Every finding on record at Bingham Memorial Skilled Nursing & Rehabilitation

Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for 3 of 4 residents (#5, #11, and #28) reviewed for quality of care. Residents were at risk for adverse outcomes when they did not have Physician orders for medications that residents received or Physician orders did not document all the required elements to prevent adverse drug reactions. These failed practices had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice. Findings include: 1. Resident #5 was admitted to the facility on the 11/13/25, with multiple diagnoses including aftercare following surgery on the digestive system and dislocation of the left hip. On 11/17/25 at 8:12 AM, observed LPN #1 administer Optase eye drops, 2 drops in both eyes, to Resident #5. On 11/17/25 at 10:47 AM, record review of Resident #5's medical record did not document an order for Optase eye drops. On 11/17/25 at 12:58 PM, LPN #1 stated there were no orders for the Optase eye drops in Resident #5's medical record and there should have been. 2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (a life threatening medical emergency where the body's extreme response to an infection damages its own tissues and organs) and vascular dementia.Resident #11's Physician order dated 10/31/25, documented Invanz (antibiotic) Injection Solution. Reconstituted 1 gram. Use 1 gram intravenously at bedtime for appendicitis with abscess. Her Physician's order did not document the flow rate of the Invanz. 11/17/25 at 2:50 PM, the DON stated the flow rate of an IV medication should have been on Resident #11's Physicians orders. 3. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following surgical amputation and acute osteomyelitis (bone infection) of the left foot and ankle. Resident #28's Physicians order dated 11/14/25, documented Daptomycin-Sodium Chloride Intravenous Solution (an antibiotic) 1000-0.9 MG/100ML. Use 1000 mg intravenously in the afternoon for osteomyelitis.Resident #28's Physician's order dated 11/14/25, documented Meropenem Intravenous Solution (an antibiotic). Use 1 gram intravenously every 8 hours for Osteomyelitis.On 11/17/25 at 8:15 AM, observed LPN #1 entered Resident #28's room and flushed his IV with 10mls of sodium chloride. LPN #1 hung a bag of Meropenem Intravenous Solution (an IV medication). When LPN #1 turned the IV pump on, the pump was set to administer the medication at 150 MLs per hour. LPN #1 reprogramed the IV pump to administer the Meropenem Intravenous Solution at 100 MLs per hour and began the administration of the medication to Resident #28.On 11/17/25 at 10:01 AM, a record review of Resident #28's medical record did not document an order for Sodium Chloride flush and his Meropenem order did not document a flow rate.On 11/19/25 at 10:42 AM, the DON stated there should have been IV flush orders in Resident #28's medical record and his Meropenem order should have had the flow rate documented.

Based on observation, document reviews, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens regulations 1910.1030, updated 10/19/21, states, Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure and Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.The CDC Long-term Care Facilities Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions (EBP) in Nursing Homes, dated 6/28/24, documented indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized.Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized.The facility's Hand Hygiene policy, revision date 8/20/25, documented the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.The follow was observed for infection control:1. On 11/17/25 at 8AM, observed the 300-hall medication cart outside the dining room by the front door of the facility with a can of Coke and a Styrofoam cup with a liquid substance in it on top of the cart.On 11/17/25 at 8:03 AM, LPN #1 stated the personal drinks should not have been on top of the medication cart.2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including sepsis and vascular dementia.Resident #11's Physician order dated 10/31/25, documented Invanz (antibiotic) Injection Solution. Reconstituted 1 gram. Use 1 gram intravenously at bedtime for appendicitis with abscess.Resident # 11's Physician's order dated 11/6/25, documented EBP every shift for IV-line use. Every day and night shift to reduce transmission of multi resistant organism.On 11/17/25 at 9:46 AM, observed Resident #11 sitting in her room. She had a PICC line in her left arm. There was no EBP signage present to notify staff of isolation precautions. There were no PPE supplies available near Resident #11's room for staff to donn prior to entering her room as required per EBP protocol.3. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following surgical amputation and acute osteomyelitis (bone infection) of the left foot and ankle.Residents #28's Physicians order dated 11/13/25, documented EBP every shift for: PICC Line. Every day and night shift for reduce transmission of Multi resistant organism. Patient has single lumen PICC to left upper arm.Resident #28's Physicians order dated 11/14/25, documented Daptomycin-Sodium Chloride Intravenous Solution (an antibiotic) 1000-0.9 MG/100ML. Use 1000 mg intravenously in the afternoon for osteomyelitis.Resident #28's Physician's order dated 11/14/25, documented Meropenem Intravenous Solution (an antibiotic). Use 1 gram intravenously every 8 hours for Osteomyelitis.Resident #28's Physician's order dated 11/17/25, documented left knee wound: cleanse gently with Normal saline, ensure skin remains intact. Pat dry. Apply AMD Telfa non-adherent dressing then secure with foam dressing. May apply ABD dressing on top of left knee when wrapping left lower extremity with kerlix and ACE wrap for extra protection from Knee immobilizer. Change dressing 2x/wk. every night, shift every Mon, Thu.On 11/17/25 at 8:15 AM, LPN #1 entered Resident #28's room and administer IV medication. LPN did not donn a gown prior to administering IV medication. There was no EBP signage present to notify staff of isolation precautions. There were no PPE supplies available near Resident #28's room for staff to donn prior to entering her room as required per EBP protocol.On 11/17/25 at 9:32 AM, LPN #1 stated residents with wounds and IV should have been placed on EBP isolation and should have had PPE outside their rooms.4. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a group of lung diseases that block airflow and make it difficult to breath) and hypertension.Resident #30 had an order for Enoxaparin Sodium (anticoagulant) prefilled Syringe 40 MG/0.4ML. Inject 40 mg subcutaneously in the morning for post-surgical anticoagulant.On 11/19/25 at 8:29 AM, the MDS coordinator donned gloves prior to administering the Enoxaparin injection. The MDS coordinator did not perform hand hygiene before he donned gloves.11/19/25 at 8:35 AM, the MDS coordinator stated he should have cleaned his hands before applying gloves but, he just gets out of the habit of doing it since he does not work the cart that often.

Based on observation and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately, this was true for 1 of 2 nurses observed for medication pass and 1 of 1 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication and created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:1.On 11/17/25 at 8 AM, the 300-hall medication cart was observed outside the dining room, by the front door of the facility, unlocked. On top of the medication cart was the medication cart keys. No staff were present.On 11/17/25 at 8:03 AM LPN #1 stated the medication cart should have been locked and she should not have left the key to the medication cart on the cart.2. On 11/17/25 at 8:17 AM, observed the 300-hall medication cart outside room # 316, unlocked.On 11/17/25 at 8:20 AM, LPN #1 stated she should have locked the medication cart when she went into the resident's room.3. On 11/17/25 at 9:46 AM, observed on Resident #11's bedside table a bottle of Allergy relief nasal spray. Resident #11 was unable to demonstrate the proper use of the medication.On 11/17/25 at 3:05 PM, the DON stated Resident #11 was not able to administer her own medications and the nasal spray should not have been in her room.4. On 11/17/25 at 9:55 AM, observed in room Resident #28's room a 12 ml Heparin 5500 units syringe on the nightstand by the door.On 11/17/25 at 10:00 AM, RN #1 stated medications were not to be left in the resident's room and heparin was medication and should not have been in Resident #28's room.5. On 11/17/25 at 10:04 AM, observed on the floor, in the 300-hall a peach-colored pill (Flexeril).On 11/17/25 at 10:10 AM, LPN #1 stated the pill should not have been on the floor.6. On 11/19/25 at 8:05 AM, the 300-Hall medication cart was audited with the MDS coordinator present. Observed on the bottom of the second drawer 1 oval shaped white tablet (Lasix 20 mg).On 11/19/25 at 8:09 AM, the MDS Coordinator stated he did not know what the white tablet was but it should not have been loose in the medication cart.On 11/19/25 at 10:42 AM, the DON stated the medication cart should have been locked when the nurse was not present and medication are not to be left in the resident's room.

Based on record review and staff interview it was determined the facility failed to ensure care plans were comprehensive and individualized for 1 of 2 residents (Resident #1) whose comprehensive care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans being incomplete and not person-centered. Findings include:Resident #1 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including stage 3 pressure ulcer to the coccyx, MRSA (a type of bacteria that is resistant to several antibiotics), and neurogenic bladder (a condition caused by damage to the nerves controlling the bladder).Resident #1's admission MDS dated [DATE], documented she had a suprapubic catheter.Resident #1's comprehensive care plan interventions documented CATHETER: I have (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Resident #1's comprehensive care plan was not person-centered and did not specify the size or type of catheter.On 11/19/25 at 10:20 AM, the DON stated Resident #1's comprehensive care plan interventions should have been personalized to include type and size of catheter, but was not.

Based on policy review, record review, and staff interview it was determined the facility failed to include necessary healthcare information for 2 of 4 residents (#1 and #2) on resident's baseline care plans. This failure created the potential for resident specific needs to go unrecognized due to lack of information for caregivers. Findings include:The facility's Baseline Care Plan policy dated 10/2/25, documented [NAME] Memorial Skilled Nursing and Rehab will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.1. Resident #1 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including stage 3 pressure ulcer to the coccyx, MRSA (a type of bacteria that is resistant to several antibiotics), and neurogenic bladder (a condition caused by damage to the nerves controlling the bladder).Resident #1's hospital Discharge summary dated [DATE], documented suprabupic remains in place due to incontinence of urine and importance in maintaining wound cleanliness.Resident #1's baseline care plan dated 10/28/25, did not document she had a suprabupic catheter.On 11/19/2025 at 10:20 AM, the DON stated Resident #1's suprabupic catheter should have been documented on her baseline care plan, but was not.2. Resident #2 was admitted on [DATE], with multiple diagnoses including aftercare following joint replacement surgery, chronic kidney disease, and overactive bladder.Resident #2's hospital discharge instructions dated 10/21/25, documented she had a suprapubic catheter.Resident #2's Licensed Nurse assessment dated [DATE], documented she had a suprapubic catheter.Resident #2's baseline care plan dated 10/22/25, did not document she had a catheter.Resident #2's admission MDS dated [DATE], documented she has an suprapubic catheter.Resident #2's care plan meeting summary dated 11/5/25, documented she has suprapubic catheter.On 11/19/25 at 10:21 AM, the DON stated Resident #2's suprapubic catheter should have been documented on her baseline care plan, but was not.

Based on Appendix PP of the State Operations Manual, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness, intellectual disability, or a related condition. This was true for 1 of 3 residents (Resident #4) reviewed for PASARR level II evaluations. This deficient practice had the potential to cause harm if an appropriate state-designated authority did not evaluate a resident's mental health needs. Findings include: Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia, bipolar, anxiety, and PTSD, each classified as a serious mental illness.On 10/10/25, Resident #4's PASRR level I screening documented she did not have a serious mental illness.On 10/11/25, Resident #4's history and physical documented she had a diagnosis of schizophrenia, bipolar, anxiety, and PTSD.On 10/16/25, Resident #4's MDS assessment documented she had a diagnosis of schizophrenia, bipolar, anxiety, and PTSD. On 10/24/25, Resident #4's psychiatric physician note documented she had a diagnosis of schizophrenia, bipolar, anxiety, and PTSD. On 11/18/25, the administrator and social worker stated they had not updated the PASRR level I with the newly identified mental health diagnoses or contact the state mental health authority for further evaluation of Resident #4, and they should have.

Based on record review, policy 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 1 of 1 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 in the facility. Findings include: The facility's Medication Administration policy revision date 9/25/25, documented if medication is a controlled substance and packed in a medication card or bottle, sign the narcotic book. Count every incoming and outgoing shift to evaluate any discrepancy.On 11/19/25 at 10:17 AM, the following was observed during the hall 300-medication cart audit:- the narcotic accountability record, dated 11/1/25 to 11/19/25, had 16 licensed nurse signatures not document. - the narcotic count sheet for Resident #1's Butrans transdermal 7.5mg patch documented 10 patches available. Observed 2 patches in the narcotic box. After reviewing medication with the DON, it was noted that only 4 patches were delivered, and 2 patches had not been signed out on the narcotic count sheet.On 11/19/25 at 10:21 AM, the MDS coordinator stated the nurses should have signed the medication cart narcotic accept/release sheet when they accepted the medication cart or released the medication cart. He also stated he was not sure why Resident #1's narcotic count sheet for Butrans Transdermal patch documented 10 patches available when there were only 4 patches delivered, and he said there were only 2 patches in the narcotic box, and he was not sure where the other 2 patches were but he would check into it. On 11/19/25 at 10:46 AM, the DON stated Resident #1's missing Butrans Transdermal patch was signed out on the MAR but had not been signed out on her narcotic count sheet and should have been.

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure resident's privacy was protected for 1 of 1 medication carts reviewed for privacy and confidentiality. This deficient practice placed residents at risk of embarrassment and loss of control over their personal information. Findings include:In the facility's admission packet the Health Information Privacy Act Amendment and Actives form, undated, documented all health care professionals, employees, staff, personnel, and volunteers who are authorized to enter information into medical charts and who share information with each other for treatment, payment, and office operations must abide by HIPAA Rules. 1. On 11/17/25 at 8:00 AM, observed hall-300 medication cart outside the dining room with the computer open to resident information. No staff were present.On 11/17/25 at 8:03 AM, LPN #1 stated she should have locked her computer when she went into the dining room.2. On 11/17/25 at 8:25 AM, observed on hall 300, the 300-hall medication cart with the computer on top of it with the screen open to resident #28's information and the cart was unlocked.On 11/17/25 at 8:33 AM, LPN #1 stated she should have shut down her computer and locked her cart before going to give the resident his medications.

Based on observation, policy review and interviews, it was determined the facility failed to ensure all call light buttons or pads were easily accessible to residents. This was true for 2 of 19 residents (#14 and #15) whose rooms were observed for call light device locations. This failure had the potential for harm if residents were not able to summon staff for assistance. Findings include:The facility's Call Lights: Accessibility and Timely Response policy revision date 3/1/2025, documented staff will ensure the call light is within reach of each resident and secured, as needed.1. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including malnutrition and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath).Resident #14's annual MDS dated [DATE], documented was cognitively intact.Resident #14's care plan documented he was able to consistently use his call light.On 11/17/25 at 8:53 AM, Resident #14's call light device was observed draped over the head of the bed, between the bed and the wall, not accessible to him.2. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (the narrowing of the spinal canal) and weakness.Resident #15's quarterly MDS dated [DATE], documented was cognitively intact.Resident #15's care plan documented he was able to consistently use his call light.On 11/17/25 at 8:59 AM, Resident #15's call light device was observed draped over the head of the bed, between the bed and the wall, not accessible to him.On 11/17/25 at 9:09 AM, RN #1 stated the residents should have had their call lights within reach.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect 17 of 17 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. Review of the facility's Food Storage policy, dated 6/27/23, documented perishable food in open containers, or outside of their original containers will be discarded after 72 hours. Review of the facility's Use and Storage of Food Brought in by Family or Visitors policy, revised 3/26/24, documents all food items that are already prepared by family or visitor brought in must be labeled with resident's name and opened date. The facility may refrigerate labeled and dated food and beverages in the nourishment refrigerator or freezer. On 8/21/24 at 7:20 AM, the following was observed in the dry food storage area, with the RD present: - Pearl barley, open date 3/12/24, should have been disposed on 6/12/24. - Granola, open date 3/2/24, should have been disposed on 6/2/24. The RD stated the dry food items should have been used within 3 months of opening or should have been disposed. On 8/21/24 at 7:32 AM, the following was observed in the reach-in refrigerator, with the RD present: - Whipped cream, use by date 8/17/24, was unsealed. - Undated facility-prepared single serve ranch dressing cups. - Undated single serve sugar free ice cream cups. - Undated slice of pie on a plate. The RD stated any refrigerated food items had to be used within 72 hours of opening or disposed of. On 8/21/24 at 7:40 AM, the following was observed in the walk-in refrigerator, with the RD present: - A container of raw meat used for meatballs, dated 8/16/24, had been frozen but put in walk-in refrigerator to thaw. - Three bean salad with lid not properly closed was dated 8/2/24. - A container of vanilla pudding, dated 8/16/24, was past the 72 hours facility policy for disposal. The RD stated the items should not have been kept in the food storage areas past the assigned dates or if incorrectly packaged. On 8/21/24 at 7:53 AM, the following was observed in the walk-in freezer, with the RD present: - Raw frozen chicken stored above facility-made pizza, dated 8/6/24. - Water from freezer unit had dripped down on the boxes and then refroze into the boxes. The RD stated the raw chicken should not have been stored over other food items and the boxes with water damage should have been removed. On 8/22/24 at 8:36 AM, the following were observed in the patient care area snack storage room, with the nutrition services manager and RD present: - An opened undated ice cream 1/2 gallon container with a resident's room number on it. - Two opened loaves of bread with best used-by dates of 7/5/24 and 8/16/24 with no opened date on either loaves of bread. - An opened almond milk container, dated 7/3/2024, which was past the 72 hour disposal date. - Undated single serve juice cups. The nutrition services manager stated the single-serving juice cups came out of a box that was dated however, no one dated the cups when they were stocked in the refrigerator and they should have been. The RD stated the nursing staff should have disposed of the outdated items.

