Every finding on record at Bridgeview Estates

Based on observation, 2022 FDA Food Code, resident and staff interviews, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This deficient practice had the potential to affect all residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code states hot food will be maintained at 135 degrees F (Fahrenheit) or above and cold food will be maintained at 41 degrees F or below. The following comments were obtained during resident interviews. On 7/6/25 at 2:45 PM, Resident #46 stated meals are cold, with over or undercooked vegs that are often tasteless and mushy. On 7/6/25 at 2:52 PM, Resident #34 stated food is always cold and horrible, poorly fixed. Turkey and rice in last night’s dinner was horrible and tasted old. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Multiple Sclerosis (disease in which the immune system attacks the protective covering of the nerve cells) and depression. On 7/6/25 at 10:04 AM, Resident #6 stated food is not good. The meat is tough, and the vegetables are soggy most of the time. The meal quality is worse on the weekends. On 7/8/25 at 3:00 PM, Resident #6 stated lunch was not too good, and the hot food was often cold. On 7/8/25 at 1:12 PM, a lunch meal taste tray was provided and the following issues with the quality of the food and temperatures are listed below. - The chicken temp was 135 degrees F, the chicken did have an acceptable temp but there was a strong spicy taste in the gravy that took away from the meal. - The pudding was 65.1 degrees F which should have been much colder and the taste was off. - The peas were 132.2 degrees F and acceptable. - The carrots were 129 degrees F, these were overcooked, mushy, and had a foul taste to them. The Holding Temperature log for the pudding on 7/8/25 lunch was 53 degrees F and should have been 41 degrees or lower. On 7/9/25 at 9:02 AM, the Facility Food Service Manager stated the holding temp for that dessert should have been 50 degrees F or colder and was not. On 7/9/25 at 9:02 AM, observed the kitchen Holding temperature logs for each meal were not legible for the following dates. - June 14, 15, 16, 21, 22, 23, 2025 all dinner meals. On 7/9/25 at 9:35 AM, the Facility Food Services Manager stated those Hold Temperature logs should have legible data entered and they were not on those dates.

Based on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 7/6/25 at 10:11 AM, observed the following issues in the Walk-in Refrigerator. - a large container of cooked turkey in liquid, partially covered with plastic wrap that was down in the liquid and not properly covered.- several trays of desserts and drinks that were not dated.- various zip-lock type bags containing peanut butter and jelly sandwiches, which were not dated.On 7/6/25 at 10:15 AM, observed the following issues in the Walk-in Freezer.- a large cardboard box of green beans, opened to the air and not properly covered.- a large cardboard box of chicken opened to air not properly covered.- a large cardboard box of hamburger patties opened to air not properly covered.On 7/6/25 at 10:22 AM, the Food Service Manager stated the food items should have been properly covered and dated when opened and were not.On 7/6/25 at 10:25 AM, reviewed the kitchen dish washer logs noting they were not completed with some missing data in July on the following dates: July 4 and 5 breakfast and lunch.On 7/6/25 at 10:27 AM, reviewed the kitchen sanitizing bucket PPM log which was missing data on July 3, 4 and 5 at the following times, 7 AM, 9 AM, 11 AM, and 1 PM.The Food Service Manager stated those dates should have been documented as completed and were not.On 7/6/25 at 12:27 PM, observed containers of lemonade and iced tea that were not labeled or dated, were being served in the dining room for lunch by the DON. The DON stated the containers don't have dates on them, but they just came from the kitchen.

Based on observation, record review, and interviews, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #10). This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. On 7/6/25 at 1:51 PM, observed in Resident #10's room [ROOM NUMBER] tubes of Cortisone-10 cream on her overbed table. Resident #10 stated she self-administers the medication when she needs it. Resident #10's medical record had not contained a self-administration assessment for the Cortisone-10 cream.On 7/8/25 at 2:15 PM, the DON stated Resident #10 should have been assessed for the Cortizone-10 cream to allow her to have it in her room to self-administer and was not.

Based on observation, interview, and record review, it was determined the facility failed to ensure the MDS assessment accurately reflected the resident's status. This was true for 1 of 1 resident (Resident #10) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and cared for or monitored due to inaccurate assessments. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. Review of Resident #10's Level I PASRR dated 10/6/23, and Level II PASRR dated 10/10/23, and noted PTSD was listed as a diagnosis. Review of Resident #10's MDS dated [DATE], 1/18/25, 10/18/24, 7/20/24, 4/19/24, 1/18/24, and 10/18/23 which documented under I6100 Post Traumatic Stress Disorder (PTSD) was marked NO.On 7/7/25 at 1:20 PM, the DON stated once PTSD is listed on the PASSR's it should have been documented in each MDS and was not.

Based on observation, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #10) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include: Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. Resident #10's comprehensive person-centered care plan had not documented PTSD diagnosis with goals and interventions.On 7/8/25 at 2:19 PM, the DON stated Resident #10's PTSD diagnosis should have been care planned and was not.

Based on policy review, record review, and staff interview, it was determined the facility failed to update care plans when changes occur to resident's care. This was true for 2 of 14 residents (#12 and #34) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided as resident's needs changed. Findings include:The facility's policy, Comprehensive Care Plans and Conferences dated 9/5/24, documented resident’s care plans must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), congestive heart failure, and repeated falls. On 3/3/25, Resident #12 had a fall when his quad-cane bent during a transfer, resulting in a laceration and skin tear. The incident report documented an intervention to replace the quad-cane. On 4/19/25, a PT (Physical Therapy) Evaluation and Plan of Treatment documented Resident #12’s prior level of functioning required minimum to maximum assist for self-cares using a hemi-walker, power wheelchair, and manual wheelchair. The evaluation did not document the use of a quad-cane. On 4/23/25, a PT treatment encounter note documented Resident #12 was to ambulate short distances with staff using a hemi-walker. The treatment encounter note did not document the use of a quad-cane. Resident #12’s care plan, with a last review completed date of 7/2/25, documented he requires 1 person transfer assistance with a quad-cane. The care plan did not document the use of a hemi-walker. On 7/8/25 at 4:30 PM, the DON stated the quad-cane was replaced with a hemi-walker after Resident #12’s fall on 3/3/25. The care plan should have been updated to change the quad-cane to hemi-walker but was not. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth). On 7/6/25 at 2:53 PM, observed Resident #34’s left leg was very red and swollen and was not wearing Tubi grips. Resident #34’s physician order dated 3/12/25, documented Apply edema wear (Tubi grips size F) to bilateral lower extremity. Apply from base of toes to 1 below the knee. To prevent rolling, turn over the top of edema wear making a 3 cuff. Edema wear is washable but must hang to dry. It may be removed for skin care and assessment, then replaced. Resident #34’s Weekly Skin Assessment 6/25/25 and 7/3/25, documented SEVERE edema to bilateral lower extremities. Resident noncompliant with Tubi grips and foot elevation. Resident #34’s comprehensive person-centered care plan had not documented the use of Tubi grips daily. On 7/8/25 at 2:17 PM, the DON stated Resident #34’s Tubi grips should have been care planned and were not.

Based on facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 3 of 4 Residents (#34, #41, and #43) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include: The facility standing orders and protocols documented BM (Bowel Movement) Step 1: Lactulose 10GM/15ML: 30 ml PO daily PRN for no bowel movement X 72 hrs +. If no results within 8 hrs proceed to step 2: BM Step 2: Dulcolax Suppository 10mg: give one Suppos rectally PRN daily for NO BM X 72 Hrs +. If no results within 8hrs proceed to step 3. BM Step 3: Fleet Enema 7-19 GM/118 ml: Give one Enema rectally PRN daily for NO BM X 72 Hrs+. If no results within 8 hours Notify MD for further instructions. a. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth). Resident #34 had a BIMS of 15. Review of Resident #34's medical record contained a signed facility standing order for bowel care.On 7/7/25 at 9:47 AM, Resident #34's medical record had documented bowel movement (according to B&B CNA task) on 6/12/25 at 8:20 PM, and not again until 6/16/25 at 12:20 PM, 87 hours later. Resident #34's physician's orders dated 8/19/24, related to bowel care were as follows:- Lactulose Solution 10 GM/15ML Give 30 ml by mouth as needed for No BM x72 hours Step ONE. If no results within 8 hours, proceed to step TWO, - Step TWO, Dulcolax Suppository 10 MG (Bisacodyl) Insert 10 mg rectally as needed for constipation - if no results from Lactulose Step TWO. If no results within 8 hours, proceed to Fleet enema, step THREE, - Step THREE Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for constipation - no results from suppository Step THREE. If no results, notify MD.Resident #34's MAR documented Lactulose, Dulcolax, and Fleet Enema were not given during the month of June 2025. Resident #34's medical record contained no documentation that the physician had been notified after 87 hours without a BM.Resident #34 was documented as eating 75 to 100 percent of his meals 6/8-13/25. On 6/14 Breakfast - 51 to 75%, Lunch - 100%, Dinner - 26 to 50%On 6/15 all meals eaten at 51 to 75%.Resident #34's medical record documented no behavioral related issues or refusals of care related to toileting during June or July 2025.On 7/8/25 at 2:20 PM, the DON stated nursing staff should have followed physician's orders and the facility standing order for Resident #34's bowel care and had not. b. Resident #41 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fracture of left and right femur and heart failure.Resident #41 had a BIMS of 15.Review of Resident #41's medical record contained a signed facility standing order for bowel care.Resident #41's had documented bowel movement (according to B&B CNA task) on 6/11/25 at 3:46 PM, and not again until 6/14/25 at 9:32 PM, 77 hours later.Resident #41's had documented bowel movement (according to B&B CNA task) on 6/18/25 at 9:08 PM, and not again until 6/22/25 at 1:12 AM, 76 hours later.Resident #41's had documented bowel movement (according to B&B CNA task) on 6/27/25 at 1:51 AM, and not again until 6/30/25 at 9:59 PM, 92 hours later.Resident #41's physician's orders related to bowel care were as follows:- Lactulose Solution 10 GM/15ML dated 6/13/23, Give 30 ml by mouth as needed for No BM x72 hours Step ONE. If no results within 8 hours, proceed to step TWO, - Step TWO, Dulcolax Suppository 10 MG (Bisacodyl) dated 7/5/23, Insert 10 mg rectally as needed for constipation - if no results from Lactulose Step TWO. If no results within 8 hours, proceed to Fleet enema, step THREE, - Step THREE Fleet Enema 7-19 GM/118ML (Sodium Phosphates) dated 6/13/23, Insert 1 application rectally as needed for constipation - no results from suppository Step THREE. If no results, notify MD.Resident #41's MAR documented Dulcolax was given on 6/11/25, while Lactulose and Fleet Enema were not given during the month of June 2025. Resident #41's medical record contained no documentation that the physician had been notified of BM related issues during the month of June 2025.Resident was documented as eating the following percentage of his meals of the following dates.- 6/11/25 - Dinner 26 to 50%- 6/12/25 - Lunch 51 to 75%, Dinner 76 to 100%- 6/13/25 - None listed- 6/14/25 - None listed - 6/18/25 - Lunch 50 to 75%, Dinner 76 to 100%- 6/19/25 to 6/20/25 Lunch 76 to 100%, Dinner 76 to 100% - 6/27/25 - to 6/30/25 Dinner 76 to 100% Resident #41's medical record documented no behavioral related issues or refusals of care related to toileting during June or July 2025.On 7/8/25 at 2:20 PM, the DON stated nursing staff should have followed physician's orders and the facility standing order for Resident #41's bowel care and had not. c. Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and need for assistance with personal cares.Resident #43 had a BIMS of 15.Review of Resident #43's medical record contained a signed facility standing order for bowel care.On 7/7/25 at 9:49 AM, Resident #43's medical record had documented bowel movement (according to B&B CNA task) on 6/19/25 at 12:59 PM, and not again until 6/23/25 at 1:22 PM, 96 hours later. Resident #43's physician's orders dated 9/22/23, related to bowel care were as follows:- Lactulose Solution 10 GM/15ML Give 30 ml by mouth as needed for No BM x72 hours Step ONE. If no results within 8 hours, proceed to step TWO, - Step TWO, Dulcolax Suppository 10 MG (Bisacodyl) Insert 10 mg rectally as needed for constipation - if no results from Lactulose Step TWO. If no results within 8 hours, proceed to Fleet enema, step THREE, - Step THREE Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for constipation - no results from suppository Step THREE. If no results, notify MD.Resident #43's MAR documented Lactulose, Dulcolax, and Fleet Enema were not given during the month of June 2025. Resident #43's medical record contained no documentation that the physician had been notified after 96 hours without a BM.Resident #43 was documented as eating 75 to 100 percent of her meals 6/20-22/25.Resident #43's medical record documented no behavioral related issues or refusals of care related to toileting during June 2025.On 7/8/25 at 2:20 PM, the DON stated nursing staff should have followed physician's orders and the facility standing order for Resident #43's bowel care and had not.

Based on observation, policy review, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 5 residents (#34 and #43) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: a. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth).On 7/6/25 at 2:52 PM, observed Resident #34 was not using his oxygen concentrator located in his room. Resident #34 stated he uses it when he feels he needs it.Resident #34's physician's order dated 1/27/25, documented oxygen at 3 liters per minute continuously via nasal canula. Document every shift.Resident #34's care plan documented OXYGEN SETTINGS: O2 via nasal cannula at 3 LPM continuously and humidified. Date Initiated: 9/13/2024 Resident's medical record documented the following:Date & Time O2 SpO2 Staff- 7/7/25 at 7:07 96.0% Room Air RN #1 - 7/6/25 at 22:48 91.0% Room Air RN #1 - 7/6/25 at 22:47 91.0% Room Air RN #1 - 7/6/25 at 16:08 93.0% Room Air LPN #1 - 7/6/25 at 6:52 94.0% Room Air LPN #4 - 7/5/25 at 9:42 94.0% Room Air LPN #3 - 7/5/25 at 7:14 94.0% Room Air MAC #2 - 7/4/25 at 11:45 96.0% Room Air LPN #2 - 7/4/25 at 11:45 96.0% Room Air LPN #2 - 7/4/25 at 1:01 92.0% Room Air MAC #3 - 7/4/25 at 1:01 92.0% Room Air MAC #3 - 7/3/25 at 6:50 97.0% Room Air LPN #2 - 7/3/25 at 6:49 97.0% Room Air LPN #2 - 7/2/25 at 23:21 92.0% Room Air MAC #3 - 7/2/25 at 23:21 92.0% Room Air MAC #3 - 7/2/25 at 6:38 93.0% Room Air RN #1 - 7/1/25 at 23:54 91.0% Room Air MAC #3 - 7/1/25 at 23:54 91.0% Room Air MAC #3 - 7/1/25 at 14:29 91.0% Room Air LPN #6- 7/1/25 at 14:29 91.0% Room Air LPN #6 - 7/1/25 at 6:37 97.0% Room Air RN #1 On 7/8/25 at 2:25 PM, the DON stated nursing staff should have contacted Resident #34's physician to either cancel or update the oxygen order and had not.b. Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and need for assistance with personal cares.Facility BiPAP / CPAP Administration policy dated 9/3/24, documented humidifier reservoir should be filled daily with sterile or distilled water to the fill-line. Each day when the patient is removed from the machine the reservoir should be emptied and left to air dry. Once weekly, the reservoir should be washed with warm soapy water and rinsed well, then left to air dry. Weekly cleaning should be documented in the patient record.On 7/6/25 at 1:17 PM, observed Resident #43's CPAP nasal pillows sitting on the bed side table uncovered. Resident #43 stated it had been a while since the facility staff had cleaned the mask and she had never seen staff clean the humidifier.Resident #43's TAR documented CPAP / BiPAP: Clean PAP nasal mask with warm soapy water and allow to air dry every dayshift. Order date 10/2/23. There was no documentation that Resident #43's CPAP mask had been cleaned on 6/19/25.RN #2 and LPN #5 documented in June 2025, they had cleaned the CPAP mask per physician's order and the care plan.RN #1 and LPN #2, #3, #4 documented in July 2025, they had cleaned the CPAP mask per physician's order and the care plan.On 7/8/25 at 2:24 PM, the DON stated she interviewed the nurses regarding the cleaning of Resident #43's CPAP mask. The nurses were not cleaning the mask or humidifier according to the physician's order and care plan and should have been.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 7/8/25 at 8:57 AM, during Sawtooth Hall medication cart audit, observed the narcotic accountability record, dated 5/3/25 to 7/8/25, with 3 licensed nurse signatures not documented. On 7/8/25 at 9:01 AM, LPN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 7/8/25 at 9:10 AM, during Sun Valley Hall medication cart audit, observed the narcotic accountability record, dated 5/28/25 to 7/8/25, with 5 licensed nurse signatures not documented. On 7/8/25 at 9:36 AM, RN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 7/8/25 at 3:37 PM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 19 Residents (Resident #28). This failure created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:The facility’s Storage and Expiration Dating of Medications and Biologicals policy revision date 8/1/24, documented the following: - the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is not accessible by residents and visitors. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis, lumbar region (condition where spaces narrow, putting pressure on the spinal cord and nerves) and diabetes. On 7/8/25 at 8:47 AM, the following was observed in Resident #28’s room; LPN #1 administered oral medications to resident then left insulin pen on resident’s overbed table when leaving the room to get a needle for the insulin pen. LPN #1 reentered resident’s room and administered the insulin. On 7/8/25 at 8:54 AM, LPN #1 stated she should not have left the insulin pen at Resident #28's bedside. On 7/8/25 at 10:05 AM, the DON stated medications should not have been left at Resident #28's bedside unattended. The facility's General Dose Preparation and Medication Administration policy dated 12/1/07, documented the facility staff should ensure that medication carts are always locked when out of site or unattended. On 7/7/25 at 1:48 PM, observed an unattended and unlocked medication cart next to the nurses’ station. MAC #1 stated the medication cart should have been locked when I was not at the cart. On 7/7/25 at 2:27 PM, the DON stated the medication carts are to be locked when staff are not next to the cart.

Based on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: Department of Health and Welfare - Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator.U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 7/6/25 at 10:30 AM, observed various trash cans in the kitchen food prep area were not sealable, with round holes cut in the center to keep open.On 7/6/25 at 10:35 AM, the Food Services Manager stated she was not aware of the requirement to have closed garbage can lids in the food prep areas.

