Every finding on record at Canyon West of Cascadia

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 4/12/26 at 9:30 AM, observed the following in the kitchen with the food service manager.- In the dry food storage area - a container of garlic powder with a use by date of 12/18/24, a container of chili powder with a use by date of 2/25/25, an opened bag of taco seasoning with no opened date or use by date, a container of chocolate sauce with a use by date of 3/13/26.- In the refrigerators - cut onions in a container with use by date of 4/10/26, an opened undated bag of cut cabbage, a tray with bagged cheese and an unsealed bag of salami with liquid in it that had leaked on to the tray that held both the cheese and salami, ham in a container with no use by date, small individual cups labeled as salad (dressing) with a prepped date of 3/28, but no use by date.- In the freezers - opened undated bag of chicken wings, opened unsealed and undated box of seasoned beef patties.- In the clean pan area - a skillet with encrusted food on the inside and outside of the pan.On 4/12/26 at 10:10 AM, the Food Service Manager stated the opened food items should have been closed and sealed correctly, all food items needed use by dates, and the encrusted pan should have been cleaned correctly.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 4/13/25, during review of the facility Daily Staffing sheets, the surveyor observed the following issues: - September 2025 - 23rd, 24th, 25th, 26th: Missing census data on the Daily Staffing sheets.- September 2025 - 27th, 28th, 29th: Missing Daily Staffing sheets. - January 2026, 18th, 19th, 20th: No nursing data (number of hours worked by nurses) documented on Daily Staffing sheets.On 4/16/26 at 10:26 AM, the CNO and Director of Clinical Resources stated the Daily Staffing sheets should not have been missing, nor missing required data but were.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were assessed for safety to self-administer medication. This was true for 1 of 1 resident (Resident #2) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if Resident #2 self-administered inhaler medication and received too much or too little of the medication. Findings include:The facility's Self-Administration of Medications policy revised 9/16/25, documented residents may self-administer medications when it was determined to be safe and appropriate.Resident #2 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung disease characterized by increasing breathlessness) and diabetes.Resident #2's physician's order dated 4/9/26, included an Albuterol Sulfate (inhaler) HFA Inhalation Aerosol solution mcg/act, one puff inhale orally every four hours as needed for shortness of breath, and he may keep the medication at his bedside.A Self-Administration of Medication Evaluation dated 3/24/26, documented Resident #2 was fully capable of administering nebulizer treatments after set-up by the nurse.Review of Resident #2's physician's order did not include an order for him to use a nebulizer.On 4/12/26 at 10:53 AM, an inhaler was observed on Resident #2's over the bed table. Resident #2 stated he had asthma, and used the inhaler when he needed it. When asked how often he uses the inhaler, Resident #2 stated, sometimes two times a day.On 4/13/26 at 9:40 AM, Resident #2 was observed taking two puffs of the inhaler albuterol. On 4/13/26 at 4:36 PM, the CNO stated Resident #2 had an assessment to self-administer his inhaler. Surveyor told CNO that an assessment to self-administer the inhaler was not found in his record. CNO stated she would look for Resident #2's assessment to self-administer the inhaler.On 4/14/26 at 10:15 AM, the CNO stated she was unable to find Resident #2 was assessed to self-administer the inhaler and he should have one.

Based on record review, policy review, SOM Appendix PP, and staff interview, it was determined the facility failed to ensure comprehensive centered care plans' interventions were implemented. This was true for 1 of 20 residents (Resident #2) whose care plans were reviewed. This failure created the potential for harm should Resident #2 experience complications and receive inappropriate or inadequate care. Findings include:The State Operations Manual Appendix PP dated 7/23/25, documented, The comprehensive care plan must reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.The facility's Comprehensive Care Plans revised 9/3/25, documented the facility will ensure that each resident has a timely, person-centered comprehensive care plan developed and maintained in accordance with professional standards of practice. The care plan will reflect the resident's individual conditions, risks, needs, behaviors, cultural values, and preferences and will include measurable goals, appropriate interventions, and realistic timeframes.Resident #2 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including diabetes, and chronic obstructive pulmonary disease.A physician's order dated 12/27/25, directed staff to administer apixaban (anticoagulant) oral tablet 5 mg by mouth two times a day to Resident #2.A care plan initiated 12/27/25, documented Resident #2 was on anticoagulant therapy and staff were directed to give the medications as directed by the physician and monitor/document the effectiveness and potential side effects: abnormal bleeding/bruising, black stools, pink-tinged urine, leg/pain swelling, nausea and vomiting, sudden onset of chest pain/shortness of breathing, and to notify the physician as indicated.Review of Resident #2's records did not include documentation he was being monitored for the side effects of his anticoagulant.On 4/14/26 at 10:15 AM, the CNO stated Resident #2 did not have monitoring for his anticoagulant and there should be a monitor.

Based on review of records, policy review, and staff interviews, it was determined the facility failed to ensure residents' comprehensive care plans were revised timely and as needed. This was true for 2 of 20 residents (#8 and #11) whose care plans were reviewed. This deficient practice created the potential for residents to receive inappropriate or inadequate care due to inaccurate information in their care plans. Findings include:The facility's Resident Care Plan Revisions policy revised 9/3/25, documented when a resident's condition, response to treatment, or care needs change, the facility would promptly review and revise the care plan to reflect those updates. 1. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, dysphagia (difficulty swallowing), and bilateral hearing loss. A care plan revised 3/10/24, documented Resident #11 used an antidepressant related to depression, and appetite. Review of Resident #11's Medication Administration Record, documented that the Mirtazapine (antidepressant) had been discontinued on 4/6/26. On 4/14/26 at 1:14 PM, the CNO stated Resident #11's care plan should have been updated when her antidepressant was discontinued due to her refusal to take the medication. 2. Resident #8 was readmitted to the facility on [DATE], with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema (the abnormal accumulation of fluid in the lungs, which impairs oxygen exchange). A physician's order dated 2/4/26, documented for Resident #8 to receive oxygen at 2 LPM continuously per nasal cannula via O2 concentrator and/or tank. A review of Resident #8's care plan directed staff to provide oxygen therapy as ordered via nasal cannula. Resident #8 was observed on the following dates and times not wearing her nasal cannula: -On 4/13/26 at 8:45 AM, while eating breakfast. -On 4/13/26 at 2:15 PM, while lying in bed. -On 4/14/26 at 9:30 AM, while sitting up in a chair. On 4/15/26 at 1:44 PM, LPN #3 stated Resident #8 frequently did not wear her nasal cannula or BiPAP, and staff were verbally instructed to ensure she wore her nasal cannula or document if she did not. On 4/15/26 at 1:46 PM, after a review of Resident #8's medical record, LPN #3 was unable to find any notes to or from staff directing them to ensure Resident #8 wore her cannula or to document it in her medical record. On 4/15/26 at 3:02 PM, the facility provided a physician's note dated 4/13/26, which documented Resident #8 refused to wear her nasal cannula and BiPAP, and requested a consideration to reduce oxygen requirements and/or physician's orders. On 4/15/26 at 3:03 PM, the CNO stated Resident #8's care plan related to nasal cannula and BiPAP refusal behaviors should have been updated on 4/13/26, when the physician saw her.