Based on observation and staff interview, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals served in their rooms. This failure had the potential to impact 2 of 3 residents (#12 and #15) observed during meal service for hand hygiene, placing them at risk for cross-contamination and infection. Findings include: On 8/20/24 at 5:25 PM, surveyor observed food tray delivery and set up on Resident #12's overbed table, however CNA #1 did not offer to help him wash his hands before eating. On 8/20/24 at 5:29 PM, surveyor observed food tray delivery and set up on Resident #15's overbed table, however CNA #2 did not offer to help him wash his hands before eating. On 8/20/24 at 5:37 PM, CNA #1 stated she should have offered hand washing and did not know why the facility had not required that. On 8/20/24 at 5:38 PM, CNA #2 stated she should have offered hand washing and did not know why the facility had not required that. On 8/22/24 at 9:59 AM, the DON stated the CNAs should have been asking residents, who eat in their rooms, if they would like to wash their hands before meals.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given treatment and services to maintain or improve their ability to carry out activities of daily living. This was true for 3 of 6 residents (#1, #4, and #15) reviewed for restorative nursing services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life. Findings include: 1. Resident #1 was admitted [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and traumatic brain injury. Resident #1's care plan, dated 1/18/21, documented she needed a restorative program to assist in maintaining her mobility status. A progress note, dated 9/30/22, documented Resident #1 was discharged from therapy services on 9/28/22 and referred to restorative nursing services. The Follow-Up Question Report, dated 6/1/24 - 6/29/24, documented restorative therapy minutes for 6/11/24. No other restorative therapy minutes were documented in resident's medical record. Resident #1's care plan, initiated on 7/28/24, and revised on 8/12/24, documented she needed restorative services related to decreased range of motion to her upper body, due to poor mobility and balance. A Nursing Focus Assessment, dated 8/16/24, documented Resident #1 was to receive restorative nursing services. Resident #1's medical record did not document she received restorative nursing services. 2. Resident #4 was admitted on [DATE], and readmitted on [DATE], with multiple diagnoses including osteoporosis and chronic pain. A restorative progress note, dated 8/4/22, documented Resident #4 received a new restorative plan of care from therapy. A nursing note, date 8/25/23, documented Resident #4 was screened by therapy and recommended continuing the restorative program. Resident #4's care plan, initiated 6/18/24, and revised on 8/12/24, documented she needed restorative services due to impaired mobility and balance. A Nursing Focus assessment dated [DATE] documented Resident #4 was not receiving restorative nursing services. The Follow-Up Question Report, dated 6/1/24 - 7/1/24, documented restorative therapy minutes for 6/11/24. No other restorative therapy minutes were documented in resident's medical record. Resident #4's medical record did not document that she had received restorative nursing services. On 8/19/24 at 1:51 PM, Resident #4 stated she used to be on restorative, but it was stopped. 3. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses of spinal stenosis, muscle weakness, and iron deficiency. Resident #15's Physical Therapy (PT) Evaluation and Plan of Treatment Assessment Summary, dated 3/1/24, documented Resident #15 had decreased strength, balance, transfers, and gait secondary to increased neck pain. He was at risk for decreased level of mobility, decreased participation with functional tasks, falls, increased dependency upon caregivers, increased pain, and muscle atrophy. Resident #15 Summary documented he would benefit from further PT to increase strength, balance, and increase independence during functional mobility. Resident #15's care plan interventions, dated 10/18/22, include: - Encourage to participate with restorative plan of care 6 times per week. If Resident #15 prefers not to participate with the plan of care, re-approach 3 times. - RNA program: Strengthening upper body. - RNA program: Mobility/Ambulation. - RNA program: Strengthening lower body. Resident #15's care plan, dated 7/17/24, documented the need for restorative services. Resident #15's medical record did not document that he received restorative nursing services. On 8/19/24 at 3:40 PM, Resident #15 stated he has trouble holding his head up and has numbness in his fingers because of a spinal injury. Resident #15 stated he was working with physical therapy but stopped after his insurance stopped paying for it. On 8/21/24 at 8:11 AM, the Activities Director stated she did not do the restorative program but, she did 1 on 1 range of motion with the residents and documented it under the activities tab in PCC (electronic medical record). She also stated she does what exercises the residents want to do, she does not follow the resident's care plan interventions and she does not document the minutes spent with the resident. On 8/21/24 at 11:53 AM, CNA #1 stated the facilities restorative program is being revamped. She also stated there is a restorative book for the staff to look at for the resident's restorative plans, but the floor staff is not documenting what restorative therapy is being done because there is no place to document it. CNA #1 stated the facility has been working on changing the restorative program for a couple of months and the Activities Director and RN #2 were completing the charting for those residents on a restorative program. She stated she should have documented when residents received restorative therapy or if they did not receive restorative therapy. On 8/21/24 at 3:13 PM, RN #2 stated the the restorative program should be documented. She stated the facility is changing the restorative program and there is no place for staff to document on each resident once restorative therapy was completed. On 8/21/24 at 3:48 PM, the DON stated Restorative Therapy minutes had not been documented and the Restorative Program is under review by QAPI. 49552

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 3 of 6 residents (#1, #4, and #15) whose care plans were reviewed. This failure placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Restorative Nursing Programs policy, dated 7/22/24, documented: - The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. - The Restorative Nurse, or designee will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. 1. Resident #1 was admitted [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and traumatic brain injury. A care plan, dated 1/18/21, documented Resident #1 needed a restorative program to assist her in maintaining her mobility status. Resident #1's care plan interventions, dated 10/27/23, directed the staff to assess and determine her individualized therapy plan and to make changes to her plan of care quarterly and as needed. Resident #1's medical record did not document her restorative care plan interventions had been evaluated or updated. 2. Resident #4 was admitted [DATE], and readmitted [DATE], with multiple diagnoses including osteoporosis and chronic pain. Resident #4's care plan, dated 4/13/21, directed Therapy to review and modify her care plan every 3 months and as needed. The following screenings were documented: - Therapy Assessment and Restorative Program Referral forms, dated 6/27/22, 8/16/22, and 8/30/23, were documented as completed for Resident #4. - An undated Resident Screening Referral form, documented Resident #4 was on a restorative program. Resident #4's restorative care plan interventions were dated 10/27/23. A care plan for Resident #4, initial date 6/18/24, and revision date of 8/12/24, documented she needed restorative services due to impaired mobility and balance. Resident #4's medical record did not document her restorative care plan interventions had been evaluated or updated. Resident #4's record did not include documentation of completed screenings or reviews by Therapy between 4/13/21 to 6/27/22. 3. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses of spinal stenosis, muscle weakness, and iron deficiency. Resident #15's Physical Therapy (PT) Evaluation and Plan of Treatment Assessment Summary, dated 3/1/24, documented Resident #15 had decreased strength, balance, transfers, and gait secondary to increased neck pain. He was at risk for decreased level of mobility, decreased participation with functional tasks, falls, increased dependency upon caregivers, increased pain, and muscle atrophy. The Summary documented Resident #15 would benefit from further PT to increase strength, balance, and increase independence during functional mobility. Resident #15's care plan interventions, dated 10/18/22, include: - Encourage to participate with restorative plan of care 6 times per week. If Resident #15 prefers not to participate with the plan of care, re-approach 3 times. - RNA program: Strengthening upper body. - RNA program: Mobility/Ambulation. - RNA program: Strengthening lower body. Resident #15's care plan, dated 7/17/24, documented the need for restorative services. Resident #15's record did not include documentation that he had received restorative services. On 8/21/24 at 3:13 PM, RN #2, who was the facility's Restorative Services Nurse, stated the restorative book and residents' care plans should have been updated with resident changes. She confrimed routine screenings for restorative services were not being performed for residents. 50983

Based on observation, interview, and policy review, it was determined the facility failed to ensure residents were provided evening snacks. This was true for 2 of 2 resident's (#19 and #22) who attended the Resident Council meeting. This failure created the potential for residents to experience hunger between meals, increased fatigue, weight loss, and poor quality of sleep. Findings include: The Facility Offering/Serving Between Meal and Bedtime Snacks policy, revised date 3/18/24, documented the nursing staff will offer bedtime snacks daily to all residents in accordance with the residents' needs, preferences, and requests. 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including gastroenteritis and colitis, nausea, and dehydration. Resident #19's nutrition snacks task for August 2024 documented she had refused evening snacks on 8/5, 8/6, 8/13, 8/14, 8/19, 8/20, and 8/21. On 8/21/24 at 10:43 AM, Resident #19 stated during the Resident Council meeting that she had never been offered snacks in the evening and did not know she could ask for them. 2. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including displaced fracture of left femur and difficulty walking. Resident #22's nutrition snacks task for July 2024 documented she had refused evening snacks on 7/14, 7/15, 7/16, 7/17, 7/22, 7/23, 7/24, 7/29, 7/30, and 7/31. On 8/21/24 at 10:44 AM, Resident #22 stated during the Resident Council meeting that she had never been offered snacks in the evening and did not know she could ask for them. On 8/22/24 at 9:55 AM, the DON stated the CNAs should have offered each resident an evening snack.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were dated when opened and not expired. This was true for 1 of 1 medication storage rooms inspected. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices, dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer stated another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. On 8/20/24 at 11:14 AM, with RN #1 present, a Tubersol solution (a clear colorless solution used for detection of tuberculosis infection) vial with no opened date, was observed in the resident medication refrigerator. RN #1 confirmed there was no open date on the bottle of Tubersol solution, or the box the solution was in. On 8/20/24 at 11:17 AM, the DON stated the Tubersol solution should have been dated when it was opened.

Based on observation, interview, and record review, it was determined the facility failed to ensure the MDS assessment accurately reflected the resident's status. This was true for 1 of 4 residents (Resident #225) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments. Findings include: Resident #225 was admitted to the facility on [DATE], with multiple diagnoses including shoulder joint surgery, diabetes, muscle weakness, and abnormal gait and mobility. During an interview on 8/20/24 at 1:12 PM, Resident #225 stated he had dentures and needed help from the staff with cleaning and putting them in. A nurse advanced skilled evaluation, dated 7/28/24, documented Resident #225 had his own teeth. Resident #225's admission MDS, dated [DATE], did not include documentation that he needed assistance with dental care. Resident #225's care plan did not include interventions for dental care. On 8/22/24 at 2:15 PM, the DON stated the nurse who had completed Resident #225's evaluation should have done a better assessment to identify that he did have dentures and needed to have assistance with dental care.

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 or infection risks. This was true for 1 of 17 residents (Resident #22) whose rooms were observed. This deficient practice created the potential for diminished quality of life and psychosocial distress for Resident #22 when the flooring in her room was not cleaned daily and a portion of the floor tile was missing. Findings include: Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including displaced fracture of left femur and difficulty walking. On 8/19/24 at 1:37 PM, the following were observed in Resident #22's room: the flooring was noted to have numerous small cracks in the middle of the room; one large crack with a one inch by one inch wide, 1/4 inch deep hole at the doorway entrance; and leaf debris on the floor that Resident #22 stated had been there for a few days. On 8/20/24 at 11:23 AM, it was observed the leaf debris in Resident #22's room remained on the floor. On 8/22/24 at 10:05 AM, the DON stated housekeeping should have been sweeping and mopping residents' rooms each day, and if there were leaves or debris stuck to the floor in a resident's room, housekeeping should have removed it. Additionally, the hole in the floor should have been repaired to prevent falls.

Based on review of the facility's admission agreement, record review, and staff interview, it was determined the facility failed to ensure residents and/or their representatives were not explicitly informed of their right to not sign the agreement as a condition of their admission or that they had the right to revoke the agreement. This was true for 12 of 12 residents (#3, #4, #5, #7, #9, #14, #15, #16, #17, #18, #19, and #20) who were newly admitted to the facility. This failure had the potential to cause significant psychosocial distress to residents and/or their representatives by not clearly knowing their rights. Findings include: The facility's Admission Agreement, undated, included 11 sections on 3 pages. At the end of the agreement there were 3 lines labeled patient name, signature, date/time. The section titled Agreement, stated the following: The undersigned agrees to defend and hold the facility harmless of any claims or suits by the resident based on any cause other than negligence or intentional misconduct of the facility or its employees. The section titled Agreement, was unclear whether this was a condition of admission. This section also did not clearly specify the resident and/or their representative had the right to revoke the agreement within 30 days of signing. During an interview, on 6/28/23 at 4:30 PM, the LSW stated she was the person responsible for going over and having a new resident sign their admission paperwork. She stated when explaining [the section titled Agreement] she tells them they agreed not to hold the facility harmless of any incidents unless there were acts of abuse or negligence. The LSW stated she explained to the resident by signing they would not file a lawsuit while residing at the facility. The LSW stated sometimes the resident requested to wait until their representative was present to understand before they signed the agreement and she accomodated the request. She agreed the section Agreement was not distinct from the other sections in the Admission Agreement.

Based on observation, policy review, review of manufacture instructions for use, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene, properly sanitize and disinfect equipment, and follow proper handling of equipment. This was true for 3 of 11 residents (#1, #2, and #10) observed during medication pass and this was true for 1 of 1 (Resident #9) observed during wound care. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: 1. During observation of medication administration staff did not follow infection prevention practices. Examples include: a. The Hand Hygiene policy, revised on 1/5/23, stated hand hygiene should be done before preparing or handling medications. This policy was not followed. On 6/27/23 beginning at 1:59 PM, RN #1 was observed administering medications. He did not perform hand hygiene before handling and administering medications to Resident #1, Resident #2, and Resident #10. RN #1 did not perform hand hygiene in between administering medications to each resident. b. The facility's Glucometer Disinfection policy, revised on 4/1/23, stated after obtaining a blood glucose sample, remove and discard gloves and perform hand hygiene prior to exiting the room. Then retrieve 2 disinfectant wipes to clean and disinfect the glucometer (a device used to measure blood glucose levels). The policy documented to use the first wipe to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. Use the second wip to disinfect the glucometer thoroughly following the manufacture's instructions. This policy was not followed. On 6/27/23 at 11:38 AM, RN #1 was observed obtaining a blood glucose sample, he did not perform hand hygiene prior to leaving the room. RN #1 was observed sanitizing the glucometer with contaminated gloves. On 6/29/23 at 11:55 AM, the IP was observed obtaining a blood glucose sample, she did not perform hand hygiene prior to leaving the room. She was observed sanitizing the glucometer with contaminated gloves. On 6/28/23 beginning at 11:38 AM, the IP stated staff were expected to perform hand hygiene prior to sanitizing the glucometer as well as before medication administration. She stated sanitation should be done with Clorox Healthcare Bleach wipes or Clorox Hydrogen Peroxide wipes. Nova Biomedical manufacture instructions, provided on 6/28/23, recommended the use of Clorox Healthcare Bleach Germicidal wipes, EPA Registration #67619-12, or any disinfecting product with EPA Registration # 67619-12. The CloroxPro website, accessed on 7/13/23, documented the following instructions when disinfecting with their product: - Put on PPE - Remove gross soil if present or if disinfecting - Wipe the surface until completely wet - Wait for the contact time (3 minutes for all pathogens listed on the product label) - Discard the wipe On 6/28/23 at 4:45 PM, the IP stated she preferred to use Clorox Healthcare Bleach wipes, but she was not aware they could not use the Clorox Hydrogen Peroxide wipes. The IP stated the director of the laboratory instructed her and the staff at the facility to use the Clorox Hydrogen Peroxide wipes, not the wipes with bleach. 44210 2. The facility policy for Negative Wound Therapy, revised 1/30/23, stated Negative pressure wound therapy is an active wound care treatment which uses negative pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel-and-stick, and includes an evacuation tube and a computerized pump (wound vac) that applies the negative pressure. The guidelines include: - The wound vac machine will be placed on the bed's footboard and have a barrier on the device (including a pillowcase or bag) for the patient's privacy. The staff will put the wound vac in a basket to provide a barrier from the floor if the wound vac has no clamp to place on the bed. - The staff were to maintain the evacuation tube between the wound and the wound vac away from the floor when the resident was in bed or in a wheelchair. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including orthopedic aftercare following surgical amputation. On 6/26/23 between 4:00 PM to 4:11 PM, Resident #9 was observed sitting in a wheelchair; her wound vac and evacuation tube were inside a white pillow case hanging on the back of her wheelchair and touching the floor while she was in her room and later while being transported to the activity room. On 6/28/2023 at 3:00 PM, during wound care provided by RN #2 and the IP, Resident #9 was observed resting in her bed with her wound vac evacuation tube resting on the floor while connected to the wound vac inside a white pillow case on the floor. When asked, the IP stated the wound vac and the evacuation tube should not be touching the floor; instead, the staff should place a basket on the floor and put the wound vac and evacuation tubing inside the basket.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 1 of 16 residents (Resident #1) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information in the care plan. Findings include: The facility's Care Plan Revisions Upon Status Change policy, revised 1/18/23, documented the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. This policy was not followed. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including traumatic brain injury, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety. Resident #1's care plan, revised 6/6/23, documented she was taking psychotropic medications for schizophrenia. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. The care plan documented the medications were Seroquel, Ativan, and Lunesta. Resident #1's record did not include physician orders for Lunesta (a medication used to help with sleep disturbances). During an interview, on 6/29/23 at 2:45 PM, the DON stated upon review of Resident #1's care plan, the care plan should have been revised at the time changes were made to her medications.

