Every finding on record at Boundary County Nursing Home

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received restorative services as ordered. This was true for 2 of 3 residents (#17 and #18) reviewed for limited range of motion who did not receive restorative services as ordered. It was also determined the facility failed to assess the need for restorative services for 1 of 3 residents (Resident #19) whose records were reviewed for limited range of motion. These failures created the potential for decline in residents' range of motion. Findings include:The facility's Restorative Nursing Program policy, revised 10/19/25 documented, the purpose of the program is to maintain or improve the resident's optimal level of physical, mental, and psychological function.1.Resident #17 was admitted to the facility on [DATE] with diagnoses including age related osteoporosis, chronic pain, and a fracture of the left hip joint. A review of the resident's restorative nursing program documented the following restorative interventions: -Range of motion in sitting position: marching in place with 2 lb ankle weights, 10 repetitions for 3 sets.-Long arc quad (LAQ) exercises with 2 lb weight, 10 repetitions for 3 sets.-Sit to stand from chair, 10 repetitions. A review of Resident #17's care plan, initiated 5/22/25 documented, Resident #17 was to receive restorative nursing services 5 times per week. A review of Resident #17's restorative record dated 2/1/26 through 4/26/26, documented the following restorative sessions:-2/1/26 – 2/7/26 3 sessions-2/8/26 – 2/14/26 2 sessions -2/15/26 - 2/21/26 2 sessions-2/22/26 – 2/28/26 3 sessions -3/1/26 – 3/7/26 0 sessions-3/8/26 – 3/14/26 1 session-3/15/26 – 3/21/26 3 sessions-3/22/26 – 3/28/26 3 sessions-3/29/26 – 4/4/26 3 sessions-4/5/26 – 4/11/26 2 sessions-4/12/26 – 4/18/26 1 session-4/19/26 – 4/25/26 2 sessions The review of restorative services documented on several occasions Resident #17 was not offered services as per his plan of care 5 times per week. 2.Resident #18 was admitted to the facility on [DATE] with diagnoses including advanced physical debility, chronic pain, and chronic bilateral hand tremors. A review of Resident #18's restorative nursing program documented the following interventions:-Active range of motion to the left hand: open hand wide (high five) for 5 repetitions.-Active range of motion to the left hand using a squeeze ball for 5 repetitions.-Finger to thumb pinches through all fingers for 5 repetitions. A review of Resident #18's care plan, initiated 6/25/25 documented, restorative services were to be provided 5 times weekly, and directed the restorative nurse to review the monthly program and as needed. A review of Resident #18's restorative record dated 2/1/26 through 4/26/26, documented the following restorative sessions:-2/1/26 – 2/7/26 1 session-2/8/26 – 2/14/26 0 sessions-2/15/26 – 2/21/26 0 sessions-2/22/26 – 2/28/26 5 sessions-3/1/26 – 3/7/26 3 sessions-3/8/26 – 3/14/26 2 sessions-3/15/26 – 3/21/26 2 sessions-3/22/26 – 3/28/26 0 sessions-3/29/26 – 4/4/26 4 sessions The review of restorative services documented Resident #18 was not offered services as per her plan of care 5 times weekly. On 4/30/26 at 4:22 PM, the Restorative Nurse stated residents receiving restorative services are scheduled for therapy on Tuesdays, Thursdays, and Saturdays. Upon review of the restorative therapy administration schedules for Residents #17 and #18, the Restorative Nurse confirmed the residents did not receive restorative services as indicated in their plans of care. 3. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses including severe Alzheimer's dementia. On 4/28/26 at 9:57 AM, Resident #19 was observed lying in bed with the left hand closed in a fist. Resident #19's representatives were at the bedside. When asked about Resident #19's left fist, Resident #19's representatives stated the facility staff were notified, and the staff were going to look into occupational therapy for an evaluation of a hand splint. When asked if Resident #19 could open the left hand, Resident #19's representatives stated not really. Resident #19's representatives then opened Resident #19's left hand and placed the leg of a stuffed animal in Resident #19's hand. Resident #19's representatives stated they visited the facility often and would place the stuffed animal in Resident #19's hand to help keep the left hand open. A review of Resident #19's record documented the following Progress Notes: -On 4/13/26 at 1:03 PM, a Nursing Progress Note documented staff noted Resident #19 had been clenching her left hand. The note further documented an assessment was completed by the Restorative Nurse and both hands were noted to be clasped together but was able to open her hands upon request and touch. -On 4/20/26 at 1:03 PM, a Nursing Progress Note documented the Restorative Nurse assessed the left hand of Resident #19 and she was able to open the left hand after the inside of the hand was touched. The Nursing Progress note documented Resident #19 stated ow when opening the hand. Fingernails were noted to be making marks to the skin on the inside of the hand but was able to keep the hand open and was encouraged by the Restorative Nurse to keep the hand open. The Nursing Progress Note further documented the Restorative Nurse would consider a palm protector. On 4/30/26 at 6:21 PM, when asked about the palm protector, the DON confirmed there were no further notes entered regarding the palm protector by the Restorative Nurse. The DON further stated restorative services were discontinued on 4/26/26. A review of Resident #19's record did not show documentation Resident #19 was on restorative services. When asked why restorative services were discontinued, the DON stated she could not find any documentation from the Restorative Nurse. When asked if the physician had been notified of Resident #19's hand pain and clenching, the DON stated the provider was notified in February 2026 but did not see any further communication with the physician.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee effectively identified, monitored, and corrected ongoing systemic issues related to the Restorative Nursing Program. This failure resulted in continued inability to meet the facility's established benchmark for restorative service (RA) completion and documentation across multiple consecutive quarters from 2024 through 2026. These findings demonstrate the QAPI Committee did not ensure the implementation of effective corrective actions or sustained performance improvement as required. Findings include:The facility's Quality Management Plan revised 1/29/26, documented the Interdisciplinary Quality Program's purpose is to develop and implement a systematic, coordinated, facility-wide approach to providing quality care and sustainability including efforts to pursue opportunities to continually improve patient care services, clinical performance, cost-effective care, and resolve identified areas of concern.The facility's Performance Improvement Plan (PIP), initiated January 2024, documented quarterly QAPI reports repeatedly identified failure to meet the benchmark that 75% of residents on a Restorative Program would have documentation completed per their individualized plan of care.A review of QAPI quarterly reports identified the following:2024: Third and fourth quarter reports documented: Benchmark not met. We will continue this project.2025: Fourth quarter report documented: Only 63% of residents had documentation of receiving RA.Benchmark was not met in the 1st, 2nd, 3rd, and 4th quarters.2026: Quarterly review documented: Completion only 67%, below the 75% benchmark.A review of the PIP from January 2024 through March 2026 documented that despite repeated failure to meet benchmarks, the QAPI Committee continued the same interventions quarter after quarter without implementing new or more effective corrective actions.A review of the PIP showed the same issues were identified in every quarterly report from January 2024 through March 2026, including:-Staff not always charting what they do in the new charting system.-CNAs not always checking the Restorative book for changes.-Charge nurses not proactive with ensuring RA completion daily.-Ongoing time constraints and staffing issues.A review of the PIP revealed no evidence that the QAPI Committee escalated the issue, revised the PIP, or implemented new strategies when benchmarks continued to be unmet.On 5/1/26 at 12:09 PM, the DON stated the plan had been in place for several years and confirmed they audit monthly and review findings with the committee. She also stated that education had recently been provided to all CNA's to assist with meeting resident needs for restorative services.Cross reference F688 and F726.

Based on observation and staff interview, it was determined the facility failed to ensure a food service employee wore a properly positioned hair restraint while preparing and handling resident food, as required by FDA Food Code SS2 501.11 and 2 402.11. This failure had the potential to result in hair contamination of residents' meals who consume food provided by the facility. Findings include:FDA Food Code S2 501.11 requires that food employees wear hair restraints-such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair-that are designed and worn to effectively prevent hair from contacting exposed food.FDA Food Code S2 402.11 states that consumers are particularly sensitive to food contaminated by hair. Hair can serve as both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when touching their hair. Proper hair restraints prevent dislodged hair from falling into food and may deter employees from touching their hair.On 04/30/26 at 12:12 PM, during a tray line observation, Nutritional Aide #1 was observed in the kitchen preparing resident meal trays. Her hair guard was positioned only over the center of her head, leaving her bangs exposed and not fully contained within the hair restraint.During the same observation, Nutritional Aide #1 was asked to assist with preparing mashed potatoes for residents. She was observed leaving her tray line station and engaging in food preparation activities while continuing to wear the improperly positioned hair guard, with hair not fully restrained as required.On 04/30/26 at 12:27 PM, the Nutritional Services Director stated she had not noticed that Nutritional Aide #1's hair was not fully contained within the hair guard. She confirmed that the employee's hair should have been completely secured inside the hair restraint in accordance with facility policy and food safety standards.

Based on record review, observation, facility policy, and staff interview, it was determined the facility failed to ensure residents were free from medication error rates greater than 5%. This failure had the potential to affect all residents who receive medications in the facility by increasing the risk of adverse health outcomes. Findings include:The facility's Medication Administration Policy, revised 4/15/26, documented that the following rights of medication administration must be followed to ensure accurate identification of the medication and the resident prior to administration:-Right drug-Right dose-Right time (within one hour of the time ordered)-Right route of administration-Right patient/resident-Verification of accuracy if the resident questions a medicationOn 4/29/26 at 9:24 AM, LPN #1 was observed preparing and administering medications to Resident #3. During the medication preparation process, LPN #1 was asked to verify the following physician orders:-Metamucil capsule: give 1 capsule by mouth daily for constipation-Cranberry supplement: give 2 capsules for cystitis prevention (UTI prevention)On 4/29/26 at 9:29 AM, LPN #1 was unable to identify the correct dosage for the cranberry and Metamucil supplement and stated the order should have been clarified to include the specific dose to administer.