Based on record review and staff interview, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 1 of 1 resident (Resident #12) whose records were reviewed. This deficient practice resulted in incomplete documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident. Findings include:Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), congestive heart failure, and repeated falls.A physician's order dated 1/30/25, documented Resident #12's inappropriate sexual comments towards staff were to be documented on the TAR and include number of episodes, intervention, and outcome.A care plan dated 2/21/25, documented Resident #12 makes sexually inappropriate comments to staff and a behavior tracking document is in place for this behavior.On 7/8/25 at 9:30 AM, the DON with the Executive Director present stated Resident #12 did not receive a shower on 6/14/25, 6/28/25, and 7/2/25 due to his inappropriate sexual comments towards staff. The Administrator stated Resident #12 has had these behaviors for a long time and was documented in his medical record.A review of Resident #12's TAR and progress notes from 2/1/25 - 7/8/25, did not document any sexually inappropriate comments or behaviors.On 7/9/25 at 11:45 AM, the DON stated Resident #12's inappropriate sexual behaviors towards staff should have been documented on the TAR and a behavior note written on 6/14/25, 6/28/25, and 7/2/25, but was not.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination from dirty to clean areas in the kitchen. This had the potential to affect the 41 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food and Nutrition policy, Prevention of Cross-Contamination, revised 12/17/21, documented all Food and Nutrition Services associates were trained in infection control techniques to prevent the contamination of food and the spread of infection to ensure food was stored, prepared, distributed and served in accordance with professional standards for food safety, and per federal, state and local requirements. The Idaho Food Safety and Sanitation Manual, Page 33, revised 2/2018, stated hands must be washed after handling garbage, dirty dishes or soiled equipment, and before handling food or clean food-contact surfaces of equipment or utensils. These policies and guidelines were not followed. On 4/25/22 at 11:35 AM, Kitchen Staff (KS) #1 was observed washing pots and pans in the 3-compartment sink. KS #1 rinsed food off the dishes, washed dishes in soapy water, rinsed dishes in clean water, dipped dishes in sanitizing solution, removed dishes from the sanitizing solution, and set them on a rack to dry. KS #1 did not perform hand hygiene after washing and rinsing dirty dishes and before removing clean dishes from the sanitizing solution. On 4/25/22 at 12:30 PM, KS #1 was observed continuing to wash pots and pans. KS #1 did not perform hand hygiene after washing and rinsing dirty dishes and before removing clean dishes from the sanitizing solution. On 4/25/22 at 12:30 PM, the Registered Dietitian (RD) stated hand hygiene should be performed between the handling of dirty and clean dishes. She stated dishes should be washed, rinsed and placed in the sanitizer. She stated hands should be washed before dishes were removed from the sanitizer and set to dry or put away. On 4/25/22 at 12:32 PM, KS #1 stated he was employed at the facility for about 3 to 4 months. KS #1 stated he washed dishes, rinsed them, sanitized them, and set them to dry. KS #1 stated during his orientation and training he was not instructed to wash hands between dirty and clean dishes. KS #1 stated KS #2 trained him on the dishwashing procedure. KS #1 pointed to the poster on the wall above the dish sink as his guide for the proper way to pre-rinse soiled dishes, wash, rinse, sanitize, and set dishes to air dry. The poster on the wall did not indicate hand hygiene should be performed after washing and rinsing dirty dishes and before removing clean dishes from the sanitizer. On 4/25/22 at 12:34 PM, KS #2, stated he trained KS #1 on the dishwashing procedure. KS #2 stated dishes should be washed, rinsed, and placed in the sanitizer. KS #2 stated hand hygiene should be performed prior to taking dishes out of the sanitizer and setting them to dry. KS #2 stated he provided that information to KS#1 when he trained him.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents had comprehensive, resident-centered care plans which included individualized, resident-centered interventions and goals. This was true for 3 of 24 residents (#7, #21, and #25) whose care plans were reviewed. This failure placed residents at risk for negative outcomes if services were not provided, or provided incorrectly, due to lack of information in their care plans. Findings include: The facility's care plan policy, revised 5/10/21, stated the facility developed a comprehensive person-centered care plan, consistent with residents' rights. The care plan was developed by the Interdisciplinary Team and described the services to be furnished to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being. This policy was not followed. 1. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 4/3/22, documented Resident #25 was prescribed [CONDITION(S)] medications related to depressive disorder and staff were directed to administer her medications as ordered by the physician and observe her for any side effects of the medications every shift. Resident #25's care plan did not include the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/28/22 at 3:39 PM, the DON stated Resident #25 was being monitored for negative mood such as self-isolation. The DON stated she did not see documentation in Resident #25's care plan for behavior monitoring. 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Monitor and document behavior for anger and agitation towards others, ordered 11/19/20. *Monitor and document behavior for delusions, ordered 1/11/21. *Monitor and document behavior for perseveration and fixation on health issues, ordered 5/19/21. Resident #7's care plan for depression and anxiety, initiated 9/20/19, included interventions directing staff to administer her medications as ordered by the physician and observe her for signs and symptoms of depression and anxiety: anger, agitation, social isolation, and tearfulness. Resident #7's care plan did not include interventions to monitor her specific target behaviors, including delusions, perseveration, and fixation on health issues as ordered by the physician. On 4/29/22 at 9:50 AM, the RDCS said Resident #7's care plan did not include all of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 3/15/22, directed staff to monitor and document Resident #21's behaviors for statements of hopelessness and negative verbalization related to self or situation. Resident #21's care plan for [CONDITION(S)] medication use, initiated 4/3/22, documented Resident #21 was prescribed medication related to depression. The care plan directed staff to administer his medication as ordered by the physician and observe him for effectiveness and side effects of the medication every shift. Resident #21's care plan did not include interventions to monitor his specific behaviors for statements of hopelessness and negative verbalization related to self or situation, as ordered by the physician. On 4/29/22 at 9:50 AM, the RDCS said Resident 21's care plan did not include the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The RDCS said the care plan should monitor each resident's defined behaviors based on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #25) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include: The facility's policy, [CONDITION(S)] Medication Management, undated, documented the following: *[CONDITION(S)] drug is defined in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior. *The resident's medical record must include documentation of adequate indications for a medication's use and the diagnosed condition for which a medication is prescribed. *Involvement of the resident, his or her family, and/or the resident representative in the medication management process. (A consent is required for each medication). *Selection of medication(s) based on assessing relative benefits and risks to the individual resident. The facility's Pharmacy Services and Procedures Manual for the policy on [CONDITION(S)] Medication Use, revised 1/1/22, stated Facility staff should inform the resident and/or resident representative of the initiation, reason for use and risks associated with the use of [CONDITION(S)] medications, per facility policy or applicable state regulations. These policies were not followed. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #25's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (medication to treat confusion related to dementia) 5 mg, one tablet by mouth at bedtime, ordered on 3/16/22. *[MEDICATION(S)] (antidepressant) 50 mg, one tablet by mouth once a day for depression, ordered on 3/16/22. *[MEDICATION(S)] (antipsychotic) 25 mg, 0.5 tablet by mouth at bedtime for adjunctive treatment related to major depressive disorder, ordered on 4/5/22. Resident #25's Psychoactive Medication Informed Consent for [MEDICATION(S)] and [MEDICATION(S)], dated 3/16/22, signed by her representative documented the side effects of the medications. The consent did not include the reason why the medications were prescribed to her and the expected benefits of the medications. A consent for Resident #25's [MEDICATION(S)] was not in Resident #25's record. The Drugs.com website, accessed 5/12/22, stated [MEDICATION(S)] is used to help improve mental function in people with Alzheimer's disease. On 4/28/22 at 9:03 AM, the DON stated Resident #25's informed consent for [MEDICATION(S)] and [MEDICATION(S)] had missing information. The DON stated the reasons the medications were prescribed and expected benefits of the medications should be included in the informed consent. The DON stated the facility did not obtain consent from Resident #25 or her representative for [MEDICATION(S)] because it was not a [CONDITION(S)] medication.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a resident's contact isolation was addressed on the baseline care plan. This was true for 1 of 5 residents (Resident #243) reviewed for baseline care plans. This failure created the potential for spread of infection if residents' contact isolation intervention was not initiated. Findings include: The facility's Baseline Care Plan policy, revised 5/19/21, directed staff to develop a baseline care plan within 48 hours of admission to provide an initial set of instructions needed to provide an effective and person-centered care of the resident that meets professional standards of care. This policy was not followed: Resident #243 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 4/20/22, directed staff to place Resident #243 on contact precautions (masks, gowns and gloves must be used by health care providers when in the infected patient's room) in addition to standard precautions due to his [CONDITION(S)] infection to his left foot. Resident #243's Baseline Care Plan, dated 4/20/22, did not include documentation he was to be placed on contact isolation precautions as ordered by the physician. On 4/27/22 at 12:21 PM, the DON reviewed Resident #243's baseline care plan. The DON stated Resident #243's baseline care plan did not include he was to be placed in contact isolation. The DON stated the baseline care plan should include contact isolation as an intervention for Resident #243's [CONDITION(S)] infection.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure medications were administered in a manner that was consistent with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure created the potential for adverse effects for Resident #20 and Resident #38 should they experience a life-threatening situation due to low or high blood sugar, and for Resident #31 when he received doses in excess of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Nursing 2019 Drug Handbook stated the eight rights of medication administration were right drug, right patient, right dose, right time, right route, right reason, right response, and right documentation. The facility's General Dose Preparation and Medication Administration policy, revised 1/1/22, documented the facility staff should verify the correct medication, dose, route, rate, time, and resident before administrating a medication. The facility's Medication Administration Times policy, revised 1/1/22, documented medications should be administered to the resident following the scheduled time determined by the facility's pharmacy committee and/or Physician/Prescriber. The policy stated medication must be given within 60 minutes before the designated times of administration and should be completed by 60 minutes after the designated times of administration. These policies were not followed. 1. The Drugs.com website, accessed 5/12/22, stated, Insulin [MEDICATION(S)] is a long-acting insulin that starts to work several hours after injection [to lower blood glucose] and keeps working evenly for 24-hours. The website stated insulin [MEDICATION(S)] may be given at any time of the day; however, once a time is chosen, it is best to inject it within three hours of that time every day. The website stated low blood sugar may happen with this medicine. Very low blood sugar could lead to seizures, passing out, long [MEDICATION(S)] brain damage, and sometimes death. The Mayo clinic website, accessed on 5/12/22, stated, Blood sugar that's either too high or too low for too long may cause various serious conditions, all of which can lead to a diabetic coma. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Resident #20's physician orders, dated 6/11/21, documented Resident #20 was to receive 10 units of insulin [MEDICATION(S)] (long-acting insulin) 2 times a day in the morning at 7:00 AM and before sleep at 8:00 PM. On 2/20/22 the facility revised the order for the insulin [MEDICATION(S)] morning dose to be administered at 7:30 AM. Resident #20's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] * Greater than 181 minutes to 240 minutes in the morning on 1/4/22, 1/24/22, 3/8/22. * Greater than 121 minutes to 180 minutes in the morning on 1/12/22, 1/13/22,1/17/22, 2/12/22, 2/26/22, 3/2/22, 3/5/22, 3/10/22, 3/19/22, 3/22/22, 3/24/22, 3/30/22, 4/16/22, 4/25/22, 4/26/22. * Greater than 121 minutes to 180 minutes before sleep on 1/15/22. * Greater than 61 minutes to 120 minutes in the morning on 1/1/22, 1/7/22, 1/9/22, 1/14/22, 1/16/22, 1/21/22, 2/2/22, 2/7/22, 2/15/22, 2/22/22, 2/23/22, 2/25/22, 3/1/22, 3/4/22, 3/9/22, 3/11/22, 3/20/22, 3/29/22, 4/4/22, 4/6/22, 4/8/22, 4/9/22, 4/14/22, 4/18/22. * Greater than 61 minutes to 120 minutes before sleep on 1/4/22, 3/3/22, 4/20/22. On 04/27/22 at 2:40 PM, the RDCS said the acceptable administration time for insulin [MEDICATION(S)] was 1 hour before and after the scheduled time in the MAR. If given past the 1 hour of the scheduled time, it was considered being given late. On 4/28/22 at 8:15 AM, when asked, the DON said there was no documentation why Resident #20's insulin was given late. She stated the nurse was to notify Resident #20's physician and document if insulin [MEDICATION(S)] was given late. 2. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] Propionate Suspension (a nasal steroid spray) 50 mcg, one spray in each nostril once a day for nasal congestion. On 4/27/22 at 8:04 AM, LPN #1 administered two sprays of [MEDICATION(S)] nasal spray to each of Resident #31's left nostril and right nostril. On 4/27/22 at 8:13 AM, LPN #1 was asked how many [MEDICATION(S)] sprays Resident #31 should receive in each nostril. LPN #1 reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated she thought it was two nasal sprays in each nostril because Resident #31 always wanted to receive two nasal sprays in his nostril. 3. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Drugs.com website, accessed on 5/12/22, documented when insulin [MEDICATION(S)] is used as a mealtime insulin, it should be taken within 15 minutes before a meal or immediately after a meal. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility provided a document, updated 10/4/21, documenting breakfast was served between 7:25 AM and 8:10 AM. On 4/27/22 at 9:43 AM, LPN #1 administered 55 units of insulin [MEDICATION(S)] to Resident #38's right abdomen. On 4/27/22 at 11:29 AM, Resident #38 stated she had her breakfast at about 8:45 AM, approximately 1 hour before her insulin was administered. On 4/27/22 at 10:59 AM, LPN #1 was asked when Resident #38 should receive her insulin [MEDICATION(S)]. LPN #1 reviewed Resident #38's insulin order and stated Resident #38's insulin [MEDICATION(S)] should be given before her meals. When asked if she administered Resident #38's insulin [MEDICATION(S)] before her meals, LPN #1 stated she did not. Resident #38's insulin [MEDICATION(S)] was not given before her meal as ordered by the physician. b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included special instructions for Resident #38 to rinse her mouth out with water and spit back into the cup after administration. The Drugs.com website, accessed on 5/4/22, stated the mouth should be rinsed with water without swallowing after inhalation of [MEDICATION(S)] Discus to help reduce the risk of oral fungus. On 4/27/22 at 9:43 AM, Resident #38 was observed to take one inhalation of [MEDICATION(S)] Discus orally and gave the inhaler back to LPN #1. LPN #1 then gave Resident #38 her oral medications and asked to drink her water mixed with [MEDICATION(S)] ([MEDICATION(S)]). Resident #38 did not rinse her mouth after inhaling the [MEDICATION(S)] Discus. On 4/27/22 at 10:59 AM, LPN #1 stated she did not ask Resident #38 to rinse her mouth after taking the [MEDICATION(S)] Discus. LPN #1 stated she should have told Resident #38 to rinse her mouth with water and spit it out. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 40 medications (5%) which affected 2 of 7 residents (#31 and #38) whose medication administration was observed during the medication pass. This failed practice placed residents at risk of not receiving medications as ordered by their physician and the potential for harm when Resident #31 received doses in excess of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The Nursing 2019 Drug Handbook stated the eight rights of medication administration were right drug, right patient, right dose, right time, right route, right reason, right response, and right documentation. 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/22 at 8:04 AM, LPN #1 administered two sprays of [MEDICATION(S)] nasal spray to each of Resident #31's left nostril and right nostril. On 4/27/22 at 8:13 AM, LPN #1 was asked how many [MEDICATION(S)] sprays Resident #31 should receive in each nostril. LPN #1 reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated she thought it was two nasal sprays in each nostril because Resident #31 always wanted to receive two nasal sprays in his nostril. 2. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 1/22/22, documented Resident #38 was to receive insulin [MEDICATION(S)] Solution (fast-acting insulin) 55 units before meals for diabetes. On 4/27/22 at 9:43 AM, LPN #1 administered 55 units of insulin [MEDICATION(S)] to Resident #38's right abdomen. On 4/27/22 at 10:59 AM, LPN #1 was asked when Resident #38 should receive her insulin [MEDICATION(S)]. LPN #1 reviewed Resident #38's insulin order and stated Resident #38's insulin [MEDICATION(S)] should be given before her meals. When asked if she administered Resident #38's insulin [MEDICATION(S)] before her meals, LPN #1 stated she did not. On 4/27/22 at 11:29 AM, Resident #38 stated she had her breakfast at about 8:45 AM, approximately 1 hour before her insulin was administered. Resident #38's insulin [MEDICATION(S)] was not given before her meal as ordered by the physician.

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to provide a safe and sanitary environment. These failures created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. The facility's policy for screening contractors, dated 5/7/20, documented, All visitors, vendors, and contractors will be screened for COVID-19 symptoms in accordance with current CDC, CMS, and local and state guidelines. This screening will include a temperature check. On 7/1/20 at 11:05 AM, CDM #1 stated the dietary employees worked for the ALF and the facility had a contract with them to provide services. On 7/1/20 at 11:30 AM, CDM #2 stated the dietary employees were screened at the front desk at the ALF. CDM #2 stated the dietary employees were responsible for delivering the food carts to the skilled nursing facility, bussing the dining room for residents who needed assistance, and delivering the snack cart. On 7/1/20 at 4:45 PM, CDM #2 and the DNS stated they collaborated with the ALF on the screening process which included temperature checks. CDM #2 stated when a dietary employee answered yes to any of the questions on the screening log or had a temperature greater than 99.0 degrees Fahrenheit, the administration of the ALF assessed the dietary employee and sent them to the doctor to get tested for COVID-19. The DNS stated CDM #2 notified her when a dietary employee called in sick, was tested for COVID-19, and for results of the COVID-19 test. The DNS stated she did not review the screening logs for the dietary employees. The DNS stated the dietary employees were not screened when they entered the skilled nursing facility. 2. Chapter 4 of the facility's Guide to Infection Prevention and Control Manual for COVID-19, revised 6/25/20, stated HCP should wear a facemask at all times while they are in the healthcare facility. A memo to All Associates of Bridgeview Estates, dated 5/22/20, stated As of March 2020, Bridgeview has always required all Associates to wear masks. On 7/1/20 at 12:16 PM, Dietary Aide #1 entered the facility pushing a lunch cart and was not wearing a mask. After the cart was delivered to the front of the Sawtooth Hall, Dietary Aide #2 was asked where she came from and why she was not wearing a mask. She answered The kitchen. She did not answer any other questions asked by the surveyor and left the facility.