Based on staff interviews and review of clinical records, medication error reports and a facility/hospice agreement, it was determined the facility failed to: communicate and coordinate care with a hospice provider, develop a coordinated plan of care with hospice, and designate an IDT member to work with hospice for 1 of 2 residents (#5) reviewed for hospice services. The failures resulted in harm when Resident #5 experienced increased pain and discomfort in her final days of life after orders to increase pain medications were delayed or not implemented and an indwelling urinary catheter for comfort care order was not followed. Findings include: A 2015 facility/hospice provider agreement provided by the facility's Administrator on [DATE] documented, .Facility and Hospice agree to cooperate .in carrying out each Patient's Joint Plan of Care .Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care .Hospice and Facility each shall maintain a copy .Hospice and Facility each shall designate a registered nurse responsible for coordinating the implementation of the JPOC for each Patient .Concurrently with the execution of this Agreement, Hospice and Facility each shall designate one or more individuals to serve as liaisons and facilitate cooperation between the Parties . Two Exhibits were attached to the Agreement. Exhibit F Delineation of Nursing and Aide Services documented hospice RN responsibilities included, Collaboration with Facility Staff in delivery and updating Joint Plan of Care .Communication and coordination of patient care services of Facility Staff . and facility RN/LVN responsibilities included, Coordination with Hospice Staff in implementation and update of Joint Plan of Care. Administration of medication .Notifying Hospice of change in symptoms, Patient/family distress . Exhibit G documented the hospice and facility were both responsible to participate in the development, review, and revision of the Joint Plan of Care. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses, including right-sided weakness related to [MEDICAL CONDITION] terminal [MEDICAL CONDITION] with hospice care in place. Resident #5 died in the facility on [DATE], five days after her admission. Resident #5's [DATE] Cancer/Comfort Care/Hospice/Care Plan facility care plan problem areas included terminal diagnosis and .on Hospice Care. The goals included kept comfortable and coordination of care with hospice staff. Approaches included monitor pain/discomfort and implement ordered interventions; listen to client and resolve concerns as soon as possible; and medications/lab work as ordered. In addition, an undated, handwritten approach documented, .unresponsive medicate as directed follow up with family for any pain complaints. Resident #5's [DATE] Self Care Deficit facility care plan identified impaired mobility, decreased strength, easily fatigues and pain as problems. Approaches included to assist Resident #5 with ADLs as needed and record the amount of assistance needed for each ADL. The Point of Care History, for [DATE] - [DATE], documented Resident #5 needed total assistance by 2 or more people with bed mobility, dressing, and toileting and total assistance by 1 to 2 people for personal hygiene. Neither a hospice care plan, nor a Joint Plan of Care between the facility and hospice provider, were found in Resident #5's closed clinical record. On [DATE] at 1:30 pm, the BFS (State Survey Agency) received a Collaborative Plan of Care via fax from the facility. This Collaborative Plan of Care was signed by a facility LN on [DATE], the day after Resident #5's death. Resident #5's [DATE] Discharge Medication Reconciliation Order Report included continuation of a [MEDICATION NAME] 25 mcg/hr patch every 72 hours. Resident #5's [DATE] hospice orders included [MEDICATION NAME] ER 30 mg po BID and [MEDICATION NAME] sulfate 20 mg/ml solution 0XXX,[DATE] ml po every ,[DATE] hours prn pain. A [DATE] facility pain assessment documented Resident #5's pain was crushing, sharp, shooting and stabbing and almost constant at 9 on a scale of ,[DATE]. The [DATE] Medication Flowsheet documented Resident #5's pain was 5 on [DATE] night shift and [DATE] day shift, 4 on [DATE] day shift, then increased to 8 on [DATE] day shift, and was 0 on [DATE] day shift. The pain was not documented as assessed on the night shift on [DATE] through [DATE]. A [DATE] at 10:00 am, hospice physician telephone order documented liquid [MEDICATION NAME] 20 mg/mL ([MEDICATION NAME]) 1 mL po every hour and to discontinue [MEDICATION NAME] 30 mg ER effective [DATE]. The order was noted as received and performed by a hospice nurse. A [DATE] facility Occurrence/Med Error Report documented a hospice nurse noticed [MEDICATION NAME] (sic) order was not processed and it was brought to the charge nurse's attention. The correction at the time of the occurrence was, Processed order hospice ordered new med order. Processed that order . The root cause was, Poor communication between hospice & (facility) staff. On [DATE] at 11:15 am, LN #1 said she was the charge nurse on [DATE] when a hospice nurse reported the order for [MEDICATION NAME] solution 20 mg/mL every hour had not been processed. LN #1 said the medication was started immediately. LN #1 also said the hospice nurse who took the [DATE] 10:00 am order had also signed the order as processed but did not communicate with facility staff about the change. LN #1 said the hospice nurse may have put the order away before the facility staff saw it. Resident #5's [DATE] Medications Flowsheets did not include the order for [MEDICATION NAME] solution 20 mg/mL 1 mL po every hour. Two more telephone orders by the hospice physician, both dated [DATE] at 1:00 pm, discontinued [MEDICATION NAME] 25 mcg/hr and increased the [MEDICATION NAME] to 100 mcg/hr every 72 hours. These orders were also noted as received and performed by the same hospice nurse. The [DATE] Medications Flowsheets documented [MEDICATION NAME] 25 mcg/hr patch was administered on [DATE] at 8:00 pm. However, [MEDICATION NAME] 100 mcg/hr was not included in the Medications Flowsheets. Resident #5's [DATE] Medications Flowsheets also documented the [MEDICATION NAME] ER 30 mg was administered on [DATE] at 3:00 am and 3:00 pm, held both times on [DATE], without explanation, then discontinued. There were blanks in all of the spaces for documentation of the prn [MEDICATION NAME] solution 20 mg/mL 0XXX,[DATE] mL prn every ,[DATE] hours. The flowsheets also listed [MEDICATION NAME] solution 20 mg/5 mL (4 mg/mL) 0XXX,[DATE] mL po hourly was administered hourly from 7:30 pm - 11:30 pm on [DATE]; from 12:30 am - 4:30 am, 6:30 am, 11:30 am - 3:30 pm, then 7:30 pm - 11:30 pm on [DATE]; and 12:30 am - 2:30 am on [DATE] with initials circled at 5:30 am and 7:30 am - 10:30 am on [DATE], without explanation, and blanks in the spaces for documentation from 4:30 pm - 6:30 pm on [DATE]. However, an order for [REDACTED]. There was no documented evidence of collaboration between the facility and the hospice provider regarding the pain medication changes in the handwritten hospice notes, dated [DATE] at 9:00 am to [DATE] at 8:33 pm, facility progress notes, dated [DATE] at 5:30 am to [DATE] at 4:42 am, or facility Focused Observation Notes, dated [DATE], [DATE] and [DATE]. On [DATE] at 8:00 am, a hospice nurse requested and received a verbal order for a Foley catheter (brand of indwelling urinary catheter), essential in maintaining patient comfort throughout the dying process for Resident #5. However, there was no documented evidence in the previously noted handwritten hospice notes or facility progress notes of collaboration and coordination between the facility and hospice regarding the Foley catheter. Additionally, facility Focused Observation Notes for [DATE], [DATE] and [DATE], documented a urinary catheter was not in place and Resident #5's [DATE] General Flowsheet did not include a urinary catheter. Resident #5 was harmed when she experienced increased pain and discomfort during her last days of life when the facility and the hospice provider failed to communicate, collaborate, and coordinate with one another regarding pain medication changes and the need for an indwelling urinary catheter for comfort care.

Based on record review and staff interview, it was determined the facility failed to ensure orders to increase pain medications were implemented timely and that a different concentration and dose of pain medication was not administered without an order. This was true for 1 of 6 sample residents (#5) and resulted in harm when Resident #5 experienced increased pain when changes to pain medications were delayed or not implemented at all and a different concentration and dose of [MEDICATION NAME] solution than ordered was administered. Findings included: Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5 died in the facility on [DATE]. Resident #5's [DATE] Discharge Medication Reconciliation Order Report included continuation of a [MEDICATION NAME] 25 mcg/hr patch every 72 hours and the [DATE] hospice orders included [MEDICATION NAME] ER 30 mg po BID and [MEDICATION NAME] sulfate 20 mg/ml solution 0XXX,[DATE] ml po every ,[DATE] hours prn pain. Resident #5's [DATE] facility pain assessment documented crushing, sharp, shooting and stabbing pain almost constantly at 9 on a scale of ,[DATE]. A telephone order from the hospice physician on [DATE] at 10:00 am discontinued the [MEDICATION NAME] 30 mg ER and ordered [MEDICATION NAME] (short-acting, immediate release [MEDICATION NAME] solution) 20 mg/mL 1 mL po every hour. The order was noted as received and performed by a hospice nurse. Two other telephone orders from the hospice physician, both dated [DATE] at 1:00 pm, discontinued the [MEDICATION NAME] 25 mcg/hr patch and increased it to [MEDICATION NAME] 100 mcg/hr every 72 hours. These orders were also noted as received and performed by the same hospice nurse. Resident #5's Medication Flowsheets documented the following: * Pain 5 on [DATE] night shift and [DATE] day shift, 4 on [DATE] day shift, increased to 8 on [DATE] day shift and 0 on [DATE] day shift. The pain level was not documented on the night shift for [DATE], [DATE], [DATE] or [DATE]. * [MEDICATION NAME] ER 30 mg was administered on [DATE] at 3:00 am and 3:00 pm, held both times on [DATE] without explanation, then discontinued. * PRN [MEDICATION NAME] solution 20 mg/mL 0XXX,[DATE] mL prn every ,[DATE] hours with blanks in all of the spaces for documentation. * [MEDICATION NAME] solution 20 mg/5 mL (4 mg/mL) 0XXX,[DATE] mL hourly was administered hourly from 7:30 pm - 11:30 pm on [DATE]; from 12:30 am - 4:30 am, 6:30 am, 11:30 am - 3:30 pm, then 7:30 pm - 11:30 pm on [DATE]; and 12:30 am - 2:30 am on [DATE]. Initials were circled at 5:30 am and 7:30 am - 10:30 am on [DATE] without explanation and the spaces for documentation were blank from 4:30 pm - 6:30 pm on [DATE]. an order for [REDACTED]. * [MEDICATION NAME] 25 mcg/hr patch was administered on [DATE] at 8:00 pm. The Medication Flowsheets did not include the orders for [MEDICATION NAME] solution 20 mg/mL 1 mL every hour or [MEDICATION NAME] 100 mcg/hr patch every 72 hours, which were issued by the physician on [DATE] at 1:00 pm. In addition, orders for [MEDICATION NAME] solution 20 mg/5 mL (4 mg/mL) 0XXX,[DATE] ml every hour were not found in Resident #5's clinical record, nor were they provided by the facility. Resident Progress Notes, dated [DATE] at 5:30 am and [DATE] at 7:58 am, documented Resident #5 was medicated several times with liquid [MEDICATION NAME] during the night shift. However, the specific dose and times of administrations were not documented in Resident #5's clinical record, nor were they provided by the facility. A [DATE] Occurrence/Med Error Report documented, Hospice agency .noticed [MEDICATION NAME] (sic) order was not processed, brought to charge nurse. Charge nurse processed order. The root cause was noted as, Poor communication between hospice & (facility) staff. A [DATE] Controlled Substance Administration Record for [MEDICATION NAME] sulfate 20 mg/mL 1 mL po every hour documented the first dose was administered to Resident #5 on [DATE] at 3:30 am, but was not consistently administered every hour as ordered. The facility did not provide additional Controlled Substance Administration Records for [MEDICATION NAME]. A Resident Progress Note, dated [DATE] at 7:21 pm, documented, .medicated every hour this shift after 1330 (1:30 pm) .patient showed high levels of pain . Focused Observation Notes documented Resident #5's pain was mild on [DATE]; Resident #5 was experiencing pain or hurting on [DATE]; and on [DATE] at 8:26 am, expresses experiencing pain or hurting: Unable to answer .Facial expressions (frowning, grimacing, wincing, wrinkled brow) .non-verbal sounds (sighing, moaning, groaning, crying, gasping). On [DATE] at 11:15 am, LN #1 said that on [DATE] in the afternoon a hospice nurse reported the order for [MEDICATION NAME] solution 20 mg/mL every hour had not been processed. LN #1 said the medication was started immediately. LN #1 said the hospice nurse who took the order had also signed the order as processed but did not communicate with facility staff about the change. LN #1 said the hospice nurse may have put the order away without the facility staff seeing it. On [DATE] at 2:38 pm, LN #4 said he cared for Resident #5 two nights in a row and he administered prn [MEDICATION NAME] to her. The LN said he documented the administrations on a Controlled Substance Administration Record provided by the hospice but not on the facility's MAR. On [DATE] at 3:12 pm, LN #2 said she cared for Resident #5 one day and she administered pain medications prn until a hospice nurse said it was ordered every ,[DATE] hours. LN #2 said she gave the [MEDICATION NAME] every hour after that because Resident #5, looked like she needed it. On [DATE] at 5:10 pm, RN #3 said she administered prn [MEDICATION NAME] to Resident #5 and documented it on controlled substance sheets but not on the facility's MAR. RN #3 said after the [MEDICATION NAME] was changed to hourly she did not always administer it hourly. LN #3 said she was not comfortable giving [MEDICATION NAME] when there were no signs of pain or restlessness. Resident #5 was harmed when her pain and discomfort increased when the facility failed to process and implement orders for [MEDICATION NAME] solution 20 mg/mL 1 mL (20 mg) every hour on [DATE] and failed to administer [MEDICATION NAME] 100 mcg/hr every 72 hours as ordered on [DATE]. In addition, the facility administered different concentrations and doses of [MEDICATION NAME] solution than ordered.