Based on observation, record review, resident and staff interviews, it was determined the facility failed to ensure physician's orders for bowel care were followed. This was true for 1 of 4 residents (Resident #8) reviewed for bowel care management. This deficient practice created the potential for residents to experience discomfort related to constipation. Findings include:Resident #8 was readmitted to the facility on [DATE], with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema.Physician's orders documented the following:-Miralax oral powder, 17 gm/scoop, give 17 gm by mouth two times a day for bowel care mix with at least 4 oz fluid of choice, ordered 3/16/26.-Bisacodyl EC Oral Tablet Delayed Release 5 mg, give 1 tablet by mouth one time a day for constipation prevention, ordered 3/16/26.-Senna plus oral tablet 8.6-50 mg, give 2 tablets by mouth two times a day for bowel care, ordered 2/16/26.-Senna oral tablet 8.6 mg, give 3 tablets by mouth as needed for bowel protocol step #1 if no BM in 72 hours (day 3), ordered 3/24/26.-Bisacodyl Oral Tablet Delayed Release 5 mg, give 3 tablets by mouth as needed for bowel protocol step #2 if no BM in 96 hours (day 4), ordered 3/24/26.-Bisacodyl Rectal Suppository 10 mg, insert 1 suppository rectally as needed for bowel protocol step #3 if no BM by morning following after (day 5) completing oral bisacodyl, ordered 3/24/26.A review of Resident #8's medical record documented she did not have a bowel movement from 4/9/26 through 4/12/26 (4-days).A review of Resident #8's MAR dated 4/9/26 to 4/13/26, documented she did not receive bowel protocol step #1, step #2, or step #3.No records were available for 4/12/26 related to bowel care.On 4/14/26 at 9:35 AM, the ACNO confirmed Resident #8's MAR did not document she had received bowel protocol medication on 4/12/26 or 4/13/26. She confirmed there were no progress notes related to Resident #8's refusal or education provided by staff.

Based on policy review, observation, 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 6 Residents (#1 and #20), and providing oxygen without a physician's order for 1 of 6 residents (Resident #89), whose records were review for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels, or having oxygen provided without physician oversight. Findings include:The facility's Oxygen Administration, Safety, Storage and Maintenance policy dated 8/4/23, directed staff to document procedure/administration in resident medical record, provide ongoing documentation of routine and PRN oxygen use, notify physician as indicated with resident changes of condition and/or complications with supplemental oxygen use, and to store oxygen and respiratory supplies in bag labeled with resident's name when not in use. 1. Resident #1 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) and chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness). On 4/12/26 at 10:38 AM, Resident #1 was observed not wearing his oxygen cannula. RN #2 entered Resident #1's room to empty his half full urinal and left his room without addressing that he was not wearing his oxygen cannula. Resident #1's physician oxygen order dated 8/4/25, documented oxygen at 2 LPM continuously per nasal cannula via O2 concentrator and/or tank, as tolerated or allowed. Resident #1's care plan dated 12/5/25, documented oxygen therapy as ordered via nasal cannula. On 4/16/25 at 10:28 AM, the CNO and Director of Clinical Resources stated the RN should have addressed Resident #1 not wearing his oxygen cannula. 2. Resident #20 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes. On 4/13/26 at 12:41 PM, Resident #20's CPAP mask was sitting on the bedside table not covered or bagged. On 4/16/25 at 10:30 AM, the CNO and Director of Clinical Resources stated the RN should have addressed Resident #20's unbagged CPAP mask sitting on the bedside table. 3. Resident #89 was admitted to the facility on [DATE], with multiple diagnoses including acute and chronic respiratory failure with hypoxia (low oxygen in the blood) and asthma. On 4/12/26 at 2:39 PM, Resident #89 was observed with an oxygen concentrator next to her bed with an attached nasal cannula and oxygen tubing located on the floor. Resident #89 stated her nasal cannula is normally stored on top of her oxygen concentrator and hoped that staff would change out the cannula as it had fallen on the floor. Resident #89 stated she had been using oxygen at 4 LPM since her admission on [DATE]. On 4/13/26 at 8:46 AM, Resident #89's nasal cannula was observed hanging over the oxygen concentrator. Resident #89 stated neither the oxygen tubing nor nasal cannula were replaced, but staff had added a sticker with the date of 4/13/26 onto the oxygen tubing. A review of Resident #89's medical record on 4/12/26 and 4/13/26 did not document a physician's oxygen order. A review of Resident #89's care plan did not document oxygen therapy until 4/13/26. On 4/13/26 at 3:14 PM, it was observed Resident #89's oxygen concentrator was set at 4 LPM. On 4/13/26 at 3:37 PM, the CNO confirmed the oxygen concentrator was set at 3.5 LPM. Resident #89 disagreed with the CNO and stated she had been using oxygen at 4 LPM as she did while at home. On 4/13/26 at 3:48 PM, the CNO confirmed there was an oxygen order dated 4/13/26 for 2 LPM. She further stated, Resident #89's oxygen should not have been set at 3.5 or 4 LPM. When asked if oxygen is normally provided to residents without a physician's order, the CNO stated, a physician's order should have been received before Resident #89 was placed on oxygen.

Based on record review and staff interviews, it was determined the facility failed to have an RN on duty for at least 8 consecutive hours a day. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect all residents residing at the facility. Findings include:On 4/13/25, during review of the facility Daily Staffing sheets and licensed nurse timesheets, the surveyor noted the facility only had 3 hours of RN coverage in a 24 hour period for August 10, 2025.On 4/14/26 at 3:36 PM, the Director of Clinical Resources stated an RN had not worked for at least eight hours during August 10, 2025, and should have.

Based on observation, record review and staff interview, it was determined the facility failed to ensure medications were stored securely. This was true for 1 of 1 resident (Resident #5) whose medication was observed in the room with no physician orders, and a medication cup with pills observed on the medication cart unattended. This deficient practice created the potential for harm if residents picked up and took medication not prescribed to them. Findings include:The facility's policy, Medication Storage & Labeling, released 10/13/25, stated, The facility will ensure that medications are stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles to ensure safety, efficacy and compliance.1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including toxic encephalopathy (a brain dysfunction caused by toxic exposure to toxins) and acute respiratory failure with hypoxia (sudden inability to oxygenate the blood).On 4/13/26 at 10:08 AM, Resident #5 was observed storing a bottle of Lactaid (provides lactase enzymes for lactose intolerance) in her bedside nightstand. Resident #5 stated she was sensitive to milk, and takes Lactaid one or two tablets as needed. On 4/15/26 at 10:07 AM, LPN #1 reviewed Resident #5's MAR for Lactaid, and stated she did not have an order for Lactaid, then stated, I will get them out of the room.2. On 4/14/26 at 9:30 AM, LPN #1 left the medication cart and entered a resident's room, a medication cup containing a small pill was observed unattended on top of the medication cart. When asked about leaving the medication out, LPN #1 stated, I shouldn't have done that.

Based on observation, staff interviews and record review, it was determined the facility failed to ensure an Enhance Barrier Precaution was implemented. This was true for 1 of 1 resident (Resident #89) whose medication administration was observed. This deficient practice created the potential for the spread of infection and its associated complications. Findings include:Resident #89 was admitted to the facility on [DATE], with multiple diagnoses including nicotine dependence, hypertension, anxiety, and insomnia.A physician's order dated 4/10/26, directed staff to administer meropenem (an antibiotic) intravenous solution reconstituted one gram three times day for septic shock related to urinary tract infection.A care plan revised 4/12/26, documented Resident #89 was on enhanced barrier precautions to reduce the risk of MDRO (multiple drug-resistant organism) transmission related to PICC (Peripherally Inserted Central Catheter). The care plan directed staff to use gowns and gloves when performing high-contact resident care (dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care).An Enhanced Barrier Precaution signage was observed posted on Resident #89's door.On 4/14/26 at 3:39 PM, LPN #2 entered Resident #89's room with the meropenem medication in her hand. LPN #2 performed hand hygiene and donned gloves. LPN #2 sanitized the PICC's line needle connector cap, flushed the line with normal saline and then administered the meropenem. LPN #2 was not observed to put on a gown before accessing Resident #89's PICC line.On 4/14/26 at 3:40 PM, LPN #2 stated she forgot to put on the gown. She stated she should have put on the gown before accessing Resident #89's PICC line.On 4/14/26 at 4:14 PM, the IP stated, Yes, gown is required prior to administering the antibiotic. The nurse should have worn a gown.