Based on record review and staff interview, it was determined the facility failed to ensure residents were comprehensively assessed for a history of trauma, including identification of trauma related triggers. This was true for 3 of 3 residents (#7, 17, and 18) whose records were reviewed for trauma informed care. This failure created the potential for psychosocial harm related to re traumatization. Findings include:1.Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including anemia, moderate dementia, and chronic pain.A review of Resident #7's care plan documented she had experienced sexual assault during her lifetime and expressed feeling safe in the facility.The care plan did not document the need for an annual trauma evaluation.A review of Resident #7's record identified an Annually/Quarterly Trauma Evaluation form, dated 4/24/26.The form included a section titled Staff Assessment asking whether the resident had exhibited any of the following since the last trauma evaluation:-Change in sleep patterns-Change in appetite/eating patterns-Patterns of behavioral change in response to specific situations-Change in caregiver preference with certain characteristics-New complaints of pain or health problemsThe form also included a section titled Licensed Nurse Determination with the following options:-Resident had changes that may be related to a post traumatic event-Resident does not have changes related to a post traumatic eventA review of Resident #7's evaluation showed the Staff Assessment section was blank, with no documentation completed by a licensed nurse. 2.Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including age related osteoporosis, chronic pain, and a fracture of the left hip joint.A review of the resident's care plan documented he reported traumatic events but stated he felt safe in his current environment. The care plan directed licensed nursing staff to complete a person centered trauma evaluation annually, per resident preference.A review of Resident #17's record identified an Annually/Quarterly Trauma Evaluation form, dated 4/28/26.The form included a section titled Staff Assessment asking whether the resident had exhibited any of the following since the last trauma evaluation:-Change in sleep patterns-Change in appetite/eating patterns-Patterns of behavioral change in response to specific situations-Change in caregiver preference with certain characteristics-New complaints of pain or health problemsThe form also included a section titled Licensed Nurse Determination with the following options:-Resident had changes that may be related to a post traumatic event-Resident does not have changes related to a post traumatic eventA review of Resident #17's evaluation showed the Staff Assessment section was blank, with no documentation completed by a licensed nurse. 3. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including advanced physical debility, chronic pain, and chronic bilateral hand tremors.A review of the resident's care plan, initiated 3/21/23, directed the licensed nurse to complete a Person Centered Trauma Evaluation annually, after a fall, or with a significant change. The care plan also documented that Resident #18 requested not to be evaluated quarterly.A review of Resident #18's record identified an Annually/Quarterly Trauma Evaluation form, dated 1/27/26.The form included a section titled Staff Assessment asking whether the resident had exhibited any of the following since the last trauma evaluation:-Change in sleep patterns-Change in appetite/eating patterns-Patterns of behavioral change in response to specific situations-Change in caregiver preference with certain characteristics-New complaints of pain or health problemsThe form also included a section titled Licensed Nurse Determination with the following options:-Resident had changes that may be related to a post traumatic event-Resident does not have changes related to a post traumatic eventA review of Resident #18's evaluation showed the Staff Assessment section was blank, with no documentation completed by a licensed nurse.On 4/30/26 at 3:55 PM, the ADON stated the trauma evaluations should be completed and confirmed the licensed nurse is responsible for documenting the assessment and determination.

Based on the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure a copy of a resident's advance directive was maintained in the medical record. This was true for 1 of 2 residents (Resident #12) whose records were reviewed for advance directives. This failure created the potential for an adverse outcome if Resident #12 became unable to communicate treatment preferences and those preferences were not available to guide care. Findings include:The State Operations Manual, Appendix PP, defines an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.The Manual further explains that a Physician Orders for Life Sustaining Treatment (POLST) form is a portable medical order designed to communicate a patient's treatment preferences during a medical emergency, based on the patient's current medical condition. The POLST form ensures emergency personnel and clinicians understand the patient's wishes regarding life sustaining treatment. A POLST form is not an advance directive.Resident #12 was admitted to the facility on [DATE] with multiple diagnoses including coronary artery disease (CAD- a serious heart condition caused by plaque buildup that narrows arteries and restricts blood flow to the heart), major depressive disorder, and dementia.Resident #12's care plan revised 1/27/26 documented, Resident #12 had one page of a living will and Durable Power of Attorney for Health Care (DPOAHC) in their chart.On 4/29/26 at 2:29 PM, Resident #12's hard copy chart was reviewed for a living will and DPOAHC. One page of an untitled document dated 2/6/25 was located in Resident #12's hard copy chart which documented under Advanced Directive the following:Does the patient have a living will? The box titled yes was checked. If yes, where is the living will located? The line was left blank.Does the patient have a Durable Power of Attorney for Health care? The box titled yes was checked. Name of the person with the power of attorney: The line was left blank.On 4/29/26 at 2:32 PM, when asked about the complete living will and DPOAHC, the DON stated the documentation in Resident #12's chart was all the facility had. The ADON further stated Resident #12's POA refused to bring in a copy of the living will.On 4/29/26 at 2:34 PM, a request was made for documentation of refusals to provide a copy of the living will. No documentation was provided.On 4/29/26 at 2:51 PM, the DON confirmed the facility did not have a copy of Resident #12's advance directives.

Based on record review and staff interview, it was determined the facility failed to notify the Ombudsman of a resident's discharge. This was true for 1 of 1 residents (Resident # 23) whose record was reviewed for discharge documentation. This failure created the potential for adverse outcomes including the need for an advocate when the Ombudsman was not notified of Resident #23's discharge. Findings include:The State Operations Manual (SOM), Appendix PP, Notice before transfer, revised 7/23/25 documented:Before a facility transfers or discharges a resident, the facility must-Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.Resident #23 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's dementia (memory loss and confusion) and epilepsy (seizure disorder).Resident #23's medical record documented Resident #23's spouse elected to take her home for care at home.A review of Resident #23's medical record did not include documentation the Ombudsman was notified of the discharge.On 4/30/26 at 11:11 AM, when asked for documentation of notification to the Ombudsman, the DON confirmed there was no documentation the Ombudsman had been notified of Resident #23's discharge.

Based on record review and staff interview, it was determined the facility failed to ensure the comprehensive, person centered care plan was revised to reflect accurate and current information for 1 of 8 residents (Resident #7) whose record was reviewed for care planning. This failure created the potential for inaccurate care planning and inconsistent implementation of care. Findings include:Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including anemia (when blood doesn't have enough healthy blood cells), moderate dementia, and chronic pain.A review of Resident #7's physician orders documented:-An order dated 12/15/25 directing staff to administer aspirin 81 mg by mouth once daily for CAD.-An order dated 2/5/26 directing staff to administer sertraline (Zoloft-an antidepressant) 50 mg by mouth once daily for depression and chronic pain.A review of Resident #7's comprehensive care plan documented:-A problem statement indicating the resident had a history of anemia and required daily aspirin for antiplatelet therapy, with an initiation date of 5/5/20.-A directive for licensed nursing staff to administer antidepressants for chronic pain, with an initiation date of 7/17/24.On 4/30/26 at 11:45 AM, the MDS nurse stated the care plan should have been revised to reflect that sertraline (Zoloft) is administered for depression and chronic pain. She also stated Resident #7 no longer has an active diagnosis of anemia, and the care plan should have been updated to clarify the current clinical rationale for aspirin therapy.