Based on observations, record review, and resident, family and staff interview, the facility failed to ensure 4 of 19 sampled residents (#1, #7, #12 and #13) were provided care and services in a manner enhancing their dignity and respect. This resulted in harm to Resident #1 when she experienced resentment and demoralization when a tab alarm was attached to her clothing and the loud alarm that sounded when she moved or stood. It also placed Resident #7 at risk of psychosocial harm when she was not provided with toileting assistance necessary to avoid incontinence and incontinence briefs were put on her when she had been continent previously. Residents #12 and #13 were administered insulin injections during meals in the main dining room, creating the potential of embarrassment and humiliation. Findings include: 1. Resident #1 was admitted to the facility on [DATE]; current [DIAGNOSES REDACTED]. Resident #1 received hospice care for end stage [MEDICAL CONDITION]. Review of the 4/20/16 quarterly MDS indicated Resident #1 was usually understood by others, had no behavioral symptoms, and had a history of [REDACTED]. Resident #1's Care Plan, reviewed and revised on 6/10/16, stated a tabs alarm was initiated to address the problem of potential for falls on 3/21/16. Documentation included, I may hide or disable it because the sound bothers me, remind me it alerts the staff that I may need help. Resident #1 was observed with large writhing movements, primarily of her arms and upper body, at various times during the survey (6/12/16 at 8:00 pm - 8:30 pm, 6/13/16 at 7:00 am and 9:30 am, and 6/14/16 at 6:10 pm). Resident #1 was interviewed on 6/13/16 at 9:30 am, and reported she had a history of [REDACTED]. She stated she resented the alarm due to the loud sound that emanated when it went off. She stated it was very important to remain independent as much as she could. Resident #1 was interviewed a second time on 6/14/16 at 9:50 am, and stated she was capable of disconnecting the alarm by unclipping it from her clothing. Resident #1 stated she had unclipped it at times because it bothered her, but was encouraged by staff to keep it connected. Resident #1 reported she had not disconnected it recently. Resident #1 concluded, stating the tab alarm use was upsetting and made her feel, Like a dog on a leash. Resident #1 was observed during the survey, between 6/12/16 and 6/17/16, a number of times without the alarm connected. She was also observed during the survey with the alarm connected. On 6/14/16 at 6:10 pm, Resident #1 was observed eating dinner in the dining room. Within a period of 5 minutes (6:10 pm - 6:15 pm), the alarm sounded with a loud, piercing beep, 4 times. Within 5 seconds of each incident, a staff member turned the sound off and reconnected the alarm to Resident #1's clothing. Resident #1 reached down once to pick something up off the floor; however, in the other 3 instances the alarm was set off by Resident #1's writhing movements of her upper body in the wheelchair. She was not attempting to stand, get out of the chair, or do something unsafe in 3 of the 4 instances the alarm sounded. CNA #1 was interviewed on 6/13/16 at 9:30 am, and stated Resident #1 was to have the tab alarm on when she was in the wheelchair and verified Resident #1 removed it at times. She stated Resident #1 had a history of [REDACTED]. The DNS was interviewed on 6/16/16 at 5:30 pm, and verified Resident #1 had a history of [REDACTED]. She verified Resident #1 was capable of removing the tab alarm and it was not an effective measure to prevent falls. She stated Resident #1 was stubborn, knew what she wanted, and desired independence. 2. Resident #7 was admitted to the facility on [DATE], for rehabilitation following a total knee replacement. She had an admission [DIAGNOSES REDACTED]. Resident #7 required staff assistance for toileting and transfers when admitted . During an interview on 6/13/16 at 2:10 pm, Resident #7 stated that she had problems with her bladder when she was initially admitted after knee replacement surgery. She stated it was hard for her to get to the bathroom on time. Resident #7 stated it took 2 to 3 staff to assist her with toileting initially, because of her limited weight bearing status following surgery. She stated she was prescribed [MEDICATION NAME] and was incontinent the first couple days because staff did not help her. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back but did not come back. She stated she remained in wet incontinence briefs for extended timeframes. Resident #7 stated staff got angry when they had to come and assist her to the toilet. It took several staff to do so and reported one staff member stated, Again? when she needed assistance to toilet. Family Member #1 was interviewed on 6/14/16 at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago. Family Member #1 stated Family Member #2 was with Resident #7 during the day she was admitted (6/3/16) to the facility following surgery. Family Member #1 stated he was with Resident #7 during the second day (6/4/16) following Resident #7's admission and that both he and Family Member #2 went and spoke with the Administrator due to their concerns. Family Member #1 stated Resident #7 had been completely continent prior to the surgery and was aware when she needed to use the toilet. Family Member #1 stated Resident #7 had a catheter in the hospital but it was removed prior to her coming to the facility. He stated Resident #7 was put into incontinent briefs when she was admitted to the facility even though she was continent. Family Member #1 stated both he and Family Member #2 observed Resident #7 waiting too long for assistance and Resident #7 was incontinent, urinating in her brief, as a result. He stated he had medical training and helped Resident #7 to the toilet twice when he was visiting because staff did not come timely and Resident #7 had already been incontinent. Family Member #1 stated he was concerned because Resident #7 had what looked like skin breakdown to her bottom. A Bowel and Bladder Continence Evaluation, dated 6/8/16, documented Resident #7 was incontinent of urine a total of 4 times on 6/3/16 and on 6/4/16. On 6/5/16 and 6/6/16, there were no recorded incidents of incontinence; however, there was one incident of Resident #7 being wet. A SNRC Admission Assessment, dated 6/3/16, noted Resident #7's buttocks area was red and excoriated. The Administrator was interviewed on 6/16/16 at 2:00 p.m. He stated Family Member #1 and Family Member #2 came into his office on 6/6/16 and expressed their concerns regarding Resident #7's lack of care, including toileting. He stated he grabbed a complaint form and documented their concerns at that time. He stated he went to the charge nurse after the discussion and began investigating the concerns immediately. He stated that he found out Resident #7 was admitted with an incontinence brief on and had since been progressed to an incontinence pull up. He stated he directed staff to respond timely to call lights and toileting assistance after talking with Family Member #1 and Family Member #2. 3. On 6/13/16 at 7:00 am, Resident #12 was observed in the small dining room eating breakfast. LN #7 had administered Resident #12's oral medications. LN #7 then assisted Resident #12 in lifting the left corner of her shirt and administered Resident #12's insulin. On 6/16/16 at 9:30 am, Resident #12 stated she was not asked about getting her injection in the dining room, that it was just how it was done. 4. On 6/13/16 at 7:20 am, Resident #13 was observed in the small dining room eating breakfast. LN #7 had administered Resident #13's oral medications. LN #7 then assisted Resident #13 in lifting the right corner of his shirt and administered Resident #13's insulin. On 6/16/16 at 10:00 am, Resident #13 stated he was not asked about getting his medications in the dining room and he had always got his insulin in the dining room. Resident #13 stated he had not been asked.

Based on resident and staff interview and record review it was determined the facility failed to ensure a resident who had a physician's order for NWB (non-weight bearing), on her right ankle after surgery maintained NWB and the facility failed to implement a system to direct the CNAs on the how to transfer a resident with NWB status. This was true for 1 of 8 (#7) residents sampled for quality of care. This failed practice resulted in harm when the resident required additional surgical interventions to her right ankle. Findings include: Resident #7 was admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #7 did not have an MDS completed. Resident #7's Admission Care Plan for 11/2/13 or 11/27/13 did not address non-weight bearing status on her right leg nor the need to use a Hoyer lift for transfers. Note: The emergency room Addendum, dated 10/28/13, documented, Resident #7 was transported from her home to the emergency room , via ambulance after she felt, "her ankle turn in,"and sustained an open fracture of her right ankle. This fracture required an ORIF with the application of metal plates and screws for proper alignment. The resident's Physician's Orders and Plan of Care, dated 11/2/13, documented the following: * Weight Bearing Status: non wt (weight) bearing RLE. * Additional Orders: Elevate RLE to heart level, do not (change) surgical dsrg (dressing)... The resident had an order written [REDACTED]." The resident's Physician's Orders and Plan of Care, dated 11/28/13, documented the following: * Weight Bearing Status: "No weight bearing on (Right) foot." physician progress notes [REDACTED]. * 11/2/13, at 1500 (3:00 p.m.), "NWB to (Right) LE." * 11/8/13, "Continue NWB (Right) LE." Resident #7's Plan of Care/Statement of Necessity for Physical Therapy Services, started on 11/2/13, documented the following: * Functional mobility: Bed mobility = min(imum) (assist) supine (to) sit, max(imum) (assist times 2 people) for resituating in bed. * Gait: RLE = NWB, LLE = painful (secondary) recent fall and pulled muscles. Gait not attempted at this time. * Sensation/reflexes: (decreased) sensation in lower extremities from knees down (bilateral secondary) to diabetic [MEDICAL CONDITION]. * Comments: Pt is an obese woman (with) muscular injury to Left LE status [REDACTED]. She requires a Hoyer lift for transfers. The Resident's Rehabilitation Services Skilled Intervention Record, for Physical Therapy documented the following: * 11/4/13, "Pt is an obese woman (with) (Bilateral) LE injuries and NWB on Right (lower extremity)." * 11/5/13, N/S (No Service), schedule to see (with) OT did not work out today to use Hoyer to get pt OOB (patient out of bed). * 11/7/13, "Pt was unable to maintain NWB status on (Right) LE while standing in parallel bars..." * 11/8/13, "Pt states that she cannot stand from w/c (wheel chair) even with parallel bars without bearing weight on (Right) LE...Nursing was notified that the Pt is unable to comply (with) weight bearing precautions while (transferring) from w/c and that a Hoyer or other accommodations must be implemented until she is able to comply on her own." * 11/12/13, "Pt reports not using a Hoyer to (transfer) to bed or w/c and was advised to use Hoyer as she cannot comply (with) NWB precautions..." Note: The CNAs work 12 hr shifts from 6 a.m. - 6:30 p.m. or Day shift (D) and 6:00 p.m. to 6:30 a.m. or Night shift (N). The letters (D) and/or (N) will be used to identify shifts on the Nursing assistant flow sheet below. Resident #7's Nursing Assistant Flow Sheet documented the following numbers under Transfers: * 11/6/13, (N) Extensive Assistance of 1 person with the Hoyer, * 11/7/13, (D) and (N) Extensive Assistance of 1 person with the Hoyer, * 11/8/13, (D) and (N) Limited Assistance of 1 person without Hoyer, * 11/9/13, (D) Extensive Assistance of 2 people with the Hoyer, * 11/9/13, (N) Extensive Assistance of 1 person without the Hoyer, * 11/10/13, (D) Extensive Assistance of 1 person without the Hoyer, * 11/11/13 through 11/14/13 (D) and (N) Extensive Assistance of 1 person without the Hoyer. Resident #7's Nursing Assistant Flow Sheet documented from 11/9/13 through 11/14/13, (N) and (D) the resident was a 1 person Extensive Assist with toileting. Note: Nurse's notes reviewed for 11/3/13 through 11/15/13 did not document any information related to Resident #7's transfer status via Hoyer lift nor did the notes indicate there were any concerns with the resident being "non-compliant" with the the NWB status or concerns addressed at her follow-up physician's visits. Note: Resident #7 was seen on 11/13/13 at the physician's office for follow-up on the right ankle fracture. The resident stated to the physician, "she (the resident) had remained non-weight bearing," however in the physician's progress note (Physician's name) documented, "Interestingly her foot actually looks a little bit out of placement when compared to the last visit." The Physician then ordered an x-ray to check the alignment and repair of the ankle. On 11/14/13 the x-ray results included the following documentation, "In comparison to 10/31/13, fracture alignment has disrupted with the talus and medial malleolar fragments displaced 2.5 - 3.0 cm medially with 25 degrees medial angulation. The plates are bent, but screws are still in position." Note: On 11/15/13 Resident #7 was discharged from the facility and admitted to the hospital for surgical repair to her right ankle. The Operative Report, dated 11/15/13, documented the following: - Preoperative/Postoperative Diagnosis: [REDACTED]." - Operative Indications: The resident recovered in the hospital and was sent to the nursing home, "where she promptly began to walk on her ankle for whatever reason in direct [MEDICATION NAME] to the instruction of not bearing weight on her right foot... she basically displaced the fracture again, bending all the hardware and ruining the entire fixation." Note: Resident #7 stated to the Physical Therapist on 11/7/13, that she (the resident) was unable to maintain NWB status on (Right) LE while standing in parallel bars... and on 11/8/13 that she was physically unable to stand from w/c (wheel chair) even with parallel bars without bearing weight on (Right) LE. Additionally, Resident #7's medical record did not document any instances of "non-compliance" by either the CNAs or nursing staff. On 12/6/13, the surveyor was provided with a letter from (Physician's name) which documented the following, "The ankle fracture had resumed its original displacement and she (the resident) had again opened the original lateral wound...It would take a very large one time force to deform these plates in such a way. I believe that there is only one explanation for the plate bending and fracture to displace and that is that the patient was walking on her fractured ankle. I do not believe that minimal weight bearing on one or a few occasions would cause this catastrophic failure of her hardware." On 12/2/13 at 6:45 p.m., during the initial tour the surveyor asked Resident #7 about her stay at the facility. The resident stated it had been good except she had to have a second surgery on her right ankle because the CNA's had transferred her (the resident) from her wheel chair to her bed without using the hoyer lift. "We had to hurry and get me to the bed and I had to step down on my right foot." On 12/3/13 at 3:50 p.m., RN #3, the charge nurse was asked by the surveyor how the CNAs know how to transfer and toilet new admissions. RN #3 stated the charge nurse at the facility receives report from the nurse at the hospital or transferring facility. The charge nurse then gives a report to the floor nurse at the facility and a quick report to the CNAs. If the resident is alert and oriented the CNAs ask the resident how many times the staff got he/she up and if the transferring facility used any assistive devices. On 12/4/13 at 10:15 a.m., CNA #5 was asked by the surveyor what Resident #7's transfer status was upon admission on 11/2/13. The CNA said the resident was a two person extensive assist with transfers and stated, "They (nursing or therapy) did not tell me Resident #7 was a hoyer lift until 11/14/13. The hoyer lift was never used by me until the day before the resident went to the hospital for her second surgery." Resident #7 told CNA #5 on 11/13/13 that the resident was going to have another surgery on her right foot and was upset because the physician had told the resident she might lose her foot. CNA #5 asked the resident what happened and the resident told the CNA on 11/11/13 or 11/12/13 the resident needed to use the bathroom urgently and the CNAs working with the resident took her to the bathroom via wheel chair and had encouraged the resident not to be incontinent in the wheel chair. Resident #7 told CNA #5 that when she was transferred from the wheel chair to the toilet the CNAs transferred the resident too quickly (without the hoyer) and the resident had to put weight on her right foot. On 12/4/13 at 10:30 a.m., Resident #7's family member was interviewed about the use of the hoyer by the CNA's when Resident #7 was transferred. The family member stated whenever she (family member) was at the facility Resident #7 was transferred by two CNAs, and not until after the resident's second admission was the resident transferred with the hoyer lift. On 12/4/13 at 1:25 p.m., CNA #6 was asked by the surveyor what Resident #7's transfer status was upon admission on 11/2/13. The CNA stated Resident #7 was to stay in bed until Physical Therapy could evaluate the resident. CNA #6 said the hoyer lift was never used to transfer the resident out of bed. The CNA said the resident was full weight bearing on her left lower extremity and "very limited" weight bearing on her right lower extremity. On 12/5/13 at 6:45 p.m., CNA #7 was asked about Resident #7's transferring status. CNA #7 stated on 11/11/13 or 11/12/13 she had responded to the resident's call light and the resident requested assistance to the bathroom. CNA #7 told Resident #7, the CNA did not know how to transfer the resident and would need to find another CNA to assist. The resident told the CNA, " I know how the CNAs transferred me." The resident then told the CNA, "This is how CNA #5 transferred me (the resident), CNA #5 assisted me to transfer from the bed to the wheel chair and then I (the resident) transfer myself to the toilet. I limped and tip toed on my right foot." CNA #7 stated she did not know Resident #7 was non-weight bearing and the only day the hoyer was used by her (CNA #7) was on 11/15/13, when the resident transferred to the hospital. On 12/5/13 at 7:00 p.m. the Administrator and DNS were informed about the above findings. The DNS and the administrator provided the surveyor with additional information for review. On 12/6/13 at 10:15 p.m., Physical Therapist #7 was interviewed. The therapist stated when a new resident is admitted the CNAs know to seek the expertise of the Physical Therapists to identify a resident's weight bearing status and precautions. The physical therapist then stated, "the CNAs should know what weight bearing status is for example, NWB, 25%, 50%, it is in their (the CNAs) training." Resident #7 was harmed when: - The facility failed to ensure the physician's orders for NWB were followed. - CNAs did not receive consistent instruction on how to transfer the resident. - The facility failed to have a system in place to direct CNAs on the day to day cares for residents to ensure quality of care is maintained. - The resident's NWB status was not included on the care plan. 2. During interviews with staff it was found there was no process to assure residents received care from the CNAs in a consistent manner. (Note: See example #1) The Unit manager and DON stated in an interview, on 12/3/13 at 9:30 a.m., the Kardex's were discontinued when the DON started. They were concerned after the last survey because they were cited for not keeping the Kardex's current. The discontinuation tool and not putting a replacement process in place resulted in a resident being harmed. CNAs were providing cares to residents without a tool to provide direction of what the resident's needs were. The Administrator and DON were informed on 12/5/13 at 7:00 p.m. No further information was provided.