Based on staff interview and record review, it was determined the facility failed to provide the required Registered Nurse (RN) coverage for two of 92 days (8/18/24 and 8/25/24), reviewed for weekend staffing. This failure placed the residents at risk for inadequate assessments, delay in care and services by an RN, unmet care needs, and diminished quality of life. Findings include: As required, the facility provided payroll based data to CMS quarterly. Review of the Payroll Based Journal (PBJ) staffing data report for July 1-September 30, 2024, triggered excessively low weekend staffing during the fourth quarter of 2024. PBJ staffing defines a day as starting at 12 midnight to 12 midnight. The facility's employee timecards for RNs, Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) were reviewed for those weekend dates and documented the following: -Sunday 8/18/24 documented zero RN hours worked, -Sunday 8/25/24 documented four RN hours worked. On 2/7/25 at 1:00 PM, the Human Resources Staff Manager confirmed the RN scheduled to work on 8/18/24 called off and the facility was unable to get another RN to come in, and on 8/25/24 the facility had scheduled only one RN to work a total of 4 hours.

Based on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained, cleaned, and sanitized. These deficiencies had the potential to affect the 71 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment. Findings include: The Food Drug Administration (FDA) Code, Section 4-602.12 Cooking and Baking Equipment: Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 2/3/25 and 2/7/25, it was observed during the kitchen inspections and tray line observations, staff were using cookware (sheet pans, pots, and food skillets) which had black residue encrusted along the bottom rims, on the corners, and at least 1-inch along the top of the skillet pans. On 2/6/25, at 12:15 AM, a black rimmed stainless steel skillet was observed being used to make quesadilla's for the resident's lunch meal. On 2/7/25 at 11:10 AM the DM stated, dishes and cookware are cleaned and sanitized according to manufacturer instructions. However, she added, Nothing special is done for the stainless steel other than regular cleaning and sanitation. These pots, pans, and cookware have been in the facility for years, are black, and need to be replaced. On 2/7/25 at 11:11 AM, the Dietitian confirmed the cookware is approved stainless steel food grade pots, pans, and cooking sheets, but agreed they needed to be replaced as there was a black buildup on the skillets, pans, and pots.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control practices were consistently implemented as they related to environmental cleaning. Failure to ensure the shower rooms were cleaned and disinfected to maintain a sanitary environment was true for 1 of 3 showers observed. This failure had the potential to impact all residents, staff, and guests in the facility. Findings include: The facility's Infection Prevention and Control Program, revised 10/15/22, documented measures to prevent infections and appropriate use of disinfectants. On 2/5/25 at 4:45 PM, the shower room on the 200 hall was observed with the Maintenance Director. He confirmed that there was a thick, fuzzy, raised black substance along the area where the wall meets the floor directly behind the movable shower chair and an area on the ceiling that looked like mold. The Maintenance Director stated it was the responsibility of the nursing staff to disinfect the shower between uses and he cleans the grout in the shower rooms monthly or sooner if notified by staff that there is a need. He added, based on his training with identifying and preventing the growth of mold, the amount of mold growth observed would have taken 3-4 weeks to reach that size, and should have been identified by every nursing staff who had assisted residents with using that shower. On 2/6/25 at 10:09 AM, CNA #1 stated, there was no onboarding training or expectations given to CNA's regarding cleaning or disinfecting the showers between resident use. On 2/6/25 at 10:55 AM, the Housekeeping Manager and Laundry Aid #1 both stated the resident shower rooms were cleaned at the end of their shift by spraying disinfectant spray on walls and behind the shower chair. They further stated any evidence of mold would be immediately alerted to the Maintenance Director.

Based on observation, and resident and staff interview, it was determined the facility failed to protect and promote the rights of residents to be treated with respect and dignity in a manner that promoted enhancement of their quality of life. This was true for 1 of 18 residents (Resident #63). This deficient practice created the potential for psychosocial harm if residents felt they were not treated with dignity and respect. Findings include: The Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), Appendix PP, section 483.10(a)(1), documented: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy (an underlying condition causing confusion, memory loss, and possible loss of consciousness), spinal stenosis in the cervical region (a narrowing of spaces in the spine compressing the spinal cord and nerves), and bed confinement status. On 2/3/25, at 10:30 AM, Resident #63 was observed in her bedroom calling out that she was hungry. LPN #1 stated Resident #63 was a feeder and had already been assisted with her breakfast. On 2/7/25 at 11:44 AM, the DON stated, if anyone is heard using the term 'feeder', the facility provided a written education proving that they had educated the staff on the appropriate and inappropriate usage of various descriptive language, and anyone requiring help to eat should be referred to as 'an assist.'

Based on observation, and resident and staff interview, it was determined the facility failed to ensure the residents had a homelike environment. This was true for 4 of 4 residents (#5, #13, #49, #55) observed dining with plastic cutlery. This deficient practice created the potential for psychosocial harm if residents felt isolated when they were not provided the same homelike environment as other residents. Findings include: On 2/3/25, at 12:27 PM, 4 of 4 residents in the independent dining room were observed eating their lunch with plastic cutlery. On 2/3/25 at 3:13 PM, the Dietary Manager (DM) stated, she ordered more silverware on 1/29/25 and is not sure when it was supposed to arrive but found more silverware that afternoon in storage to provide during meals. On 2/4/25 at 2:10 PM, Resident #5 stated, the residents in the independent dining room had been given plastic cutlery for both breakfast and lunch that day. On 2/5/24 at 12:45 PM, the DM stated, she was unaware why residents would have been given plastic cutlery when the facility had found additional silverware to accommodate all residents.

Based on record review and staff interview, it was determined the facility failed to ensure a resident was provided quality care when they were not administered their medications as ordered. This was true for 1 of 18 residents (Resident #7) whose bowel records and medication administration records were reviewed. This failure placed Resident #7 at risk for harm if she were to suffer discomfort or complications from constipation, such as bowel obstruction. Findings include: Resident #7 was admitted to the facility on [DATE] for care following a stroke, and had multiple diagnoses including a seizure disorder and fibromyalgia (a chronic condition which causes widespread pain). Resident #7's physician orders, with a start date of 3/6/24, documented the following bowel protocol medications: -Milk of Magnesia Suspension (MOM) 1200 mg/15 ml, Give 30 milliliter orally as needed for no bowel movement for two (2) days. If no results within 24 hours, see Dulcolax Suppository order. -Dulcolax Suppository 10 mg, Insert 1 suppository rectally as needed for bowel care, give if no results from MOM. If no results in 24 hours, see Fleet Enema order. -Fleet Enema 7-19 gm/118 ml, Insert 1 unit rectally as needed for bowel care, give if no results from MOM and subsequent Dulcolax Suppository. Complete bowel assessment and notify MD if no results. On 2/4/25 at 11:06 AM, Resident #7's electronic medical record (EMR) documented her last bowel movement was on 1/31/25. On 2/7/25 at 10:40 AM, Resident #7's EMR documented her last bowel movement was on 2/6/25. Resident #7's nursing progress notes did not document her bowel protocol was followed, and her medication administration record (MAR) did not document she had been given her bowel protocol medications as prescribed. On 2/7/25 at 11:20 AM, the Clinical Resource Nurse confirmed Resident #7's EMR did not contain documentation she had a bowel movement or bowel protocol medications between 1/31/25 and 2/6/25. On 2/7/25 at 11:30 AM, the DON stated the notification their EMR system shows to alert nurses regarding bowel movements was cleared by a nurse who failed to administer an as needed (PRN) medication, therefore oncoming nurses were not alerted Resident #7 required bowel protocol medication interventions.