Based on Observation, record review, policy review, and staff interview, it was determined the facility failed to store the nebulizer mouthpiece appropriately and failed to change CPAP tubing. This was true for 1 of 1 residents (Resident #2) whose CPAP and nebulizer supplies were observed. This failure placed Resident #2 at risk of respiratory infection due to growth of pathogens (Organism that cause illnesses) in the respiratory equipment. Findings include:The Facility's nebulizer policy titled: Administering Medications through a small Volume (Handheld) Nebulizer documented the following:-Disassemble the nebulizer and wash with mild soap and water and rinse well. Place on paper towels or regular towel by the sink to air dry.-When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. a. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Obstructive Sleep Apnea (OSA- a serious sleep disorder causing repeated airway collapse and breathing interruptions during sleep) and Chronic Obstructive Pulmonary Disease (COPD- a disease that causes airflow blockage and breathing related problems)A care plan initiated 12/16/25, directed staff to wash tubing and apparatus (mouthpiece) with soap and water after each use, and to let the pieces dry between uses.A physician's progress note dated 4/7/26 documented, Resident #2 was to continue formoterol fumarate (medication used to treat COPD) 20 mcg / 2 mL nebulizer twice daily.On 4/28/26 at 11:56 AM, Resident #2 was observed sleeping in a recliner in the den. Resident #2's nebulizer apparatus (mouthpiece) was observed resting on top of a book without a barrier on the bedside table next to the recliner. On 4/29/26 at 8:42 AM and 5:33 PM, Resident #2's nebulizer apparatus (mouthpiece) was observed in Resident #2's room in pieces on top of the bedside nightstand sitting on a white washcloth / towel.On 4/29/26 at 6:10 PM, RN #1 was asked to explain the facility's nebulizer process after administration of a breathing treatment. RN #1 explained the nebulizer apparatus (mouthpiece) gets washed out and laid out to dry on a towel. When asked how long it takes for the apparatus pieces to dry, RN #1 stated it took about an hour for the nebulizer pieces to dry. When asked where nebulizer pieces are stored, RN #1 stated the pieces are put back together and stored on a towel in the resident's nightstands.RN #1 then accompanied the surveyor to Resident #2's room where nebulizer pieces were observed on a white washcloth / towel on top of the bedside nightstand. RN #1 was observed putting the pieces of the apparatus back together and placed on a towel in Resident #2's bedside nightstand drawer. On 4/29/26 at 6:38 PM, when asked about nebulizer storage, the DON stated nebulizers should be stored in a bag. b. A care plan initiated 12/16/25 documented, Resident #2 used a Continuous Positive Airway Pressure (CPAP) machine related to obstructive sleep apnea. The care plan directed staff to obtain CPAP supplies per Lincare as recommended and to see the supply list in the hard copy chart. The care plan further directed the licensed nurses to check monthly and reorder / replace as needed.On 4/27/26 at 12:57 PM, Resident #2's CPAP machine was observed sitting on the bedside nightstand with the tubing dated in black ink 12/29.On 4/29/26 at 6:10 PM, RN #1 and the surveyor went to Resident #2's room. Resident #2's CPAP machine was observed on top of the bedside nightstand. RN #1 confirmed the CPAP tubing was dated 12/29. When asked how often CPAP tubing is changed, RN #1 stated she thought tubing was changed every 6 months.On 4/29/26 at 6:25 PM, the MDS nurse reviewed Resident #2's care plan and stated CPAP supplies are changed/replaced per Lincare recommendations and recommendations were listed in Resident #2's hard copy chart. The MDS nurse, and RN #1, with the surveyor reviewed Resident #2's hard copy chart which documented CPAP tubing was to be changed/replaced every 3 months. When asked when Resident #2's CPAP tubing should have been changed, RN #1 and the MDS nurse confirmed Resident #2's CPAP tubing should have been changed in March 2026.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure staff with the appropriate competencies directed the care and oversight of the Restorative Nursing Program. This was true for 1 of 1 Restorative Nurse whose personnel record was reviewed for required competencies. This failure placed residents at risk for unmet or undetected restorative needs due to the absence of qualified assessments and oversight. Findings include:The facility's Restorative Nursing Program Policy, revised 10/29/25, documented the Restorative Nurse, Restorative Aide, physical therapist, occupational therapist, speech therapist, and the Director of Nursing are responsible for overseeing the program.The policy further documented that an assessment and evaluation is to be initiated for all residents when a functional decline is noted, and that a nurse or appropriate therapist is responsible for re evaluating and initiating or updating the restorative plan of care.1. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses including severe Alzheimer's dementia. On 4/28/26 at 9:57 AM, Resident #19 was observed lying in bed with the left hand closed in a fist. Resident #19's representatives were at the bedside. When asked about Resident #19's left fist, Resident #19's representatives stated the facility staff were notified, and the staff were going to look into occupational therapy for an evaluation of a hand splint. When asked if Resident #19 could open the left hand, Resident #19's representatives stated not really. Resident #19's representatives then opened Resident #19's left hand and placed the leg of a stuffed animal in Resident #19's hand. Resident #19's representatives stated they visited the facility often and would place the stuffed animal in Resident #19's hand to help keep the left hand open. A review of Resident #19's record documented the following: -On 4/13/26 at 1:03 PM, a Nursing Progress Note documented staff noted Resident #19 had been clenching her left hand. The note further documented an assessment was completed by the Restorative Nurse and both hands noted to be clasped together but able to open hands upon request and touch. -On 4/20/26 at 1:03 PM, a Nursing Progress Note documented the Restorative Nurse assessed the left hand of Resident #19 and she was able to open the left hand after the inside of the hand was touched. The Nursing Progress note documented Resident #19 stated ow when opening the hand. Fingernails were noted to be making marks to the skin on the inside of the hand but was able to keep the hand open and was encouraged by the Restorative Nurse to keep the hand open. The Nursing Progress Note further documented the Restorative Nurse would consider a palm protector. On 4/30/26 at 6:21 PM, when asked about the palm protector, the DON confirmed there were no further notes entered regarding the palm protector by the Restorative Nurse. The DON further stated restorative services were discontinued on 4/26/26. A review of Resident #19's record did not show documentation Resident #19 was on restorative services. When asked why restorative services were discontinued, the DON stated she could not find any documentation from the Restorative Nurse. When asked if the physician had been notified of Resident #19's hand pain and clenching, the DON stated the provider was notified in February 2026 but did not see any further communication with the physician. 2.Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including advanced physical debility, chronic pain, and chronic bilateral hand tremors. A review of Resident #18's care plan, initiated 6/25/25 documented, restorative services were to be provided 5 times weekly, and directed the restorative nurse to review the program monthly and as needed. A review of the Resident #18's restorative program documented the following interventions: -Active range of motion to the left hand: open hand wide (high five) for 5 repetitions-Active range of motion to the left hand using a squeeze ball for 5 repetitions-Finger to thumb pinches through all fingers for 5 repetitions A review of restorative documentation from 2/1/26 through 4/26/26 documented, Resident #18 frequently refused restorative services due to pain. A review of the Nursing Progress Notes documented the following: -On 2/25/26 at 11:01 AM: Resident #18 frequently refused restorative services; the restorative nurse documented she would evaluate the need for increased pain medication. -On 3/31/26 at 9:33 AM: Resident #18 refused her left hand palm protector on 3/30/26 due to painful manipulation of the hand. -On 4/30/26 at 12:53 PM: the Restorative Nurse documented, Resident #18 did not tolerate passive range of motion to the left hand and staff could barely place the palm protector. On 4/28/26 at 4:39 PM, Resident #18 was heard yelling from her room in a high pitch tone. A licensed nurse was observed applying a palm protector to her left hand while the resident vocalized pain. On 4/30/26 at 8:30 AM, RN #2 stated Resident #18 is always in pain during palm protector application and sometimes refuses restorative services due to pain. He stated Resident #18 did not have a set pain management plan prior to restorative interventions and that he sometimes administered PRN pain medication beforehand but not all the time. On 4/30/26 at 4:29 PM, the Restorative Nurse stated she had notified the provider of Resident #18's pain and completed an evaluation that resulted in discontinuation of the restorative program. A request for documentation of provider notification was made, and no documentation was provided. On 4/30/26 at 4:32 PM, when asked who oversees the restorative program and determines initiation or discontinuation of services, the Restorative Nurse stated she completes the assessment and sends a notification to the provider to inform him whether the resident is appropriate for restorative services. On 5/1/26 at 8:57 AM, a request was made for the Restorative Nurses' job description and competency records. No documentation was provided. On 5/1/26 at 9:54 AM, the Director of Nursing stated the facility did not have a Restorative Nurse job description, and the Restorative Nurse did not have qualifications, training, or education documentation in her personnel file related to restorative services.

Based on observation, SOM, and staff interview, it was determined the facility failed to ensure the required daily staffing information was posted in a manner that informed residents, visitors, and resident representatives of the staff available to meet resident needs. This failure had the potential to affect all residents who receive services in the facility by limiting access to accurate staffing information. Findings include:The SOM, Appendix PP requires facilities to post the following information daily in a location readily accessible to residents and the public:-Facility name-Current date-Total number of hours worked by each staff category per shift (Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant)-Resident censusDuring observations the posted staffing information on these dates did not include all required elements, including the facility name, current date, census, and the breakdown of licensed and unlicensed staff by category (Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant).- 4/27/26 at 1:38 PM- 4/28/26 at 10:30 AM- 4/26/26 at 5:30 PMOn 4/29/26 at 5:33 PM, the DON confirmed the posting is required to include the facility name, the current date, census, and the number of licensed and unlicensed staff by category (Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant) and she confirmed the posting did not include all required elements.