Based on record review and staff interviews, it was determined the facility failed to ensure the resident's environment remained as free from hazards as possible. This affected 1 of 4 (#1) residents sampled for accidents. Resident #1 was harmed when a warm compress was applied to the resident's left shoulder for one hour with no monitoring of the compress by nursing staff. This resulted in a thermal burn to the resident's left shoulder pacemaker site. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's 5/6/13 admission MDS coded, in part: * Moderately impaired cognition and mild depression, * Required extensive assistance for all ADLs except eating, * Range of Motion limitations, upper extremity impairment on one side, * Surgical wound, and * Occasional pain intensity of 6 on a numeric scale of 0-10 On 6/19/13, the resident's physician ordered, in part, "Warm compress to pacer site for (one) hour 3 x a day (for one hour three times a day)...dry + (and) place gauze pad over area to catch secretions daily after warm compress treatment. It would be good to have (RN #1) wound care specialist see (Resident #1)..." On 6/19/13, the resident's "physician progress notes [REDACTED]. On 6/20/13 at 15:15 (3:15 p.m.), Resident #1's Nurses Progress Notes (NPNs) documented, in part, "...Order received to see pt (patient) regarding superficial pacer site on left shoulder. Areas was red...no drainage...Applied warm compress to left shoulder and left in place...1 hour (one hour) later...pt had sustained a thermal burn injury. Area blanches easily...measured 19 cm (centimeters) by 6 cm..." The entry was signed by RN #1. On 6/20/13, the resident's physician discontinued the warm compress order. On 6/21/13 at 8:00 a.m., Resident #1's NPNs documented, in part, "...redness has diminished significantly...one sm (small) dried scab present..." The entry was signed by RN #1. Resident #1's June 2013 Nurse's Treatment Notes (NTNs) documented, in part, * "6/20 (2013)...washcloth...heated up in microwave + wrapped in saran wrap then place {sic} in pillow case. (RN #1) allowed pack to cool to warm temp (temperature) then placed warm pack on pt over (left) shoulder + pacer site. Upon removal of pack 1 hr later pt had sustained thermal injury. Incident report filed. (RN #1) notified (Resident #1's physician)..." * "6/21 (2013) Assessed site (with RN #1). Pt's thermal injury to (left) shoulder diminished in redness...Dried sm scab present on pacer site. No exudate present..." Resident #1's 6/20/13 Accident/Incident Report documented, in part, "...pt found with thermal injury to (left) shoulder after warm compress applied..." The "Recommended Steps to Prevent Recurrence" section documented, "Check on pt after first 10 min (minutes) to determine response." The "Resident's Statement of What Happened" section documented, "It's been burning so I leaned forward + then fell asleep + when I woke up it wasn't burning..." The Report was signed by RN #1. On 10/8/13 at 7:55 a.m., the DON and RN #1 were both interviewed. RN #1 stated, "I took a moist cloth, warmed it up in the microwave, put it in plastic (a simple plastic bag) and wrapped it in a pillow slip. I placed the warm compress over (Resident #1's) flannel shirt. I documented 'thermal' meaning heat induced to distinguish from other types of burn. It did blister therefore it was a second degree burn." On 10/9/13 at 12:30 p.m., the Administrator and the DON were informed Resident #1 was harmed due to the thermal burn. The Administrator stated, "The nurse was following the physician's orders [REDACTED].

Based on record review, resident and staff interview, it was determined the facility failed to ensure that residents did not acquire pressure ulcers in the facility. This was true for 1 of 2 sampled residents (#2). Resident #2 was harmed when he acquired 1 unstageable pressure ulcer to his left posterior thigh, and 3 unstageable pressure ulcers to his right ischium. Findings included: Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's quarterly MDS assessment, dated 5/17/13, documented in part: * Cognitively intact with a BIMS score of 15; * Total dependence with the assistance of 2 or more people for bed mobility, transfers, and dressing; * Extensive assistance of 1 person for toilet use and personal hygiene; * Total dependence with the assistance of 1 person for locomotion on and off the unit; * Impairment on both sides of the upper and lower extremities; * Mobility devices of a wheelchair and limb prosthesis; * Indwelling catheter and [MEDICAL CONDITION]; * Resident at risk for developing pressure ulcers; * One or more unhealed pressure ulcers at Stage I (One) or higher; * One pressure ulcer present upon admission; * Pressure reducing device for chair and bed; * Turning/repositioning program; * Nutrition or hydration intervention to manage skin problems; * Ulcer care; * Application of nonsurgical dressings and ointments/medications other than to feet; and, * [MEDICAL TREATMENT]. A Norton Plus Pressure Ulcer Scale for Resident #2, dated 2/20/13, documented in part: * Fair physical condition; * Alert mental state; * Bedrest for activity; * Very limited mobility; * Not incontinent; * [DIAGNOSES REDACTED]. * 5 (or more) medications; and, * Total Norton Scale Score of 12 which indicated moderate risk for pressure ulcers. Resident #2's Interim Skin Care Plan, dated 2/20/13, documented in part: * Problem/Need - Potential or actual skin breakdown R/T (related to) poor mobility, friction/sheer, nutritional deficit, sacral osteo[DIAGNOSES REDACTED], left BKA ([MEDICAL CONDITION]), and right toes amputated; * Approaches - Pressure reducing cushion in w/c (wheelchair) - Roho, offer fluids regularly while awake as appropriate, pressure reducing mattress to be on bed to promote skin integrity - turning, use turn sheet to turn and reposition resident to avoid shearing forces on skin as needed, assess skin daily by CNAs and weekly by wound care nurse, observe and report any signs of infection, in the event of skin breakdown use facility protocols for TX (treatment) of wounds, pressure relieving cushion in w/c - Roho, and treatments/dressings as ordered. Notify MD if treatments are not effective. Note: An interview with the DON on 10/9/13 at 9:53 a.m. revealed that the Interim Care Plans are completed by the floor LNs if the wound nurse is unavailable. Once the wound nurse is available, she would complete a Working Care Plan. A Skin Integrity Working Care Plan for Resident #2, dated 2/20/13, documented in part: * Problem - Diabetic, history of skin breakdown, resident is dependent with ADL's (activities of daily living) and/or requires assist with ADL's, pressure ulcers - 1 unstageable to the left ischium; * Approach - Low Air loss bed (Turn Q air bed), RD (Registered Dietitian) to assess diet, Encourage resident to get out of bed daily as tolerated, Maintain safe environment to prevent skin injuries, and PT (Physical Therapy) to treat as ordered. N: The Roho cushion to w/c approach from the Interim Care Plan was not carried over to the Working Care Plan. Underneath the Low Air loss bed (Turn Q air bed) was "Clinatron Bed" written in ink with no correlating date. Neither care plan included an intervention for frequency of repositioning. Resident #2's Nutrition Working Care Plan, dated 2/20/13, documented in part: * Problem - Altered nutrition AEB (as evidenced by) Diabetes; and, * Approach - Diet: CCHO (consistent carbohydrate). A SNRC (Skilled Nursing and Rehabilitation Center) physician's orders [REDACTED]. * Diet: Diabetic 1800 calorie Renal Medium CCHO, Boost TID (three times per day) and Glutasolve 1 packet BID (two times per day); and, * Additional Orders: Restrict sitting in chair to 1 hour BID for 2 months. Note: The resident went for [MEDICAL TREATMENT] treatment 3 days per week for 3-4 hours each time. Resident #2's physician's orders [REDACTED]. * Air bed. Patient to be on Turn Q bed to promote skin integrity; * Roho Cushion. Roho pad to be used in patient w/c and in [MEDICAL TREATMENT] chair to promote skin integrity and protect skin flaps; * 3/13/13 - Liquacel solution (a complete protein source) 2 oz (ounces) p.o. (by mouth) every other day on [MEDICAL TREATMENT] days; and, * 4/22/13 - discontinue Turn Q bed and put patient on a Clinitron bed for wound healing and skin integrity. a. On 3/13/13 a Wound Evaluation Flow Sheet (WEFS)was completed for Resident #2 identifying a newly developed unstageable pressure ulcer to the left posterior thigh measuring 6 cm (centimeters) in length and 4 cm in width with no depth and no exudate. The wound margins were documented as red and the surrounding tissue normal. The current treatment was documented as [MEDICATION NAME] dressing. The Wound Evaluation Flow Sheet documented the pressure ulcer was acquired In House. On 3/18/13 the current treatment on the Wound Evaluation Flow Sheet documented, "PT treating." The Physical Therapist was a Certified Wound Specialist. A Rehabilitation Services Skilled Intervention Record (RSSIR) was completed by the PT for Resident #2 that documented in part: * 3/19/13 - "New measures 5.1 by 2.7 by 1.0. Deeper, more necrotic tissue, larger. There is ongoing pressure. Not from bed. Not from Roho. Suspect the sling lift he is transferring with. PT checking for alternative transfer options, debrided, dressing with Santyl, [MEDICATION NAME]; * 3/20/13 - No new necrosis. Beginning to respond to Santyl (An enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level). Debrided, irrigate; * 3/22/13 - No new necrosis. No periwound erythmia. Patient does use Roho for [MEDICAL TREATMENT]. Has different sling for transfers now; * 3/25/13 - New measures 4.5 by 2.0 by 0.9; * 4/19/13 - Extensive debridement of proximal wound. Will need KCI VAC (promotes wound healing through negative pressure wound therapy via vacuum) next week." b. On 4/22/13 a Wound Evaluation Flow Sheet was completed for Resident #2 identifying a newly developed pressure ulcer acquired In House. The current treatment was documented as, "Treated (and) eval (uated) by PT." A Rehabilitation Services Skilled Intervention Record (RSSIR) was completed by the PT for Resident #2 that documented in part: *4/22/13 - "Discouraged about wife's death - does not want to eat - Three new sores - pressure ulcers - right ischium - This is most likely unavoidable due to patient unwillingness to change position and unwillingness to eat - desires to die to be with his wife." PT documented measurements and photos of the 3 new pressure ulcers on a Physical Therapy Wound Photos sheet, dated 4/22/13, and were as follows: The medial 2.8 by 1.3 unstageable, lateral 1.0 by 1.5 unstageable, distal 1.2 by 1.4 unstageable; NOTE: The pressure ulcer documentation sometimes identified the wounds as 'unstageable' but never identified the pressure wounds as Stage 1, 2, 3 or 4. Also, while the therapist documented the new wounds were 'likely unavoidable due to patient unwillingness to change position' the care plan did not address any refusals of repositioning. * 4/26/13 - "States he has again begun eating his meals. States he ate 100 percent today. I observed him drink 100 percent of Ensure after dinner. Now on Clinitron bed, now on antibiotics. On exam - No new pressure areas, minimal drainage. No odor noted - Improved granulation on left side. Extensive debridement of eschar right side - yellow slough remains - but wounds are small; * 4/30/13 - New measures. medial 2.5 by 1.1 unstageable. lateral 1.1 by 1.4 unstageable. distal 1.0 by 1.0 unstageable; * 5/20/13 - Medial pressure ulcer closed. Lateral 0.5 by 0.5 by 0.1. Distal 1.4 by 0.7 by 0.2; * 5/24/13 - number 3 and 4 (the medial and lateral pressure ulcers) closed. number 5 (the distal pressure ulcer) irrigate and debride; * 6/26/13 - Right ischium, all wounds closed." On 10/8/13 at 9:10 a.m., the DON was asked what interventions were put into place when Resident #2 was admitted to the facility. She stated, "(He) came from the hospital on a turn Q bed and ordered wound care by PT." She added the resident had a Roho cushion for his w/c and [MEDICAL TREATMENT] chair. When asked what interventions were put into place after the first pressure ulcer developed, the DON said the treatment nurse did an inservice to put a pad on top of the Hoyer sling because transfers were suspected to have caused the pressure issue. When asked what interventions were put into place after the second pressure ulcer developed, the DON said that the facility got an order to discontinue the turn Q bed and put the resident on a Clinitron bed and, "Did bed baths to decrease transfers." The DON added that the facility, "Made a request to have ([MEDICAL TREATMENT]) treatment in the supine position" but the [MEDICAL TREATMENT] center refused. When asked if the chairs at [MEDICAL TREATMENT] reclined, the DON said she didn't know if they had recliner chairs. The surveyors were provided with inservice documentation regarding using a pad on top of the sling for transfers, dated 3/13/13, to do bed baths to decrease transfers, dated 4/24/13, and education on the new Clinitron bed, no date included, and how to use it. The DON provided the surveyors with a letter from the [MEDICAL TREATMENT] center, dated 9/5/13, that documented, "This letter is in regard to request for (resident's name) to receive [MEDICAL TREATMENT] at your facility. Unfortunately due to the nature of [MEDICAL TREATMENT] this would not be possible, chronic [MEDICAL TREATMENT] treatment must be performed in a [MEDICAL TREATMENT] center. We also looked into the option of the patient being transported in his hospital bed to the facility for [MEDICAL TREATMENT]. Unfortunately due to the space constraints we would not be able to accommodate this. We did discuss efforts to coordinate with (the facility) when (resident's name) is dropped off and picked up. We have also coordinated with care center for patient to minimize transfers, and patient is being transferred to and from [MEDICAL TREATMENT] in a [MEDICAL TREATMENT] chair." On 10/8/13 at 9:50 a.m., Resident #2 was asked if he had developed any pressure ulcers at the facility. He responded, "I got a couple of them here. They're getting better." When asked if he ever refused to eat at meals he said he usually doesn't eat breakfast because, "(I'm ) not a morning person." Resident #2 added that he thinks he has a pretty good appetite and doesn't refuse meals other than breakfast. The resident was asked if the chairs at [MEDICAL TREATMENT] reclined and he stated, "(They) have recliner chairs" and he can sit straight up or recline all the way back. When asked if he reclines the [MEDICAL TREATMENT] chair, Resident #2 replied, "I don't like it reclined all the way back." Note: Resident #2 was admitted on [DATE] with no pressure ulcers on either ischium, and [DIAGNOSES REDACTED]. He was determined to be at moderate risk for pressure ulcers by the Norton Plus Pressure Ulcer Scale. On 3/13/13 the resident developed a new pressure ulcer to his left upper posterior thigh. The new interventions put in place included padding on top of the Hoyer sling (The facility suspected the Hoyer sling was the cause of the pressure ulcers) and pressure ulcer treatment by PT. Despite the new interventions, on 4/22/13 three new pressure ulcers developed on Resident #2's left ischium. Interventions put in place were pressure ulcer treatment by PT, bed baths to decrease transfers, and a Clinitron bed. The facility did not maintain a safe environment to prevent skin injuries when using the Hoyer lift for Resident #2, nor were there adequate care plan interventions put into place, such as a specific repositioning plan that would address minimizing sitting time during [MEDICAL TREATMENT], to prevent further pressure ulcer development. On 10/9/13 at 12:15 a.m., the Administrator and DON were informed of the pressure ulcer issue. However, no further information or documentation was provided that resolved the issue.