Based on policy review, record review, staff interview, and review of the State Survey Agency's Long Term Care Reporting Portal, it was determined the facility failed to ensure residents were free from abuse for 4 of 16 residents (#10, #13, #999, and #42) reviewed for abuse. This resulted in the potential for residents to be subjected to ongoing abuse. Findings include: The facility's abuse policy, revised 7/23/19, stated abuse, including verbal and physical, was strictly prohibited. This policy was not followed. 1. The State Survey Agency's Long Term Care Reporting Portal incidents, dated 4/1/21 to 9/17/21 was reviewed. Incident reports documented residents were subjected to abuse as follows: a. The facility's Unusual Occurrence report, dated 6/20/21, documented Resident #216 entered Resident #10's room, uninvited. Resident #10 shouted, Out! at him and he was redirected to his own room by staff. Approximately an hour later, Resident #216 reentered Resident #10's room and told him, I'm going to bash your brains in and I'm going to kill you. The facility's investigation of the incident, dated 6/20/21, substantiated Resident #216 was verbally abused by Resident #10. b. The facility's Unusual Occurrence report, dated 6/28/21, stated Resident #42 reported to nursing staff Resident #216 came into his room and kicked his right shin. The report stated Resident #216's shin appeared bruised with an abrasion. The facility's investigation, dated 6/28/21, documented, At this time we are unable to substantiate the claim as it was not witnessed. Although the probability of this happening is high. [Resident #216's] behavior has been escalating lately with increased intrusive wandering and verbal aggression. It is reasonable to assume that this incident could have taken place. c. The facility's Unusual Occurrence report, dated 7/26/21, documented Resident #216 entered Resident #13 and Resident #999's room. Resident #13 told Resident #216 to leave, and Resident #216 replied, I will kill the both of you, who in the hell do you think you are? The facility's investigation of the incident, dated 7/26/21, substantiated Resident #13 and Resident #999 were verbally abused by Resident #216. The Administrator and the CRN were interviewed on 9/24/21 at 11:17 AM. During the interview, the Occurrence Reports which reported abuse were reviewed. The Administrator stated the facility was aware of the abuse incidents. The facility failed to ensure Residents #10, #13, #999, and #42 were free from verbal and physical abuse.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' comprehensive MDS assessments were completed prior to the required completion date. This was true for 4 of 16 residents (#3, #6, #41, and #42) whose comprehensive MDS assessments were reviewed. This failure created the potential for harm if the care was not provided due to a delay in completion of the comprehensive MDS assessments. Findings include: The CMS's Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.17.1, Chapter 2, documented the comprehensive MDS assessment completion requirements as follows: * Comprehensive assessments included the Admission MDS assessment and Annual MDS assessment. The assessment completion was defined as completion of the Care Area Assessment (CAA) process in addition to the MDS items. * The RN assessment coordinator signs and dates both the MDS and CAA(s) completion attestations. * The Comprehensive assessment included completion of both the MDS and the CAA process. The assessment timing requirements for a Comprehensive assessment applies to both the completion of the MDS and the CAA process. * The requirement for the Admission MDS assessment completion date is no later than 14th calendar day of the resident's admission (admitted plus 13 calendar days). * The requirement for the Annual MDS assessment completion date on is no later than the assessment's reference date plus 14 calendar days. The facility's Resident Assessment policy, released 11/28/17, documented the Comprehensive MDS assessment frequencies were required by the Centers for Medicare and Medicaid Services (CMS). The MDS and CAAs were considered a Comprehensive assessment (full assessment) and was conducted at a minimum of one for each newly admitted resident within 14 calendar days after admission. The CMS requirements and the facility's policy were not followed. a. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 41's Annual MDS assessment, dated 2/6/21, documented the RN assessment coordinator verified the completion of the assessment on 3/14/21, 22 days later than the required completion date on 2/20/21. b. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 3's Admission MDS assessment, dated 2/26/21, documented the RN assessment coordinator verified the completion of the assessment on 3/19/21, 19 days later than the required completion date on 2/28/21. c. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 42's Admission MDS assessment, dated 5/10/21, documented the RN assessment coordinator verified the completion of the assessment on 5/26/21, 10 days later than the required completion date on 5/16/21. d. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident # 6's annual MDS assessment, dated 5/31/21, documented the RN assessment coordinator verified the completion of the assessment on 6/22/21, 9 days later than the required completion date on 6/13/21. On 9/24/21 at 10:00 AM, the MDSC stated the Admission MDS assessment must be completed before the 14th day from admission and the Annual MDS assessment must be completed on day 15 of the assessment reference date. The MDSC stated Resident #3, #6, #41, and #42's Comprehensive MDS assessments were completed late.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with baths or showers consistent with their needs. This was true for 4 of 16 residents (#3, #19, #46, and #217) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment due to lack of personal hygiene. Findings include: The facility's Activities of Daily Living policy, documented bathing, dressing and grooming were to be done per resident preferences, with reasonable accommodations being made. The facility's ADL policies for morning and evening/bedtime care, stated staff were to provide a shower, tub bath or bed bath as scheduled. These policies were not followed. 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .(feelings of excessive, Resident #3's quarterly MDS assessment, dated 8/29/21, documented she was severely cognitively impaired and required two-person extensive physical help with bathing. Resident #3's care plan related to bathing, initiated on 2/13/21, documented she was totally dependent on staff to provide a bath, shower, sponge or bed bath. Resident #3's record documented she was to have a bath or shower on Tuesdays and Fridays. Resident #3's bathing documentation for the month of August 2021, did not include documentation of a bath until 8/17/21, 17 days. Resident #3 had a shower on 8/24/21 and the next documented shower was on 9/3/21, 10 days later. On 9/23/21 at 10:55 AM, CRN #2 stated there was not a shower aide at the time of the missing documentation. CRN #2 stated the provision of showers and their documentation fell on the remaining staff. CRN #2 confirmed showers were not documented during the first part of August 2021, and not more than once per week in September, 2021. 2. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's quarterly MDS assessment, dated 6/28/21, documented Resident #19 was cognitively intact and required one-person physical help for part of bathing. Resident #19's care plan related to bathing, documented Resident #19 required limited assistance for bathing with one staff, and he needed a shower chair for a shower. On 9/22/21 at 12:12 PM, Resident #19 stated he was scheduled for 2 showers a week on Wednesday and Saturday but recently only received one shower a week. Resident #19's record for bathing documented the following: Resident #19 received a shower on Wednesday 8/4/21, and received his next shower on Wednesday 8/11/21, 7 days later. Resident #19 received a shower on Saturday 9/4/21. His next shower was on Saturday 9/11/21, 7 days later. On 9/22/21 CRN #2 stated the facility should honor Resident #19's wish to have a shower provided 2 times a week. 3. Resident #46 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's quarterly MDS assessment, dated 8/19/21, documented he was mildly cognitively impaired and required two-person extensive physical help with bathing. Resident #46's care plan related to bathing, initiated 1/22/21, documented he was totally dependent on staff to provide a bath, shower, sponge or bed bath. Resident #46's ADL documentation noted he was to have a bath or shower on Tuesdays and Fridays. Resident #46's bath/shower documentation for the month of August 2021, documented no bath or shower for the beginning of August, with the first documented shower on 8/13/21, 13 days. Resident #46 refused a shower on 8/17/21, 8/20/21 and 8/24/21. His next shower was on 8/27/21, 14 days from his last shower. Resident #46 refused a shower on 8/31/21. Resident #46's bath/shower record was documented as NA on 9/3/21. He received a shower on 9/7/21, 10 days from his last shower. His shower was documented NA on 9/10/21, with his next shower on 9/14/21, 7 days from his last shower. On 9/23/21 at 10:55 AM, CRN #2 and the DON stated there was not a shower aide at the time of the missing documentation, as they had some turnover in staff. CRN #2 stated NA was not proper documentation for showers. The CRN #2 confirmed showers were not documented during the first part of August 2021, and not consistently in September 2021. 4. Resident #217 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #217's quarterly MDS assessment, dated 6/22/21, documented he was mildly cognitively impaired and required one-person limited physical help with bathing. Resident #217's care plan related to bathing, initiated 6/16/21, documented he required set up and one-person assistance with bathing. Resident #217's ADL documentation noted he was to have a bath or shower on Tuesdays and Fridays. Resident #217's bathing documentation for the month of June, 2021, documented no bathing from his date of admission on 6/16/21 until 7/2/21 (16 days). He refused bathing on 7/6/21 and was discharged [DATE]. His documentation indicated he received one shower during his 21-day stay. On 9/23/21 at 10:50 AM, the DON confirmed there was no documentation of a bath or shower during the first two weeks of Resident #217's stay at the facility.