Based on review of the SOM, record review, and staff interview, it was determined the facility failed to ensure residents were free from duplicate medication orders. This was true for 2 of 5 residents (#10 and #12) whose records were reviewed for unnecessary medications. This failure placed Resident #10 and Resident #12 at risk for psychosocial harm if they did not receive the least invasive treatment first. Findings include:The SOM, Appendix PP, revised 7/23/25 documented: Duplicate therapy refers to two or more medications of the same pharmacological class/category without a clear distinction of when one medication should be administered over another.1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including severe dementia and constipation.Resident #10's care plan dated 6/25/25 directed licensed staff to monitor for constipation, if no bowel movement on 2nd, 3rd, or 4th day, the licensed nurse was to administer medications and treat as ordered. The care plan further directed staff to offer prune juice and if no bowel movement on day 3 to consider PRN Dulcolax tab.Resident #10's Medication Administration Record (MAR) documented the following medication orders:-Bisacodyl (Dulcolax) suppository 10mg: 1 rectally as needed (PRN) for constipation, dated 3/11/24-Bisacodyl (Dulcolax) 5mg tab: 1 by mouth at 8:00 AM and 5:00 PM for constipation, dated 10/23/24-Bisacodyl (Dulcolax) 5mg tab: 1 by mouth daily as needed (PRN) for constipation, dated 7/3/25There was no indication documented in Resident #10's MAR on which medication to give first.On 4/30/26 at 3:33 PM, when asked which medication should be administered first, the DON stated the least invasive medication was always administered first. When asked when Resident #10 last received the oral and rectal PRN bisacodyl, the DON stated Resident #10 last received the oral PRN bisacodyl on 1/31/26 and received the rectal PRN bisacodyl on 2/18/26. When asked if Resident #10 received the oral PRN bisacodyl on 2/18/26, the DON stated there was a progress note documenting Resident #10 received prune juice on 2/16/26, milk of magnesia (over-the-counter laxative) on 2/17/26, and then was administered the rectal PRN bisacodyl on 2/18/26. The DON further stated she believed the suppository was administered because Resident #10 already had scheduled oral bisacodyl tablets. 2. Resident #12 was admitted to facility on 2/6/25 with multiple diagnoses including dementia, right sacral fracture (a break in the tailbone), and chronic pain.A review of Resident #12's care plan dated 2/19/25 directed licensed nurses to assess Resident #12's pain three times per day, as needed, and to monitor for non-verbal signs and symptoms of pain.Resident #12's MAR documented the following medication orders:-Acetaminophen (Tylenol) 650mg suppository: 1 rectally every 6 hours as needed for pain, dated 12/29/25-Acetaminophen (Tylenol) 325mg tab: 2 tablets (650mg) by mouth over 4 hours for chronic pain, dated 2/25/25There was no indication documented in Resident #12's MAR on which medication to give first.On 4/30/26 at 3:38 PM, when asked which medication should be administered first, the DON stated the oral tablet should be administered first. The DON further stated Resident #12 probably had never used the suppository. The DON did a 90 day look back and stated Resident #12 had not used the suppository. The DON further stated that Resident #12 had used the oral PRN acetaminophen medication on 4/16/26. When asked if the oral PRN acetaminophen was effective, the DON stated an assessment had been conducted after Resident #12 was administered the medication and stated the assessment documented zero pain, indicating the medication was effective. When asked if the rectal PRN acetaminophen was necessary, the DON stated, probably not.

Based on review of McGeer's Criteria Surveillance for Infection, record review, and staff interviews, it was determined the facility failed to ensure antibiotic stewardship was implemented and residents had appropriate clinical indications for the use of antibiotics. This was true for 1 of 1 resident (Resident #10) whose record was reviewed for antibiotic use. This deficient practice created the potential for Resident #10 to receive unnecessary treatment for a suspected urinary tract infection and/or develop multi-drug-resistant organism. Findings include:The Revised McGeer's Criteria for urinary tract infection (UTI) without an indwelling catheter documented both 1 and 2 must be fulfilled:1. At least one of the following signs or symptoms:-Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate-Fever or leukocytosis (extremely high white blood cell count), and 1 or more of the followingAcute costovertebral angle pain or tenderness (pain elicited at the angle formed by the 12th rib and spine)Suprapubic painGross hematuria (the presence of visible blood in the urine)New or marked increase in incontinenceNew or marked increase in urgencyNew or marked increase in frequency- If no fever or leukocytosis, then 2 or more of the following:Suprapubic painGross hematuriaNew or marked increase in incontinenceNew or marked increase in urgencyNew or marked increase in frequency2. At least one of the following microbiologic criteria: 10 cfu/mL of no more than two organisms in a voided urine sample 10^2 cfu/mL of any organism in a catheterized specimenResident #10 was admitted to the facility on [DATE] with multiple diagnoses including severe dementia, recurrent UTIs, and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early).Resident #10's care plan dated 12/9/19, documented Resident #10 was incontinent of bowel and bladder related to impaired cognition with the inability to recognize the need to toilet. Resident #10's care plan directed staff to monitor for signs and symptoms of UTI.A nursing progress note dated 3/16/26 at 6:14 PM, documented Resident #10 was exhibiting manic behavior, was loud, hallucinating, and had decreased oral intake. The note documented urinary incontinence, a urine dip was performed, the provider was notified, and an order was obtained for a urine culture and Keflex (antibiotic) was started.A review of Resident #10's record did not include documentation of worsening urinary symptoms meeting McGreer's Criteria.On 4/30/26 at 3:48PM, the IP confirmed the facility followed McGreer's Criteria for antibiotic stewardship. The IP showed the surveyor a quarterly tracking report for antibiotics which documented Resident #10 did not meet McGreer's Criteria. When asked if the nursing staff should have done a urinalysis on Resident #10, the IP stated no. When asked if the nurses followed McGreer's Criteria, the IP stated no.

Based on record review and staff interview, it was determined the facility failed to ensure Certified Nursing Assistants (CNAs) received a minimum of twelve (12) hours of annual in service training as required. This was true for 1 of 3 CNAs (CNA #1) reviewed for annual competency requirements. This deficient practice had the potential to affect all residents receiving care from CNAs, as inadequate training places residents at risk for harm due to staff not being fully prepared to safely provide required services. Findings include:On 04/29/26 at 11:57 AM, a request was made for the annual education records of three CNAs.A review of CNA #1's education documentation showed 10.47 hours of completed training for the current annual period, which did not meet the required 12 hour minimum.On 04/29/26 at 2:39 PM, the DON confirmed CNA #1 did not have the required 12 hours of annual CNA training. The DON stated CNA #1 had been skipping the course and taking the test, resulting in incomplete training hours. The DON further stated the facility was implementing a new program that would require staff to complete the full course content before being permitted to take the test.

Based on observation, policy review, review of the Idaho Food Code, and staff interview, it was determined the facility failed to appropriately store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 18 of 18 residents who received meals prepared in the facility's kitchen and placed residents at risk for potential contamination, use of spoiled foods, and adverse health outcomes including contracting food-borne illnesses. Findings include: 1. The Idaho Food Code, revised February 2021, documented, for food safety, food prepared and held in a food establishment will be clearly marked to indicate the date by which the food will be consumed on the premises or discarded. The facility policy titled Food Storage and Handling, dated [DATE], documented Food will be properly stored & handled in a way to minimize the risk of contamination and transfer of infection. The policy also documented All opened containers will be stored in sealed containers that are labeled as appropriate and dated with open date. On [DATE] at 2:20 PM, the walk-in refrigerator was observed with the Certified Dietary Manager (CDM). Open containers were found that included: -a block of cheese inside a zip top sandwich bag with no dates, -a container of dill pickles with no open date, -2 bags of cheese with expiration dates of ,d+[DATE], -a bottle of Italian dressing with an open date of ,d+[DATE] with a broken/ cracked lid. The CDM stated the expired cheese should have been discarded and the Italian dressing with the broken lid needed to be thrown away. She stated she was unsure how long the other opened items were safe to be used or discarded. On [DATE] at 2:25 PM, the walk-in freezer was observed with the CDM. Open containers were found that included: -2 bags of cookies, both with no date, -1 bag of cardiac pork with no date. The CDM stated the opened packaging should be labeled with the date on it when opened and she did not know how long they had been opened or if they were safe to serve. On [DATE] at 2:30 PM, the dry goods storage was observed with the CDM. Open containers were found that included: - a bag of dry pasta with no open date and no expiration date, - a bag of corn flakes with no open date and an expired use by date of [DATE], - a bag of bran flakes with no open date and an expired use by date of [DATE], - a bag of granola opened with no open date and best by date of [DATE], - a bag of pecans with no opened date and an expired use by date of [DATE]. The CDM stated the opened packaging should be labeled with the date on it when opened and she did not know how long they had been opened or if they were safe to serve and expired food should be thrown away. 2. The facility's Infection Control in Food Services policy, dated [DATE], documented, All food service employees will demonstrate consistent personal sanitation and infection control practices. and wash hands frequently utilizing the hand washing procedure: frequently during food preparation, after touching raw meat, poultry, or eggs. Additionally, the policy stated clean, disposable gloves, must be worn when handling food without a utensil and there will be no bare hand contact with any ready to eat foods. On [DATE] at 7:36 AM, Dietary Staff #1 was observed in a food preparation area with an active and productive cough without wearing a mask, and was observed performing the following food service tasks: -reaching her uncovered hand/arm into a blender to spoon out food from the bottom of the blender, -cleaning a countertop with a cloth and disinfectant spray, rinsed her hands for 3 seconds under running water without using soap or friction, then dried them in a paper towel and returned to food preparation, -rinsing a dirty knife in the sink labeled for hand-washing use and wiping food off with a paper towel before using it to slice toasted bread. -donning one glove on right hand, using same hand to reach into ,d+[DATE] full bread bag and removing bread then placing into the toaster, removed glove, and started toaster without performing hand hygiene, -carrying 3 eggs, cracking them over stovetop barehanded, no hand washing witnessed, then got out a plate and sat it on the counter - donned gloves and finished cooking eggs. Removed gloves, retrieved toast from toaster and buttered it without gloves and held toast bare handed. She then placed the toast on plates. She then washed her hands. On [DATE] at 8:35 AM, the CDM stated the staff should always be wearing gloves when touching food. On [DATE] at 9:30 AM, Dietary Staff #1 described the correct hand washing process as use water, soap scrub for 20 seconds, then rinse and dry. She stated she should wash her hands whenever they are visibly dirty, after removing gloves, and after using the restroom. Dietary Staff #1 stated gloves should be worn whenever touching food.