Based on observation, staff interview, medical record review it was determined the facility had failed to ensure that residents did not acquire pressure sores. - Resident's #2 and #9 were harmed when they acquired Stage III pressure sores. Resident #2 had a sore on the right heel and Resident #9 had a sore on the left ishium. - Resident #3 was harmed when she had multiple unstageable pressure sores on the coccyx, right heel and buttock. This was true for 3 of 14 (#s 2, 3, and 9) sampled resident. Findings include: 1. Resident #2 was admitted to the facility 6/24/12 with [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], documented the resident: * had moderate cognitive impairment, (BIMS = 8) * required limited assistance of one staff for eating, * was frequently incontinent of bowel and bladder, * had a stage II pressure sore. The resident had a Stage III pressure sore on the heel. The resident's care plan for pressure sores was not located in the medical record with the rest of the care plans. The pressure sore care plan was in the treatment book with the treatment sheets. In addition to the two care plans, there was a third one the facility called a mini care plan and this had information for the CNA's to use to provide cares to the residents and were discarded at the end of the day. The "Skin Integrity Care Plan," dated 6/29/12, documented pressure ulcers, Stage II, Location: Right Heel. There were 18 interventions, several that may have applied to the CNA staff were: "* Pressure reducing cushion in wheel chair. * Static air overlay. * Turning and positioning (as needed), use care when lifting or turning to prevent skin alterations. * Float heels while in bed (as needed). * Encourage adequate nutrition. * Encourage resident to get out of bed daily as tolerated. * Apply treatments and dressings as ordered." The "Mini Care Plan," dated 8/21/12, documented: "* Fragile skin: PRAFO to right foot/ankle - to be on at all times except when ambulating to bathroom. * Air overlay." The incident and accident report for 6/29/12 documented: "Wound to (right) heel." The description was, "Day shift nurse on 6/28/12 observed. Covered wound (with) alleyvn (sic) heel dressing, appears from tight shoes. Shoes removed air shoes applied." A witness statement completed, on 6/28/12 at 6:45 p.m., by an LPN documented,"CNA came and told fluid was draining from right heel, is on sheets. Nurse assessed, skin peeled back off heel. Area cleansed (with) (normal saline)/placed allevyn, heels floated." The nurse's treatment notes documented: "6/29/12 - Noted open blister like area on R (right) heel. Measures 5.5. cm x 6.1 cm. Appears from tight shoes. Cleansed and Alleyvn (sic) drsg (dressing) applied. Air boots applied to B (bilateral) feet. Staff inserviced, family notified." "7/1/12 - Drsg changed to R heel per order. Wound dark in color appears scab like. Air boot in place. Preventative measures in place." "7/4/12 - Drsg to R heel (changed) per order. Noted serous sang(uinous) drainage (without) odor. Cleansed and redressed...Air boot in place." "7/7/12 - Removed R heel dressing. moderate amount of sero-sanguinous drainage on old drsg. Cleansed with wound wash. Applied allevyn 4 x 4 then allevyn heel drsg and [MEDICATION NAME] wrap. Padded heel protector in place...." The resident was seen by the physician on 7/11/12 and he documented: "S) ....He developed a PU (pressure ulcer) to R posterior calcanal surface about 2 weeks ago and it became odorous about 2 -3 days ago.... O) Alert, oriented, elderly fragile R heel (with) 5.0 x 3.8 x 0.1 cm Stage III PU (with 60 - 70 % covered (with) a soft eschar, odor present, minimal purulent exudate and minimal surrounding [DIAGNOSES REDACTED].... A) 1) Stage 3 PU, R posterior calcanal surface, unstable eschar; + evidence of infection, 2+ [MEDICAL CONDITION] - may need treatment.... P) 1) Culture, begin [MEDICATION NAME] DS pending results...hope to be able to debride earlier next week - PRAFO to be initiated." On 7/18/12 the physician documented that a debridement was done and the "dimensions" of the wound were unchanged. On 7/25/12 the physician documented: " Progress: The stage III pressure ulcer located on the right posterior calcaneous...The pressure ulcer measures 3.7 cm x 2.3 cm x 0.3 cm. It has increased in size from its original measurement of 3.2 cm x 2.3 cm x 0.2 cm. There is a minimum amount of serosanguinous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue. The skin around the pressure ulcer is normal...." On 8/1/12 the physician documented: "Progress: The Stage III pressure ulcer located on the right posterior calcaneous....The pressure ulcer measures 3.4 cm x 2.2 cm x 0.3 cm....There is a minimum amount of serosanguineous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue..." On 8/8/12 the physician documented: "Progress: The Stage III pressure ulcer located on the right posterior calcaneous...The pressure ulcer measures 3.2 cm x 2.3 cm x 0.2 cm. It has decreased in size from the original measurement...there is a minimal amount of serous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue. The skin around the pressure ulcer is normal...." A culture was done at this visit, the results were e-coli [MEDICAL CONDITION]. The resident was started on Keflex 500 milligrams three times daily and [MEDICATION NAME] DS twice a day. The Nurse's treatment notes document the resident was seen by the physician on 8/15/12. There was lacking documentation of the physician's visit in the medical record. The nurses notes did not give a description of the pressure sore, only that there was an improvement to the wound. The resident was seen by the physician on 8/22/12, the physician documented the resident's "wound continues to improve and [MEDICAL CONDITION] is controlled at this time." The DON was interviewed on 8/23/12 at 8:30 a.m. about the pressure sore. The DON agreed the sore was caused by the resident wearing tight shoes which created the blister. The sore deteriorated after the discovery, but preventative boots and a dressing were put in place immediately. The physician provided additional documentation which he indicated that the sore was unavoidable but failed to address the cause which was ill fitting foot wear. The resident was harmed due to: * The resident was not assessed and monitored for footwear, which resulted in a Stage III sore, * The pressure sore care plan is not available to all nursing staff and did not contain all interventions, e.g. PRAFO boot, * The CNA "mini care plans," did not give all interventions that the aides could implement. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS dated [DATE] documented the resident: * short and long term memory were intact, * had modified independence with decision making skills, * required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. * does not have a pressure sore. The resident had a healing stage III pressure sore on the Left Ileum at the time of of the survey. The resident had three different care plans. One care plan in the active medical record, one in the treatment book and a mini-care plan that the CNA's carried that was discarded at the end of their shift. The care plan for the pressure sore located in the treatment book dated 5/18/12 documented a problem for "Skin Integrity Care Plan" of: "Resident is at risk for skin alterations due to the following Diagnoses: [REDACTED]." was checked. There were 20 interventions listed. Some of the interventions that may be needed for the CNAs to use were: "* Pressure reducing cushion in wheel chair." "* Pressure reducing Mattress on bed." "* Turning and Repositioning PRN(as needed), use care when lifting or turning to prevent skin alterations." "* Float heels while in bed PRN." "* Keep resident clean and dry and free of irritants (feces and urine)." "* Encourage adequate nutrition." "* Encourage resident to get out of bed daily as tolerated." The "mini care plan" dated 8/21/12 documented information that conflicted with what was on the care plan. The documentation was: * had an air mattress, * "Knee Hi TED Hose - on in a.m., off at H.S." * "must be laid down between meals." The "Nurse's Treatment Notes" documented: "7/10/12 - Wkly (weekly) skin assessment complete. Noted open excoriation to L (left) (upper) thigh/buttock region....preventative measures in place." "7/17/12 - Wkly skin (check) complete. Open excoriation appears denuded (with) white slough. Cleansed and covered..." "7/20/12 - Drsg (change) done. Noted strong odor..." (Note: The physician was contacted and referred the resident to the wound clinic.) "7/25/12 - (Wound Physician) in and (evaluated) wound. Debrided white slough revealing red moist, non odorous tissue. (Antibiotic) continues. New orders received and noted. Continues on frequent repositioning and preventative devices to promote healing...." The wound clinic reports available for review started on 8/1/12 and documented: "Progress: The Stage III pressure ulcer located on the left ishium has been present for approximately 14 days. The pressure ulcer arises from an unknown origin. The pressure ulcer measures 1.8 cm x 0.8 cm x 0.1 cm. It has decreased in size from its original measurement of 1.8 cm x 1 cm x 0.5 cm. There is a minimum amount of serosanguinous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue...." The 8/8/12 documentation by the wound physician was: "Progress: The Stage II pressure ulcer located on the left ishium has been present for approximately 2 weeks...The pressure ulcer measures 1.8 cm x 6 cm x 0.1 cm. It has increased in size from its original measurement of 1.8 cm x 1 cm x 0.5 cm. There is minimum amount of serosanguinous exudate draining from the pressure ulcer. The pressure bed has exposed subcutaneous tissue. The skin around the pressure ulcer is normal.... The patient is seen at (facility) LTC for followup evaluation of a pressure ulcer, now stage 2 but healing from a stage 3 on the left ishium...." The Nurse's treatment notes document the resident was seen by the physician on 8/15/12. There was lacking documentation of the visit in the medical record. The nurse documented, "(physician name) in to examine wound. Debridement done. Redressed as ordered...." The physician examined the wound on 8/22/12 and documented: "...On 7/25 I saw patient and evaluated his wound which presented as a stage II PU to left ishium. I debrided the wound at that time and staged it as a Stage III after debridement. The wound has continued to improve and is not closed with no evidence of pressure or infection. However it is still very fragile..." The DON, MDS nurse and treatment nurse were interviewed on 8/23/12 at 8:30 a.m. They explained the sore started as shearing and excoriation, it wasn't until after the physician debrided it that it was a stage III. The care plan differences were discussed and changes were made to the minicare plan to reflect the information that was not on it. The resident was observed on 8/21/12 at 10:00 a.m., 8/21/12 at 2:15 p.m., and 8/22/12 at 9:45 a.m. At all the observations the resident had an air mattress on his bed. The resident was not getting the benefit of the mattress as he was on top of the covers, which included sheets and bedspread, and he had his attends and street clothes on. The resident was harmed due to: * The resident had [MEDICAL CONDITION] disease and incontinence so he was at risk for skin breakdown. The resident was not monitored and positioned to prevent shearing and excoriation which resulted in a Stage III sore, * The pressure sore care plan is not available to all nursing staff and did not contain all interventions, e.g. "must be down between meals." * The CNA "mini care plans" did not give all interventions that the aides could implement. * The care plan stated 'Turning and repositioning PRN;' it did not provide direction to staff on frequency of turning and repositioning. 3. Resident #3 was admitted to the facility on [DATE] from an acute care hospital. The resident had [DIAGNOSES REDACTED]. The resident had several discharges to the hospital and readmissions to the facility. One of the hospital admissions in June 2012 resulted in a [MEDICAL CONDITION] of the left lower extremity. The residents MDS assessments were as follows: *5/03/12- Initial admission to nursing home. No pressure sores or history of documented. *5/10/12- OBRA required admission assessment. No pressure sores or history of documented. *5/17/12- Discharge assessment. No pressure sores or history of documented. *5/24/12- Re-entry admission assessment. No pressure sores or history of documented. *6/09/12- Discharge assessment. No pressure sores or history of documented. *6/11/12- Re-entry admission assessment. No pressure sores or history of documented. *6/17/12- Discharge assessment. No pressure sores or history of documented. *7/10/12- Re-entry admission assessment. No pressure sores or history of documented. Skin treatment and assessments from the time of the first admission on 5/3/12 were requested. The following documentation was received: *May 2012: 5/3- "Admission skin assessment completed. Pt (Patient) has multiple bruises from fall...Healed incision R(ight) groin. Both buttocks are blanchable red (with left) buttock has very small scab (less than 0.2 x 0.2)... c/o (complaints of) sensitive heels... 2 pillows brought for floating heels-will bring heel protectors. Abrasion outer R calf from fall 3.2 x 0.3 x 0.1 open to air - no s/s (signs/symptoms) of infection..."(NOTE: These measurements were the only ones documented for May). 5/8- "Weekly skin (check)... R calf abrasion healed - open to air. Buttocks intact, heels intact..." 5/14- "(Weekly) skin assessment...(continues) to have heel protects (sic) in bed. Continues on preventative measures." Facility "Non-Pressure Skin Condition Record" forms were provided. They indicated the scab came off the buttocks and was healed underneath as of 5/14. The outer calf was documented as healed as of 5/8/12. The forms did not include the red heels. The resident was discharged to hospital on 5/17 and returned to the facility on ,[DATE]. The following skin assessments were provided: 5/25- "Weekly skin check completed. Heels are blanchable. Bilateral lower extremities have dry/flaky skin present...No open areas noted. Buttocks intact. Continue with preventative measures." 5/31- "(Weekly) skin (check) complete- scabs & bruises healing well. (No) open areas. Preventative measures in place." A "Norton Plus Pressure Ulcer Scale" assessment was completed on 5/24 (score 15), 5/29 (score 12) and 6/5 (score 12). All scores placed the resident at moderate risk (scale 11- 15) for pressure sores. *June 2012: 6/04- "Weekly skin assessment complete...Continues to wear heel protector to L(eft) foot. (No) open areas. No new skin issues. Continues on preventative measures." The resident was discharged to hospital on 6/9 and returned to the facility on ,[DATE]. The following skin assessments were provided: 6/12- "New admission on 6/11/12... Noted closed red (with) dark unlay (sic) area to L heel. Spongy to touch appears fluid filled. Does not blanche covered (with) allevyn heel drsg (dressing) & secured with [MEDICATION NAME] film. Noted open denuded area to R inner buttock. Cleansed with wound cleanser & applied [MEDICATION NAME] AG mesh & covered with allevyn. Noted unstageable area to sacrum. Covered (with) allevyn. Pt. placed on turn every bed (type of air bed) to promote wound healing. Heel protectors placed to prevent further breakdown..." 6/14- "Drsgs clean, dry, intact to L heel. & R inner buttock. Continues on preventative measures." 6/15- "Drsg (change) to L heel as ordered. Wound continues fluid filled & intact. Drsg to sacrum (changed). Area to sacrum pink & healing well. Area R inner buttock healing well. Preventive measures continue." 6/16- "Dressing to L heel dry & intact. (Resident #3) had a bed bath today so sacrum & buttock dressings (changed). Sacrum wound pink, healing, buttock healing. Continue (with) current preventive measures." "Non-Pressure Skin Condition Record" forms were provided with various bruises and a skin tear documented. The denuded area to the right buttock was documented on one of these forms dated 6/12. The description included: L(ength) 1.0 x W(idth) 1.8 x D(epth) superficial. Noted to be measured in cm (centimeters). Other discriptions included: partial thickness loss, no exudate, pink/pale tissue, new, initial evaluation. "Wound Evaluation Flow Sheet" forms were provided for pressure ulcers to the left heel and sacrum. Both were documented as closed and non-stageable. Both were red with dark underlay and the heel was spongy. Measurements were documented for both one time in June on 6/12 as follows: * "Sacrum- L, 3.1 x W, 2.8 x D, 0 cm. *Left heel- L, 3.2 x W, 4 x D, 0 cm." There was no staging done even though the description of the heel and sacrum appeared to be at Stage II. No eschar was noted. There was no documentation these two areas were resolved. A "Norton Plus Pressure Ulcer Scale" assessment was completed on 6/11 (score 11) and 6/12 (Score 12). Both scores placed the resident at moderate risk for pressure sores. The resident's skin was deteriorated after her hospitalization . The facility did not document she was admitted with worsening skin and did not do her assessment until the day after she was admitted . The documentation for the denuded areas to the buttock did not indicate assessment for cause that was not related to pressure. *July 2012: 7/4- "New admission on 7/3/12... (Returned from hospital after below knee amputation), severe [MEDICAL CONDITION] Noted (2) small denuded areas to (both) buttocks. Cleansed & applied Calmoseptene oint(ment)... Placed on turn (every) bed for wound healing. Foley patent to DD (down drain)." 7/8- "Calmoseptene applied after cleansing of denuded areas. Skin pink preventative measures continue." 7/9- "Wkly (Weekly) skin assessment complete. No new skin issues. Cleanses area to buttocks...Area smaller and healing well..." 7/16- "...Buttocks clear. Calmoseptene applied to protect. Preventative skin measures in place." 7/23- "Wkly skin assessment complete. No new skin issues...Area to anal area closed... (NOTE: First documentation of skin records of anal area). 7/30- "Wkly skin check complete...Excoriation resolved to anal area... Skin preventative measures in place." "Non-Pressure Skin Condition Record" forms for July documented the following: 7/4- "R buttock- L, 0.2 x W, 0.2 x D, (not documented). Resolved 7/16/12." 7/4- "L buttock- L, 0.1 x W, 0.1 x D, (not documented). Resolved 8/3/12." *August 2012: 8/6- "Wkly skin check complete. No new skin issues. Surgical wound to L stump remains intact with black eschar...Area behind R leg remains intact without change..." (NOTE: The area on the back of the leg was documented as a bruise on a non-pressure skin condition record dated 7/16/12). 8/13- "Wkly skin assessment complete. No new issues... Area behind R leg remains intact & noted discolored..."8/21- "...Noted fluid filled blister to R heel intact. Cleansed and applied allevyn heel drsg. Pt. has vascular (disease). Appears arterial related...consult with Dr. (name of wound specialist) to eval & (treat)... Area to back of leg larger & dark purple in color..." 8/22- "Dr. (name of wound physician) in to eval wounds to R heel & calf. Orders rec'd and noted. Dr. talked to family about possibility of hyperbarics on L stump...R heel blister remains intact. Discoloration to R posterior calf remains intact..." 8/28- "...Drsg intact to L stump, R heel, R calf..." 8/29- "Dr. (name of wound physician) in to examine wounds. C&S (culture & sensitivity) obtained from L stump wound. R heel & R calf remains intact. Orders need & noted for culture. Measurements obtained..." A physician telephone order was documented on 8/21/12 (10:40 am), "1) Cleanse area to R heel (with normal saline). Apply heel drsg & secure (with) [MEDICATION NAME] check placement daily change every 3 (days) & prn. 2) Dr. (name) to eval & tx (treatment)." The pressure ulcer care plan was requested for the time the resident came back from the hospital on [DATE]. The facility "Working Care Plan" identified the resident was at risk for skin alteration dated 6/11/12. Current pressure ulcers were documented in this section as: 6/11/12, "unstageable coccyx, unstageable heel." At the bottom of the page a hand written entry indicated, "6/11/12, denuded area to R inner buttock." Approaches included, "Turn Q (every) air bed, pressure reducing cushion in wheel chair, turning and repositioning prn (as needed), float heels while in bed prn, adequate nutrition, heel protectors, etc." The current care plan, in the medical record, was a series of printed pages that listed a problem with directives to circle any factors listed that applied to the resident. The problem for "Potential or actual skin bread-down" was identified 7/2/12. There was an additional hand written entry, "Area of problem: R heel, L BKA (below knee amputation) incision. Other type of skin problem- healing sacral ulcer." The goal also contained choices for actual or potential pressure ulcers. Under the actual column the goal chosen was to have the pressure ulcer resolved by discharge. There was no date to ensure the goal was measurable. Approaches included 13 choices. None were identified. An air mattress was identified as a "decubitus mattress" and not identified as the "Turn Q mattress." There was no approach for the heel protector boots or to float her heels. The care plan did not indicate the resident resisted care related to pressure ulcer prevention. The DON was interviewed on 8/21/12 regarding the development of facility acquired wounds for Resident #3. The DON was asked to provide all the skin sheet documentation from the first admission on May 2012 to current. The skin sheets for August were not provided and faxed to the Bureau of Facility Standards on 8/29/12. None of the information from the wound physician's evaluation of Resident #3's wounds was provided. During a meeting with the DON and Administrator on 8/24/12 the surveyor asked for all information regarding the resident's wounds and any assessments that for how they determined if they were avoidable or unavoidable. The facility sent a fax to the Bureau of Facility Standards on 8/27/12 with a copy of a note from the resident's attending physician. The physician documented, "Despite preventative measures and interventions that have been in place for (Resident #3) it is my opinion that skin breakdown is unavoidable due her (sic) multiple co-morbidities." The physician did not address all the skin breakdown. While the [MEDICAL CONDITION] could complicate skin care on the lower extremities there was no mention of the sacrum or buttocks areas that had open areas and healed. The facility did not prevent multiple open wounds to the coccyx and buttocks for Resident #3.