Based on record review and staff interview, it was determined the facility failed to coordinate care to prevent the development of an avoidable pressure ulcer. This was true for 1 of 2 residents (Resident #29) who were reviewed for pressure ulcers. Staff failed to follow physician orders [REDACTED]. This resulted in harm for Resident #29 when they developed a pressure ulcer which required skin grafting and a lengthy healing period. Findings include: Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #29's hospital discharge summary, dated 7/4/18, documented Upon arrival at new facility: Encourage up in Chair every 4-6 hrs (hours) or 3 times daily. Non-weight bearing right lower extremity. Work on bed to chair transfers. Remove brace for physical therapy. Resident #29's (MONTH) (YEAR) MAR indicated [REDACTED]. Encourage up in chair every 4-6 hours or 3 times daily. Work on bed to chair transfers; remove brace for physical therapy. The MAR indicated [REDACTED]. Review of Resident #29's TAR, dated 7/4/18 through 7/20/18, did not include documentation her skin was monitored around and under the RLE brace. Resident #29's Physical Therapy Evaluation and Plan of Treatment, dated 7/5/18 through 7/26/18, identified the following precautions/contraindications: non-weight bearing of the right lower extremity, fall risk, and knee immobilizer on at all times. A telephone order, dated 7/19/18 at 1:00 PM, documented Resident #29 had a consultation with a wound care nurse for right lateral (outer) ankle decubitus ulcer. The order included discontinuing the knee immobilizer. A Nursing Progress Note, dated 7/20/18, documented Resident #29 was seen at the orthopedic physician's office and a 7 cm (centimeter) by 4 cm unstageable wound (unable to see the bed of the wound), was identified on the posterior calf related to the leg brace. Resident #29's Treatment Record, dated 7/20/18, documented wound care orders were initiated. Resident #29's Wound Clinic physician progress notes [REDACTED]. The wound bed was 100% non-viable tissue. Debridement (removal of unhealthy tissue) is needed, but the tissue was too adherent for sharps debridement today. The wound measured 4.0 cm x 3.5 cm x 0.1 cm. Resident #29's Nursing Progress Note, dated 9/4/18, documented Resident continues with mechanical injury to right posterior calf from a brace that continues to be unstageable, wound bed measures 5.5 cm x 3 cm x <0.5 cm. White tendon present in middle of wound bed. Slight odor noted. Resident is followed by (physician name) for wound orders to RLE. Procedure for right leg debridement and [DEVICE] placement are scheduled on 9/20/18. A Nursing Progress Note, dated 9/28/18, documented a [DEVICE] to Resident #29's right posterior calf was changed on that day per physician orders. The wound was surgically debrided and measured 5.0 cm x 2.5 cm x 0.5 cm. A hospital operative note, dated 10/18/18, documented Resident #29 had a skin graft (a procedure to remove skin from her right thigh and suture it onto the wound). Tissue that measured 5.0 cm x 5.0 cm was removed from her right thigh and sutured on top of the wound on her RLE. Resident #29's (MONTH) (YEAR) Treatment Record documented the wound resolved on 11/20/18. On 11/29/18 at 9:38 AM, the DON said if a resident had a non-removable device the nurse should check the skin around the area of the brace and document on the TAR every shift. On 11/29/18 at 3:18 PM, the Director of Therapy confirmed she did not reference the admission orders [REDACTED]. The Director of Therapy said the nurse who noted the therapy orders did not communicate the brace was to be off during therapy and it was not her practice to check physician orders. The Director of Therapy said Resident #29 had a RLE brace and received therapy 6 days a week from 7/4/18 through 7/19/18, but the therapy department did not remove the brace. On 11/30/18 at 10:08 AM, the DON said the admission nurse failed to communicate to therapy the physician order [REDACTED]. The DON did not provide a facility policy for skin checks under a brace or device. On 11/30/18 at 8:54 AM, LPN #3 stated, When I took care of the resident the brace was not supposed to come off. LPN #3 said if skin checks were done they would be documented on the weekly skin sheet.

Based on observation, staff interview, and record review, it was determined the facility failed to prevent the deveopment of a pressure ulcer for 1 of 24 sampled residents (Resident #1). This failure resulted in harm when a resident developed an unstageable pressure ulcer to his right heel. Findings included: Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses, including Diabetes Mellitus and aftercare for repair of a left [MEDICAL CONDITION]. On 7/18/15, a Foot Risk Assessment form, which instructed the assessor to examine both feet without shoes, documented both of Resident #1's heels were soft, without discoloration, and no sores present. Blanchable redness was noted to the right great toe. The form documented the resident's heels were floated. The back of the form depicted a front and back body diagram with a notation of 1-plus [MEDICAL CONDITION] to the right lower extremity. Resident #1's Risk for Pressure Ulcers care plan, initaited 3/4/13, documented interventions of avoiding prolonged periods of skin-to-skin contact, encouraging the resident to use the trapeze over his bed to assist with repositioning, and encouraging the resident to float heels while in bed. The care plan also documented the use of a pressure reduction mattress. A new pressure ulcer care plan intervention, added on 7/18/15, was a warning the resident could bruise spontaneously from aspirin use. There was no documentation on the care plan regarding post surgery and readmission floating of the resident's heels or that the trapeze had been re-evaluated as an appropriate means of repositioning without causing the resident to experience additional friction, shear, or pressure to his heels. On 7/19/15 at 12:28 pm, a NN documented the resident used a wheelchair for mobility and his skin was warm and dry, with blanchable redness noted to the right great toe. At 1:29 pm, a NN documented the resident had been in bed all day and his heels heels were soft with 1-plus [MEDICAL CONDITION] to the right leg. On 7/20/14 at 12:39 am, a NN documented the resident required 2-3 person maximum assistance for transfers, used a wheelchair for mobility, and had been up to take his evening meal in the dining room. He had trace [MEDICAL CONDITION] noted in his right leg, and had worked with therapy that day. At 2:29 am, his skin was noted to be pink, warm, and dry. At 2:20 pm, his extremities were noted as dry and warm to the touch. On 7/20/15 at 11:04 pm, a NN documented the resident had spent most of the day in bed. On 7/21/15 at 3:43 am, a NN documented the resident was noted with skin that was pink, warm, dry, and with no [MEDICAL CONDITION]. At 2:53 pm, compression stockings were applied to the resident's lower extremities. He had worked with therapy. On 7/21/15, a physician's progress note documented the resident had no sores, rashes, or [MEDICAL CONDITION]. On 7/22/15 at 12:34 am, a NN documentd the resident required 2-person extensive assistance with bed mobility and transfers. His skin was noted as pink, warm, and dry. At 2:38 pm, the resident was noted to have 1-plus [MEDICAL CONDITION] to his lower extremities, with compression stockings in place. The resident was documented as using a wheelchair for mobility, but required someone to propel him to his destination. On 7/22/15 at 11:26 pm, a NN documented the resident's skin was warm to the touch and, While staff was helping resident to bed staff noticed a blister-like area to right heel. The resident was noted with 2-plus [MEDICAL CONDITION] to the right lower extremity. A 7/22/15 PUSR, untimed, documented Resident #1 had an unstageable pressure ulcer to his right heel, 8 cm long X 12 cm wide. The form documented the area was first observed on 7/22/15 and was present on admit with no further explanation documented. On 7/23/15 at 4:39 PM, a Wound Note entry in Resident #1's NN documented, Blister found to right posterior/plantar heel. Blister is fluid filled but does have some areas where blood is visible which would make it an SDTI. Redness with warmth surrounding the blister . The note documented wound treatments were initiated and Sage boots were applied and were to be worn at all times. The resident's care plan was updated at that time to reflect the use of Prafo boots at all times. On 7/25/15, Resident #1's Change of Condition MDS coded the resident was unable to participate in a cognitive assessment interview, but needed assistance with decisions in new or unfamiliar situations; required externsive assist of two staff for bed mobility and transfers; did not ambulate; relied on staff assistance for mobility in a wheelchair; experienced occasional pain as high as 7/10 on a 10-point pain scale; did not receive routine pain control, but used as needed medications; and had one unstageable pressure ulcer with SDTI in evolution, which was not present on admission. On 7/25/15, Resident #1's Pressure Ulcer CAA documented the resident developed a facility-acquired SDTI. On 7/27/15, the Pressure Ulcer Status Record documented the blister had deroofed. On 8/5/15 at 10:45 am, a Wound Note documented the blister had deroofed, extra skin had debrieded off, and, The wound bed appears superficial and red/pink but does have a few dispersed areas that are dark. The PUSR documented the wound was unstageable, and the appearance of the wound was granular. On 8/12/15 at 4:06 pm, a Wound Note documented the wound bed appears superficial and is red with some areas that are dark. The PUSR documented the wound was unstageable, and the appearance of the wound as granular. On 8/18/15 at 1:52 pm, a Wound Note documented, The blister de-roofed leaving an open wound . The wound is now red with some yellow areas in the place of dark areas. All areas appear superficial at this time, but depth is unknown . The wound was SDTI and is unstageable . The PUSR documented the appearance of the wound as both granular and exhibiting slough. On 8/19/15 at 11:23 pm, a NN documented the resident reported pain to his right heel/foot approximately every 4 to 5 hours, and requested medication for relief. On 8/25/15 at 1:27 pm, a Wound Note documented the slough in the wound bed was softening and decreasing. The PUSR documented the appearance of the wound as both granular and with slough. On 12/1/15 at 4:09 pm, the resident's right heel pressure ulcer was observed during a dressing change with the WCN. The WCN assessed the wound as 3cm X 1cm with no measurable depth. On 12/3/15 at 8:45 am, RCM #11 said she was unsure if the resident developed a pressure ulcer before his admission to the facility on [DATE]. After reviewing the Foot Risk Assessment form for that date, the RCM said the assessment documented the resident did not have a pressure ulcer present upon admission. She said the resident should have had a comprehensive skin assessment upon admission, and another skin assessment 24 hours later. RCM #11 stated the second skin assessment was not signed, and she could not see where the resident's heels were assessed again until 7/22/15. She said the interventions in place when the resident was admitted included a trapeze and a pressure relieving mattress. The RCM stated she recalled the resident had been transferred with a 2-person stand pivot assist to his wheelchair many times between 7/18/15 and 7/22/15. The RCM stated the resident was using foot pedals in his wheelchair to support his lower extremities while in the wheelchair. The RCM stated the resident had been wearing compression stockings and slipper socks, but no further measures were in place to protect his heels after readmission to the facility. The RCM stated the compression stockings would help with the resident's [MEDICAL CONDITION], but if there was indication that the resident was developing a pressure ulcer the compression stockings would further increase the risk. The RCM reviewed the NN from 7/18/15 through 7/22/15, and stated the nurses likely did not remove the residents socks when assessing his skin, before documenting the skin was pink, warm, and dry, and would not have necessarily noticed whether an SDTI was present. The RCM indicated there should have been more interventions at the time of admission. On 12/3/15, the facility provided the manufacturer's specifications for the resident's mattress, which was identified as pressure redistributing foam surface, but not a pressure relieving surface. On 12/3/15 at 10:25 am, the WCN said she did not know what interventions were in place between 7/18/15 and 7/22/15, aside from the resident being encouraged to float his heels in bed. She did not know what interventions were in place to protect the resident's heels during transfers, or when he was sitting with his feet on the wheelchair foot pedals during that timeframe. The WCN said the application of Sage boots did not occur until after the pressure ulcer was identified on 7/22/15. The WCN indicated the intervention of floating heels was a standard intervention for all residents, and not necessarily an individualized intervention for Resident #1.

Based on observation, interview and record review, it was determined the facility failed to adequately supervise and assist residents to prevent falls and injury. This was true for 2 of 24 sampled residents (#1 and #6). This failed practice resulted in harm when Resident #1 fell and sustained a left hip fracture requiring surgical repair. Resident #6 was at risk for more than minimal harm when he/she was transferred in a manner inconsistent with the comprehensive assessment and care plan. Findings included: 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses, including lower extremity weakness, chronic vertigo, hypertension, and fracture. The resident's Annual MDS assessment, dated 6/16/15, documented the resident was cognitively intact; required limited assistance of one staff for toileting and transfers; had not ambulated in his room for the previous 7 days; required limited assistance of one staff to ambulate in the corridor; and required balance assistance when moving from a seated- to a standing position, walking, or turning. Mild cognitive impairment was also noted in a 5/15/15 physician's progress note. An 11/7/14 Incident/Accident Report documented Resident #1 fell at 1:05 pm while attempting to go to the bathroom. No new interventions were added to the resident's care plan at that time regarding changes in the resident's toileting cares or level of assistance provided. A physician progress notes [REDACTED]. A 6/1/15 a physician's orders [REDACTED]. On 6/5/15, a Berg Balance Scale documented the resident was at high risk for falls. A Fall Risk Evaluation, and a second Berg Balance Scale, dated 6/16/15, documented the resident remained at high risk for falls. On 6/19/15, a Rehabilitation Services Multidisciplinary Screening Tool documented the resident had experienced two episodes of incontinence. The form documented the resident said he was having increased difficulty controlling his bowel and bladder. The form documented the resident was to have a urinal placed close to him, but the resident's care plan was not updated with this information. On 7/1/15, a PT progress note documented the resident continues to demonstrate significant balance deficits and is at risk for falling according to all the outcome measures. On 7/10/15, PT documented the resident refused ambulation due to lower extremity weakness and concern with his left knee buckling. On 7/13/15 at 12:34 pm, PT documented the resident had a Berg evaluation which showed some improvement in standing balance, however the resident's score indicated he continued to be at risk for falls. A 7/13/15 Incident/Accident Report documented Resident #1 fell at 2:45 pm, when he stood up from bed to void, could not find his urinal, and was attempting to urinate into a pink basin. The I/A Report documented Resident #1 lost his balance when he stood up resulting in falling to the floor landing on his left side. According to the Report, Resident #1 was to be toileted every two hours, but was last toileted at noon. The Report did not document where the urinal was located at the time of the fall. The resident complained of pain to his left hip that was 10 out of 10 on a 10-point pain scale. Nursing Progress notes from 7/13/15 to 7/15/15 documented the resident continued to complain of left hip pain prior to being transferred to a hospital and diagnosed with [REDACTED]. On 12/1/15 at 4:09 pm, the wound care nurse and surveyor entered Resident #1's room. The resident reported he was incontinent of urine, which had run down my leg. The resident's pants were observed to be wet with urine. The wound care nurse and CNA #20 assisted the resident to the bathroom, removed his pants, provided peri-care, and changed his adult brief. The resident's urinal was at his bedside during the observation. On 12/3/15 at 3:45 pm, RCM #1 said Resident #1 preferred to have his urinal on his bedside table, as it was important to him to take care of his personal needs as independently as possible. She was aware of the rehab recommendation from 6/19/15 to place the urinal at bedside, but did not know why that intervention had not been added to the care plan. She stated for infection control purposes, the urinal typically sat in a large pink basin, rather than directly on the table surface. She said at the time of the fall the resident should have been toileted every two hours because he was not able to toilet independent of staff assistance. On the day of the fall, the RCM stated, the urinal had been taken to the bathroom to be rinsed out, but was not returned to the bedside. When the resident needed the urinal and could not find it, he tried to stand and maneuver to urinate into the pink basin where the urinal usually sat, lost his balance, and fell . 2. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The current ADL Care Plan documented the resident required extensive- to total assistance of 1-2 staff for ADLs and a mechanical lift with 2 staff assisting for transfers. Resident #6's Quarterly MDS, dated [DATE], documented the resident was cognitively intact, had bilateral upper and lower extremity impairment, and required the total assistance of two staff for transfers. On 12/1/15 at 4:40 pm, CNAs #17 and #18 were observed transferring Resident #6 from a Broda chair without the use of a mechanical Hoyer lift; LN #8 was present during the transfer. Each CNA supported the resident under either arm, instructed the resident to help, lifted her to a standing position, and quickly pivoted her onto the bed. The resident was not provided with a gait belt during the transfer. LN #8 asked the two CNAs why the resident did not have a gait belt on during the transfer and explained the gait belt was needed for safety with Resident #6. CNA #18 stated she had a gait belt with her, but had failed to place the belt on the resident. On 12/3/15 at 9:20 am, RCM #11 stated the resident was extremely weak upon admission to the facility and required the mechanical lift for transfers. RCM #11 said the resident was recently assessed by Physical Therapy and was determined to be capable of helping with transfers with the assistance of one-to-two staff. The RCM stated the facility's transfer policy required 1-to-2 staff and use of a gait belt.