Based on record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents were safe from abuse. This was true for 1 of 18 residents (Resident #15) whose records were reviewed for abuse. This failure placed all residents at risk of abuse and physical and psychosocial harm. Findings include: Resident #15 was admitted to the facility on [DATE] with multiple diagnoses including dementia, depression, and anxiety. Resident #15's care plan dated 11/21/22 directed staff to allow and encourage her to make choices and promote her independence. The care plan documented she may reject care due to difficulty understanding and directed staff to explain all care before providing it. On 5/29/24 at 9:00 AM, Resident #15 stated CNA #1 had forcefully removed her sweatshirt the night before and twisted her left forearm causing a bruise. Resident #15 stated she had told CNA #1 no when prompted to change her sweatshirt because she liked to sleep in her sweatshirt, and she would change it the next morning after her shower. Resident #15 stated CNA #1 said it was their duty to change Resident #15's sweatshirt and they tussled and she was trying to resist when CNA #1 was pulling the sweatshirt off. Resident #15 was assessed by a nurse to have purpura (a mark that occurs when small blood vessels leak blood under the skin) on her left forearm just above the wrist, a small bruise on her left elbow, and 3 small red marks on the back of her left forearm. The facility's investigation report for this allegation of abuse was added to the State Survey Agency's Long-Term Care Reporting Portal on 6/4/24 at 10:05 AM. The investigation report documented an interview with CNA #1 on 5/29/24 in which the following was stated: [CNA #1] was called to discuss the incident. [CNA #1] recalled the incident with clarity. She stated that it was reported to her that [Resident #15] had not changed her sweatshirt that morning by the dayshift CNA and had been wearing it for two days. She stated that when she went to assist [Resident #15] with [bedtime] care she told her that the sweatshirt needed to be changed. [Resident #15] at that time had replied that she did not want to change it since she had a bath in the morning. [CNA #1] did not believe that as she says that all the time and the resident was unable to tell her what day her bath day was to confirm in her own mind that [Resident #15] did indeed have a bath. She stated that [Resident #15] was upset, threw a fit and [CNA #1] stated I'm just doing my job and tried to remove the sweatshirt by pulling it up from behind [Resident #15] and over her head. When asked if she had touched [Resident #15's] left arm or wrist, [CNA #1] stated yes, to get her arm out of the sleeve, but she was fighting me, and it could have left a mark. The conclusion of the incident report documented the following statement: The results of the investigation did substantiate the allegation of abuse. It was determined that [CNA #1] acted with willful intent in her attempt to remove the resident's sweatshirt which resulted in actual physical injury of the resident. Administration was consulted and [CNA #1's] employment was terminated. On 9/12/24 at 1:46 PM, the DON stated during the interview with CNA #1, she admitted she grabbed Resident #15's arm when forcing her to remove her sweatshirt. The DON stated the allegation of abuse was substantiated.

Based on observation, policy review, and staff interview, it was determined the facility failed to provide safe and sanitary food handling and distribution of food for the residents who received dietary services from the facility's kitchen and had the potential to affect all 19 residents currently in the facility. This failed practice had the potential to expose residents to food borne illness. Findings include: The facility's policy Infection Control in Food Service, revised 6/8/23, documented all food service personnel will demonstrate consistent personal sanitation and infection control practices which included: - Wash hands frequently - Wash hands frequently during food preparation - Wash hands anytime hands should become soiled - Clean, disposable gloves must be worn when handling food without a utensil - No Bare hand contact with any ready to eat foods - There must be a physical barrier between your clean hand and the ready to eat food This policy was not followed. On 7/27/23 beginning at 11:36 AM, an observation was conducted during the lunch service. Staff in the kitchen were observed with breeches of infection control and prevention. Examples include: a. Dietary Aide #1 did not perform hand hygiene frequently or when needed, wear gloves, and change gloves following infection control and prevention guidance, as follows: - Dietary Aide #1 had a glove on her right hand and no glove on her left hand while ladling soup into a cup. Dietary Aide #1 then picked up a stack of plastic lids to cover the soup cups with her gloved hand and used the ungloved left thumbnail to separate the lids and then placed those lids she touched without a glove on the soup cups. - Dietary Aide #1 picked up a sandwich from an uncovered pan with multiple sandwiches on it and placed it on a plate without using gloves. - Dietary Aide #1 used her left hand, which did not have a glove, to reach into a bag to get a bun and placed it on a plate. Then using both hands, with a glove on her right hand and no glove on her left hand separated the top and bottom of the bun. She then used her right hand, which had the same glove, to grab a set of tongs to pick up meat and then placed the meat on the bottom of the bun, and using her ungloved left hand placed the top of the bun on the meat. - Dietary Aide #1 pushed a rack of trays with both hands, out of the way and went to the walk-in refrigerator and with her ungloved left hand opened the door, reached inside and returned to the food service line with the sandwich, which was placed on a plate. Dietary Aide #1 did not remove her gloves and perform hand hygiene between each action. She then used her ungloved left hand to hold the sandwich while cutting it in half and placed one half on a plate for a food tray and the other half on a plate which was placed on top of a toaster. (The half placed on the toaster was later used for another food tray). b. Dietary Aide #2 did not perform hand hygiene frequently or when needed, wear gloves, and change gloves following infection control and prevention guidance, as follows: - Dietary Aide #2 was observed touching utensils, cups, and napkins and placing them on residents' trays without gloves. - A rack containing food trays for residents of the facility were taken by Dietary Aide #2 to the hallway and then up in an elevator to the nursing home for staff to pass out to the residents. Upon return, Dietary Aide #2 placed a rack next to the end of the food service line, proceeded to the other end, then began placing napkins, utensils, and cups on trays. Dietary Aide #2 did not perform hand hygiene prior to placing items for use by the residents onto their trays. On 7/27/23 at 2:50 PM, the Kitchen Manager stated dietary personnel were not trained to use one glove, staff were to use utensils or gloves on both hands. The Kitchen Manager stated Dietary Aide #2 should not have been wearing gloves, there was no reason to wear gloves to set up trays. She stated staff typically do not perform hand hygiene after delivery of trays, but they probably should as the elevator button was not the cleanest.