Based on a complaint from the general public, staff interview, physician interview, and facility and hospital record review, it was determined the facility failed to provide appropriate care and services. This impacted 3 of 5 residents reviewed for timely assessments by staff. This resulted in harm to 2 residents and a potential for harm for a third resident. 1) Resident #1 was harmed when emergency room treatment and hospitalization was necessary for intravenous medications, intensive care and monitoring after the resident received excessive doses of potassium medication (a supplement) for 2 days after an ordered laboratory test to measure the potassium level was not done. 2) Resident #4 was harmed when: a) He developed a right lower extremity wound not discovered by staff. The wound had purulent drainage and was infected; b) He was found to be extremely lethargic and transported to the emergency room in acute respiratory distress. There was no evidence the resident's respiratory status was monitored. Both medical events were identified within a 24 hours period. 3) Resident # 5 was potentially harmed after she was started on oxygen therapy for an episode of shortness of breath (SOB), however, the staff did not perform follow-up assessments to ensure the resident's respiratory status was stable. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/6/10, the resident was readmitted to the facility after an 8/4/10 emergency room (ER) visit and 8/4-8/6/10 hospitalization , for [DIAGNOSES REDACTED]. The resident was again readmitted to the facility on [DATE], after another ER visit on 8/11/10 and 8/11-8/13/10 hospitalization for [DIAGNOSES REDACTED]. A significant change MDS assessment, dated 8/4/10, coded Resident #1, in part as: * Short-term memory problems; * Modified independent cognitive skills with some difficulty in new situations only; * Able to make self understood and understood others. On 8/4/10 at 8:43 a.m., Resident #1's potassium level was documented as 6.3 mEq (milliequivalents) per laboratory report. This was a high critical level (the low/high range was 3.5-5.0 mEq). At 8:45 a.m., the resident was evaluated in a local emergency room and admitted to the local hospital at 12:45 p.m. An 8/5/10 History and Physical (H & P) by the resident's attending physician, documented, in part, "... 4. [MEDICAL CONDITION]. It has resolved. This needs to be followed more closely. She was on potassium 60 mEq (milliequivalents) per day. This is being held at this time and we should reinstate this as needed." An 8/6/10 Discharge Summary by a second physician, documented, in part, "[MEDICAL CONDITION] activity, hypertension, and hypokalemia (low potassium) resolved...Discharge Medications: She was discharged back to the (facility) with the addition of [MEDICATION NAME] and [MEDICATION NAME] Laboratory: Upon discharge to the (facility) her potassium was normal with a level of 4.0, which was down from 5.0 the day before and from her initial level of 6.0. Discharge Instructions: She will be followed by her regular provider (the attending physician)..." A telephone order (TO) from the second physician to a hospital social worker, dated 8/6/10 at 2:00 p.m., documented, "Transfer to ECF (Extended Care Facility, also known as SNF)." A TO from the second physician, dated 8/6/10, documented, in part, "Continue all orders as before she left..." This order was documented as "8/6/10 1645 (4:45 p.m.) noted (and) verified" with an LN's signature. Another set of initials and a check mark were below this notation. The order was signed by the second physician on 8/10/10. Note: Please refer to F 271, admission orders [REDACTED]. The previous orders contained an order, dated 7/29/10, for Potassium (KCL) 20 mEq by mouth (PO) 3 times a day. Page 2 of an Additional Order Sheet physician's orders [REDACTED]. The order contained standing orders for potential medical problems such as diarrhea, headache, muscular pain and fever, etc. The order was signed by the second physician on 8/10/10. Next to the physician's signature was a handwritten note that documented, "V.O. (verbal order) given 06 [DATE] (8/6/10)." A TO from the attending physician, dated 8/9/10 at 11:50 a.m., documented, "KCL (potassium chloride) level today r/t (related to) high potassium." The order was documented as, "noted/verified 8-9-10" with LN's initials. The physician's initials, undated and timed, were next to the LN's signature. No other initials/signatures and no check mark was on the order. A physician progress notes [REDACTED]. (week)...May have had ischemic [MEDICAL CONDITION] - didn't appear to be metabolic or toxic. Was (illegible) by (increased) K (potassium)...Re(check) K." An order signed by the attending physician, dated 8/10/10, but not timed, documented, "Lab: Chem 8 Dx: [MEDICAL CONDITION] (chemistry analysis of 8 different levels, including potassium, for the [DIAGNOSES REDACTED]." The time of the LN's notation was not documented. Note: No potassium level lab report was found in the clinical record for 8/10/10. A Chem 8 lab report, drawn at 5:47 a.m. and verified at 7:07 a.m. on 8/11/10, documented, in part, "...potassium 8.4...called to (attending physician's name) (at 7:05 a.m.) 8/11/10 Read back by (attending physician's name)...Comment: same was repeated and redrawn to confirm..." A TO from the attending physician, dated 8/11/10 at 7:30 a.m., documented, * "[MEDICATION NAME] (removes potassium from the body) 30 grams PO x (times) 1 then repeat dose in 2 hrs (hours). * Repeat K+ (potassium) lab drawn 4 hrs after 1 dose of [MEDICATION NAME] * 1 Amp D50 IVP (One [MEDICATION NAME] of [MEDICATION NAME] 50 percent (a water-soluble high sugar solution) by intravenous push.) * 10 u Reg Insulin IVP (ten units Regular Insulin by intravenous push.) * DC PO K+ (discontinue potassium by mouth.)" The order was documented as, "noted verified 8-10-10 0745 (7:45 a.m.)" with the LN's initials. Another set of initials and 8/11/10 7:30 a.m. was below the LN's notation. Another TO by the attending physician, dated 8/11/10 at 1:00 p.m., documented, "Pt. to ER...r/t Dynspea (sic) (and) [MEDICAL CONDITION] (Patient to the emergency room ...related to dyspnea and [MEDICAL CONDITION])." The August MAR, signed by an LN on 8/6/10, documented that KCL extended release 20 mEq was administered to the resident three times a day on 8/7 through 8/10/10. Note: Resident #1 received 60 mEq of KCL for 4 days. Review of Nurses Progress Notes (NPN) and Skilled Assessment (SA) records from 8/6/10 at 2:20 p.m. to 8/11/10 at 12:45 p.m. revealed the following: * 8/6/10 2:20 p.m. - "readmitted ..." Note: There were no other NPN entries for 8/6/10. * 8/9/10 10:00 a.m. - "PT/INR (bleeding time laboratory test) drawn..." Note: No other laboratory tests were documented as having been done on 8/9/10. * 8/11/10 6:45 a.m. - "Lab notified this LN of Pt. critical K+ level of 9.1, lab down to redraw (at) (7:00 a.m.), (attending physician's name) notified, second lab value received (at) (7:30 a.m.) K+ 8.4. (Attending physician's name) notified, ordered [MEDICATION NAME] Insulin...oral K+ DC'd, Repeat K+ lab draw...supervisor in to start IV...22 gauge...50 (and) insulin given as ordered as well as [MEDICATION NAME]" * 8/11/10 9:30 a.m. - "(Second) dose [MEDICATION NAME] given..." * 8/11/10 12:30 p.m. - Pt (up) for lunch, very lethargic, having trouble breathing, not responsive to verbal commands, lab down to draw second lab, (attending physician's name) notified of pt. status." * 8/11/10 12:45 p.m. - Lab (K+) received, cont(inue) to be critical high, 8.0, Pt sent to ER per (attending physician's name)." An Emergency Provider Record, timed 1:12 p.m., but not dated, though contained a bar code Patient Stamp with 8/11/10 on it, documented, "...Clinical Impression(:) [MEDICAL CONDITION]/RI (respiratory infection)." An Emergency Department Nursing Observation record, timed 1:00 p.m., also not dated, but contained the same 8/11/10 bar code Patient Stamp, documented the following: * "Nursing History (and) Assessment...(:) [MEDICAL CONDITION] (and) SOB (shortness of breath) (and) difficulty breathing. Worsened at 1200 (noon)." * "[MEDICATION NAME] 50 gms per rectum" at 1:48 p.m. * "Calcium [MEDICATION NAME] one amp IV" at 1:50 p.m. * "[MEDICATION NAME] (antibiotic) 500 mg IV" at 4:35 p.m. * "Regular Insulin 10 units IV" at 5:00 p.m. * "D50 one amp IV" at 5:00 p.m. * "18 G IV (B) AC x 1 attempt blood drawn 1340 (18 gauge IVs inserted at both antecubital areas (bend in elbow) on first attempt, blood drawn at 1:40 p.m.)." * "(4:25 p.m.) ...foley catheter (indwelling urinary catheter) inserted..." * "(5:25 p.m.) ...tx to ICU 2 via stretcher...(...transported to Intensive Care Unit room [ROOM NUMBER]...)." An Emergency Department Addendum, dictated on 8/11/10 at 6:34 p.m., documented, "...History of Present Illness: In summary,...brought up from the Extended Care Facility secondary to an elevated potassium. This morning her potassium was 8.4...Repeat potassium was...8. She was then sent up from the ECF to the Emergency Department for further evaluation. Of note, the patient reported to the nursing home staff that she was having some difficulty breathing... Also, reviewing the patient's records, she was started on potassium Chloride 20 mEq t.i.d. on 08/07/10... Emergency Department Course: The patient was given...calcium [MEDICATION NAME][MEDICATION NAME] per rectum...and some further insulin and D-50 IV...Condition: Guarded. Diagnoses: [REDACTED]. 2. Acute [MEDICAL CONDITION]" An Internal Medicine Consultation, dictated 8/11/10 at 10:59 p.m., documented, in part, "History of Present Illness: ...When I went to see the patient I spoke with the ER physician, (physician's name). He reported the patient was doing much better than when she came from the ECF...Assessment and Plan: 1. [MEDICAL CONDITION]. ...admitted with a potassium of 8. Of note, patient was taking KCL 20 mg p.o. q (every) 8 hours, [MEDICATION NAME], and [MEDICATION NAME]. We are going to hold those medications...Followup (sic) potassium a couple of hours later after treatment showed the potassium had decreased to 5.4. Besides the 3 medications that could be causing her [MEDICAL CONDITION], the patient is also in acute [MEDICAL CONDITION]. Her creatinine is 2.4. See below. 2. Acute [MEDICAL CONDITION]. The patient's BUN is 38 from a previous 14 and creatinine 2.4 from a previous 0.9...We are going to follow the renal ultrasound results...We are going to closely follow her electrolytes and her kidney function..." A Progress Note by the Internal Medicine physician, dated 8/12/10, documented, in part, "...Assessment and Plan: 1. Acute [MEDICAL CONDITION] BUN is 33 and creatinine is 1.5. Her electrolytes are doing much better. Her potassium now is 4.6, from 8.0 yesterday..." A Progress Note by the Internal Medicine physician, dated 8/13/10, documented, in part, "...Assessment and Plan: 1. [MEDICAL CONDITION], resolved. Potassium is now under control. [MEDICATION NAME], potassium supplement, and [MEDICATION NAME] were held while the patient was on the Medical-Surgical floor...2. Acute [MEDICAL CONDITION], resolved...At this moment will recommend holding any nephrotoxic medications..." On 9/8/10 at 9:55 a.m., LN #13 was interviewed regarding the Resident #1's readmission to the facility on [DATE]. Employee #13 said, "I wasn't going to take her because we didn't have orders. We didn't have anything." LN #13 said 2 or 3 telephone calls were made to the hospital in an effort to get admission orders next in line", said to admit the resident and the physician would be in later to sign orders. LN #13 also said that when the hospital staff gave report there was no mention that the resident's potassium had been high. LN #13 was asked if any paperwork, perhaps a transfer sheet or medication list, came with resident from the hospital. LN #13 stated, "Transfer sheet. There's not one. No. We didn't have anything." LN #13 said after the resident arrived, another LN called the physician for verbal orders while LN #13 did the admission nursing assessment. LN #13 was shown a "M.A.R.-Temporary" dated 8/5/10 11:00 p.m. to 8/6/1/ 11:59 p.m. and asked what it was. LN #13 said, "When the temporary MAR comes down you check it against the doctor's orders and when the pills come down you check them against the MAR." LN #13 was asked if this temporary MAR came to the facility on [DATE]. LN #13 said, "Probably not by the time we got off. Night shift would have done that. It wasn't here by the time our shift ended." LN #13 was shown the Additional Order Sheet, dated 8/6/10. LN #13 said, "It contains standing orders." LN #13 was asked what "See MAR" meant on page 1 of the Additional Order Sheet. LN #13 said, "That refers to the MAR-Temporary that (second physician's name) signed on 8/10/10 but I have no idea when it came." LN #13 stated, "I would have questioned resuming KCL but we did not have this documentation at the time." On 9/9/10 at 2:40 p.m., LN #10 was interviewed regarding Resident # 1's readmission to the facility on [DATE] and the missed potassium laboratory test ordered for 8/9/10. LN #10 said, "We didn't have anything, no MD orders or anything (on 8/6/10)." LN #10 stated, "Financial Coordinator's name) said yes, you're taking her. (Second physician's name) will be here." LN #10 stated, "I thought she (Resident #10) had a stroke. Not until later did I find out she had had high potassium. Usually we do get all paperwork. I called (second physician's name). I told (physician) I needed orders. He said resume all previous orders with the exception of [MEDICATION NAME] and [MEDICATION NAME], new meds." LN #10 stated, "I got the orders from (second physician's name) and sent them to the pharmacy. I had no paperwork by the time I left at 6:30." LN #10 stated, "I never saw the MAR-Temporary form. The next day we had the (facility's) MAR." LN #10 showed the survey team that the August MAR contained the night shift LN's signature dated 8/6/10 and said, "That would mean she would have checked this MAR against the meds from pharmacy." LN #10 stated, "I don't think (second physician's name) came in that evening. But this is just through talking with other staff." LN #10 said she was off work when the potassium laboratory test was ordered. On 8/7/10 at 4:38 p.m., Ward Clerk #11 was shown the 8/9/10 physician TO for a potassium level that day. She was asked if she had seen the order before. Ward Clerk #11 stated, "Yes, a few days after, but not on 8/9/10. The chart did not come to me on that date." Ward Clerk #11 was asked to recount the process for taking off orders. Ward Clerk #11 stated, "If a LN writes it (an order), it goes to me, then I put it in the (computer) system. If an MD writes an order, it goes to the LN, then to the ward clerk. We fax the medication orders to pharmacy. " Ward Clerk #11 was asked who verified ward clerks' entries. "Nobody. We do it backwards. I did a 24 hours chart check but for some reason I missed this order. There's a big mess with this chart...The chart had no MD signatures. It waited until Monday." Ward Clerk #11 stated, "The ward clerk signs off on every piece of paper." On 8/8/10 at 6:05 p.m., LN #14 was interviewed and shown Resident #1's clinical record. LN #14 stated, "I