency room ) et released back to SNF. Res likely thought garbage can was commode et attempted to urinate in can, fell to floor when can tipped. CP (care plan) updated with new problem, goal et interventions. PT (physical therapy) ordered for strengthening. Still uncertain whether fx is new or possibly old. (signed by DON)" The resident's MAR, dated [DATE], documented the following pain medications: * Order date: [DATE] Tylenol 500 mg (milligrams) ,[DATE] tablets po (by mouth) every 6 hours PRN (as needed) for mild pain. * Order date: [DATE] Naproxen 500 mg po BID (twice daily) for pain. * Order date: [DATE] Ultram 50 mg ,[DATE] tablets po every 8 hours PRN for pain. (changed [DATE]) * Order date: [DATE] Hydrocodone ,[DATE] mg 1 or 2 (tablets) PO TID (three times daily) PRN for moderate to severe pain. * Order date: [DATE] Tramadol 50 mg ,[DATE] tablets Q 6 (every 6 hours) PRN for pain. The resident's MAR, dated [DATE], documented the following additions or changes to pain medications: * Order date: [DATE] Duragesic patch 50 mcg/hr (micrograms per hour) for pain. (Check) Q (every) shift. (change) Q 72 hours. The resident's MAR, dated [DATE], documented the following addition/change to pain medications: * Order date: [DATE] Duragesic patch 75 mcg/hr for pain. (check) placement Q shift, (check) pain q shift. (Change) Q 72 hours. A Daily Skilled Nurse's Note, dated [DATE], documented, "...1 assist with ambulation and ADL's, feeds self, need (sic) reoriented throughout the day, denies pain at present..." Nursing Notes, dated [DATE], documented, "...C/O (complains of) R hip pain this a.m. before (Staff CNA) got her up for the day. C/O lower back pain et generalized pain...Limp noted on ambulation." The MARs for Resident #10, documented she received the following pain medications after she fell : * Lortab (hydrocodone): Administered on ,[DATE] twice, ,[DATE], ,[DATE] twice, ,[DATE]-,[DATE], ,[DATE], ,[DATE] three times, ,[DATE] twice, ,[DATE], ,[DATE] twice, ,[DATE] twice, ,[DATE] twice, ,[DATE] twice, ,[DATE] three times, ,[DATE], ,[DATE] three times, ,[DATE], ,[DATE], ,[DATE] twice, ,[DATE], ,[DATE] twice, ,[DATE] twice, ,[DATE] twice, ,[DATE] three times, ,[DATE] twice, ,[DATE] twice, ,[DATE] twice, ,[DATE] three times, ,[DATE] twice, ,[DATE] twice, ,[DATE], ,[DATE], ,[DATE] twice, ,[DATE], ,[DATE], ,[DATE], ,[DATE] twice, ,[DATE] three times, ,[DATE], ,[DATE], ,[DATE] twice, ,[DATE] three times, ,[DATE] three times, ,[DATE] twice, ,[DATE], ,[DATE], ,[DATE], ,[DATE] three times, ,[DATE], ,[DATE] three times, ,[DATE], ,[DATE] twice, ,[DATE], ,[DATE], and ,[DATE] * Ultram (tramadol) 50 mg: Administered on ,[DATE], ,[DATE], ,[DATE], ,[DATE] twice, ,[DATE], ,[DATE], ,[DATE], ,[DATE] twice, ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE] * Tylenol 500 mg: Administered on ,[DATE], ,[DATE] twice, and ,[DATE] NOTE: The resident expired on [DATE]. In a physician's progress note, dated [DATE], it was documented, "...Apparently since the patient fell approximately one week ago and has a fractured pelvic ring, her condition has declined..." In a later physician progress notes [REDACTED]. We thought maybe some of it was pain related to her pelvic fracture, so we have increased her Duragesic which has maybe helped somewhat." In a Death Summary note, dated [DATE], the physician stated, "...Several months prior to her death, the patient had a fall, sustaining a pelvic ring fracture, and since that time her mobility and mental status have worsened. She required stronger pain medication and her behavior became more of an issue with increased anxiety... Her condition continued to worsen where she was sleeping more often and she subsequently succumbed on [DATE]...." In a fax received from the DON on [DATE] at 6:00 pm, she verified the resident did not have her care-planned intervention of a chair alarm in place at the time of either the first or second fall. The Incident and Accident Report for the first fall stated the resident was in line of sight of a nurse sitting at the nurse's station, and the care-planned chair alarm would have alerted the nurse the resident was attempting to ambulate without assistance. The resident reported pain in her right hip when she was receiving morning cares the morning after the first fall, but no immediate assessment was found. The second fall did not have the care-planned chair alarm in place and the resident's door was shut, according to the Incident and Accident report. This precluded the staff from keeping close observation of the resident, and they were unaware of her confused mental status that morning. Her care plan required supervision with ambulation but with no chair alarm to alert them and the door closed, the facility was unaware of her attempt to toilet herself with an altered mental status. The resident was harmed when she sustained the pelvic ring fracture and suffered a physical decline, requiring multiple medications for pain management prior to her death nine weeks later. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated [DATE], documented the following: * Cognitively intact * Extensive assistance requiring at least two persons for physical assistance with bed mobility, transfers, and toilet use * Walking in the room or corridor did not occur * Limited assistance requiring one person for physical assistance with locomotion on the unit and personal hygiene * Frequently incontinent of urine * Occasionally incontinent of bowel * Not steady, only able to stabilize with human assistance for moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers * Functional limitation in range of motion on both lower extremities The resident's Care Plan Review, documented the Problem, "Potential for injury from falls r/t (related to) hx (history) of falls," dated [DATE] and [DATE]. Interventions included: "1. Mechanical lift for transfers between bed and wheelchair. 2. (Three) person assistance needed for transfer to and from wheelchair and BSC (bedside commode). Resident's knees tend to buckle without warning. Assure wheelchair or commode behind resident during transfer in case of knees buckling. Resident becomes progressively weaker throughout day. May need to use bedpan during periods of extreme weakness. 3. Requests safety belt in wheelchair. Resident is able to fasten/unfasten safety belt independently. 4. Resident is able to call for assistance as needed. Does not attempt to transfer or stand unassisted. Assure call light is within reach at all times." a. A facility Incident and Accident Report for the resident, dated [DATE] at 6:45 pm, documented: "CNA (staff name) et CNA (staff name) were standing Res at end of bed to get Res on to commode. Res knees began to buckle. CAs (sic) asked Res to stand straight (up). Res stated she couldn't. CNAs prompted Res x 2 (two times) more et then began to lower her to her gluteus et then laid Res to back on pillow..." b. A second facility Incident and Accident Report for the resident, dated [DATE] at 6:40 pm, documented 2 CNAs with the resident at the time of the fall and included the following: "CNA reported to nurse's station that resident had to be lowered to ground when transferring to wheelchair from commode. Resident felt weak and asked to be lowered to floor. CNAs with resident at all times...Resident was holding on to end of bed with aides at side while on commode and when standing..." The facility failed to follow the care-planned intervention of utilizing 3 persons for assistance with transfers to and from the resident's wheelchair and bedside commode. The DON was interviewed on [DATE] at 4:35 pm. She verified the above mentioned Incident and Accident Reports documented the care plan was not followed as it related to physical assistance with transfers for this resident. No further information was received from the facility.