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 5 of 9 residents (#6, #8, #12, #13, and #18) whose care plans were reviewed. This created the potential for harm if care and/or services were not provided appropriately due to inaccurate information in the care plan. Findings include: The facility's policy Care Plan Development and Implementation, revised 2/24/23, stated care plans were to be revised as changes in the resident's condition indicated. This policy was not followed. 1. Resident #13 was admitted to the facility on [DATE], with multiple diagnose including dementia. An annual MDS assessment, dated 7/17/23, documented Resident #13 was severely cognitively impaired and required assistance from one person for transfers and repositioning. The care plan, dated 7/20/23, documented Resident #13 required 2-person assistance for bed mobility. Resident #13's care plan also documented Resident #13 required 1 person assistance with transfers and 2-person assistance for transfers if Resident #13 was showing signs of fatigue and/or confusion. The care plan did not specify signs of fatigue and/or confusion for staff to monitor and use to determine whether to have 1- or 2-person assistance. On 7/26/23 at 10:45 AM, Resident #13 was observed requesting assistance to transfer into a recliner. Resident #13 was transferred by 1 unidentified CNA to the common area recliner. On 7/27/23 at 4:41 PM, the DON stated the care plan was not clear if Resident #13 required assistance by 1 or 2 staff. She stated CNAs cannot make the assessment to determine when to use 1 or 2 staff based on the direction of the current care plan. The DON stated the care plan needed to be updated to be clear to staff. 2. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including depression, heart failure (the heart is unable to pump enough blood to meet the body's needs), and chronic pain. A quarterly nutrition assessment, dated 3/11/23, documented Resident #18 was on a regular diet and independent with eating. The nutrition assessment state Resident #18 was having a very difficult time finding food that she enjoyed from the kitchen. The nutrition assessment also documented Resident #18 consumed 54% of her meals. A quarterly nutrition assessment, dated 6/12/23, documented Resident #18 was on a regular diet and independent with eating. The dietician spoke to Resident #18 regarding her dissatisfaction with her meals. The nutrition assessment documented Resident #18 continues to be unhappy with a lot of meals and Resident #18 stated, No one knows how to cook down here. The nutrition assessment also document Resident #18 was upset meat was overcooked. The assessment documented the dietician told Resident #18 the facility would try to do better with overcooked meats. The nutrition assessment documented Resident #18's care plan would be updated to reflect her concerns. Resident #18's nutrition care plan was not revised to include her food concerns and preferences which were documented in the quarterly nutrition assessment on 6/12/23. On 7/27/23 at 9:46 AM, the DON reviewed Resident #18's care plan and stated the dietitian should have updated Resident #18's food preferences in her care plan. 3. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including falls and age-related physical debility. The facility's restorative meeting note, dated 6/13/23, documented Resident #8 was not in the restorative nursing program. A quarterly MDS assessment, dated 6/29/23, documented Resident #8 was severely cognitively impaired, had lower and upper extremity range of motion (ROM) impairment, and did not walk. The quarterly assessment documented Resident #8 was not receiving physical or occupational therapy and was not in a restorative nursing program. The quarterly assessment also documented Resident #8 had a recent fall with an injury. A care conference note, dated 7/6/23 at 8:58 AM, documented the IDT discussed current interventions and attempts at restorative exercises with Resident #8's refusing. On 7/26/23 at 2:00 PM, the DON reviewed Resident #8's record and state there was no care plan for Resident #8's ROM needs and refusal for restorative nursing exercise, and it should be in the care plan. 4. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including depression, insomnia, and chronic pain. Resident #6's pain care plan, revised 3/23/23, documented for a licensed nurse to apply medication patch as ordered and to monitor for adverse reactions. The care plan also documented to review the MAR for medication-specific side effects. Resident #6's record included a physician order for fentanyl 50 mcg patch (a type of opioid) for pain management. The order stated to apply one patch once a day for chronic pain. Resident #6's MAR for pain management, dated 7/1/23 to 7/25/23, documented Resident #6 received his pain medication as ordered. Resident #6's care plan did not include a list of specified side effects to be monitored for the pain medication fentanyl. On 7/27/23 at 11:00 AM, the DON stated Resident #6's care plan did not include the list of adverse side effects to be monitored and they should have been documented in the care plan. 48402 5. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including dementia. A quarterly MDS assessment, dated 5/1/23, documented Resident #12 had difficulty falling or staying asleep nearly every day. A care plan, dated 5/4/23, documented Resident #12 had a history of sleep disturbance and was not taking any medications. Resident #12's care plan directed staff to monitor for side effects related to insomnia medications. Resident #12's record did not include a physician order for insomnia medication. The care plan was unclear whether Resident #12 was taking insomnia medication or if it was discontinued. On 7/27/23 at 9:34 AM, the DON stated the care plan should have been revised when the insomnia medication was discontinued.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure resident care was provided in accordance with professional standards of care when neurological checks were not completed, and skin treatment was not provided as ordered. This was true for 2 of 9 residents (#8 and #13) reviewed for quality of care. These failures also placed residents at risk for worsening of their condition and status. Findings include: 1. The facility's Falls Prevention Program policy, revised 2/24/23, documented in the event of a fall, neurological (neuro) checks were to be initiated per protocol for any unwitnessed fall unless the resident was alert and oriented and was able to verbalize no injury to the head. The facility's Neurological Observation Record form directed staff to assess for eye-opening, motor, and verbal responses as part of the neuro checks, and included a schedule to monitor vital signs along with neuro checks as follows: - Every 15 minutes x 1 hour. - Every 30 minutes x 1 hour. - Every hour x 4 hours. - Every 4 hours x 24 hours. The policy and the neuro check schedule were not followed. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including falls, dependence on a wheelchair, and age-related physical debility. An I&A report, dated 6/25/23, documented Resident #8 had a fall and he was found face down and slightly on his left side in front of his recliner in his room. The report documented Resident #8 sustained a laceration to the left side of his forehead and a bruise on his left wrist. The I&A documented Resident #8 was sent to the emergency room for further evaluation, and he returned to the facility on [DATE] at 3:45 PM. Resident # 8's Neurological Observation Record form, dated 6/25/23 and 6/26/23, was not completed per the times indicated on the form as follows: - On 6/25/23 at 3:45 PM, 4:15 PM, 5:15 PM, 6:15 PM, 7:15 PM, 8:15 PM - On 6/26/23 at 12:15 AM, 4:15 AM, and 8:15 PM On 7/26/23 at 5:00 PM, the DON reviewed Resident #8's record and reviewed the Neurological Observation Record had areas which were blank and documented staff had documented asleep. She stated the neuro checks and vital signs should have been completed and documented. 2. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including dementia. Resident #13's care plan, dated 7/14/23, documented there was an area of split skin on the coccyx (tailbone). The care plan directed staff to monitor the site for signs and symptoms of infection. The care plan also directed staff to monitor the area until it resolved and apply Calazime with each contact. On 7/26/23 at 10:45 AM, Resident #13 was observed during cares by staff. Resident #13 had an open area to the coccyx. The ADON stated the wound was documented as resolved on 7/23/23 and based on the skin appearance no Calazime had been applied. On 7/27/23 at 4:41 PM, the DON stated staff were not documenting skin assessments daily and monitoring for potential infection per Resident #13's care plan. 44210