don't recall having orders for (Resident #'s name), but the MAR and meds were already there that I remember. I checked the MAR against the MD orders and signed my name on the MAR. I don't know which MD orders I used to verify the MAR. I don't recall this sheet (she pointed to the MAR-Temporary), but I would have had to see some order." LN #14 was asked is she had seen the 8/6/10 TO to continue the previous orders. LN #14 stated, "I think I do remember seeing this." LN #14 said she had to call (the second physician) for an order for [REDACTED]. But I can't recall which order sheet I was looking at. Again, I don't recall seeing the temporary MAR." On 9/9/10 at 12:20 p.m., the survey team interviewed the second physician regarding Resident #1 readmission to the facility on [DATE]. The second physician stated, "I saw her in the hospital and admitted her to the facility under (attending physician's name)." The second physician was asked if orders were given for the resident's readmission to the facility. The physician stated, "I wouldn't send a patient down (to the facility) without orders." The physician said that on 8/10/10 one of the facility LNs approached him with the 8/5-8/6/10 MAR-Temporary in hand and demanded that he sign it. The physician said that on 8/10/10, he did sign the MAR-Temporary and the 8/6/10 VO to continue the previous orders which included the Additional Order Sheet physician's orders [REDACTED]. that (the physician pointed to the MAR-Temporary). I would have said resume the previous meds, that would be all meds, including the potassium because it was dropping about a point a day." The physician was asked if he saw Resident #10 after she was readmitted to the facility on [DATE]. The physician said that typically he parked his vehicle in the facility's parking area so he would have to walk through the facility at the end of the day and then he would see residents in the facility, if he had not seen them earlier in the day. On 9/9/10 at 11:30 a.m., the Admissions/Financial Coordinator (AFC) was interviewed and asked for the facility's usual process when admitting or readmitting a resident. The AFC said that after the facility would receive notification of a possible admission, paperwork that included an H and P, physician orders, medication list, code status, insurance information, and other admission papers, would be sent, usually via fax, for the AFC and the DON or another LN to review. Then if the resident was accepted, the Ward Clerk would notify the AFC of the time the resident arrived at the facility. The AFC was asked who in the facility approved the final admission step. The ADC stated, "The Administrator and the DON. If they are not here we call them by phone or might defer to the LN to review the paperwork." The AFC was asked if there had been any exceptions to this process. The AFC stated, "There have been." The AFC indicated that the Medical Director had accepted residents before paperwork was available then would come to the facility after one of the LNs called him. The AFC was asked if the Administrator or the DON were available on 8/6/10. The AFC stated, "I'm not for certain. I don't know if (DON's name) was here that day. I do not recall getting a call from any staff about this resident." The AFC indicated that she had no conversation with any staff about their concerns of admitting Resident #1 without any paperwork/physician orders/MAR/H and P and said she had not heard of any concerns. The AFC was interviewed again on 9/14/10 at 10:55 a.m. The AFC said that on 8/6/10, the second physician was ill but still on-call. The AFC said she called the Administrator and was told they needed to have a physician write orders. The AFC said she called the second physician's office and was told the physician would be over later. The AFC was asked if the physician came to the facility after Resident #1 was readmitted on [DATE]. The AFC stated, "I had already gone home, so I don't know if he came in after 5 (p.m.). I don't remember checking for orders before I left. I'm not aware of any packet coming with the patient." On 9/14/10 at 11:40 a.m., the Administrator was interviewed. The Administrator said the AFC told her that morning about Resident #1's readmission on 8/6/10 and that the second physician was ill that day. The Administrator said she was aware that the second physician had been ill at one time but indicated that it was not on 8/6/10. The Administrator stated, "I'm just finding out this piece of information from (AFC's name). If (AFC's name) agreed (to admit Resident #1) then this is not good. I don't understand why (hospital) staff would send a patient without orders. The breakdown was the hospital transfer process." Regarding the missed potassium laboratory test ordered for 8/9/10, the Administrator stated, "I wasn't aware we missed a lab until you started the survey." The Administrator indicated that she would conduct a thorough investigation of both incidents. On 9/14/10 at 4:00 p.m., the Administrator and DON were informed of concerns of harm when Resident #1 returned to the facility without physician orders [REDACTED]. No further information was received from the facility. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His most recent annual MDS, dated [DATE], identified he was independent in his cognition and could make himself understood and understood others, was independent in transfers and toilet use, and required one person physical assist/assistive device when walking in the corridor. He was continent of bowel and bladder. There were no skin conditions identified. The Care Plan, dated 6/30/10, included the Approach: "...Monitor feet and skin daily for problems R/T (related to) DM and circulatory problems..." The Treatment Record and ADL Flow sheets for the months of July and August 2010, directed: "Follow Facility Protocol with weekly skin checks". The LNs recorded their initials to verify the skin checks were performed. The last documented LN initial was on 7/23/10. The Nursing Monthly Summary report, dated 7/10/10, identified the resident had "good skin turgor", and "[MEDICAL CONDITION] LE bil (lower extremities bilaterally.)" The report, dated 8/10/10, identified the resident had "fair, dry & fragile skin turgor", and "[MEDICAL CONDITION] bilat ext (bilateral extremities.)" There was also an arrow sign which pointed down, to indicate either "decreased or lower." There were no other skin conditions identified. Resident #4's Nurses Progress Notes (NPN) sequentially documented the following in part: 8/24/10, 11:00 am: Res(ident) told this LN that his R(ight) shin was hurting. Upon assessment noted two sores both 2 inch by 1 inch in size. Area red, warm & hard, drainage purulent, noted from site. Call into (Physician) regarding pt (patient) status. Allevyn & TAB (wound dressing and antibiotic) ointment applied to site." 8/24, 12:00 pm: "(Physician) called & ordered pt (patient) to have C&S (culture and sensitivity) of wound on R shin. ((Physician) said he will be in later tonight to assess pt." NOTE: There was no documented evidence the physician assessed the resident's leg wound on 8/24/10. 8/25, 6:30 am: "During report this am, aide informed this LN of pt. status. Stated, 'I cannot get (Resident) to wake up for breakfast. He won't even open his eyes.' Upon assessment, pt extremely lethargic, VS: O2 sats (Vital signs: oxygen saturation) 73 (%) P(ulse) 115, T(Temperature) 102, BP (blood pressure) 120/60. O2 on per NC (nasal cannula) running @ 2 lpm (liters per minute.) O2 adjusted to 3 L per NC, resp(iratory) therapy called to eval(uate. Name of staff) Resp (Respiratory Therapist) adjusted O2 to 6 L per NC, sats went up to 80%. Pt cont(inous) to be lethargic, not responding to verbal stimuli. (Physician) notified of pt status. Ordered Res to go to the ER (emergency room .)...Res. taken to ER per (physician's orders [REDACTED]. NOTE: *Resident #4's NPNs were reviewed from 7/26/10 through 8/24/10. There were no respiratory assessments documented and no mention of increased shortness of breath or sputum production. *The Nursing Monthly Summary reports, dated 7/10/10 and 8/10/10 contained 14 resident assessment categories. There was no category for Respiratory status and no documented evidence that the resident's respiratory status was assessed. The hospital records documented the following: *emergency room Record, dated 8/25/10 at 8:10 am: "Pt found (decreased) responsive." NOTE: The statement, "Continues in ER" was circled. "Initiating event: Upper respiratory illness...Pt (with) cough SOB (shortness of breath.)" The following associated symptoms were circled: "Fever/chills; short of breath, severe; coughing/productive..." The following physical examination findings were circled: "General appearance: Moderate distress; confused; Respiratory: prolonged expirations; decreased air movement; rhonchi; Cardiovascular: [MEDICAL CONDITION] Skin: pallor; Decubitus, (lesion LE (lower extremity) was handwritten;) Psychiatric: Depressed mood; Clinical Impression: [MEDICAL CONDITION]/Pneumonia." -Emergency Department Nursing Observation: "...(c/o) complaint of difficulty breathing; sputum productive cough...T. 99.9 (Temperature 99.9 degrees Farenheit.) O2 sat 76/66..." -Emergency Department Addendum: "...presents to the emergency department secondary to increasing shortness of breath and [MEDICAL CONDITION] (oxygen deficiency)...Significant for dramatic diminished breath sounds with coarse rhonchi bilaterally and some retractions. [MEDICAL CONDITION] noted as well...Chest x-ray reveals an infiltrate bilaterally with a congestive component. Blood work is significant for a white count of 23,000 with a significant left shift of 26 bands...." NOTE: the normal range for white blood count is 5,000 to 10,000 units. The normal range for bands is 0-85. The blood cell structure of "26 bands" represents an acute infection. *History and Physical, dated 8/25/10: "...He (Resident) has had increased dyspnea over the past few days, increasing cough that is productive, and increasing oxygen need...Extremities: There is significant lower extremity [MEDICAL CONDITION] bilaterally with right shin wound. Lab and X-ray: Wound culture on the right shin wound show positive for group A strep (streptococcus)..." *Internal Medicine Consultation, dated 8/26/10: "...Despite diuretics & antibiotics, he has failed to improve. He is now being supported (with) [MEDICAL CONDITION] (Bilevel Positive Airway Pressure, commonly used for critically ill hospital patients with [MEDICAL CONDITION]) and he remains acidotic and relatively hypoxemic. His mental status has deteriorated substantially this afternoon. Nursing reports an apneic, hypotensive event (suspension of breathing, abnormally low blood pressure) earlier today that preceded his decline..." -Physical Assessment: "...in obvious respiratory distress...T 102.8 (degrees)...diaphoretic and not responsive unable to evaluate neck veins...Coarse, bilateral rales (without( wheezing, heart tones very distant due to body habitus...Yeast [MEDICAL CONDITION] under abd(dominal) apron and inguinal folds. 2-3 (+) bipedal [MEDICAL CONDITION]. 2 cm (centimeter) open sore RLE...already cultured. Marked [DIAGNOSES REDACTED] (redness of skin) and warmth LLE (left lower extremity) from foot to groin (HOT!) and firm (;) obtunded (reduced level of consciousness)...Plan:..Lab reports Gm (Gram) + organisms from RLE (with, name of longterm care facility) exposure, we'll add Vanco ([MEDICATION NAME] intravenous antibiotic) and place [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) precautions. (Increase the) spectrum of antibiotics) ([MEDICATION NAME].)..." *Hospital Course, dictated 9/10/10: "...His health continued to deteriorate. (Physician's) assessment showed [MEDICAL CONDITION] with [MEDICAL CONDITIONS] with [MEDICAL CONDITIONS] (inflammation of the tissue under the skin), and acute [MEDICAL CONDITION] on 08/27/10... -Discharge Summary: "...The patient was on antibiotics and [MEDICATION NAME]. The blood gases were abnormal and continuing to become more abnormal. On 08/29/10...the patient did pass away secondary to the complications as stated above." NOTE: Resident #4's facility record contained no documented evidence of lower extremity skin assessments within the weeks prior to 8/24/10 when the resident alerted the staff due to pain in his right leg. There was no assessment of his left lower extremity which, according to the hospital record, had "marked [DIAGNOSES REDACTED] and warmth from foot to groin (HOT!)" On 9/13/10 at 3:30 pm, the DON was interviewed and asked to provide all the skin Incident/Accident (I/A) reports for July and August, 2010. These were received at 4:40 pm. There was no skin I/A on Resident #4. At 18:05 pm, the DON stated,"I didn't see it either. I'll look again." At 6:35 pm, the DON verified there was no I/A investigation report for Resident #4's right lower extremity wound. On 9/13/10 at 3:45 pm, the survey team requested the medical record staff to provide any wound care sheets for Resident #4. On 9/14/10 at 10:30 am, the DON was interviewed regarding Resident #4's wound assessment documentation. "We put the information on the treatment sheets." She acknowledged there was no right lower wound identified on the treatment sheet. The DON was asked if the facility investigated to determine the probable cause of the wounds. She answered "No." Resident #4 was harmed when the facility failed to perform respiratory and skin assessments resulting in not identifying the resident's deteriorating conditioin. 3) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing Assessment form, dated 8/23/10, identified the resident was alert, oriented and had clear appropriate speech. Her respirations were unlabored. She had diminished lung sounds and a dry cough. The physician's orders [REDACTED]. The daily Skilled Assessment nurses notes (NN) and Vital Sign Flow Sheet (VSFS) documented in part: *NN: 8/24/10, 8:30 am: "Assessment completed...Denies SOB (shortness of breath), non-productive cough, lungs diminished, wheezy/rhonchi in upper lobes B(ilaterally.)..O2 sats 90% RA (oxygen saturation levels 90% on room air)..." *VSFS: 8/24, pm shift: 02 sats "94%" *NN: 8/25, 8:00 am: "Assessment completed...O2 sats 90% RA. Breath sounds CTAB (clear to auscultation bilaterally)..." *VSFS: 8/25, pm shift: 02 sats "93%" *NN: 8/26, 7:00 am, "Pt (Patient) in bed resting (with) eyes closed. Resp(irations) even un-labored... -0830 (8:30 am), Assessment completed...Denies SOB...O2 sats 90% RA, CTAB..." -1830 (6:30 pm), "...resp even, non-labored... -0100 (1:00 am, 8/27/10)...resp. even non-labored..." *8/27, 1000 (10:00 am) Physical assessment done...Oxygen: 2L NC (2 liters nasal cannula) SOB - occasional, breath sounds CTAB, diminished RLL, LLL (right lower lobe, left lower lobe)..." NOTE: The entry did not include an oxygen saturation level. The subsequent 1:00 and 5:30 pm entries contained no respiratory assessments. There was no entry on the VSFS for 8/27/10, am shift. A physician order, dated 8/27/10, at 11:00 am, directed, "2L NC keep SaO2 greater than 90% as needed." NOTE: The MARs reviewed for the months of August and September 2010 did not include the physician's orders [REDACTED].