Based on policy review, record review, resident and staff interview, it was determined the facility failed to inform residents, their representatives, and families by 5 PM the next calendar day following the occurrence of an identified COVID-19 infected staff member or cluster of staff who were infected with COVID-19. This was true for 8 of 16 resident (#3, #6, #19, #38, #43, #45, #52 and #55) whose records were reviewed for COVID-19 related notifications. This failure had the potential to deprive residents, their representatives, or families of having the opportunity to choose whether residents remained in the facility and being informed of the extent of COVID-19 cases in the facility. Findings include: The facility's Management of Coronavirus COVID-19 policy, revised 9/15/21, stated the facility would provide notification to inform residents, resident advocates by 5 PM on the next calendar day via email, website posting, letters/paper notification, or recorded telephone message following the occurrence of a single confirmed COVID-19 infection. The policy further stated the facility would document the communication with the resident, resident advocate, or family members in that resident's medical record. This policy was not followed. A report of COVID-19 test results, dated 9/6/21 to 9/13/21, was reviewed and documented staff positive tests as follows: CNA #1: tested positive for COVID-19 on 9/6/21. CNA #2: tested positive for COVID-19 on 9/8/21. LPN #1: tested positive for COVID-19 on 9/13/21. LPN #2: tested positive for COVID-19 on 9/13/21. On 9/20/21 at 3:31 PM, Resident #43 stated she had not been notified of staff any testing positive for COVID-19. Resident # 43's record did not contain documentation she was notified of staff confirmed COVID-19 infections. On 9/24/21 at 8:00 AM, Resident #19 stated he had not been notified of any staff testing positive for COVID-19. Resident # 19's record did not contain documentation he was notified of staff confirmed COVID-19 infections. On 9/24/21 at 8:35 AM, the Administrator stated he could not locate COVID-19 related notification documentation in Resident #3, #6, #19, #38, #43, #45, and #55's records. The Administrator stated the facility's last voice call notification to residents' family members was on August 2021. In September 2021, the facility sent out 3 mail notifications to all the residents' family members. The Administrator stated the facility did not have documentation of when the letter was sent out. Staff members were responsible for notifying the residents residing in the facility.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure the physician was notified of a significant change in a resident's condition. This was true for 1 of 1 resident (Resident #19) reviewed for change of condition. This failed practice resulted in harm to Resident #19 when he experienced a change in condition that resulted in hospitalization due [MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to an infection), community acquired pneumonia, urinary tract infection, and Influenza [NAME] Findings include: The facility's policy for Resident Change of Condition, dated 11/28/17, documented the following: * Upon recognition of a potentially life-threatening condition or significant change in status, the nurse should communicate with other health care providers to meet the needs of the resident. * The physician was informed at the time of the event, as soon as possible. * Notification occurred immediately if any symptom was sudden in onset, a marked change from the usual signs and symptoms, and unrelieved by prescribed measures. * For non-immediate notification, the physician was informed of the event during office hours and generally no later than the next regular business day. If a non-immediate event occurred on a weekend or holiday, good nursing judgment determined if the notification could wait until the next business day or if it should occur during the weekend or holiday. * The facility informed the resident, consulted with the physician, and notified the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. This policy was not followed. Resident #19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]., and history of [MEDICAL CONDITION]. A progress note by the Medical Director, dated 1/2/20, documented he saw Resident #19 due to increased urinary sediment, which necessitated staff changing his catheter every 5 or 6 days. The progress note documented Resident #19's skin was warm and dry. The Medical Director recommended encouraging fluids and changing Resident #19's catheter as needed due to obstruction. A Progress Note by the NP, dated 1/7/20, documented he saw Resident #19 due to pain all over his body that felt like arthritis pain. The NP documented the pain was well controlled with Tylenol, and there was no fever or chills. Resident #19's blood pressure was 152/77, temperature was 97 degrees Fahrenheit (F), and pulse was 63. The note stated his skin was warm and dry, and his lungs were clear. The treatment plan was to continue scheduled Tylenol 325 mg 2 tablets three times a day as well as Tylenol 2 tablets three times daily as needed and follow up with urology as needed. A progress note, dated 1/9/20 at 8:30 PM, documented Resident #19 stated I'm burning up. The note documented his blood pressure was 156/77, a heart rate of 88, and a temperature of 99.0 F. A progress note, dated 1/10/20 at 3:35 AM, documented Resident #19 had a distended (swollen) abdomen with less active bowel sounds. The note documented Resident #19 told the nurse he had not had a bowel movement in two weeks. The note also documented Resident #19's had a blood pressure of 82/54, a heart rate of 91, and a temperature of 99.0 F. The nurse documented Resident #19 was medicated for his temperature and given a [MEDICATION NAME] suppository (laxative). There was no documentation Resident #19's physician was notified of his low blood pressure and he had a distended abdomen with no bowel movement in two weeks. According to the Mayo Clinic website, accessed 3/4/20, a sudden fall in blood pressure can be dangerous. A change of just 20 mm Hg (millimeters of mercury), such as a drop from 110 systolic (top number) to 90 mm Hg systolic, can cause dizziness and [MEDICAL CONDITION] when the brain fails to receive an adequate supply of blood. The Mayo Clinic website stated big plunges, such as those caused by uncontrolled bleeding, severe infections or allergic reactions, can be life-threatening. The Fundamentals of Nursing, eighth edition, by Potter and Perry (2013) stated [MEDICAL CONDITION] when associated with paleness, skin mottling, clamminess, confusion, increased heart rate, or decreased urine output is considered life threatening and should be reported to a health care provider immediately. Resident #19's systolic blood pressure had dropped 74 mmHg in eight hours. A progress note, dated 1/11/20 at 9:16 AM, documented Resident #19 complained of extreme pain, and he was perspiring profusely. His blood pressure was 88/58, the heart rate was 118, and temperature was 101 F. Resident #19 was sent to the emergency room . A history and physical from the hospital, dated 1/11/20, stated Resident #19 presented to the emergency room with rapid breathing and [MEDICAL CONDITION]. Resident #19 was admitted to the hospital with [REDACTED]. On 2/20/20 at 10:03 AM, the DON said she spoke to the NP, and he said although Resident #19 met the criteria [MEDICAL CONDITION], he did not [MEDICAL CONDITION] because his white blood cell count was normal. The DON said she did not know if the physician was notified when Resident #19 demonstrated signs of fever and becoming ill. On 2/20/20 at 12:01 PM, the Medical Director said Resident #19 was chronically sick and became ill rapidly when he had to go to the hospital in (MONTH) 2020. The Medical Director said the facility's nurses monitored residents' vital signs and notified him if they were abnormal. The Medical Director said Resident #19 was feeling sick, and the nurses would not necessarily notify him of things like that if the vital signs were okay. The Medical Director said Resident #19 could become ill very quickly, and he would have to read the hospital report to see if he had a urinary tract infection. The Medical Director said if one vital sign was abnormal he would not be concerned. The Medical Director said Resident #19 was at risk for infection due to the bacteria in the environment and the fact he had a catheter, a feeding tube, and immobility. On 2/21/20 at 10:19 AM, the DON said something should have been done related to Resident #19's blood pressure on 1/10/20 at 3:35 AM. Resident #19's physician was not notified when he had a significant change in his blood pressure and health status.