Based on a complaint from the general public, review of a fax transmittal fall investigation report sent by the facility to the BFS and received by the BFS on 2/13/12, review of the facility's Incident Management Process Policy and Procedures Manual, Invacare Manual/Electric Portable Patient Lift Manual which acted as the facility policy/procedure for use of the mechanical lift, Incident/Accident Data Entry Questionnaire (referred to by the facility as IDA), review of Resident #1's hospital records dated 2/4/12 to 2/6/12 and Resident #1's ER record from 2/10/12, staff interviews, and facility record review, it was determined the facility failed to perform thorough and timely nursing assessments of residents who fell in the facility. This involved 3 of 6 residents (#s 1, 2, and 6) reviewed for assessments after falls in the facility. Resident #1 was harmed when the facility failed to perform a thorough and timely nursing assessment of her skin, musculoskeletal and neurological systems after she was dropped from the mechanical lift on 2/4/12. The resident fractured her second lumbar vertebrae which required surgical intervention. In addition, a comminuted [MEDICAL CONDITION]'s right proximal humerus was found on x-ray 5 days after the resident was dropped from the mechanical lift which was attributed to the drop from the mechanical lift. Facility staff failed to identify that the resident hit her right shoulder when she fell , failed to assess the right shoulder for injury and subsequently the right shoulder fracture was not identified for 5 days. In addition, this failed practice resulted in the potential for harm to Resident #s 2 & 6. The lack of thorough and timely assessments created the potential that significant changes in residents' physical conditions would not be treated. Findings included: The Bureau of Facility Standards received a complaint on 02-10-2012. The complainant stated: * The identified resident fell from hoyer sling to the floor. * The facility reported the sling on the mechanical lift was "hooked up wrong" and it slid off the frame during transfer. * The identified resident complained of arm and back pain for 24 hours and was sent to the hospital for evaluation. X-rays showed a fractured spinal vertebrae which was surgically repaired. The resident returned to the facility the next day. * The resident continued to complain of arm pain and the facility reportedly called the doctor for an x-ray order. * The resident returned to the hospital for the x-ray of the arm and a fracture was discovered. The resident returned to the facility without treatment, no pain medication, sling or other intervention to wait until the doctor could see the resident in the office today (the day the complaint was received). On 2/13/12, the BFS received a fax transmittal, dated 2/12/12 on the fax cover sheet, from the facility's DON. In addition to the cover sheet, the faxed information consisted of a one page document dated "February 12, 2012", and recorded, in part: * "Re: resident falling out of hoyer resulting in compression fracture of L2 and fracture to right humerus * Date of incident: 02/04/12 * Resident: (Resident #1's name, date of birth, and social security number) * Staff member: (LPN/CNA #1's name, date of birth, and social security number) * On 2/4/12 at approximately 4:30 pm, (LPN/CNA #1's name, LPN) and (CNA #2) were transferring (Resident #1) from her bed to the wheelchair using the hoyer lift per plan of care. (CNA #2) had placed the two straps on the top of the hoyer sling to the hoyer itself and (LPN/CNA #1) had placed the bottom two straps to the hoyer. They then lifted her up off the bed with the hoyer. They then backed the hoyer out from under the bed and turned her towards the wheelchair. (CNA #2) went to put the wheelchair in the appropriate place, when the bottom left strap came undone on the hoyer causing (Resident #1) to slide out of the hoyer. She was approximately 3 feet off the ground and landed on the left leg of the hoyer. She did complain of immediate pain to her back. EMS (Emergency Medical Services) was summoned and she was sent to the emergency room . Upon arrival she was found to have a compression fracture of L2 and a vertebroplasty was done on 2/5/12. She returned to the facility on [DATE]. ...Of note, (Resident #1) did start complaining of pain to right arm on 2/9/12. We were able to get her in for a x-ray of right arm on 2/10/12 and she was found to have a [MEDICAL CONDITION] humerus, which was felt to have been caused from the initial fall from the hoyer. She was seen by her primary MD (physician) as well as an orthopedic surgeon and no surgery was needed for this. They did place her in a sling and will have therapy work on range of motion." Perry & Potter in Fundamentals of Nursing, 7th edition, states: * page 562, "...Record assessments in specific terms on a physical assessment form or in the nurses' notes." * page 560, "...Throughout the examination, recognize that with advancing age the body does not respond vigorously to injury or disease. Therefore older persons do not always exhibit the expected signs and symptoms. Characteristically, older adults present more [MEDICATION NAME] or atypical signs and symptoms." Perry & Potter in Clinical Nursing Skills & Techniques, 7th Edition, states: * page 157, "The nurse uses the skills of inspection and palpation during the musculoskeletal and neurological assessments. ...A more thorough assessment of major bone, joint, and muscle groups and the nervous system is indicated in the presence of abnormalities or as required by patient's condition." * page 165, Table 6-12, documented Assessing Range of Motion (ROM), either done actively by the patient or passively by the nurse, as putting upper and lower extremities through directional movements including, flexion, extension, rotation, abduction, adduction, and pronation. According to Mosby's Textbook for Nursing Assistants, 6th Edition, page 496, under the section, "The Falling Person," states, "...Do not let the person move or get up before the nurse checks for injuries. Calmly explain that the nurse will check for injuries such as broken bones." The survey team reviewed the faxed fall investigation report from the facility regarding Resident #1 before the team entered the facility on 2/14/12 at 9:00 am. In addition, the survey team obtained Resident #1's hospital records which included ER records and inpatient records which included x-ray reports and orthopedic consultation reports. The survey team also reviewed these documents prior to entering the facility. The facility's Resident Incident Report policy and procedure documented, under Procedure, "2. The charge nurse is responsible for completing and documenting the initial assessment, offering prompt medical attention as needed..." The facility's Neurological Assessment policy documented: * "Flow Sheet and Assessments - The Neurological Assessment Flow Sheet (NAFS) shall be initiated by a written physician's orders [REDACTED]." Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 2/1/12, coded: * BIMS score of 11 indicating moderately impaired cognitive skills for daily decision making * Extensive assistance of 2 or more persons required for bed mobility, transfer, dressing, toilet use, and personal hygiene * Functional limitation in upper and lower extremity on one side Resident #1's physician's orders [REDACTED]. Resident #1's Weekly Skin Integrity Data Collection form documented skin was intact with redness "under pannis" on "2/3/2 (sic)". NOTE: There were no other documented skin assessments after this date. An Incident/Accident Data Entry Questionnaire form (IDA), dated 2/4/12 at 4:30 pm and completed by RN #3, documented Resident #1 had a fall. The form documented, in part: - "Injury Description * Type of Injury ... Other * Body Part(s) affected... Back * Was outside care needed to treat and/or diagnose this injury? Yes - Incident * Full Description of Incident/Accident At 1630 (4:30 pm), aides came to nurse and notified me that resident was being transferred from bed to wheelchair. Hoyer strap slipped off of hoyer hook on front left side and resident slid off of hoyer pad onto floor and resident landed on her butt. Aides got her off floor and into wheelchair. They stated that resident did not hit her head. Resident rated pain at a '10' on scale 0 to 10 in low back L 3-L 4 area. Offered PRN APAP (as needed [MEDICATION NAME]) and [MEDICATION NAME], resident stated she did not want [MEDICATION NAME] and accepted PRN APAP for pain management. Sent to ER for Evaluation at 1900 (7:00 pm) via non-emergent ambulance. * Person who discovered Incident... (LPN/CNA #1's name and title-LPN were documented). * What Resident Assistive Device was in use at the time of the incident? Transfer lift * ...Describe the Resident's Intensity of Pain after the incident. (using the pain scale) 7-10 * ...Was first aid administered at the facility? Yes * Type of first aid provided - Pain assessment, Assessment of extremities, Vital signs, Neurological assessment. * Who provided the first aid? Nurse * Date first aid was provided - 2/4/12 * Time first aid was provided - 4:30 pm * What type of outside care was utilized? Hospital Emergency Department * Date taken to the ER...? 2/4/12 * Time taken to the ER...? 1900" * Resident #1 was alert, but forgetful before and after the fall. * The resident's vital signs after the fall were recorded as temperature of 97.6, pulse 70, respirations 16, blood pressure 124/62. * The resident's family was notified of the fall on 2/4/12 at 5:00 pm and the resident's doctor was notified of the fall on 2/4/12 at 6:00 pm. - "Investigation * What position was the Resident in when you found them? Resident was in wheelchair when nurse went to assess her." * Documented there was no loss of consciousness and that "neuro-checks" were "completed per protocol." * The "interventions in place at the time of the Incident" were "2 person staff present during hoyer lift. * "What interventions are in place now? Education about ensuring hoyer straps are securely around hoyer hooks before making the transfer." NOTE: On 2/4/12, a facility staff CNA called in that he/she would not be able to work the evening shift on 2/4/12. LPN/CNA #1 worked on 2/4/12 on the day shift as an LPN and on the evening shift as the replacement CNA. In the IDA report above and the witness statements below, she identifies herself as an LPN, but CNA #2 and RN #3 refer to her as an "aide." RN #3 was the charge nurse on the evening shift when Resident #1's fall occurred on 2/4/12 and was responsible for Resident #1. The staff schedule sheet, provided by the DON on 2/14/12 at 11:00 am, documented LPN/CNA #1's name was hand written in the "CNA" section for evening shift on 2/4/12. RN #3 was identified on the schedule as the "Licensed Nurse" responsible for "charting" and "supervision of staff" including LPN/CNA #1 and CNA #2. Three witness statements were attached to the IDA report and documented, in part: * LPN/CNA #1 documented she filled out the Witness Statement Form on 2/5/12 at 12:45 pm. She listed her title as "LPN." The date and time of the incident was recorded as "2/4/12" at "1630." NOTE: LPN/CNA #1 documented her witness statement approximately 20 hours after the incident occurred. The section under, "The following is a statement of the facts as reported by the above named witness" was handwritten, signed by LPN/CNA #1, and read, "We were hoyering Res(ident #1) in Rm (#) around 4:30 pm. Res was up in the air, as we were moving from over bed to wheelchair. Bottom left loop came off of hoyer lift. The sudden shift in wieght (sic) made hoyer swing and Res slid out of hoyer landing on hoyer leg. Her bottom hit first and hard. Res did not hit head. Res tried to laugh it off. Stating 'dont (sic) worry ill (sic-I'll) be fine.' After about 10-20 min(utes) Res could no longer sit in chair and asked to lay down. Res(ident) complained of pain in lower back. POA was called he okayed for her to be sent to ER (sic). I do believe this accident was operator error. And the bottom left hook was not on hoyer hook all the way. I hooked all four loops on but apparently did not apply the last one very well." (Please refer to F323) NOTE: The faxed investigation report from the DON stated, "(CNA #2) had placed the two straps on the top of the hoyer sling to the hoyer itself and (LPN/CNA #1) had placed the bottom two straps to the hoyer." * CNA #2 documented she filled out the Witness Statement Form on "2/4/2012" at "7:00 pm." She listed her title as "CNA." The date and time of the incident was documented as "2/4/2012" at "4:30 pm." The section under, "The following is a statement of the facts as reported by the above named witness" was handwritten, signed by CNA #2, dated "Feb. (February) 4, 2012," and read, "Resident was being lifted by hoyer by other aid (sic). I turned to retrieve her wheelchair, & the side of the strap to hoyer came loose & it was a control slip to the floor. Prior to that I was providing oral care on other resident in room while aid (sic) was providing peri-care (perineal care) on resident (Resident #1) and appling (sic) hoyer pad. I entered that side of room as she was being lifted to retrieve chair." NOTE: The faxed investigation report from the DON stated, "(CNA #2) had placed the two straps on the top of the hoyer sling to the hoyer itself and (LPN/CNA #1) had placed the bottom two straps to the hoyer." * RN #3 documented she filled out the Witness Statement Form on "2/4/12" at "2130" (9:30 pm). She listed her title as "RN." The date and time of the incident was documented as "2/4/12" at "1630." The section under, "The following is a statement of the facts as reported by the above named witness" was handwritten, without a signature, and read, "At 1630, aides (LPN/CNA #1 and CNA #2's names) came to me and notified me that the resident was being transferred from bed to wheelchair. Hoyer strap slipped off of hook on front left side and resident slid off of hoyer pad onto floor and resident landed on her butt. Aides got her off floor and into w/c. They stated that resident did not hit her head. Resident rated pain at '10' on score of 0/10 in low back L3-L4 area. Offered APAP and [MEDICATION NAME], resident stated she did not want [MEDICATION NAME] and accepted PRN APAP for pain management. Sent to ER for evaluation at 1900 in a non-emergent ambulance." NOTE: The faxed investigation report from the facility's DON to the BFS documented, "We were able to get her in for a x-ray of right arm on 2/10/12 and she was found to have a [MEDICAL CONDITION] humerus, which was felt to have been caused from the initial fall from the hoyer." RN #3's witness statement, however, did not document that she performed a musculoskeletal assessment, including passive and/or active ROM and palpation of the resident's upper extremities, when the resident had [MEDICAL CONDITION] of the right dominant side. Resident #1's Nurse's Notes contained an entry, dated "2/4/12 (2300) (11:00 pm)" and signed by RN #3 which described the fall, in part, "Resident alert this shift. Zero ASE d/t (no adverse side effects due to decrease) in [MEDICATION NAME]. Zero s/s of depression. Bruise continues to heal in L(left) arm. At 1630, aides came to me and notified me that the resident was being transferred from bed to wheelchair. Hoyer strap slipped off of hook on front, left side and resident slid off of hoyer pad onto floor, and resident landed on her butt. Aides got her off floor and into w/c. They stated that resident did not hit her head. Resident rated pain at '10' on scale of 0/10 in low back, L3-L4 area. Offered APAP and [MEDICATION NAME] to resident for pain management, and resident stated she did not want [MEDICATION NAME] and accepted PRN APAP for pain management. Sent to ER for evaluation at 1900 via non-emergent ambulance. Vital signs were stable upon assessment of resident. She was in her wheel chair at the time of the assessment. She was not having symptoms of peripheralization in legs. Called multiple times to ER to receive update on resident. ER did not answer phone and eve(ning) shift ended. Nursing will continue to monitor situation." NOTE: On the morning of 2/15/12, the DON provided a document which explained the term "peripheralization" used in the nursing documentation above. The document was from the University of Scranton-Department of Physical Therapy titled, "PT351 Orthopaedic PT Centralization and Peripheralization." The documented recorded, "Peripheralization means pain moves laterally away from the center of the spine and/or down the extremity." An interview with PT #8, on 2/16/12 at 8:45 am, confirmed peripheralization was a term used to describe pain [MEDICAL CONDITION] down the lower extremity. RN #3's nursing notes identified she took vital signs, checked for pain and determined the resident was alert. There was no documentation that RN #3 performed other physical assessments such as an assessment of the resident' skin, ROM or neurological assessment which included pupillary, motor, and sensory responses. In addition, Resident #1 had been moved prior to the assessment by RN #3. Another nursing note entry, on 2/5/12 at 3:00 am, documented, "Resident admitted to surgical unit at hospital." NOTE: During the three separate staff interviews recorded below, both surveyors took notes to document the statements made as each staff member described Resident #1's fall from the mechanical lift. *LPN/CNA #1 On 2/14/12 at 12:42 pm, LPN/CNA #1 was interviewed regarding Resident #1's fall from the mechanical lift on 2/4/12. She stated she worked the first 8 hours that day in the facility as a nurse and after finishing her nursing duties, she "hit the floor at 1600 (4:00 pm)" and worked as a CNA. LPN/CNA #1 was shown a diagram on the cover of the facility's Invacare Manual/Electric Portable Patient Lift Manual. NOTE: On 2/14/12 at 10:50 am, the DON provided the Invacare manufacture's operating manual for the mechanical lift used for Resident #1. The lift had a central vertical bar positioned on a horizontal base. Two horizontal bars with wheels extend from each end of the base, one on the left side of the base and one on the right side of the base. These horizontal bars can be adjusted by the operator to increase the distance between them to provide a larger base of support when a resident was lifted. LPN/CNA #1 used the diagram to point out Resident #1's position after she fell from the lift. LPN/CNA #1 pointed out that Resident #1's legs were positioned over one horizontal bar of the mechanical lift, her buttocks were on the floor and her shoulders were positioned on the other horizontal bar of the mechanical lift. LPN/CNA #1 stated, "I had (Resident #1) in the hoyer. I was lifting her up. I had her in the air. She slid out of the hoyer .."She hit pretty hard." LPN/CNA #1 also stated she asked, "(Resident #1) are you okay?" LPN/CNA #1 stated, "Her shoulders landed on hoyer leg. She said, 'Oh my back's sore.' We re-hoyered her into bed." LPN/CNA #1 stated that after the resident was in bed, the resident commented, "I'm fine, I'm an old lady." LPN/CNA #1 stated, "We re-hoyered her to the chair." The resident started complaining of back pain so she was returned to bed. LPN/CNA #1 was asked to describe the incident event as she recalled it. She stated she attached the bottom right and top right sling hooks, then she attached the top left and bottom left sling hooks. NOTE: The DON's investigative report was inconsistent with LPN/CNA #1's verbal statement that she alone attached the sling straps to the mechanical lift. LPN/CNA #1 was asked if CNA #2 checked the sling straps and hooks. "No...I asked (CNA #2) to get the wheelchair as I hoyered (Resident #1) up. Everything was attached. I moved her back. The bottom left hook came undone...She fell on her bottom. She slid off the pad onto the floor. Her shoulder hit the hoyer legs. Her butt hit the floor or hoyer leg. She was laying across the hoyer legs. Her shoulder hit after her butt...I lifted her shoulder off the hoyer and pillowed her head. That's where the initial pain was." LN/CNA #1 stated she, "did ROM while she (Resident #1) was on the floor...(CNA #2) and I rolled her toward the bed and placed the pad (sling) and hoyer and got her back in bed. She was incontinent, changed her bottoms." LN/CNA #1 stated she did not remove the resident's shirt. "When I touched her she said, 'Just sore all over.' I raised her right arm and she bent her left leg. There were no red marks on her back. She was hungry and wanted to get up in the wheelchair." LPN/CNA #1 stated, "(RN #3) and I checked her in bed. (RN #3) checked areas of her spine. She hurt in one area." LN/CNA #1 was asked if she recorded the assessment she had performed while the resident was on the floor. "I don't think I wrote out the assessment in the witness statement...(RN #3) wrote out the report as the LN as I was technically a CNA." She was asked if the facility used a form to document physical assessments performed after falls. She stated, "We fill out the IDA system." * CNA #2 CNA #2 was interviewed on 2/14/12 at 1:35 pm regarding Resident #1's fall from the mechanical lift. CNA #2 was shown the same diagram of the Invacare mechanical lift referenced above. She pointed to the diagram and stated the resident's hips were on one leg of the mechanical lift and her shoulders were on the other leg of the mechanical lift. CNA #2 was asked to give the details of the incident as she remembered. She stated that she was in Resident #1's room to perform cares for the roommate. LN/CNA #1 placed Resident #1 in the hoyer lift. "Everything looked good on the hoyer and straps. I heard a metal sound...The left bottom strap came off...It was a controlled slip to the floor. I placed a pillow for her head. The resident was laughing. We rolled her to the right, put the pad (sling) under her and got her back to bed...(LN/CNA #1) looked at the resident..no skin check (performed.) The resident wanted in her chair for dinner. We lifted her and put her in her chair per her request." CNA #2 was asked to describe the position Resident #1 landed after the fall. She stated, "Her hips were on the leg of the hoyer and her shoulder was on the other leg. I was worried about her shoulder. I placed the pillow. (LN/CNA#1) was checking the resident asking, 'are you okay? Wiggle your fingers, toes.' She checked her eyes, asked her her name, and repeatedly asked 'are you hurt'? (Resident #1) said, 'I'm fine get me off the floor.'..She says 'OW' to everything. You must watch her facial expressions. Her right arm is always in a sling except while in bed." CNA #2 also stated, "everything happened so quick." CNA #2 was asked if she and LN/CNA #1 used the same equipment to get the resident off the floor, to bed, then into the wheelchair. She stated, "We made sure the sling and strap were not torn before we re-used it." The CNA was asked if she checked Resident #1's straps and hooks. "The straps looked secured as I briefly looked up. I was trying to maneuver the large wheelchair." The CNA then stated, "Her whole body may have scuffed the bed as she went down." The CNA indicated she wrote a statement about the incident. * RN #3 On 2/14/12 at 2:00 pm, RN #3 was interviewed regarding Resident #1's fall from the mechanical lift. She stated she was the charge nurse on the evening of 2/4/12 and was responsible for Resident #1. RN #3 stated that on the evening of Resident #1's fall she was doing, "Med(ication) pass...The aides said that (Resident #1) fell out of the hoyer, that the front left strap came off. I asked them if she was okay, and they said, 'Yes.'" RN #3 also stated that shortly afterwards, "She (Resident #1) came wheeling out in the wheelchair." RN #3 indicated she was in the hallway at her medication cart. She stated, "I checked her back. She refused [MEDICATION NAME] and Tylenol. I checked her legs for numbness/tingling. I did not go into her room after she fell ...(LN/CNA #1) probably should have got me before getting her up, even though she's an LPN...They notified me after they got her up into the wheelchair." RN #3 was asked if LN/CNA #1 gave her a report of the incident. RN #3 stated, "(LN/CNA #1) described the fall, said she was not hurting...I started assessing her (Resident #1) and talked with her. I pulled her shirt up slightly to look at her lower back. I did range of motion to her lower extremities. There was no pain except her low back." The survey team asked RN #3 if she performed an upper body assessment. She responded, "No. I did neuro checks. It was a good day, she was more alert, not lethargic. I looked at her low back for bruising. I asked her if she wanted to go to the ER. She said 'No.' I gave her Tylenol." The RN stated the resident was then taken to the dining room for supper. "Then (LN/CNA #1) and I hoyered her to bed and looked at her bum." RN #3 was asked where she charted her post-fall assessment. She stated, "In my notes." The surveyor read the entry note, "Vital Signs stable upon assessment of Resident." The RN was informed that there was no documentation that she assessed the resident's range of motion, performed a neurological assessment or skin assessment. The RN stated, "I wonder if I recorded the assessment in IDA." The RN acknowledged that the IDA reports were not a part of residents' records. The RN stated, "I didn't chart it. I didn't chart those assessments. Absolutely normally I would have charted the assessment." RN #3 was asked if LN/CNA #1 and CNA #2 described the position of the resident immediately after she fell out of the hoyer sling. "They didn't tell me what direction she was lying, or next to the hoyer, or what position she was in. They told me she did not hit her head." The RN re-stated, "The CNAs are supposed to get an LN before (emphasis on word) moving a resident." RN #3 was shown the same diagram of the Invacare mechanical lift referenced above and asked to identify where the resident's body was positioned in relation to the mechanical lift. She was unable to identify on the diagram where the resident's body was positioned in relation to the mechanical lift. On 2/14/12 at 4:30 pm, the DON was interviewed regarding assessments performed by the LNs after Resident #1's fall. The DON was given Resident #1's record and was asked to help the surveyors find the documentation of the assessments. He replied, "I know there is nothing in the record. I already looked and there is nothing in the record." After Resident #1 was dropped approximately 3 feet onto the floor and legs of the mechanical lift, the facility failed to ensure that: * LNs performed a thorough ROM assessment on the upper and lower extremities by putting all joints both left and right through directional movements, either passively or actively, including flexion, extension, abduction, adduction, pronation, and rotation. According to the investigative report by the facility, Resident #1 "was found to have a [MEDICAL CONDITION] humerus, which was felt to have been caused from the initial fall from the hoyer." RN #3 stated she did not assess the resident's upper extremities and only assessed the resident's lower extremities while the resident was sitting in the wheelchair. LPN/CNA #1 stated she did ROM but there was no documented evidence of this assessment or the results of the assessment. * LNs performed a neurological assessment as defined in their policy and documented the results of their findings regarding pupillary response, sensory response, motor response, and limb response. RN #3 documented the resident was alert, not lethargic in the nursing notes. She documented in the incident report, which was not part of the permanent medical record, that a neurological assessment was performed. There was no documentation in the resident's record that a neurological assessment was performed or the results of that assessment. There was no NAFS in Resident #1's record. * LNs performed a comprehensive skin assessment for bruising, lacerations on the resident's entire body. RN #3 stated she assessed the resident's low back while the resident was in the wheelchair by slightly lifting up the resident's shirt. There was no documentation in the resident's record that this assessment was performed or documentation of the findings of the assessment. LPN/CNA #1 stated she provided incontinent care immediately after the fall, but did not remove the resident's shirt to examine the resident's upper body. There was no documentation of any skin assessment performed by LPN/CNA #1 or results of the assessment. The resident's Weekly Skin Integrity Data Collection form did not contain any documentation that any skin assessments were performed on or after 2/4/12. * LNs documented and shared information regarding the resident's position in relation to the mechanical lift and that the resident did not only fall onto her "butt" but landed with both of her legs over the left leg of the mechanical lift and her shoulders landed on the right leg of the mechanical lift. In addition, CNA #2 stated in the interview that the resident's "body may have scuffed the bed when she went down." RN #3 stated she did not assess the resident's upper extremities and only assessed the resident's lower extremities while the resident was sitting in the wheelchair. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 30-day MDS assessment, dated 1/11/12, coded: * BIMS score of 4 indicating severely impaired cognitive skills for daily decision making * Needs extensive assistance of one person for bed mobility, transfer, dressing, toilet use and personal hygiene The resident scored "22" on her Fall Risk Evaluation, dated 12/14/11, indicating she was a high risk for falls. Resident #6's Care Plan documented the problem, dated 1/2/12, "Resident...is at risk for fall..." An IDA investigation report, dated 1/13/12 at 5:15 am and completed by RN #5, documented in part: * "Preliminary - Type of Incident alleged - Fall * Injury Description - Type(s) of Injury... - Laceration - ...Body Part(s) affected...: Head (except face) - Was outside care needed to treat and/or diagnose this injury? Yes * Incident - ...Full Description of Incident/Accident: CNA heard residents (sic) roommate yelling. Rommate (sic) stated, 'I heard a thud.' CNA found resident sitting up next to bed with laceration to posterior skull. - Was incident witnessed? No - ...Activity at the time of the incident? Attempting to get out of bed - ...Type of first aid provided: cleansed site with NS (normal saline) and applied pressure till (sic) bleeding stopped. - Who provided the first aid? LN - Date first aid was provided: 1/13/12 - Time first aid was provided: 5:15 am - What type of outside care was utilized? Hospital Emergency Department - ...Time taken to the ER... 5:35 am - ...What immediate actions were taken to provide safety for the resident and/or others? Care planned tab alarms to bed. Sent to ER for eval(uation) r/t (related to) head injury. * Investigation -...Fall Category..: Found on floor with or w/o inj(ury) - Was fall Attended/Unattended: Unattended - What position was the Resident in when you found them? sitting up on the floor next to the bed. -...What fall reduction measures were in place at time of incident? Bed alarm -...What interventions were in place at the time of the incident? Bed pressure alarm - enabled - disfunctional (sic) - What interventions are in place now? Tab alarm initiated. Hip Protectors Initiated." NOTE: Prior to admission to the facility, Resident #5 had fractured her left hip which required surgical intervention . There was no documentation in t