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine PCV20 and honored the opportunity to share decision-making with their physician. This was true for 5 of 5 residents (#1, #6. #7, #8, and #18) reviewed for immunizations. This failure placed residents at risk of severe illness or death should they contract pneumococcal (bacterial) pneumonia. Findings include: The facility's Immunization Protocol Adult policy, revised 8/17/22, stated immunizations were offered to residents who met the criteria. The policy stated all residents were screened for immunization status during nursing admission assessments to determine if a vaccine, including pneumococcal, was needed. If the resident met the criteria for vaccination, staff were to obtain a consent form, place the order, and administer the vaccine. This policy was not followed. The CDC website, accessed 7/27/23, and last reviewed 2/9/23, stated the following: - For those who have never received any pneumococcal conjugate vaccine, CDC recommended PCV15 or PCV20 for adults 65 or older with certain medical conditions or risk factors. If PCV15 was used, it should be followed by a dose of PPSV23. - Adults [AGE] years or older can get PCV20 if they have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. - These adults can talk with their doctor and decide, together, whether to get PCV20. 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including depression, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows) and anxiety. Resident #1's immunization record documented she received PCV13 at age 69 and PPSV23 at age 71. Resident #1 was eligible to receive the PCV20 vaccine. Resident #1's record did not include documentation the PCV20 vaccine was offered, or education of the the risks and benefits was provided. 2. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including depression, insomnia, and chronic pain. Resident #6's immunization record documented he received the PPSV23 vaccine at ages 83 and 89. Resident #6 was eligible to receive the PCV20 vaccine. Resident #6's record did not include documentation the PCV20 vaccine was offered, or education of the risks and benefits was provided. 3. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, anxiety, and depression. Resident #7's immunization record documented she received the PPSV23 vaccine at ages 60, 61 and 65. Resident #7 was eligible to receive the PCV20 vaccine. Resident #7's record did not include documentation the PCV20 vaccine was offered, or education of the risks and benefits was provided. 4. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including falls, dependence on wheelchair, and age-related physical debility. Resident #8's immunization record documented he received the PCV13 vaccine at age 95 and the PPSV23 vaccine at age 96. Resident #8 was eligible to receive the PCV20 vaccine. Resident #8's record did not include documentation the PCV20 vaccine was offered, or education of the risks and benefits was provided. 5. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including depression, heart failure (heart can't pump enough blood), and chronic pain. Resident #18's immunization record documented he received the PCV13 vaccine at age 69 and the PPSV23 vaccine at age 71. Resident #18 was eligible to receive the PCV20 vaccine. Resident #18's record did not include documentation the PCV20 vaccine was offered, or education of the risks and benefits was provided. On 7/27/23 at 4:45 PM, the DON stated she had discussed with the residents' physician (facility medical director) regarding the PCV20 vaccine. She said the physician did not think residents needed the PCV20 vaccine. The DON stated the PCV20 should be offered to the residents or their representative, and discussed with the residents' physician. On 7/28/23 at 8:40 AM, the DON provided residents' immunization records and stated all 5 residents were not contraindicated to receive PCV20, the facility should offer them PCV20, and the facility did not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers. This was true for 2 of 2 sample residents (#1 and #2) reviewed for pressure ulcers. Resident #1 was harmed when unstageable pressure ulcers developed on the resident's left buttock and left heel. Resident #2 was harmed when a stage 1 left heel pressure ulcer was not initially assessed or monitored and progressed to unstageable. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 5/19/13, coded, in part: * Impaired cognition with a BIMS score of 8; * No assistance for bed mobility; * Limited assistance by 1 person for transfers and dressing; * Functional limitation in range of motion in 1 upper extremity and both lower extremities; * Wheelchair (w/c) and walker use; * Frequent urinary incontinence; * One unstageable pressure ulcer (PU) in the past 7 days, due to slough or eschar; * One unstageable PU in the past 7 days, due to suspected deep tissue injury (sDTI); * Pressure ulcer care; and, * Application of dressing to feet (with or without topical medication). Resident #1's Pressure Ulcer CAA Analysis of Findings, dated 5/21/13, documented, "...admitted with a red coccyx which has resolved. Flakey (sic) skin to (L) (left) heel found 5-16 and heel protectors placed while in bed. ... ...pressure area was brought to the daughters (sic) attention, she stated "Ya, she's had those before..." The resident's Plan of Care identified the problem, "...at risk for skin pressure due to: ... Current breakdown on coccyx... Restless leg per daughter(,) reports Hx (history) of heel wounds," on 5/19/13. The goal was, "Current pressure area to coccyx will heal and no further issues will develop." Interventions included: * "Apply cream and dressing as needed to coccyx as ordered." * "5/16 - Blue Boots on in bed RSDT (resident) removes frequently (with) restless leg. - Weekly SAR (Skin At Risk)/Wound meeting. - Weekly photo (with) wound documentation. - RSDT to wear non-skid socks instead of canvas shoes." * "Assess for skin breakdown during baths and personal cares..." * "Licensed staff skin assessment weekly." On 6/5/13 the Charge Nurse provided Photograph Documentation (PD) of Resident #1's left buttock and left heel PUs. The PD included areas in which to document: date; type: wound, laceration, bruise/contusion, burn, or other; size in centimeters (cm); depth; presence/absence of drainage; comments; nurse's signature and photographer's signature; a front and a back body diagram with instructions to "Mark Photographed Location;" and, a photograph. The PD regarding the resident's left buttock PU documented: * "5/7/13 photo taken 5/8/13" - a Stage II intact "drying" blister 0.25 by 0.5 cm adjacent and above a 2.5 x 2 cm non blanching purple area. Both of these areas were inside a 12 x 7 cm red blanching area. Areas to document depth and drainage were blank. "Comments: Will treat (with) [MEDICATION NAME] (with) attend (changes) Gel cushion in w/c CNA's (sic) to turn (and) repo(sition) Q (every) 2 (hours), Family had been treating at home." The posterior body diagram contained 2 Xs in the left buttock area and the photograph (photo) showed the aforementioned 3 areas as described above. * 5/15/13 - "Type: Wound and Size...See back." A MediRule wound measurement tool, documented a superior wound as 4 cm x 2 cm and an inferior wound as 4.5 cm x 3.2 cm. Areas to document depth and drainage were blank. The posterior body diagram contained an X in the left buttock area. The photo revealed a superior and an inferior wound at the left inner buttock. The superior wound bed appeared white with dry flakes at the left top edge. The inferior wound bed appeared red with a white patch at the right side of the wound and dry flaky skin around the wound. * 5/21/13 - "Type: Wound (and) Other: excoriation(;) Size... 1 cm x 2 cm(;) Depth: superficial." The space to document drainage was blank. "Comments: [MEDICATION NAME] tissue noted." The posterior body diagram contained a circle at the left lower, inner buttock area. However, the photo showed 2 circular areas, a small wound above a larger wound. Both wounds appeared dry and white (possibly [MEDICATION NAME]). Note: The 5/21/13 PD did not identify to which wound the measurements correlated. The PD regarding the resident's left heel PU included: * 5/16/13 - "Type: Bruise/Contusion Other: (L) heel." Areas to document depth, drainage, and comments were blank. The posterior body diagram contained a circle at the left heel. The photo documented a large black wound with what appeared to be yellow flaky areas in and around the wound. * 5/21/13 - "Type: Other: Drying pressure ulcer(;) Size...(;) 2 cm x 3.5 cm(;) Depth: unknown(;) ...Drainage: (none)(;) Comments: Borders beginning to lift." The posterior body diagram contained an arrow drawn to the left heel. The photo showed an oblong black area with dry flaking tissue at the top and bottom of the blackened area and a small pink area below the blackened area. * 5/27/13 - "Type: Wound(;) Size...: 4 cm diameter." Areas to document depth and drainage were blank. "Comments: RSDT not cooperative (with) blue boots, legs restless in bed. RSDT to wear non-skid socks vs (versus) shoes." The posterior body diagram contained an arrow to the left heel. The photo showed a large, slightly oblong wound with a red base near the center and bottom of the wound with gray/black patches around and on the right side of the red tissue. On 6/5/13 at 10:15 a.m., the Charge Nurse (CN) was asked about Resident #1's left heel and left buttock PUs. The CN provided a 5/7/13 7:50 p.m. emergency department visit note which documented, in part, "Skin/Healing History...pressure area's (sic) on bilateral feet and buttocks, not open." The CN stated the resident was admitted with a calloused area on the right heel, nothing on the left heel, and 2 stage II PU areas on the left buttock. The CN added, "I have no documentation prior to June. All I have is what's here because all those daily checks would be in (the system identified as the facility's software program provider of their electronic medical record (EMR))." Note: Refer to F514 regarding the accuracy, completeness, accessibility, and systematic organization of residents' clinical records related to the EMR. On 6/6/13 at 9:15 a.m., the CN was asked to provide documentation of Resident #1's admission nursing assessment with any identified areas of skin breakdown, the admission and any subsequent PU risk assessments, and weekly skin checks by a LN. The CN stated, "We probably are not going to get anything out of (the EMR system). At this point we have no access, no way to get it." On 6/6/13 at 11:30 a.m., with Resident #1's agreement, LN #3 showed the surveyor the resident's heels and buttock. A large oblong PU was on the back of the left heel. The top half of the left heel PU was covered in dry, cracking black eschar that was lifting at the edges. Pink granular tissue was in the lower half of the left heel PU. The right heel was intact without any reddened or boggy areas. The buttocks were intact with darkened pigmentation noted at the inner aspect on the left and the right. The darkened skin on the left was about 3 inches wide. It covered the area just below the sacral level to just below the rectal area. The darkened skin on the right was about 2 inches wide and much smaller than the left side. The facility's documentation about Resident #1's PUs was inconsistent. The 5/19/13 MDS documented 2 unstageable PUs were present during the previous 7 days while the 5/21/13 PU CAA noted only redness at the coccyx and flaky skin on the left heel. No other PU area concerns were noted in the CAA. Also, the PD revealed that eschar (unstageable by definition) was present on the left heel PU. The resident developed an unstageable left heel pressure ulcer and, per facility documentation, an unstageable left buttock PU when the facility failed to assess the resident's skin and PU risk upon admission to the facility on [DATE] and did not monitor the resident's buttock for 7 days and the left heel for 8 days after admission. On 6/5/13 at 4:15 p.m. and 6/6/13 at 3:45 p.m., the Administrator and the CNO were informed of the harm issue regarding the PUs to Resident #1's left buttock and left heel. However, the facility did not provide any other information or documentation about the PUs. 2. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE] status [REDACTED]. The resident's 5/14/13 admission MDS assessment coded, in part: * Severe cognitive impairment, with a BIMS score of 3; * Extensive assistance of 2 people for bed mobility and transfers; * Total assistance of 1 person for dressing, hygiene, and bathing; * At risk for pressure ulcers (PU); * No unhealed PU, venous/arterial ulcers, or other skin problems. Resident #2's June 2013 Plan of Care identified the problem, "...potential for impaired skin integrity..." Interventions included, "Skin assessment weekly and as needed (by LN). Monitor skin on bath day and during cares for s/sx (signs and/or symptoms) of skin breakdown... (by NA). Assist/cue to turn every 2 hours and as needed (by NA). Check left heel on even nights (by LN)." In handwriting and dated 5/15/13 was, "Blue boot on at all times (except with) transfers. Photo(graph) of heel wound (every) week. Weekly SAR (skin at risk) meeting." On 6/4/13 at 9:50 a.m., 10:30 a.m., and 12:35 p.m., Resident #2 was observed with a dark blue Prevalon boot on the left foot. On 6/5/13 at 11:00 a.m., the Charge Nurse (CN) was asked about Resident #2's left heel. The CN confirmed the resident had a left heel PU and stated, "The first Nurses' Note on the pressure ulcer would have been in (the EMR) and that's lost. The first available documentation is 5/12/13." Note: Refer to F514 regarding the accuracy, completeness, accessibility, and systematic organization of residents' clinical records related to the EMR. On 6/5/13 at 12:15 p.m., the CN stated Resident #2 was admitted with an intact left heel PU that was caused by [MEDICAL CONDITION] after IV (intravenous) fluids during an acute care stay. The CN provided a 5/7/13 acute care physician note and pointed out the following documentation, "Abnormal: [MEDICAL CONDITION] (trace left LE (lower extremity) [MEDICAL CONDITION]." This 5/7/13 note also documented, "Integumentary Normal: No Ulcers." The CN added, "We don't have access to our Nurses' Notes." She also stated, "I might be able to go back in the old chart and care plan to show we were checking her heel every other evening." At that time, the CN provided Photograph Documentation (PD) and Physician/Staff Communications (P/SC) regarding Resident #2's left heel PU. The PD included areas in which to document: date; type: wound, laceration, bruise/contusion, burn, or other; size in centimeters (cm); depth; presence/absence of drainage; comments; nurse's signature and photographer's signature; a front and a back body diagram with instructions to "Mark Photographed Location;" and, a photograph. The PD and P/SC documentation included: * 5/12/13 PD - "Type: Other: Non blanchable red area on left heel(;) Size...: 1.5 fluid filled 2.5 whole wound(;) Depth: unknown(;) ...Drainage: (no) drainage(;) Comments: protective boot applied." The posterior body diagram contained an X at the left heel and the photo showed a large bright red, intact wound. * 5/12/13 P/SC - "...increased leg [MEDICAL CONDITION] has a pressure blister (with) fluid underneath on her heel." The physician ordered an increase in [MEDICATION NAME] (diuretic). * 5/15/13 - "Type: Bruise/Contusion Other: (L) heel." Areas to document the size, depth, drainage, and comments were blank. The posterior body diagram contained a circle at the left heel and the photo showed a large black wound with redness on one side of the eschar and dry peeling skin on the opposite side of the eschar. The physician wrote, "I will come (and) see her." * 5/15/13 P/SC - "...lg (large) blood blister looking area to heel..." * 5/21/13 PD - "Type: Other: pressure ulcer(;) Size...: 3.5 cm (by) 2.5 cm(;) Depth: unknown(;) ...Drainage: Fluid filled blister." The posterior body diagram contained an arrow drawn to the left heel and the photo showed a large intact black wound. * 5/27/13 PD - "Type: Other (blank otherwise)(;) Size...: 2 cm (by) 3 cm (irregular)(;) Comments: RSDT's (Resident's) heel cont(inue) to dry [MEDICAL CONDITION] (down), (increased oral) intake (times) last 2 days." The posterior body diagram contained a circle at the left heel and the photo showed an intact dry black wound. * 6/3/13 PD - "Type: Other (blank otherwise)(;) Size...: 2 cm (by) 3 cm(;) Depth: N/A (not applicable)(;) ...Drainage: None. Comments: Area flat. Drying. P.O. (oral) intake varied. No [MEDICAL CONDITION]." The posterior body diagram contained an arrow drawn to a circle on the left heel and, "Soft boot on foot at all times except during transfer if with sit-to-stand (type of mechanical lift). Arjo (type of lift used for total transfers) used mostly." On 6/5/13 at 1:15 p.m., the CN provided an April 2013 Plan of Care and stated that heel checks every other evening were in place. She stated, however, "I just can't show the documentation to that because it's in (the EMR system.)" The CN was asked to provide the initial nursing assessment, any identified skin issues, and the initial and any subsequent PU risk assessments when Resident #1 was readmitted to the facility on [DATE]. The CN indicated that information also was not available. Resident #2 developed an unstageable left heel pressure ulcer when the facility failed to assess the resident's skin and PU risk upon readmission the facility on 5/8/13 and did not monitor the resident's left heel for at least 4 days after readmission on 5/8/13. On 6/5/13 at 4:15 p.m. and 6/6/13 at 3:45 p.m., the Administrator and the CNO were informed of the harm issue regarding the PUs to Resident #2's left heel. However, the facility did not provide any other information or documentation about the PU.