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to identify a skin abscess on a resident. This was true for 1 of 3 residents (Resident #19) reviewed for infections. This resulted in harm to Resident #19 when he developed the skin abscess and was sent to the hospital and the abscess likely contributed to his [DIAGNOSES REDACTED]. Findings include: The facility's policy for Prevention and treatment of [REDACTED]. In addition, staff were to address potential new areas of concern. This policy was not followed. Resident #19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. history of [MEDICAL CONDITION]. Resident #19's care plan directed staff to perform daily skin inspection during cares, notify the nurse of impaired skin integrity, the licensed nurse was to perform weekly skin assessments, and staff were to monitor for increased urethral erosion from the indwelling catheter. Resident #19's weekly skin checks, dated 11/14/19 at 10:04 AM through 1/2/20 at 6:26 AM, documented he had a urethral erosion (a wound often caused by the long term use of indwelling catheters) on his penis. The skin checks did not document an abscess on his scrotum. A progress note by the Medical Director, dated 1/2/20, documented he saw Resident #19 due to increased urinary sediment, which necessitated staff changing his catheter every 5 or 6 days. The progress note documented Resident #19's skin was warm and dry. The Medical Director recommended encouraging fluids and changing Resident #19's catheter as needed due to obstruction. A progress note by the NP, dated 1/7/20, documented he saw Resident #19 due to pain all over his body that felt like arthritis pain. The pain was well controlled with Tylenol, and there was no fever or chills. The NP stated Resident #19's skin was warm and dry. A discharge MDS assessment, dated 1/11/20, documented Resident #19 had an unplanned discharge to the hospital. The assessment documented he had an indwelling catheter and there was no documentation he had skin problems. A History and Physical (H&P) from the hospitalist, dated 1/11/20 at 1:59 PM, documented Resident #19 had an abscess (a painful collection of pus, usually caused by a bacterial infection, just under the skin) in the scrotum/perineal area. The H&P documented an abscess was noted in the scrotum when his catheter was changed, and a urologist opened the abscess and placed packing (a type of dressing) into the open wound. A Urology progress note, dated 1/13/20 at 4:43 PM, documented Resident #19 had a left scrotal abscess, chronic [MEDICAL CONDITION], a urethral erosion, [MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to an infection) due to pneumonia and urinary source. The progress note documented the left scrotal abscess was also likely contributing to [MEDICAL CONDITION]. On 2/20/20 at 12:01 PM, the Medical Director said Resident #19 had a groin mass or something and was being followed by urology for that. The Medical Director said Resident #19 was at risk for infection due to the bacteria in the environment and the fact he had a catheter, a feeding tube, and his immobility. On 2/20/20 at 9:19 AM, Resident #19 said he was very ill and had to go to the hospital in January, but he did not remember how he became ill. Resident #19 said staff did not clean his catheter every day. On 2/20/20 at 10:03 AM, the DON said Resident #19's abscess was not visualized and detected by staff because it was in an area that was not easily seen. On 2/20/20 at 4:14 PM, the DON said skin checks were done weekly, and Resident #19's abscess was not noticed until his catheter was replaced at the hospital. The facility did not identify Resident #19's scrotal abscess.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with the levels of supervision necessary to prevent falls. This was true for 1 of 2 residents (Resident #25) reviewed for falls. This failure resulted in harm to Resident #25 with a fracture to his left femur. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy and procedure, dated 4/4/19, documented the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. This included systems and processes designed to: * Identify hazards and risks. * Evaluate and analyze hazards and risks. * Implement interventions to reduce hazards and risks. * Monitor for effectiveness and modify approaches when necessary. The policy also stated the facility was obligated to provide adequate supervision to prevent accidents, which was determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination was based on the individual resident's assessed needs and identified hazards in the resident environment. Resident #25 was admitted to the facility initially on 5/21/19 and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #25's MDS Assessment, dated 11/28/19, documented he was severely cognitively impaired and he required extensive assistance with two or more persons for bed mobility, toilet use, and transfers between bed, chair and standing. The assessment also documented Resident #25 required supervision with one-person physical assist when he walked between locations in his room. The Fall History section of the MDS assessment was not completed. Resident #25's MAHC-10 Fall Risk Assessments, used to determine a person's risk for falls, dated 8/4/19, 8/12/19, 9/28/19, 10/7/19, 11/27/19, and 12/6/19, documented Resident #25 was at risk for falls. A score of 4 or more out of 10 was considered at risk for falls. Resident #25 received a score of 7 to 10 on the days of his falls. Resident #25's care plan documented he was at risk for falls related to confusion, diminished safety awareness, gait and balance problems, and history of falls and significant dementia. The care plan was initiated on 6/3/19. The interventions included the following: * Wear non-skid footwear, initiated on 6/3/19 and revised on 8/3/19. * Staff need to anticipate his needs, initiated on 6/3/19 and revised on 8/3/19. * Resident #25 needs his door open, so staff can see him, initiated on 8/5/19 and revised on 12/2/19. * Encourage Resident #25 to use the grab bar near the bathroom to help balance himself, initiated on 12/2/19. Resident #25's care plan documented he had an activities of daily living (ADL) self-care performance deficit related to dementia, impaired cognition related to advanced dementia, impaired balance, and history of fall with left [MEDICAL CONDITION], initiated on 5/22/19 and revised on 12/16/20. Interventions included the following: * Toilet use: he was not to be toileted. He had a catheter and was incontinent, initiated on 5/22/19 and revised on 9/18/19. * Transfers: He needed extensive assistance from staff, using a gait belt with transferring, initiated on 5/22/19 and revised on 9/18/19. * Bed Mobility: He required extensive 2 staff participation to reposition and turn in bed, initiated on 5/22/19 and revised on 9/18/19. * Physical Therapy and Occupational Therapy were to provide evaluation and treatment per physician orders, initiated on 5/22/19. * He needed to eat all meals in the dining room, initiated on 8/5/19. Facility Incident and Accident reports for Resident #25 documented he fell 8 times from 8/4/19 to 12/6/19, with the last fall resulting in a major injury. Resident #25 had documented falls on 8/4/19, 8/11/19, 9/4/19, 9/28/19, 10/7/19, 10/11/19, and twice on 12/6/19. The reports documented the following: a. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall without injury on 8/4/19 at 8:15 AM. Resident #25 was found alone and unattended in his room during meal time, laying on his back parallel and next to his bed, with his arms at his sides, his legs straight out, and with stockings on his feet. The report documented Resident #25 had a history of [REDACTED]. The investigation documented Resident #25 had dementia, was impulsive, lacked safety awareness, and had an unsteady gait. The physician and family were notified of the fall. An Incident Conclusion and Performance Improvement Follow-Up report, dated 8/5/19, documented the Performance Improvement (PI) Recommendations post fall were to place Resident #25's bed in the low position, he was not to eat in his room, and he was to be out of his room when out of bed. Resident #25's care plan did not document his bed should be placed in the low position, or that he was to be out of his room when he was not in bed. On 2/20/20 at 1:26 PM, the DON said after the 8/4/19 fall they looked at the cause, and wanted Resident #25 to spend his time out of his room to eat and for staff to observe him. She said the care plan was changed to keep Resident #25's door open, so staff could see him due to his poor safety awareness. b. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall with injury on 8/11/19 at 11:30 PM. Resident #25 was found alone and unattended in his room, laying on his right side on the floor between the two beds, with gripper socks on, and verbally expressing he was in pain. The report documented Resident #25 rolled off the bed hitting the bridge of his nose resulting in a ¾ centimeter (cm) superficial cut and no other injuries. The report documented Resident #25 had been laying on his bed 15 minutes prior to the fall. The Incident Conclusion and Performance Improvement Follow-Up, dated 8/12/19, documented the PI Recommendations were to identify where the staff were at the time for better oversight of Resident #25, and for Occupational Therapy to screen Resident #25. Resident #25's care plan did not include documentation of new interventions related to this fall. Resident #25's record did not include an Occupational Therapy evaluation and treatment for [REDACTED]. On 2/20/20 at 1:26 PM, the DON said after Resident #25's 8/11/19 fall they evaluated where the staff was at the time of the fall, and requested Occupational Therapy to work with Resident #25, and made a therapy referral for bed safety. c. A Post Fall Investigation report, dated 9/4/19 at 2:00 PM, documented the RN was alerted by staff Resident #25 was on the floor of his room. The RN documented Resident #25 had a skin tear to his left arm which measured 2 cm x 2 cm, he had no pain, and was unable to describe how he fell . The RN wrote it looked like he was on his bed and was heading to the bathroom but fell on his back, with his arms and legs by his side, his feet were towards the bathroom door, with nonskid socks on, he did not use his wheelchair or call light, and did not wait for help. The report documented predisposing factors were a wet floor, Resident #25's recent illness, gait imbalance, impaired memory, and he was ambulating without assistance. The RN documented there was some water on the floor by the bathroom door, and Resident #25's socks were wet. The Incident Conclusion and Performance Improvement Follow-Up, dated 9/5/19, documented the PI Recommendation was to not leave Resident #25 unattended in his room. Resident #25's care plan did not include documentation of new interventions related to this fall. On 2/20/20 at 1:26 PM, the DON said the 9/4/19 fall interventions were Resident #25 was to not be left unattended when up in his room and he was to be in the line of sight. The Administrator said they liked to keep him in the hall and busy. d. A Post Fall Investigation report, dated 9/28/19 at 12:48 AM, documented after hearing a loud door slam, Resident #25 was found sitting on the floor outside of his bathroom, with his shorts around his knees, leaning on his right elbow with a 1 cm skin tear. Resident #25 said he did not hit his head and requested help. The report documented he was assessed for injury, assisted up by 3 staff members, provided first aid to his skin tear, and was assisted into bed. The report documented Resident #25 was oriented to self and situation. The report documented predisposing factors were Resident #25's confusion, gait imbalance, impaired memory, non-compliance, and ambulating and transferring without assistance. The report documented the fall was unwitnessed. The Incident Conclusion and Performance Improvement Follow-Up, dated 9/30/19, documented PI Recommendations were to change Resident #25's straight catheter times, and to scan his bladder for urine and use the straight catheter as needed in order to keep his bladder empty so he did not attempt to get up to the bathroom without assistance. Resident #25's care plan did not include documentation of new interventions related to this fall. A progress note, dated 9/30/19 at 11:24 PM, documented Resident #25 had increased confusion, he continued to self-transfer, and was unsteady on his feet. On 2/20/20 at 1:26 PM, the DON said Resident #25 had a straight catheter at this time and they reviewed the time of the straight catheterization and did routine bladder scans. The Clinical Resource Nurse said they started his straight catheterizations on 6/19/19, and they were done at 8:00 AM, 2:00 PM, and 8:00 PM. The Clinical Resource Nurse said the report indicated they changed the straight catheterization times, but no change was made in the care plan or Treatment Administration Record (TAR). e. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall on 10/7/19 at 4:40 AM. The report stated Resident #25 was found laying on his right side on the floor of his bedroom between the bed and the wall. The report stated Resident #25 said he rolled out of bed and hit his head. The report documented Resident #25 was assisted up, no bumps or bruising were noted, he was moving all his extremities, his vitals were taken, and his neurological checks were normal for him. The report documented Resident #25 was oriented to person, place, situation, and time. The report documented predisposing factors were Resident #25 was confused, drowsy, incontinent, he had a gait imbalance, and impaired memory. An Incident Conclusion and Performance Improvement Follow-Up report, dated 10/9/19, documented the PI Recommendation was to review Resident #25's straight catheterization timing. Resident #25's care plan did not include documentation of new interventions related to this fall. Resident #25's TAR documented his straight catheterization at 8:00 AM, 2:00 PM and 8:00 PM was discontinued on 10/7/19 and changed to three times a day at 5:00 AM, 1:00 PM and 9:00 PM on 10/7/19. On 2/20/20 at 1:26 PM, the DON said for the 10/7/19 fall they again reviewed the straight catheterization times and an order was placed on 10/7/19 for time changes to 5:00 AM, 1:00 PM, 9:00 PM, and as needed. The Clinical Resource Nurse said the time change did not make it into the care plan, but it was changed on the TAR. f. A Post Fall Investigation documented Resident #25 fell in the dining room on 10/11/19 at 10:30 AM. The report stated Resident #25 stood up from his wheelchair, turned, lost his balance, and fell hitting his head on the edge of the table. The report stated Resident #25 was immediately assessed for injuries with none found and was assisted up and back into his wheelchair. The report documented predisposing factors were Resident #25's confusion, incontinence, weakness, gait imbalance, impaired memory, and ambulating without assistance. The Incident Conclusion and Performance Improvement Follow-Up report, dated 10/14/19, documented a PI Recommendation of Resident #25 is impulsive. Resident #25's care plan did not include documentation of new interventions related to this fall. g. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall on 12/6/19 at 4:08 AM. The report documented the RN found Resident #25 in his room laying on the floor on his right side near the wheelchair with his right hand under his head, and his legs extended down. The report documented Resident #25 was confused, had no skin tears, and was able to move his upper and lower extremities. The report documented he was immediately assessed for injury, was assisted up off the floor with a Hoyer lift (a mechanical lift) by three staff members. The report documented predisposing factors as being Resident #25's confusion, gait imbalance, impaired memory, and ambulating without assistance. The report documented Resident #25 became agitated when told to use the wheelchair, and at times was hard to redirect. Resident #25's care plan did not include documentation of new interventions related to this fall. h. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall with major injury on 12/6/19 at 4:15 PM. The report documented Resident #25 was found after staff heard a loud crash and found him in his room on the floor on his left side on the left side of his bed and yelling I broke my hip. Resident #25 was assessed for injury and found to have his left leg shorter than the right leg and it was turned outward. Predisposing factors for the fall were documented as being Resident #25's confusion, incontinence, gait imbalance, impaired memory, improper footwear, and ambulating without assistance. An Incident Conclusion and Performance Improvement Follow Up report, dated 12/9/19, documented the PI Recommendation was to reassess Resident #25 when he returned from the hospital. A Fall with Injury report documented Resident #25's fall on 12/6/19 at approximately 4:00 PM. The report documented Resident #25 was found on the floor, 20 minutes after the RN last saw him, was assessed and transported to the hospital. The hospital reported Resident #25 had a complex [MEDICAL CONDITION] hip from the event. The report documented Resident #25 was severely cognitively impaired and was recently treated for [REDACTED].#25's fracture most likely occurred when he left his bed and fell on the floor. The wheelchair was properly positioned on the other side of the bed, and ready for self-transfer. He left the surface of the bed from the opposite side. A Final Report from the hospital, dated 12/13/19, documented Resident #25's [DIAGNOSES REDACTED]. Resident #25 was discharged and returned to facility on 12/13/19. On 2/20/20 at 2:38 PM, when asked about Resident #25's two falls on 12/6/19, the DON said there was no injury in the morning and it was not reported and provided the second fall report commenting it was reportable because he broke his hip. On 2/20/20 at 1:26 PM, the DON said for the 10/11/19 fall Speech Therapy and Occupational Therapy became involved related to balance equipment. The DON said Resident #25 kept trying to stand up, so they looked at assistive devices for mobility, including a grab bar which was placed on the wall of his room by the bathroom. The Administrator said therapy was working with Resident #25 on sequencing and his inability to complete tasks without assistance, tactile cues and proper hand placement for a slow decent into a chair. The Administrator said they were trying to work with his memory. The Administrator said Resident #25 furniture surfed to move along and stand, and he was able to use the grab bar. When asked about their discussions about supervision as a potential intervention, the Administrator said increased supervision took the form of encouraging Resident #25 to be out of his room or in activities, and on 12/6/19, the day of his fall with [MEDICAL CONDITION], he was particularly active, fidgety, and he changed his habits by getting out of bed on his non-usual side, the opposite side of his wheelchair. The facility failed to ensure Resident #25 received the level of supervision and assistance necessary to protect him from injury.