Based on a complaint from the general public received by the BFS on 2/10/12, review of a fax transmittal fall investigation report sent by the facility to the BFS and received by the BFS on 2/13/12, review of the facility's Incident/Accident Data Entry Questionnaire (referred to by the facility as IDA), Invacare Manual/Electric Portable Patient Lift Manual which acted as the facility policy/procedure for use of the mechanical lift, review of Resident #1's hospital records dated 2/4/12 to 2/6/12 and Resident #1's ER record from 2/10/12, staff interviews, and facility record review, it was determined the facility failed to secure a mechanical lift (referred to as hoyer or hoyer lift in Resident #1's record and facility documentation) sling to the lift's frame prior to transferring Resident #1. This resulted in harm when Resident #1 was dropped from the lift sustaining a L2 fracture of the spine requiring surgical repair. A comminuted fracture of the resident's right proximal humerus was detected on x-ray 5 days after the resident fell from the mechanical lift which was attributed to the fall from the mechanical lift. In addition, Resident #6 was harmed when she fell from her bed to the floor, without the care planned mat at the bedside, and sustained a 4 centimeter (cm) laceration on the back of her head requiring transfer to the ER for suture repair of the laceration. This involved 2 of 6 residents (#s 1 and 6) reviewed for falls. Findings included: 1. The complainant stated: * The identified resident fell from hoyer sling to the floor. * The facility reported the sling on the mechanical lift was "hooked up wrong" and it slid off the frame during transfer. * The identified resident complained of arm and back pain for 24 hours and was sent to the hospital for evaluation. X-rays showed a fractured spinal vertebrae which was surgically repaired. The resident returned to the facility the next day. * The resident continued to complain of arm pain and the facility reportedly called the doctor for an x-ray order. * The resident returned to the hospital for the x-ray of the arm and a fracture was discovered. The resident returned to the facility without treatment, no pain medication, sling or other intervention to wait until the doctor could see the resident in the office today (the day the complaint was received). On 2/14/12 at 10:50 am, the DON provided the Invacare manufacture's operating manual for the mechanical lift used to transfer Resident #1. The DON stated that the Invacare manual acted as the facility policy/procedure for use of the mechanical lift. The manual documented, in part: * Using the Sling, page 14, "...Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode)." * Transferring the Patient, Warning Box, page 29, "...When the sling is a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur." Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 2/1/12, coded: * BIMS score of 11 indicating moderately impaired cognitive skills for daily decision making * Extensive assistance of 2 or more persons required for bed mobility, transfer, dressing, toilet use, and personal hygiene * Functional limitation in upper and lower extremity on one side Resident #1's physician's orders [REDACTED]. An IDA report, dated 2/4/12 at 4:30 pm and completed by RN #3, documented Resident #1 sustained a fall. The form documented, in part: -*"Type of Incident Alleged - Fall - Injury Description * Type of Injury ... Other * Body Part(s) affected... Back * Was outside care needed to treat and/or diagnose this injury? Yes - Incident * "Full Description of Incident/Accident - At 1630 (4:30 pm), aides came to nurse and notified me that resident was being transferred from bed to wheelchair. Hoyer strap slipped off of hoyer hook on front left side and resident slid off of hoyer pad onto floor and resident landed on her butt. Aides got her off floor and into wheelchair. They stated that resident did not hit her head. Resident rated pain at a '10' on scale 0 to 10 in low back L 3-L 4 area. Offered PRN APAP (as needed acetaminophen) and Norco, resident stated she did not want Norco and accepted PRN APAP for pain management. Sent to ER for Evaluation at 1900 (7:00 pm) via non-emergent ambulance. * Was incident witnessed: Yes * Person who discovered Incident... (LPN/CNA #1's name and title-LPN were documented). * ...Activity at the time of the incident... Transferring * What Resident Assistive Device was in use at the time of the incident? Transfer lift * ...Describe the Resident's Intensity of Pain after the incident. (using the pain scale) 7-10 * ...Was first aid administered at the facility? Yes * Type of first aid provided - Pain assessment, Assessment of extremities, Vital signs, Neurological assessment. * Who provided the first aid? Nurse * Date first aid was provided - 2/4/12 * Time first aid was provided - 4:30 pm * What type of outside care was utilized? Hospital Emergency Department * Date taken to the ER...? 2/4/12 * Time taken to the ER...? 1900" * Resident #1 was alert, but forgetful before and after the fall. * The resident's vital signs after the fall were recorded as temperature of 97.6, pulse 70, respirations 16, blood pressure 124/62. * The resident's family was notified of the fall on 2/4/12 at 5:00 pm and the resident's doctor was notified of the fall on 2/4/12 at 6:00 pm. - "Investigation" * Documented the fall was "with or w/o injury" and was "attended" * "What position was the Resident in when you found them? Resident was in wheelchair when nurse went to assess her." * Documented there was no loss of consciousness and that "neuro-checks" were "completed per protocol." * The "interventions in place at the time of the Incident" were "2 person staff present during hoyer lift." * "What interventions are in place now? Education about ensuring hoyer straps are securely around hoyer hooks before making the transfer." NOTE: On 2/4/12, a facility staff CNA called in that he/she would not be able to work the evening shift on 2/4/12. LPN/CNA #1 worked on 2/4/12 on the day shift as an LPN and on the evening shift as the replacement CNA. In the IDA report above and in the witness statements below, she identifies herself as an LPN, but CNA #2 and RN #3 refer to her as an "aide." RN #3 was the charge nurse on the evening shift when Resident #1's fall occurred on 2/4/12 and was responsible for Resident #1. The staff schedule sheet, provided by the DON on 2/14/12 at 11:00 am, documented LPN/CNA #1's name was hand written in the "CNA" section for evening shift on 2/4/12. RN #3 was identified on the schedule as the "Licensed Nurse" responsible for "charting" and "supervision of staff" including LPN/CNA #1 and CNA #2. Three witness statements were attached to the Incident/Accident Data Entry Questionnaire form and documented, in part: * LPN/CNA #1 documented she filled out the Witness Statement Form on 2/5/12 at 12:45 pm. She listed her title as "LPN." The date and time of the incident was recorded as "2/4/12" at "1630." The section under, "The following is a statement of the facts as reported by the above named witness" was handwritten, signed by LPN/CNA #1, and read, "We were hoyering Res(ident #1) in Rm (#) around 4:30 pm. Res was up in the air, as we were moving from over bed to wheelchair. Bottom left loop came off of hoyer lift. The sudden shift in wieght (sic) made hoyer swing and Res slid out of hoyer landing on hoyer leg. Her bottom hit first and hard. Res did not hit head. Res tried to laugh it off. Stating 'dont (sic) worry ill (sic-I'll) be fine.' After about 10-20 min(utes) Res could no longer sit in chair and asked to lay down. Res(ident) complained of pain in lower back. POA was called he okayed for her to be sent to ER (sic). I do believe this accident was operator error. And the bottom left hook was not on hoyer hook all the way. I hooked all four loops on but apparently did not apply the last one very well." NOTE: The faxed investigation report from the DON stated, "(CNA #2) had placed the two straps on the top of the hoyer sling to the hoyer itself and (LPN/CNA #1) had placed the bottom two straps to the hoyer." * CNA #2 documented she filled out the Witness Statement Form on "2/4/2012" at "7:00 pm." She listed her title as "CNA." The date and time of the incident was documented as "2/4/2012" at "4:30 pm." The section under, "The following is a statement of the facts as reported by the above named witness" was handwritten, signed by CNA #2, dated "Feb. (February) 4, 2012," and read, "Resident was being lifted by hoyer by other aid (sic). I turned to retrieve her wheelchair, & the side of the strap to hoyer came loose & it was a control (sic) slip to the floor. Prior to that I was providing oral care on other resident in room while aid (sic) was providing peri-care (perineal care) on resident (Resident #1) and appling (sic) hoyer pad. I entered that side of room as she was being lifted to retrieve chair." NOTE: The faxed investigation report from the DON stated, "CNA #2 had placed the two straps on the top of the hoyer sling to the hoyer itself and LPN/CNA #1 had placed the bottom two straps to the hoyer. * RN #3 documented she filled out the Witness Statement Form on "2/4/12" at "2130" (9:30 pm). She listed her title as "RN." The date and time of the incident was documented as "2/4/12" at "1630." The area under, "The following is a statement of the facts as reported by the above named witness" was handwritten, without a signature, and read, "At 1630, aides (LPN/CNA #1 and CNA #2's names) came to me and notified me that the resident was being transferred from bed to wheelchair. Hoyer strap slipped off of hook on front left side and resident slid off of hoyer pad onto floor and resident landed on her butt. Aides got her off floor and into w/c. They stated that resident did not hit her head. Resident rated pain at '10' on score of 0/10 in low back L3-L4 area. Offered APAP and Norco, resident stated she did not want Norco and accepted PRN APAP for pain management. Sent to ER for evaluation at 1900 in a non-emergent ambulance." Resident #1's Nurse's Notes contained an entry, dated "2/4/12 (2300) (11:00 pm)" and signed by RN #3 which described the fall, in part, "...At 1630, aides came to me and notified me that the resident was being transferred from bed to wheelchair. Hoyer strap slipped off of hook on front, left side and resident slid off of hoyer pad onto floor, and resident landed on her butt. Aides got her off floor and into w/c. They stated that resident did not hit her head. Resident rated pain at '10' on scale of 0/10 in low back, L3-L4 area. Offered APAP and Norco to resident for pain management, and resident stated she did not want Norco and accepted PRN APAP for pain management. Sent to ER for evaluation at 1900 via non-emergent ambulance. Vital signs were stable upon assessment of resident. She was in her wheel chair at the time of the assessment. She was not having symptoms of peripheralization in legs. Called multiple times to ER to receive update on resident. ER did not answer phone and eve(ning) shift ended. Nursing will continue to monitor situation." Another nursing note entry, on 2/5/12 at 3:00 am, documented, "Resident admitted to surgical unit at hospital." On 2/13/12, the BFS received a fax transmittal, dated 2/12/12 on the fax cover sheet, from the facility's DON. In addition to the cover sheet, the faxed information consisted of a one page document dated "February 12, 2012", and recorded, in part: * "Re: resident falling out of hoyer resulting in compression fracture of L2 and fracture to right humerus * Date of incident: 02/04/12 * Resident: (Resident #1's name, date of birth, and social security number) * Staff member: (LPN/CNA #1's name, date of birth, and social security number) * On 2/4/12 at approximately 4:30 pm, (LPN/CNA #1's name, LPN) and (CNA #2) were transferring (Resident #1) from her bed to the wheelchair using the hoyer lift per plan of care. (CNA #1) had placed the two straps on the top of the hoyer sling to the hoyer itself and (LPN/CNA #1) had placed the bottom two straps to the hoyer. They then lifted her up off the bed with the hoyer. They then backed the hoyer out from under the bed and turned her towards the wheelchair. (CNA #2) went to put the wheelchair in the appropriate place, when the bottom left strap came undone on the hoyer causing (Resident #1) to slide out of the hoyer. She was approximately 3 feet off the ground and landed on the left leg of the hoyer. She did complain of immediate pain to her back. EMS (Emergency Medical Services) was summoned and she was sent to the emergency room . Upon arrival she was found to have a compression fracture of L2 and a vertebroplasty was done on 2/5/12. She returned to the facility on [DATE]. ...I talked to (CNA #2) and (LPN/CNA #1) and both told me that if hey felt there had been something wrong with the placement of the sling they never would have lifted her and as the hoyer had lifted her above the bed and had no problems they saw no reason to stop what they were trying to do. We did remove the hoyer from service on 2/4/12 and maintenance did look at it on 2/6/12 and found no defects on the hoyer. The sling involved was also looked at by several other staff members the residents (family member) as well as myself. There are no frayed parts and nothing is broken. We have however thrown this sling away in the off chance that it occurred d/T (due to) the sling. After talking with the staff involved it was felt that this was possibly due to the hoyer pad not properly being 'seated' into the hook of the hoyer. On 2/5/12 all staff that were working that are or would be involved with the hoyer in any way were given an inservice on how to make sure the sling is 'seated' properly on the hook. The inservicing continues until we were able to inservice all available staff that work with the hoyer. ...Of note, (Resident #1) did start complaining of pain to right arm on 2/9/12. We were able to get her in for a x-ray of right arm on 2/10/12 and she was found to have a fracture of the right humerus, which was felt to have been caused from the initial fall from the hoyer. She was seen by her primary MD (physician) as well as an orthopedic surgeon and no surgery was needed for this. They did place her in a sling and will have therapy work on range of motion." The survey team reviewed this faxed document from the facility before the team entered the facility on 2/14/12 at 9:00 am. During the three separate direct care staff interviews recorded below, both surveyors took notes to document the statements made as each staff member described Resident #1's fall from the mechanical lift. *LPN/CNA #1 On 2/14/12 at 12:42 pm, LPN/CNA #1 was interviewed regarding Resident #1's fall from the mechanical lift on 2/4/12. She stated she worked the first 8 hours that day in the facility as a nurse and after finishing her nursing duties, she "hit the floor at 1600 (4:00 pm)" and worked as a CNA. LPN/CNA #1 was shown a diagram on the cover of the facility's Invacare Manual/Electric Portable Patient Lift Manual. LPN/CNA #1 used the diagram to point out Resident #1's position after she fell from the lift. LPN/CNA #1 pointed out that Resident #1's legs were positioned over one horizontal bar of the mechanical lift, her buttocks were on the floor and her shoulders were positioned on the other horizontal bar of the mechanical lift. LN/CNA #1 was asked what she determined happened to cause the resident to fall out of the hoyer. "I don't know. Maybe the strap was not completely on the 'J' part of the hoyer." The staff member was informed that the facility's policy/procedure for hoyer operation was to double check the straps. She responded, "No, I don't believe I double checked the straps." She was also asked if CNA #2 had checked the straps before she moved the resident in the hoyer lift. She answered, "No." LPN/CNA #1 stated, "I had (Resident #1) in the hoyer. I was lifting her up. I had her in the air. She slid out of the hoyer .."She hit pretty hard." LPN/CNA #1 also stated she asked, "(Resident #1) are you okay?" LPN/CNA #1 stated, "Her shoulders landed on hoyer leg. She said, 'Oh my back's sore.' We re-hoyered her into bed." LPN/CNA #1 stated that after the resident was in bed, the resident commented,"I'm fine, I'm an old lady." LPN/CNA #1 stated, "We re-hoyered her to the chair." The resident started complaining of back pain so she was returned to bed. LPN/CNA #1 was asked by the survey team to describe the incident event as she recalled it. She stated she attached the bottom right and top right sling hooks, then she attached the top left and bottom left sling hooks. LPN/CNA #1 was asked if CNA #2 checked the sling straps and hooks. "No...I asked (CNA #2) to get the wheelchair as I hoyered (Resident #1) up. Everything was attached. I moved her back. The bottom left hook came undone...She fell on her bottom. She slid off the pad onto the floor. Her shoulder hit the hoyer legs. Her butt hit the floor or hoyer leg. She was laying across the hoyer legs. Her shoulder hit after her butt...I lifted her shoulder off the hoyer and pillowed her head. That's where the initial pain was." LN/CNA #1 stated she, "did ROM while she (Resident #1) was on the floor...(CNA #2) and I rolled her toward the bed and placed the pad (sling) and hoyer and got her back in bed. She was incontinent, changed her bottoms." LN/CNA #1 stated she did not remove the resident's shirt. "When I touched her she said, 'Just sore all over.' I raised her right arm and she bent her left leg. There were no red marks on her back. She was hungry and wanted to get up in the wheelchair." LPN/CNA #1 stated, "(RN #3) and I checked her in bed. (RN #3) checked areas of her spine. She hurt in one area." LN/CNA #1 was asked if she recorded the assessment she had performed while the resident was on the floor. "I don't think I wrote out the assessment in the witness statement...(RN #3) wrote out the report as the LN as I was technically a CNA." She was asked if the facility used a form to document physical assessments performed after falls. She stated, "We fill out the IDA system. There's no skin assessment in IDA, more of what happened. IDA doesn't have assessments per se." * CNA #2 CNA #2 was interviewed on 2/14/12 at 1:35 pm regarding Resident #1's fall from the mechanical lift. CNA #2 was shown the same diagram of the Invacare mechanical lift referenced above. She pointed to the diagram and stated the resident's hips were on one leg of the mechanical lift and her shoulders were on the other leg of the mechanical lift. CNA #2 was asked by the survey team to give the details of the incident as she remembered. She stated that she was in Resident #1's room to perform cares for the roommate. LN/CNA #1 placed Resident #1 in the hoyer lift. "Everything looked good on the hoyer and straps. I heard a metal sound...The left bottom strap came off...It was a controlled slip to the floor. I placed a pillow for her head. The resident was laughing. We rolled her to the right, put the pad (sling) under her and got her back to bed...(LN/CNA #1) looked at the resident..no skin check (performed.) The resident wanted in her chair for dinner. We lifted her and put her in her chair per her request." CNA #2 was asked to describe the position Resident #1 landed after the fall. She stated, "Her hips were on the leg of the hoyer and her shoulder was on the other leg. I was worried about her shoulder. I placed the pillow. (LN/CNA#1) was checking the resident asking, 'are you okay? Wiggle your fingers, toes.' She checked her eyes, asked her her name, and repeatedly asked 'are you hurt'? (Resident #1) said, 'I'm fine get me off the floor.'..She says 'OW' to everything. You must watch her facial expressions. Her right arm is always in a sling except while in bed. She stated everything "happened so quick." CNA #2 was asked if she and LN/CNA #1 used the same equipment to get the resident off the floor, to bed, then into the wheelchair. She stated, "We made sure the sling and strap were not torn before we re-used it." NOTE: During an interview with the Maintenance Director on 2/14/12 at 11:30 am, he stated he checked the mechanical lift used for Resident #1 on 2/6/12, but failed to document that he had done so. He provided an 11 point checklist that he used when checking mechanical lifts. He did not check the mechanical lift used to transfer Resident #1 immediately after she was dropped from the mechanical lift or before she was transferred with the same mechanical lift and sling from the floor to the bed and from the bed to the wheelchair. He stated, "Nursing staff inspect the slings." CNA #2 was asked if she checked Resident #1's straps and hooks. "The straps looked secured as I briefly looked up. I was trying to maneuver the large wheelchair." The CNA then stated, "Her whole body may have scuffed the bed as she went down." CNA #2 was asked about her knowledge of the mechanical lift process. The CNA stated, "We roll the resident, adjust the sling pad, tuck it under that side (of the resident), roll resident to other side and adjust pad to be even under the resident and level. We place the hoyer legs under the bed, bring hooks down...hook up the straps, if everything looks good, lift the resident up over the bed, get the chair next to the bed so as little time elapses, lift them off the bed just a little, check their arms, finger and fanny, and be sure arms are tucked in." The CNA was asked, "Do you check the straps in the hooks?" She stated, "Yes, double check." * RN #3 On 2/14/12 at 2:00 pm, RN #3 was interviewed regarding Resident #1's fall from the mechanical lift. She stated she was the charge nurse on the evening of 2/4/12 and was responsible for Resident #1. RN #3 stated that she was on duty the evening of Resident #1's fall and she was doing, "Med(ication) pass...The aides said that (Resident #1) fell out of the hoyer, that the front left strap came off. I asked them if she was okay, and they said, 'Yes.'" RN #3 also stated that shortly afterwards, "She came wheeling out in the wheelchair. I checked her back. She refused Norco and Tylenol. I checked her legs for numbness/tingling. I did not go into her room after she fell ...(LN/CNA #1) probably should have got me before getting her up, even though she's an LPN...They notified me after they got her up into the wheelchair." RN #3 was asked if LN/CNA #1 gave her a report of the incident. RN #3 stated, "(LN/CNA #1) described the fall, said she was not hurting...I started assessing her and talk with her. I pulled her shirt up slightly to look at her lower back. I did range of motion to her lower extremities. There was no pain except her low back." The survey team asked RN #3 if she performed and upper body assessment. She responded, "No. I did neuro checks. It was a good day, she was more alert, not lethargic. I looked at her low back for bruising. I asked her if she wanted to go to the ER. She said 'No.' I gave her Tylenol." The RN stated the resident was then taken to the dining room for supper. "Then (LN/CNA #1) and I hoyered her to bed and looked at her bum." RN #3 was asked where she charted her post-fall assessment. She stated, "In my notes." The surveyor read the entry note, "Vital Signs stable upon assessment of Resident." The RN was informed that there was no documentation that she assessed the resident's range of motion, performed a neurological assessment or skin assessment. The RN stated, "I wonder if I recorded the assessment in IDA." The RN acknowledged that the IDA reports were not a part of residents' records. The RN stated, "I didn't chart it. I didn't chart those assessments. Absolutely normally I would have charted the assessment." RN #3 was asked if LN/CNA #1 and CNA #2 described the position of the resident immediately after she fell out of the Hoyer sling. "They didn't tell me what direction she was lying, or next to the hoyer, or what position she was in. They told me she did not hit her head." The RN re-stated, "The CNAs are supposed to get an LN before (emphasis on word) moving a resident." RN #3 was shown the same diagram of the Invacare mechanical lift referenced above and asked to identify where the resident's body was positioned in relation to the mechanical lift. She was unable to identify on the diagram where the resident's body was positioned in relation to the mechanical lift. Resident #1's Operative Report, dated 2/5/12, documented in part: * "...Postoperative Diagnosis: [REDACTED]. * ...Operation performed: Vertebroplasty under fluoroscopic guidance." * ...Indications: ...She (Resident #1) was being assisted at (facility name) when she slipped and fell to the ground. The patient had severe pain at that time. ...MRI (magnetic resonance imaging) was obtained which did show acute L2 compression fracture, which was consistent with the level of her symptoms..." Resident #1's x-ray report, dated 2/9/12, documented, "Impression: Comminuted fracture, proximal right humerus." Resident #1's ER report for an ER visit on 2/10/12, to evaluate the comminuted fracture of Resident #1's right humerus, documented, "Emergency Department Course Treatment: Initially by concern for this patient beyond what had been going on over the last few days is the potential for a fall that caused this significant of an injury to potentially have caused a head or cervical spine injury..." Resident #1 was harmed when LPN/CNA #1 failed to recheck the sling hooks when the resident was lifted a few inches off her bed as indicated in the mechanical lift manual. The sling loop came off the bottom left hook causing Resident #1 to drop onto the floor and the legs of the mechanical lift sustaining a L2 fracture of the spine and a comminuted fracture of the proximal right humerus. In addition, staff used the same sling and mechanical lift to transfer the resident from the floor to the bed and from the bed to the wheelchair after the resident was dropped without an inspection of the lift by maintenance. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 30-day MDS assessment, dated 1/11/12, coded: * BIMS score of 4 indicating severely impaired cognitive skills for daily decision making * Needs extensive assistance of one person for bed mobility, transfer, dressing, toilet use and personal hygiene Resident #6's physician's orders [REDACTED]. * "12/14/11: Alarms to bed and wheelchair * 12/14/11: Landing strip next to bed" The resident scored "22" on her Fall Risk Evaluation, dated 12/14/11, indicating she was a high risk for falls and documented, "Bed against wall to (increase) functional space in room - Alarms to bed & w/c - landing strip next to bed." On 1/13/12 an entry recorded, "Tab alarm to bed." Resident #6's Care Plan documented the problem, dated 1/2/12, "Resident...is at risk for fall..." Interventions listed included in part, "...Landing strip next to bed when resident is in bed, Safety alarms to bed and wheelchair to alert staff of any unassisted transfers..." An IDA report, dated 1/13/12, documented, in part: * "Type of incident alleged: Fall * Type(s) of Injury... : Laceration * ...Body Part(s) affected...: Head (except face) * Was outside care needed to treat and/or diagnose this injury? Yes * ...Full Description of Incident/Accident: CNA heard residents (sic) roommate yelling. Rommate (sic) stated, 'I heard a thud.' CNA found resident sitting up next to bed with laceration to posterior skull. * Was incident witnessed? No * ...Activity at the time of the incident? Attempting to get out of bed * ...Type of first aid provided: cleansed site with NS (normal saline) and applied pressure till (sic) bleeding stopped. * Who provided the first aid? LN * Date first aid was provided: 1/13/12 * Time first aid was provided: 5:15 am * What type of outside care was utilized? Hospital Emergency Department * ...Time taken to the ER... 5:35 am * ...What immediate actions were taken to provide safety for the resident and/or others? Care planned tab alarms to bed. Sent to ER for eval(uation) r/t (related to) head injury. *...Fall Category..: Found on floor with or w/o inj(ury) * Was fall Attended/Unattended: Unattended * What position was the Resident in when you found them? sitting up on the floor next to the bed. *...What fall reduction measures were in place at time of incident? Bed alarm *...What interventions were in place at the time of the incident? Bed pressure alarm - enabled - disfunctional (sic) * what interventions are in place now? Tab alarm initiated. Hip Protectors Initiated." Resident #6's Nurse's Notes documented on: * 1/13/12 at 5:15 am, "Resident sent to ER. Family & MD notified. VS... Oriented to self. Noted laceration to posterior skull. Sanguinas (sic) drainage. Neuro (checks) WNL. Left per ambulance. * 1/13/12 at 9:15 am, "resident back from ER, has 12 staples to back of head..." The ER report, dated 2/13/12, documented, in part: * "Assessment 1. Closed head injury, 2. Scalp laceration, 4 cm (centimeters), 3. Left lower extremity contusion." * Description of procedure: "...It (the patient's scalp laceration) was approximated using skin staples." On 2/16/12 at 9:00 am, the DON was asked about Resident #6's fall and the landing strip. The DON stated, "I did not ask her (name of LN filling out the IDA report) about that. As far as the report - it is not in there." Resident #6 was care planned to have a "landing strip" at the bedside when the resident was in bed. The IDA report of the resident's fall on 1/13/12 documented the resident fell and was found on the floor. There was no documentation in the IDA report or in the nursing notes that the landing strip was in place at the resident's bedside while she was in bed. The resident was harmed when she fell out of bed sustaining a 4 cm laceration to the back of her head requiring emergency care consisting of 12 staples to close the wound. On 2/16/12 at 11:55 am, the Administrator, DON, Regional Vice-President, and Regional Nurse Consultant were informed of the issue.