Based on record review, staff interview, and resident interview, it was determined the facility failed to ensure a resident received the necessary assistance to prevent falls. This was true for 1 of 9 (# 4) sampled residents. Resident #4 was harmed when she did not receive the care-planned assistance and subsequently fell , sustaining a pelvic ring fracture and hospitalization . Findings included: Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's initial admission MDS, dated [DATE] and prior to her fall, documented the following: * Understood by others * Able to understand others * Moderately impaired cognitive skills * No signs and symptoms of delirium * Felt down, depressed, or hopeless 2-6 days * Felt bad about oneself 7-11 days * Independent requiring no set up help or assistance from staff for bed mobility * Walking in room or corridor did not occur * Limited assistance requiring one person for physical assistance for dressing and personal hygiene * Extensive assistance requiring two persons for physical assistance for toilet use and bathing * No indwelling catheter * Always continent of urine * Frequently incontinent of bowel * No falls in the last month prior to admission The resident's most recent admission (readmission) MDS, dated [DATE], after the accident, documented the following: * Understood by others * Able to understand others * Severe cognitive impairment NOTE: In an interview with the DON on 2/17/11 at 8:45 am, she stated the declining BIMS (Brief Interview for Mental Status) score for the resident was due to the increased anxiety due to pain at that time as the resident had just returned from her hospitalization . * No signs and symptoms of delirium * Felt down, depressed, or hopeless 7-11 days * Felt tired or had little energy 7-11 days * Poor appetite or overeating 7-11 days * Limited assistance requiring at least two persons for physical assistance for bed mobility * Transfers, walking in the room, corridor or on the unit did not occur * Extensive assistance requiring one person for physical assistance for dressing, toilet use, and bathing * Indwelling catheter * Always continent of bowel * fell in the last month prior to admission The Admission Nursing Assessment, dated 1/1/11, documented: * Two person assist * Partial weight bearing * Wheelchair only to ambulate * Words that best describe resident - Alert, Friendly, Cooperative * Answers questions readily * Quick comprehension * Good motivation The resident's admission Fall Risk Assessment, dated 1/3/11, documented a score of 14. The assessment indicated a score of 10 or higher meant the resident was at risk for falls and that interventions should be promptly put in place. The initial Care Plan for Resident #4, dated 1/6/11, had no specific care plan for falls. It did contain the problem, "Adjustment to new environment," with an intervention, "Help adjust to nursing home placement." In addition, there was an admission Resident Care Plan, with the hospital name at the top of the form, that documented the following: * Extensive assistance required for dressing and bathing upper and lower body * Two persons for physical assistance with bed mobility A Physical Therapy Initial Evaluation for Resident #4, dated 1/4/11, documented: * "Prior hospitalization : ...The patient states she has also been hospitalized in the recent past for falls." * "Precautions: The patient is a fall risk." * "Palpation: Balance/Coordination: Is greatly decreased. The patient has very poor balance and is very unsteady with the use of the walker." The Fall(s) Care Area Assessment (CAA), dated 1/11/11, documented, "No history of falls," and "...She is alert and oriented to person and time. Reluctant to move without assist. Requires assist with daily decisions and assist with ADL's. No history of falls. Will CP (care plan) under potential for injury/falls. Fear of falling and attempting to ambulate." NOTE: The resident was admitted on [DATE], with an admission MDS assessment dated [DATE]. Per federal regulations, a comprehensive care plan, based on the comprehensive assessment, should have been developed within 7 days or by 1/14/11. The comprehensive care plan was dated 1/27/11, after the resident had fallen, sustaining a fracture requiring hospitalization . Please refer to F280 as it relates to no comprehensive care plan developed for this resident within a timely fashion. The Cognitive Loss CAA, dated 1/11/11, documented, "...Requires cueing and supervision with daily decisions, and the same with ADL's. Muscle weakness, WC (wheelchair) main mode of transport. Moderate fall risk and high pressure risk. Will CP under self-care deficit, impaired mobility, Alt. (alteration) in cognition." The Activities of Daily Living-Functional Status/Rehabilitation Potential CAA, dated 1/11/11, documented, "...Requires cueing and assist with daily decisions, and for ADL's. She feels she is capable of doing more than she is capable of. Does not realize her limitations..." NOTE: The Falls CAA documented she was reluctant to move without assistance and had a fear of attempting to ambulate, which contradicted the ADL CAA that stated she did not realize her limitations. The Urinary Incontinence and Indwelling Catheter CAA, dated 1/11/11, documented the resident was admitted with a urinary tract infection for which she was being treated. Interdisciplinary Progress Notes for Resident #4 documented: * 1/2/11 (no time) "...Resident alert, pleasant, cooperative. States her balance is poor so she is unable to ambulate or transfer. States she is 'very careful' and is afraid of falling due to past hospitalization s after falling at home." * 1/2/11 9:45 pm "...Resident is a two person assist with transfers - does not ambulate..." * 1/22/11 4:10 pm "Called to res. rm. (room) by CNA at 1600 (4:00 pm). Found res. on floor between bed and closet with CNA next to her. CNA stated res. fell straight backward on way to BR (bathroom) with FWW (forward wheel walker). Res. stating I think I broke my hip. C/O (complains of) severe pain in R (right) hip..." The resident fell on [DATE]. The physician History and Physical for Resident #4, dated 1/31/11, documented, "The emergency department workup showed a pelvic ring fracture and the patient was admitted for pain control and initiation and anticoagulation. She has done fairly well so far, but continues to be in significant pain, obviating much movement." The facility Confidential Quality Management Occurrence report, dated with 1/24/11 and 1/25/11, by different staff that signed the report, documented: * "Date of occurrence: 1/22/11" * "Time of occurrence: 1600 (4:00 pm)" * "Error category: An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization ." * "Type of injury: Poss. (possible) R (right) hip fx (fracture)" * "Additional Description of Event: Res (resident) is saying she got up by herself because she thought she could do it. CNA states she was present during fall, had her hand on shoulder as Res was rounding the corner to enter the bathroom and fell straight back." * "Investigation: Res has hx (history) of unbalance per her, she was with a CNA and had FWW (forward wheel walker). Care plan states she is 2 person assist, only 1 CNA present. We were working with 1 Nurse at the time and 4 CNA due to call ins. Also did notice Res did not have gait belt on. (nurse's signature) Rec. (received) further info. (information) from CNA-stated Res was with FWW at side of bed, stood up when CNA entered room, didn't wait for CNA to get to her bedside and started walking to the BR (bathroom), CNA stated it all happened so fast she was unable to call for 2nd person and their (sic) was no gait belt in rm. (room) And as doors open in wrong direction she was opening door with one hand, holding onto Res. shoulder with other hand, Res turned back away from CNA and went backwards." * "Follow-Up by Department Manager/Director: ....CNA did not follow careplan which required a gait belt be used." NOTE: There was no mention of the required two persons for physical assistance. The resident was interviewed on 2/17/11 at 9:20 am regarding the accident. She stated she was sitting in her recliner in the corner of her room. She does not recall having a call light available where she was seated. She stated she got up because she had to use the bathroom and was using the facility FWW. She stated she would never use a facility FWW again and instead, only used her personal FWW as she felt the facility device made her feel too unsteady with ambulation. She stated she was having a difficult time with ambulation and the CNA mentioned in the accident report stood in the doorway during this time. She stated the CNA did not offer to help and she felt extremely frustrated that the CNA stood by and watched her struggle to reach the bathroom. She stated she fell backward when she attempted to open the bathroom door. She stated the CNA did not assist at all during this time and only interevened after she fell . The DON was interviewed on 2/17/11 at approximately 10:00 am, and was asked if the resident was interviewed after the accident. She stated the resident was not interviewed after the accident. When the surveyor related what the resident had explained happened in the accident, the DON stated the resident was wrong and that it did not happen that way. Irregardless of the resident's recount of the accident, the CNA stated the resident did not stand up until she entered the room. The CNA did not attempt to redirect the resident to sit while she called for additional help and retrieved a gait belt. It is unsure whether this was due to the facility not having sufficient staff as the CNA alluded to in the account of the accident. The facility failed to implement appropriate interventions for the resident upon admission, who had been assessed as at risk for falls, as well as documented in the record as having a past history of falls prior to admission. The resident suffered ongoing pain and anxiety as a result of the accident and has been bedbound as a result. The Administrator and DON were informed of this issue on 2/17/11 at 4:00 pm. No further information was received.