Based on a complaint from the general public, observation, staff interview and record review, it was determined the facility failed to ensure residents who entered the facility without pressure sores did not develop them, through conducting comprehensive skin assessments and evaluation of the effectiveness of interventions. This was true for 4 of 18 (#s 10, 11, 16, and 17) sampled residents. This resulted in harm to Resident #16 when she developed a Stage III pressure sore to her coccyx. In addition, Resident #10 developed a Stage II pressure sore to her coccyx, Resident #11 developed a Stage II pressure sore to her left ischium and Resident #17 developed a Stage II pressure sore to her right medial heel. Findings included: 1. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/4/10, documented the following: * Severely impaired cognitive skills for daily decision-making * Sometimes able to make self understood and rarely understands others * Extensive assistance requiring two persons for physical assist for bed mobility * Total dependence requiring two persons for physical assist for transfers * Extensive assistance requiring one person for physical assist for locomotion on and off the unit, dressing, eating, and personal hygiene * Limitation on both sides of legs with partial loss of voluntary movement * Incontinent of bowel and bladder * One Stage III pressure ulcer The Braden Scale scores for Resident #16 were as follows: 9/1/09 - Score 13 = Moderate Risk 12/1/09 - Score 13 = Moderate Risk 2/23/10 - Score 13 = Moderate Risk 6/2/10 - Score 12 = High Risk 7/30/10 - Score 13 =Moderate Risk The resident's RAP for Pressure Ulcers, dated 11/16/09, documented, "Resident triggered for pressure ulcers rap for having a resolved pressure sores (sic) in last 90 days...Nursing continues to apply [MEDICATION NAME] dressing to left ischial/hip for protection...Resident is also repositioned every 2 hours and prn (as needed) to prevent prolonged pressure. Resident is also at risk for skin breakdown due to needing total assistance with bed mobility and resident is incontinent of bowel..." Nurse's Notes documented the following: * 5/24/10 at 3:00 pm, "Darkened area to the coccyx - [MEDICATION NAME] applied- Res(ident) is to be last up, first down - Repositioned - tx (treatment) nurse notified of the above - Nsg (nursing) to continue to monitor." *5/24/10, at 3:15 pm, "1 W x 2 L (1 centimeters width by 2 centimeters length) SDTI (suspected deep tissue injury) found to coccyx. Foam drsg (dressing) applied. I feel that her positioning in the w/c (wheelchair) caused the area. Will ask therapy to assess," and signed by the Wound Care nurse. NOTE: In a monthly summary, dated 5/18/10, it was documented the resident had an open area to her coccyx, earlier than the 5/24/10 Nurse's Note. * 6/3/10, at 1:05 pm, further documented, "Drsg changed to coccyx. Area measures 1.5 w x 2 l x 0.5 (1.5 centimeters width by 2 centimeters length by 0.5 centimeters depth). Wound bed is covered with slough...Res(ident) is last up/first down. She is on a Medistat mattress and is never on her back in bed. I believe the area was caused d/t (due to) positioning in her w/c. Her legs are very contracted, cause her to slide and sit slouched, uneven. Therapy has assessed her numerous times. Will cont(inue) current interventions," and signed by the Wound Care nurse. It was unclear what these particular interventions were the Wound Care nurse was referencing. * 6/7/10, at 2:00 pm, "Mist done to coccyx ulcer. Area measures 1.5 W x 2.6 L x 1 D. Area has increased in size but this can occur with a SDTI..." * 6/16/10, no time specified, "Area to coccyx measures 1.5 cm W x 2.5 cm L x 1 cm deep, Slough noted to wound bed...wound appears stable..." * 6/28/10, 6:40 am, "...Ulcer to coccyx measures 2.9 L x 1 W x 1 D. Wound bed has adherent slough present to entire wound bed..." * 7/5/10 8:15 am, "...Coccyx wound measures 2.4 L x 1 x 1. Wound has adherent slough present.." * 7/14/10 11:30 am, "...Ulcer to coccyx measures 2.5 L x 1 W x 0.8 D. Adherent slough still present but decreasing..." * 7/19/10 10:20 am, "...Mist done to coccyx ulcer. Ulcer measures 2 L x 1 W x 1 D. Adherent slough has decreased. Wound bed visible in some areas...She has a Roho cushion in her w/c..." * 7/28/10 3:00 pm, "Mist done. Drsg changed to coccyx ulcer. Ulcer measures 2 L x 1 W x 1 D. Small amount of adherent slough came out of wound. * 8/2/10 12:00 pm, "Drsg changed to coccyx. Mist done. Ulcer is stable. Measures 2 L x 1 W x 0.8 D. Wound bed is yellow/pink/red..." * 8/9/10 4:00 pm, "Mist done. Drsg changed to coccyx ulcer. Ulcer measures 2 L x 1 W x 1 D. Wound has been stable for the last couple of (illegible) but I don't feel changing the tx would be beneficial. Wounds often plateau for a short time during the healing process. She is incontinent of bowel frequently, has to be up for meals which puts pressure on the ulcer. I believe these two factors are also slowing down the progression of the wound. She has a Roho cushion in her w/c, is last up, 1st down for meals. ..Res(ident) on sides in bed..." NOTE: This note from the Wound Care nurse was 11 weeks into treatment with no discernible change in progression. * 8/11/10 11:40 am, "Called (family) to discuss trying a cushion from Span that has a cut out where her coccyx sits. (family) thinks it is a great idea. Will trial." * 8/16/10 11:30 am, "Mist done. Drsg changed to coccyx wound. Area measures 2 L x 0.8 W x 0.8 W (documented as width twice). Wound bed is yellow/pink/red...Peri-wound skin has improved greatly..." * 8/23/10 5:00 pm, "Mist, drsg changed to coccyx ulcer. Ulcer measures 2 L x 0.8 x 0.5 D. Wound bed yellow/red..." * 8/30/10 11:00 am, "Mist done, dressing changed to coccyx ulcer. Ulcer measures 2 L x 0.7 x 0.5. Wound bed is red/yellow..." * 9/8/10 11:00 am, "Mist done, drsg changed to coccyx ulcer. Wound measures 1.8 L x 0.7 x 0.5. Wound bed red...Isch-Disch cushion to w/c to keep pressure off of coccyx." NOTE: No documentation of treatment and wound notes from 9/8-9/20. * 9/20/10 11:00 am, "Mist done. Drsg changed to coccyx ulcer. Area stable in size. Measures 1.8 L x 0.7 x 0.4. Wound bed pink/red..." * 9/29/10 7:45 am, "Mist done. Drsg changed to coccyx ulcer. Area measures 1.7 L x 0.5 W x 0.4. Wound bed is beefy red..." Information was received by fax on 10/12/10 at 2:33 pm. The Wound Care nurse documented the resident had chronic flexion deformities in her knees, with the right greater than the left. She stated this caused the resident to slide down in her wheelchair. She stated the resident is repositioned multiple times while in the chair but "slides right back into that position usually within minutes of being repositioned." The Wound Care nurse documented the resident had the following wheelchair cushions: Admission in 2006-10/8/08 pressure-reducing cushion 10/8/08-5/11/09 Air-alternating cushion 5/11/09-5/15/09 Resident was in hospital 5/15/09-7/29/09 Air alternating cushion, d/c'd at husband's request 7/29/09-8/9/09 Pressure-reducing cushion NOTE: Type not specified 8/9/09-8/11/10 Roho cushion 8/11/10-current Isch Dish cushion to offload wound NOTE: Stage III pressure ulcer discovered 5/24/10. Different wheelchair cushion not ordered until almost 11 weeks later. The Wound Care nurse documented the resident had the following mattresses: Admission-4/30/08 pressure-reducing mattress 4/30/08-5/11/09 Span America air alternating mattress 5/11/09-5/15/09 Resident was in hospital 5/15/09-7/29/09 Span America air alternating mattress 7/29/09-present Medistat 2 alternating pressure air mattress NOTE: Mattress has remained the same throughout the time the resident has had the Stage III coccyx ulcer. The Wound Care nurse documented she "rarely sees the resident on her back, due to her contractures in her legs preventing her from lying flat on her back," and usually laid on her sides, further implicating the poor wheelchair positioning as the reason for the pressure sore to the resident's coccyx. In a Nurse's Note dated 9/11/10 at 10:00 am, the Wound Care nurse documented the following: "Summary of investigation regarding ulcer to coccyx. Res(ident) has dementia and is unable to turn/reposition herself in her bed or w/c. She is incontinent of bowel, bladder, frequently has BMs (bowel movements). She has a deep gluteal fold which is often moist d/t incontinence, anatomy. She has had a hx (history) of denuded areas to her gluteal fold/coccyx d/t moisture, friction, shear. She has been assessed by therapy multiple times, has had multiple w/c cushions, bed. I feel that the contractures to her legs, especially the R(ight) contributes to her poor positioning in her w/c which I feel caused her pressure sore. Res(ident) rarely lays on her back in bed so the only time pressure would be an issue is in her w/c. She often sits to the side and has shearing issues while in w/c regardless of the amount of times she is readjusted, repositioned. She currently has a new w/c cushion called an isch-dish which has a 'cut out' where the coccyx sits. Since the placement of this cushion I feel there have been improvements but her frequent incontinence continues to slow area..." Again, please note the Isch Dish cushion was not ordered until almost 11 weeks after the discovery of the coccyx wound and this note was written 15 weeks post wound discovery. In addition, this summary note documented the facility was well aware of the issues for this resident and did not care plan and effectively implement interventions to prevent the development of the pressure sore to her coccyx. Other care plan interventions for skin integrity for the resident included last up before meals and first down after meals, documented in the Physician (recapitulation) Orders, dated October 2010. The Physician order [REDACTED]. In addition, the Nurse's Notes documented the resident was turned every 2 hours when in bed. There was no specific time documented for the amount of time for the resident to be up in her chair and offload pressure from her coccyx wound. NOTE: In a Care Plan Conference Record, dated 6/9/10, the (family member)of the resident was documented as stating his only concern was the evening shift was not getting the resident in bed fast enough after dinner. It was documented the evening staff would be spoken to by management. This increased time in her wheelchair would lead to that much more time that pressure was applied to the Stage III coccyx pressure sore. The Care Plan also documented a Broda wheelchair for the resident, with a start date of 9/16/10. The Wound Care nurse also stated they had used a right lateral support and foot buddy in the wheelchairs in the past although these were documented as discontinued on 9/16/10 with the change to the use of the Broda chair. The Wound Care nurse documented that multiple wheelchairs had been tried, including high back, geri-chair, standard wheelchair and a Broda chair for the second time. Again, this Broda wheelchair was instituted 16 weeks after the discovery of the coccyx ulcer and the only documentation of a change in wheelchairs was a foot buddy ordered on [DATE] and discontinued with the change to the Broda chair. In a Rehabilitation Services Resident Screening Referral form, dated 8/30/10, the resident was referred for wheelchair positioning. It documented, "Resident slopes down at times in w/c and (family member) ends up repositioning - (Resident) has open area on coccyx. Can therapy please see how Res(ident) is being placed in w/c and perhaps re-educate staff to how to place Res(ident) in w/c properly -(family member) feels this is a great implementation to his concerns with (Resident)." This referral note is of concern as it documented the husband was having to frequently reposition the resident instead of the staff and that her poor positioning had not been properly addressed many weeks after the discovery of the Stage III coccyx pressure sore. The resident was harmed when she suffered a Stage III pressure sore to her coccyx. She had been a resident in the facility for 4 years when she developed this particular wound and her medical and physical conditions were known to the facility. The resident had previous pressure ulcers on her hips where it was even more difficult to offload and they had healed. It was documented by the Wound Care nurse the coccyx wound was due to wheelchair positioning but effective preventive measures were not in place and evaluation of interventions and changes to these interventions were delayed for weeks. Federal guidance at 42 CFR 483.25(c) identifies pressure as a risk factor that may be modified promptly by the facility. In addition, in keeping with nursing standards of practice, there was no documentation of wound staging on any of the wound sheets or nursing notes for the Stage III pressure sore to the resident's coccyx. It was documented as a Stage III pressure ulcer on the MDS and in dietary notes only. The facility has alleged the pressure ulcer was unavoidable due to the fact that the resident was determined to be high risk for developing pressure ulcers upon admission. The federal guidance at 42 CFR 483.25 (c) states, "A determination that a resident is at high risk to develop a pressure ulcer has significant implications for preventive and treatment strategies, but does not by itself indicate that development of a pressure ulcer was unavoidable." 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 9/10/10, documented the following: * Severely impaired cognitive skills for daily-decision making * Mental function varies over the course of the day * Rarely/never understood and rarely/never understands others * No speech * Extensive assistance requiring one person for physical assistance for bed mobility and dressing * Total dependence requiring two persons for physical assistance for transfers and bathing * Total dependence requiring one person for physical assistance for locomotion on and off the unit, eating, toilet use, and personal hygiene * Range of motion limitation on both sides with partial loss of voluntary movement for arms, hands, legs and feet * Mechanically lifted for transfers * Incontinent of bowel and bladder * Feeding tube The RAP for pressure ulcers, dated 11/23/09, documented, "resident triggers for pressure ulcers due to being incontinent of bowel, being dependent upon caregivers for bed mobility, and being bedfast. Resident had a head to toe skin assessment upon admission and had weekly repeats. Resident has a pressure reducing mattress on her bed and cushion in her wheelchair. No further referral at this time. Will proceed to care plan." NOTE: A Nurse's Note dated 11/17/09 at 10:30 am, for Resident #10, documented, "Res(ident) admitted to the facility with a Stage I to coccyx/sacrum. Res(ident) has a peg tube so she has to have the HOB up which is creating shearing. She in incontinent of B & B (bowel and bladder) and unable to turn herself. N.O. (new order) for a Span alternating mattress. (illegible) educated the aids (sp)on turning/repo(sitioning) every 1-2 hours, even if there are slight changes made." The Stage I pressure ulcer was never coded on the admission MDS or as a resolved ulcer. The RAP for pressure ulcers, dated 9/10/10, documented, "Resident triggered for pressure ulcers rap for needing extensive assistance with bed mobility and for incontinence...Resident is encouraged and assisted to turn/reposition every 2 hours and prn (as needed), she is checked for incontinence every 2 hours and briefs are changed every 2 hours and prn. Resident has medical dx (diagnosis) of diabetes, and is at risk for skin breakdown. Interventions are in place include pressure reducing mattress on bed, Journey Elite 3 cushion in Broda chair, allevyn adhesive dressing to coccyx for protection...Licensed nurse to do weekly skin assessment, and MD is notified of any changes in skin integrity prn..." The Physician (recapitulation) Orders for Resident #10, for the period 9/1-9/30/10, documented the following: * "Do peri care every shift and as needed - apply protective cream to buttocks, start date of 11/16/09." * "Encourage/assist resident to reposition every 2 hours and as needed, start date of 11/16/09." * "Wedge to HOB (head of bed), maintain upright at 75-90 degrees, positioning in bed with chin tuck to keep airway open & (and) minimize potential for tongue to occlude airway - each shift, start date of 11/24/09." * "Defined perimeter mattress to bed, start date of 1/29/10." * "If res. (resident) has any wound(s), show any s/s (signs and symptoms) of infection ie: odor, redness, warmth, swelling, increased drainage, increased pain or change in drainage, notify the resident's primary medical doctor, start date of 5/3/10." * "Allevyn adhesive to coccyx - change every 3-5 days, start date of 5/3/10." * "Broda chair with Journey Elite 3 cushion, start date of 5/3/10." * "Full strength Glucerna 65 cc/hr (cubic centimeter per hour) per PEG (percutaneous endoscopic gastrostomy) tube to provide 1560 kcal (kilocalories) and 65 GM's (grams) of protein, start date of 5/14/10." Resident #10's Care Plan reflected these same physician orders [REDACTED]. The Braden Scale scores found for Resident #10 were as follows: 5/4/10 Score 15 = At Risk 7/17/10 Score 13 = Moderate Risk Nurse's Notes documented the following: * "2/4/10 10:50 am, 0.5 x 0.5 denuded area to coccyx. Peri wound skin intact. N.O. for EPC (external protection cream) every shift/prn. Will call therapy to find a cushion for her geri chair. Educated staff on turning/rep(ositioning), avoiding friction/shear..." * "2/11/10 11:55 am, Denuded area to coccyx measures 0.4 x 0.4, area d/t shearing and HOB (head of bed) up 30 degrees d/t feeding. N.O. to apply [MEDICATION NAME], allevyn adhesive. Res(ident) on a pressure reducing mattress." * "2/15/10 4:20 pm, Drsg changed to coccyx. Area measures 2 x 2. Wound bed yellow/pink. Allevyn placed. HOB up 30 degrees d/t feeding tube..." * "2/24/10 9:55 pm, Drsg changed to coccyx. Area measures 2 x 2 x 0.1. Wound bed is yellow/pink with mod. (moderate) exudate..." * "3/4/10 12:10 pm, Start Mist therapy Tue/Thurs (Tuesdays and Thursdays) to coccyx. Start 3/9/10. Drsg changed to coccyx. Wound measures 2 x 2 x 0.1. Wound bed yellow/pink. Min. (minimum) exudate..." * "3/9/10 2:10 pm, Mist started to denuded area to coccyx. Area measures 1.5 x 1.5 x 0.1. Wound bed is red..." * "3/16/10 10:25 am, Mist done. Drsg applied to coccyx area. Measures 2.5 W x 1.5 x 0.1. Wound bed is red...HOB up 30 degrees, approx(imately) 90 degrees which is causing shear to coccyx..." * "3/22/10 11:10 am, Drsg changed to coccyx. Wound measures 3.5 W x 0.5 L x 0.1. Wound has increased in width d/t irritation from stool..." * "4/5/10 2:00 pm, Mist tx done, drsg changed to coccyx. Wound measures 1 W x 0.5 L..." * 4/14/10 4:00 pm, Mist done. Drsg changed to coccyx. Area measures 0.3 x 0.3. Wound bed is beefy red..." * "4/20/10 12:15 pm, Mist done. Drsg changed to coccyx. Area measures 0.3 W x 0.2 L. Wound bed beefy red..." * "4/28/10 4:00 pm, Area to coccyx is healed. Area covered with white callus-like tissue..." * "5/3/10 11:20 am, Allevyn applied to coccyx. Small open area measures 0.2 L x 0.3 W. Area very superficial. Area caused by shearing..." * "5/11/10 5:00 pm, Allevyn changed to coccyx. No open areas..." On 10/6/10 at 10:00 am, the Wound Care nurse was interviewed regarding the Stage II pressure ulcer to Resident #10's coccyx. She stated she had documented it in the admission note as a Stage I pressure ulcer but stated it "really wasn't a pressure ulcer" because it was blanchable and she felt it was due to shearing. She stated it re-occurred in the same area but smaller approximately one month later. Again, she stated she did not code it as a pressure ulcer because it was due to shearing, pulling and incontinence, describing it as "denuded." The surveyor discussed with the Wound Care nurse that shearing, pulling and incontinence are all factors that contribute to skin breakdown over a bony prominence such as the coccyx and denudation was the removal of the epithelium and therefore, still a pressure ulcer. The Wound Care nurse alleged the Stage II pressure ulcer to the resident's coccyx was unavoidable due to the head of the resident's bed having to be over 30 degrees. The Care Plan for Resident #10, documented a problem, "Alteration Nutritional Status: Has Need for Tube Feedings to Meet Nutritional Needs," with a problem onset dated 9/24/10. An approach listed for this problem documented, "Elevate Head of Bed 75-90 degrees During feedings and for 1 hr. (hour) after feedings." NOTE: At 65 cc/hr, this would mean a continual 24 hour feeding with the HOB elevated at all times. Resident #10 was observed lying in her bed on 10/4/10 at 2:55 pm, on 10/5/10 at 7:15 am, 8:00 am, 10:55 am, on 10/6/10 at 7:55 am, 9:25 am, and on 10/6/10 at 1:50 pm. The resident was observed to have the head of her bed elevated no higher than 45 degrees on any of these observations. The resident was observed in the supine position in all these observations. NOTE: On 10/4/10 at 2:55 pm, a sign was observed taped over the resident's bed that documented the head of the bed was to be at 75-90 degrees. On 10/6/10 at 1:50 pm, the sign was observed to have been removed from over the resident's bed. On 10/6/10 at 10:00 am, the Primary/Village Unit Coordinator was interviewed regarding Resident #10's care planned intervention for elevation of the head of her bed. She stated she thought the intervention was due to Resident #10's past history of nausea and vomiting but stated they had not been following that physician order. She stated she had no personal recollection of the staff elevating the head of the bed to that level. She stated they had a difficult time offloading the resident since she had a history of [REDACTED]. The Primary/Village Unit Coordinator did verify that there was a current physician order [REDACTED]. Incontinence, shearing and friction are all important factors in pressure ulcer formation. The Wound Care nurse failed to properly identify the wound as a pressure ulcer. It was also noted that interventions were not addressed such as changing the degree the head of the bed should have been elevated for the resident, in order to protect her airway due to the tube feeding and offload the weight from the resident's coccyx. There was a lack of documentation of the effectiveness of the interventions in place since the wound worsened over several months before eventually healing with no change in the care plan. Information was received from the facility by fax on 10/12/10 at 2:25 pm, with no change to the findings. 3. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident; * had short term memory problems, * long term memory was intact, * had modified independence with daily decision making, * was totally dependent for transfers, dressing, personal hygiene and bathing. * was incontinent of bowel and bladder, * was bedfast all of the time, and * did not have a pressure sore. Resident #11 had a history of [REDACTED]. She was admitted to the hospital on [DATE] for surgical repair. The resident also had a history of [REDACTED]. This pressure sore returned on 10/01/10. Resident #11's medical record was reviewed. The nursing staff identified a new pressure sore on 10/1/10 on the left ischial area. The nursing notes document; * 10/01/10 (6:00 a.m.), "Open area to L (left) hip noted. [MEDICATION NAME] DRSG (dressing) applied..." * 10/02/10 (1:00 a.m.), "...L hip DRSG intact..." * 10/03/10 (1:30 a.m.), "...L hip DRSG intact..." * 10/04/10 (4:00 a.m.), "Drsg dry and intact to L ischial. (No) drainage noted..." * 10/05/10 (3:20 a.m.), "...Drsg intact..." The facility wound nurse documented in nursing notes; * 10/04/10 96:00 p.m.), "Assessed L ischial. Superficial open area that measures 0.5 x 0.5 (cm - centimeters) over 'old' wound site. Res(ident) is on a Clinitron bed is turned/rep(ositioned) every 1-2 hours. Res has MS and her health has declined over the last several months. Res does not 'feel' the area. [MEDICATION NAME] placed for protection, to promote healing. Res placed on R(ight) side in bed heels floated blanket placed between knees." The resident's care plan was reviewed and documented; Problem: "(Resident #11) has a history of stage IV Pressure sore on her coccyx, and skin flap on sacrum. (Resident #11) has hx (history) of skin issues, increased risk for bruising. Interventions were: "* Special protective devices used: Clinitron air mattress with 1/2 side rails x , and Journey Elite III cushion in wheelchair. Encourage and assist (Resident #11) to turn/reposition every two hours to prevent prolonged pressure..." The resident was observed on her back with the head of the bed elevated about thirty to forty-five degrees on 10/5/10 from 7:20 a.m. until 8:28 a.m. when her room was in constant observation by the surveyor. The resident received her breakfast during the time frame. There was no staff that entered the residents room except to deliver breakfast (8:15 a.m.) and leave. The resident was intermittently observed at 9:15 a.m., 9:35 a.m., 10:00 a.m., 11:00 a.m., and 12:00 p.m. The resident continued to be positioned on her back with the head of the bed elevated during the times she was checked by the surveyor. The resident was watching TV and resting. Observation after 1:10 p.m. showed the resident continued to be positioned on her back with the bed elevated about the same as the morning observation. The resident appeared to be watching TV. The resident was observed in the same position at 1:20 p.m. and 1:45 p.m. and the resident was under constant observation from 2:10 p.m. until 3:00 p.m. A nurse entered the room at 2:55 p.m. and came out immediately. No other staff entered the room during the observation period. The resident remained on her back with the head of the bed elevated at thirty to forty-five degrees. The facility wound care nurse was interviewed on 10/6/10 at 2:00 p.m. The nurse was asked at what stage the pressure sore was and confirmed that it was a stage II. The wound nurse was asked if there was additional documentation about the pressure sore such as depth and shape of the wound, periwound skin condition, drainage amount and character. This information was not available. The Administrator and DON were informed of the observation on 10/7/10 at 3:30 p.m. The DON submitted additional information on the resident. A "Weekly Pressure Sore Tracking Report", dated 10/4/10 - 10/8/10, and documented the resident had a stage II Left Ischial pressure sore that was 0.5 x 0.5 cm with a depth of superficial and no eschar or odor. 4. Resident #17 was admitted to the facility on [DATE] for post surgery care, related to prosthetic replacement for failed hip surgery. The resident had [DIAGNOSES REDACTED]. An "Initial Data Collection Tool/Nursing Service" form was dated 6/28/10. The form included diagrams for the body and feet. The page that had feet diagrams indicated the resident had her feet examined and no pressure ulcers were present and the resident's heels were intact without redness. The form instructed the assessor to ask the resident if she had ever had a sore on her feet that took more than two weeks to heal. Documentation indicated the resident answered, "No." The page with the body diagrams contained documentation for two dates as follows: *6/29/10- The resident had IV sites on her arms, an incision for the right hip and redness to buttocks. (Note: There was no indication if the redness was blanchable). *6/30/10- The left buttock had a denuded area, the right buttock was red. The resident also had [MEDICAL CONDITION] to both lower extremities and several old bruises and and "old sore to the left ankle" was documented. There were no other descriptors, such as staging the buttocks, measurements, etc. The resident's initial MDS, dated [DATE], documented she had no cognitive deficits, was incontinent of bladder and had no pressure ulcers. A "Braden Scale For Predicting Pressure Sore Risk" form, included assessments completed on dates 6/28, 7/6, 7/13 and 7/22/10. Each assessment documented a total score of 15 (15-18 = At risk). The back of the form indicated the resident had predisposing medical conditions of [MEDICAL CONDITION] and diabetes. Risk factors were documented as recent surgery, decreased or impaired bed/chair mobility, urinary or bowel incontinence and pain that affects movement or mood. The resident's care plan did not have the date initiated. However, a problem was identified for mild to moderate risk for pressure ulcers, date of onset 7/18/10. The goal was for the resident not to develop avoidable pressure ulcers with the aid of facility interventions as follows: - "Initial skin assessment. Weekly skin assessment. M.D. (Medical Doctor) and dietitian notification of any skin issues when noted. LN to provide fingernail/toenail care weekly due to resident being diabetic..." - "Float heels while in bed. LN to check every 8 hours. Encourage resident to reposition at least every hours and prn (as needed). (Note: The frequency of repositioning was not documented). Pressure reducing mattress to bed. Pressurre (sic) reducing cushion to w/c (wheelchair). Abduction brace on at all times." - "If Resident has any wounds show any s/sx (signs/symptoms) of infection i.e.; warmth, swelling, increased drainage, increased pain, or change in drainage, notify the resident's primary. If it's surgical site, notify resident's site (as documented)." The following hand written additions to the interventions on the care plan were as follows: - 9/15/10- "Compression stockings 10-20 mmtlg (unknown acronym) on in AM off at HS (bedtime) DX (Diagnosis): [MEDICAL CONDITION]" -10/1/10- "Prafo boot to R(ight) foot on at all times." -10/1/10- "OpSite to R heel (change) 7 days." A physician telephone order, dated 10/1/10, documented, "Blister to R medial heel. Cover (with) OpSite (change) 7 days- Protect (with) Prafo boot on at all times. LN to check every shift." The following nurse progress notes were documented: - 10/01/10, (3:30 am)- "2 blisters observed: 1) Left Malleolus red circular and tender- (no) drainage. Allevyn adhesive applied for protection. 2) Rt (Right) heel circular pale area- (no) drainage. Allevyn heel wrapped (with) [MEDICATION NAME] for protection. Heels were already floated. Pillow between knees..." - 10/05/10, (4:00 am)- "...Blister noted to R heel. Note left for wound nurse. Prafo boot on to R foot..." The WCC (wound care certified), RN was interviewed on 10/7/10 at approximately 2:00 pm. The surveyor asked her to provide information related to the development of blisters on Resident #17's feet. The WCC, RN said that there were not two blisters and added that she had no idea why the nurse documented that. She indicated the resident did have a blister to her right heel and it was improving. The WCC,

Based on observations, record review and staff interview, it was determined that the facility failed to provide psychosocial referral, assessment and interventions to address a resident's refusal of multiple areas of care. This was the case for one (#5) of 18 sampled residents. Resident #5 was harmed based on multiple refusals for care. Her refusals, and the resulting harm included; *Refusal of positioning to treat a Stage II pressure sore that had not healed, *Refusal of medications to prevent [MEDICAL CONDITIONS] which subsequently required a blood transfusion, *Refusal of bathing resulting in dry flaky feet, and going weeks without a bath, *Refusal to allow staff to weigh her, resulting in unknown gains and losses, and *Refusal of medical treatments for bowel care resulting in constipation and diarrhea. Resident #5 was a danger to her roommate based on history of; *turning heat on in the bathroom putting roommate at risk for dehydration, *socially inappropriate behavior of not wearing clothing, *turning the TV volume up and not wearing headphones. Resident #5 has a potential to alienate staff providing care as it had been noted she had an increase in profanity use with the staff that care for her. The facility failed to monitor and develop behavioral interventions for the behaviors that Resident #5 exhibited to include; * refusals for care in multiple areas, * fabricating facts, to include bowel issues and illnesses, * socially inappropriate behaviors, * infringement on the resident's roommate's rights. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/2/10, documented the resident: *had short term memory problems, *long term memory was intact, *was independent in decision making skills, *was easily distracted and was not of a recent onset, *had persistent anger with self or others and not easily altered, *exhibited almost daily repetitive health complaints, *had [MEDICAL CONDITION]/change in regular sleep patterns, *needed extensive assistance of two staff for bed mobility, transfers, and toilet use, *needed limited assistance for dressing, *needed supervision for eating and personal hygiene, *did not have a bath in the seven days of the assessment, *was continent of bowel but totally incontinent of bladder, *had a weight loss, *had a chewing problem, and *had an overall deterioration in care needs, received more support. The quarterly MDS, dated [DATE], failed to document any behavioral symptoms the resident exhibited. The resident was evaluated 5/28/10 with a "Short Portable Mental Status Questionnaire (SPMSQ)" and received a score of 2. This translated to "Intact Intellectual Functioning." The resident had multiple areas that she refused care. The nursing notes documented the following: *BATHING; -8/26/10 (11:00 p.m.), "Noncompliant (with) bathing schedule, ref(used) showers/baths..." -9/18/10 (9:15 p.m.), Skin check shows both feet covered in layers of dry flakey (sic) skin. Res(ident) very reluctant to allow inspection refuses offer of cleaning..." -9/23/10 (9:00 p.m.), "Resident also refused shower, bed bath, or assistance washing feet." *BOWEL CARE; -8/8/10 (1:40 a.m.), "requesting [MEDICATION NAME] for 'loose stool' stool was formed I explained to res that her Dr has been notified of her request...res was upset and continued to argue (with)me..." -8/26/10 (11:00 p.m.) "Res (without) BM x 3 days, Ref PRN MOM...Hx (history) of noncompliance (with) bowel care regimen..." -9/4/10 (3:30 p.m.), "(no) BM x (times) 4 days ref(used) MOM/suppository/prune juice/enema..." -9/7/10 (9:20 p.m.), "Res states she has had diarrhea (on) day shift, aides report soft BM only, Res angry..." -9/10/10 (11:00 p.m.), "Res demanding PRN (as needed) [MEDICATION NAME] despite (no) diarrhea. Res claims staff observed diarrhea. When staff interviewed, staff member reported (no) loose stool just a slight 'smear' of BM. Res became very angry and aggressive calling this writer an 'ass' and claiming persecution...." -9/30/10 (6:20 a.m.), "Resident currently on 7 days without BM (bowel movement). Refused stool softener or any other bowel regimen." -10/2/10 (2:00 a.m.), "On 8 day bowel list, refusing suppository. *PRESSURE SORE CARE for pressure sore on the right ear; -8/25/10 (11:00 p.m.), "Res reported R ear (with increase) pain, R pinna dark red/painful 0.3 cm (centimeter) open area midway over edge R pinna, white wound bed...Res refused to (change) position and lay on L(eft) side." -8/28/10 (11:45 p.m.), "DRSG intact to R ear, Ref to have DRSG (changed) states she will allow DRSG (change) tomorrow...continues to lay on R side (with) ear flat on pillow, non-compliant (with) redirection." -8/31/10 (10:00 a.m.), "DRSG intact to R ear, foam cushion for pillow attempted for (decrease) pressure on R ear. Res rejected foam - states uncomfortable..." -9/5/10 (10:10 p.m.), "DRSG (Dressing) inplace R ear, ref(uses) to reposition, R side of face and R eye swollen, redness around mouth." -9/23/10 (9:00 p.m.), "Res is still refusing to reposition off R side." -9/28/10 (9:45 p.m.), "Resident refused to allow dressing to be changed by WLN (Wound Licensed Nurse) today." -9/30/10 (6:20 a.m.), "refuses to to reposition lays on R side all night." -10/2/10 (2:00 a.m.), "encouraged to turn off of right side. Resident refusing to turn." -10/3/10 (2:00 a.m.), "dressing on R ear. Refusing to turn off of R side." -10/5/10 (3:30 a.m.), "refuses to lay on the other side stays on R (right) side all shift." *OVERALL REFUSAL OF CARES -8/26/10 (11:00 p.m.), "Res ref to leave room x to be weighed monthly, res is non-compliant (with) most interventions/plans of care/regulations, prefers to lay in bed in room only moving to eat/toilet/use call light, c/o severe pain..." -8/31/10 (10:00 a.m.), "Res to record/write pain level ... Res declined stating, "its a bad day.... No - Psych(iatric) eval(uation)..." -9/28/10 (3:35 p.m.), "Resident c/o (complained) her mattress was to(o) hard and she needed new mattress this is why she would not turn. She has been offered a new mattress the past two days and she is refusing to get OOB (out of bed) - she c/o she is to tired." The nursing notes documented, on 4/30/10 at 7:00 a.m., a call from the resident's physician that she had "critical labs - [MEDICAL CONDITION]" and the resident had to have a blood transfusion at the local hospital. The resident had an [MEDICAL CONDITIONS]. The Nurse Practitioner documented on 5/9/10 the resident "refuses iron oral." As a result the physician had been monitoring the resident laboratory blood values closely. The "Social Service Progress Notes" documented that the resident was not compliant and refused cares. The documentation was completed by the Resident Services staff. Some examples of documentation were; -5/10/10 "quarterly note:...res cont(inues) to have repetitive health related concerns, obsessive concerns (with) body functions...she is easily annoyed at others and is not easily redirected...refusing to leave her room, refuses to (illegible) dressed etc...." -5/28/10 "Large plastic bag was left on my desk full of "pull-ups"(with) a note...(Resident #5) has the staff open bags of pullups so she can count the stitching and will not use them if she does not like the stitching...went to visit...she was lying down ...res in a blouse and attend only. Our conversation was pleasant until (we)started talking about the pullups.(sic) She stated that the staff does not know what they are talking she said the pullups are tight on her sometimes creating pain for her, she also said that she has 'tight waist syndrome'...Res made several negative comments about staff and dietary and is angry (with) me because I talked to her about the pullups and that I don't understand her, not happy (with) facility I reminded her that the ombudsman came to see her and she had ask ombudsman to come at a different time....I explained that I am concerned that she is not getting up and OOB, refuses to turn on her left side to allow her face to heal, refuses to leave her room...is angry that I think she is depressed. Our visit did end on a positive note and she said that if her TV is too loud staff can turn it down." -8/9/10 "SS quarterly note: ...will not shower/bathe (with) an aid (sic) states she does it herself..." -9/2/10 "declined to have psych(iatric) eval(uation)...stated did not feel like it. Refused to allow me to reschedule." -9/15/10 "During our IDT meeting we reviewed (Resident #5) refusal of cares, treatments and concerns that she will not bathe and tells staff that she does it herself etc. ...we explained to (ombudsman's name)that (Resident #5) is refusing cares from staff, that she changes her own attends, refuses to take a shower or bath states to staff she washes herself. (Resident #5) has a sore on her R ear she refuses to lay on the other side (Resident #5) frequently requests pain meds and is focused on her bowels and frequently asking for meds...'...(Resident #5) now will lay in bed and if she wants to talk she will if not she will ask you to leave resident will avoid conversation that are about her participating in cares, allowing staff to shower her or requests that she wear clothes or cover up her bottom half if she complains of being cold..." -9/15/10 "I spoke (with) (Resident #5) today....c/o her ear still bothering her (R/T (related to) sore that res will not turn off of) I asked...she would try lying on her other side she respond 'you just don't understand'..." -9/23/10 "Bath aid (sic)...visited (with) (Resident #5) and let her know that she can schedule her anytime today for a bed bath, (Bath aide name) said (Resident #5) refused saying she was sick and in pain, using profanities...did not know why (Resident #5) swore at her..." -9/27/10 "Reported to me that (Resident #5) refused to have her bedbath, stating that she was too sick...Staff reported that (Resident #5) is having them turn the bathroom heater on and close the door to her room. Res roommate found very wet/sweaty... I told (Resident #5) that she can also have extra blankets and may need to wear bottoms at night... She said she woke up in a 'bad' mood, 'don't you ever wake up in a **** bad mood?'...I am also getting reports that you are using foul language to the staff and that she was not always doing that. ...we will talk again about how unhappy she is here (with) the care, staff etc and (Resident #5) said 'well I'll just move someplace else' I said 'if you want to move I will assist you in finding alternate placement' She became angry and said she is not in the mood to talk..." -9/30/10 "CNA/Bathaid (sic) ask (Resident #5) to allow her to give her a bed bath today, she declined saying that she is expecting a visitor today 'so not today'..." -10/2/10 "DNS and myself visited (with) (Resident #5), she was not very responsive other than to say that she needed to use the bedside commode. DNS ask(ed) if while she was using the bathroom if he could have her new mattress put on her bed, she said 'no its not a good time.'...the new mattress has been sitting here and staff have tried to put it in her bed for a week..." -10/2/10 "In response to concerns expressed during care plan conference...(Resident #5) has refused almost daily attempts offers to provide a bed bath for her and to wash her hair. No bed baths done because res had a variety of reasons. I have not seen (Resident #5) lay on her left side at all. New mattress has been purchased and staff has attempted to put mattress on res bed to no aval (sic) res repeatitive (sic) has refused (with) one excuse or another. A new dress (sic) was purchased per res request, she did not like the dresser and was cussing and telling staff to get out of her room..." The dietary department documented that the resident had refused to allow the aides to get a weight and verify an inaccurate weight. The dietary manager documented; -8/12/10 "...have asked (Resident #5) if she would let us take her wt(weight) tomorrow (8/13/10) 'I'll have to see it depends on if I have a headache' Resident has refused to let us re-weigh her since 7/21/10 when the wt was 133# which is up 5.2% since 6/25/10. This (documenter) does not feel wt of 7/21/10 of 133# is accurate however cannot know as (Resident #5) refused to have wt taken 7/26/10, 8/2/10, 8/4/10, 8/9/10, 8/11/10..." Resident care plan dated 8/16/10 documented a problem for Resident #5; Self Care deficit: requires supervision to extensive assist for completion of ADL cares. Interventions were; "*(Resident #5) is independent with ADL cares, she is to have a bath/shower 1-2 times a week, shampoo hair at least once a week...needs oral care BID (two times a day) and PRN, she has poor dentition. *...chooses to have her door of her room closed most of the time. *...prefers to lay on top of bed with t-shirt and attends on only. Educate on privacy and rights of roommate to have visitors. ...turns on heat due to being cold - reminded to put comfortable clothes on to ensure temp comfortable for roommate also." Resident care plan dated 08/16/10 documented problem; (Resident #5) has minimal difficulty hearing when not in quiet setting. An interventions was; "*...refuses to wear ear-phones due to bothering ears, observe for loudness of TV so that it is not affecting roommate." Resident care plan dated 8/16/10 documented problem; Alteration in continence (Resident #5) is usually continent of bowel and incontinent of bladder, she has history of hemorrhoids, and refuses MD recommendation to treat constipation. Resident has fixation re: bowels. Interventions were: "* Monitor bowel pattern and follow bowel brigade PRN. * Treatment per MD order. *Check at least every 2 hours and PRN. Toilet per request. Provide peri care after toileting and after each incontinent episode. (Resident #5) wears briefs to aid in continency care." Resident care plan dated 8/16/10 documented problem; (Resident #5) has tendency to fabricate facts with regard to cares, timing. Frequent complaints about various staff, cares. Has history of not getting along with roommate. Interventions were; "* Respond to call light and concerns as quickly as possible. * Visit with (Resident #5) 1:1, offer support. Try to establish trusting relationship. * Observe temp. of room to ensure (Resident #5) does not control temp. at roommates discomfort. * Approach (Resident #5) with two care givers when ever possible." Resident care plan dated 8/16/10 documented problem; (Resident #5) may be risk for depression d/t (due to) decline in independence, limited support system and possible change in living situation. Interventions were; "*Educate (Resident #5) on various options if antidepressant needed and the benefits of getting up and out of her room to decrease risk of depression. * (Resident #5) denies depression, she does not want antidepressant. * Monitor for S/S (signs and symptoms) of depression on behavior monitoring sheet in the MAR. * Visit 1 : 1 offer support and encouragement. * Encourage visits and involvement from son and friend. Does have limited support system. * Encourage any interests in diversional activities and interaction with peers and staff. * Encourage (Resident #5) to verbalize her feelings and concerns." Resident care plan dated 9/24/10 documented problem; (Resident #5) consistently refuses to be bathed, states that she does her own bed bath, but would like for staff to assist her, however when approached by staff resident refuses, swears at the staff and tell them she is too sick to have a bed bath. Interventions were; "* Let (Resident #5) know that she (sic) have time to give her a bed bath today, allow her to give input as to when would be a good time for her.(sic) Do not argue with (Resident #5), if she refuses document on the behavior monitoring sheet in the MAR. * Always approach (Resident #5) in a calm manner, allow her time to respond. * Praise (Resident #5) when she cooperate with plan of care.(sic) * Approach resident warmly and positively. * Inform Social Services of inappropriate behaviors such as use of foul language towards staff. * Social Services to monitor with at least weekly visits, involve Ombudsman as needed. * Educate (Resident #5) on the positive aspects of good hygiene. * Try to always offer (Resident #5) choices so that she feels in control of the situation." Resident #5's "Behavior Intervention Monthly Flow Record" were requested. The DON on 10/6/10 at 1:30 p.m. stated there were no August and September 2010 behavior intervention sheets to review. Interview with the DON and Resident Service manager on 10/7/10 at 9:30 a.m. was revealed that the documents had not been completed and placed in the MAR for staff to document Resident #5's behaviors. The June and July 2010 "Behavior Intervention Monthly Flow Record" tracked two behaviors these were; "S/S of Depression" and "Refusal to leave her room." The form for both months had "All" in the "Refusal to leave her room" behavior. The Resident Service Manager was asked about the other behaviors that the resident exhibited in the medical record and the response was that refusals were the "normal behaviors" for the resident. The October 2010 "Behavior Intervention Monthly Flow Record" was given to the surveyors the afternoon of 10/7/10 and it had different behaviors listed then what was on the June and July 2010 forms, these were; "1. Refusal of Meds, treatments, baths, changing linens, brushing teeth, weighing, turning every 2 hours." and "2. Socially inappropriate (ie: not covering self, wearing attends only(without) covers, wearing T-shirt only, not wanting curtain pulled." The documentation on the form was the night shift for 10/6/10 and documented the resident had 4 episodes of behaviors #1 and the intervention was "5. Return to room." and the outcome of the intervention was "0 Unchanged." The form did not document which of the refusals for care that the resident was documented as doing four times. There was no indication that a Licensed Social Worker had been involved in aiding the IDT develop a care plan or treatment modalities for Resident #5. During the survey a surveyor, on two occasions, attempted to talk with the resident. Resident #5 requested, on 10/5/10, that the DON advise the survey team she did not want them to have any interactions with her. This request was honored by the survey team. The Administrator and DON were informed about the resident behavioral issues on 10/8/10 at 11:15 a.m. The facility submitted further documentation to the agency. The information was reviewed. The resident's physician was aware of the refusals and had written an order 8/31/10 for a "psych(iatric) eval(uation)" which the resident refused. The physician further documented in a letter dated 10/8/10 "(Resident #5) makes her own decisions about care. I believe she is mentally competent to make her decisions even though she often makes bad decisions - i.e. refusing to get up, refusing physical therapy, making strange diet choices, refusing to roll over and take pressure off her pressure points, refusing psychiatric help or assessment. These are her choices." The additional documentation indicated that the resident's behaviors may be increasing as documented by refusals, profanity, pressure sore care and socially inappropriate behavior and the involvement of the ombudsman. The facility failed to submit any type of behavioral intervention plan that would protect the resident, staff and roommate.