Based on record review and resident and staff interview, it was determined the facility failed to ensure residents were provided with bathing and oral care consistent with their needs. This was true for 4 of 8 (#41, #24, #27, and #159) residents sampled for bathing, and 4 of 8 (#17, #20, #24 and #44) residents sampled for oral care. Resident # 41 experienced psychosocial harm when she had ongoing embarrassment and a decline in her feelings of self-worth after she did not consistently receive showers to prevent body odors. This failure created the potential for residents (#17, #20 #24, #27, #44, and #159) to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include: 1. Resident #41 was readmitted to the facility on [DATE], with multiple diagnoses, which included [MEDICAL CONDITION] (stroke). Resident #41's quarterly MDS assessment, dated 5/7/18, documented her cognition was severely cognitively impaired and was totally dependent on two staff members with bathing. Resident #41's (MONTH) (YEAR) ADLs Report documented her bathing schedule was every Monday, Wednesday, and Friday. Resident #41 did not receive a bath on 6/6/18, 6/8/18, 6/11/18, 6/13/18, 6/15/18, 6/18/18, 6/20/18, 6/22/18, 6/27/18, and 6/29/18. Resident #41 received 2 baths out of 11 baths scheduled for the month of June. Resident #41's (MONTH) (YEAR) ADLs Report, documented she received 2 baths out of 4 baths scheduled from 7/1/18 to 7/9/18. On 7/10/18 at 10:34 AM, upon entering Resident #41's room, a fish like odor was noted. The odor was more pronounced closer to Resident #41's bed. On 7/10/18 at 11:48 PM, two surveyors entered Resident #41's room. Both surveyors noticed the fish like odor upon entering the room and noticed it was more pronounced near Resident #41's bed. On 7/10/18 at 11:51 AM, CNA #11 said due to two nose injuries she could not recognize the smell in Resident #41's room. On 7/10/18 at 11:51 AM, RN #2 said Resident #41 needed to be groomed. RN #2 said the CNAs gave baths to the residents and she did not know why Resident #41 did not receive her baths as scheduled. 2. Resident #44 was admitted to the facility on [DATE] with multiple diagnoses, including hypertension and a urinary tract infection. The admission MDS assessment, dated 6/8/18, documented Resident #44 was moderately cognitively impaired and required total assistance from one person for personal hygiene, including toothbrushing. The 14-day MDS assessment, dated 6/15/18, documented Resident #44 was cognitively intact and required limited assistance from one person for personal hygiene, including toothbrushing. On 7/9/18 at 2:52 PM, Resident #44 stated the facility had not provided a toothbrush or toothpaste, since she was admitted to the facility (6/1/18). Resident #44 stated she was able to brush her own teeth independently, if she had the supplies to do so. Resident #44's care plan, dated 7/7/18 documented, (Resident #44) requires set up assistance with personal hygiene. Resident #44's (MONTH) (YEAR) ADL Report for personal hygiene, including toothbrushing, documented 28 out of 59 opportunities she required assistance; 21 out of 59 opportunities she was independent; and 10 out of 59 opportunities were left blank. Resident #44's (MONTH) (YEAR) ADL Report for personal hygiene, including toothbrushing, documented 6 out of 22 opportunities she required assistance; 13 out of 22 opportunities she was independent; and 3 out of 22 opportunities were left blank. On 7/11/18 at 11:47 AM, CNA #2 stated Resident #44 was independent with her ADL's including brushing her own teeth. CNA #2 asked Resident #44 where she stored her toothbrush and toothpaste and Resident #44 stated, I don't have any and never have and denied CNA #2 approval to look through her 3 drawer nightstand. CNA #2 brought a toothbrush and toothpaste to Resident #44 and Resident #44 allowed her to place them in her nightstand. CNA #2 was unable to find a toothbrush or toothpaste in Resident #44's 3 drawer night stand. On 7/11/18 at 1:41 PM, the DNS and the Clinical Resource Nurse stated the Admission Coordinator was the person that provided toiletries to newly admitted residents. On 7/11/18 at 1:46 PM, the Administrator stated the Admission Coordinator did not always provide toiletries to new residents. On 7/11/18 at 2:06 PM, the Admission Coordinator stated she made sure the new resident's room was ready and the CNA assigned to the hallway was responsible to provide the toiletries to the new resident. On 7/11/18 at 2:12 PM, CNA #10 stated when a new resident arrived her responsibilities were to check the new resident's vital signs and weight. CNA #10 stated the central supply person provided the toiletries to new residents. On 7/11/18 at 2:29 PM, the DNS stated the central supply person only worked two days a week and was not available for interview. The DNS and the Clinical Resource Nurse, also present, stated they needed to work on a better system to communicate responsibilities for new residents. The DNS was unaware the CNAs were documenting Resident #44 required assistance with personal hygiene and Resident #44 did not have a toothbrush or toothpaste until CNA #2 provided them on 7/11/18. 3. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses, including end stage [MEDICAL CONDITION], and diabetes mellitus with [MEDICAL CONDITION]. A quarterly MDS assessment, dated 5/16/18, documented Resident #27 was cognitively intact and required extensive assistance from two people for bathing. On 7/10/18 at 2:04 PM, Resident #27 stated she was provided a shower once a week and would like to have a shower two times a week. Resident #27's care plan, revised on 9/1/17, documented, one staff assist with showers. The care plan did not include the days Resident #27 was scheduled to receive showers. The (MONTH) and (MONTH) (YEAR) ADL Reports documented Resident #27 was scheduled for showers on Tuesdays and Thursdays. The ADL Report documented Resident #27 received a shower on the following days: * 6/5/18 * 6/7/18 resident refused * 6/12/18 * 6/14/18 was left blank * 6/19/18 * 6/21/18 resident refused * 6/26/18 * 6/28/18 was left blank * 7/3/18 * 7/5/18 resident refused * 7/10/18 On 7/12/18 at 5:03 PM, the DNS and Clinical Resource Nurse stated Resident #27 should have had showers twice a week and the care plan should be more specific on what days Resident #27 was scheduled for showers. The DNS stated when a resident refused a shower, the staff should offer one the next day. The DNS was unable to provide documentation Resident #27 was offered a shower the day following her refusals. 4. Resident #24 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/11/18, documented Resident #24 had a moderate cognitive impairment. The MDS assessment documented she was totally dependent on 1 to 2 staff members for all cares. The care plan area addressing Resident #24's ADL care, revised 3/22/16, documented Resident #24 required 1 staff member's assistance with bathing and did not specify how many staff members she required for personal hygiene. On 7/9/18 at 2:44 PM through 4:16 PM, Resident #24 was observed with stringy like greasy hair. a. The 5/1/18 through 7/11/18 ADL Report documented Resident #24 was to be provided oral care twice daily. The ADL documentation showed staff did not provide assistance with oral care 36 out of 143 opportunities. b. The 5/1/18 through 7/11/18 ADL Report documented Resident #24 was to be provided showers Wednesdays and Saturdays. The ADL documentation showed Resident #24 received a shower on 5/16/18 and was not provided a shower on 5/19/18. Resident #24's next shower was on 5/23/18, 6 days later. Resident #24 was not provided a shower on 5/26/18 and her next shower was provided on 5/30/18, 6 days later. Resident #24 received a shower on 6/2/18 and refused a shower on 6/6/18, was not provided a shower on 6/9/18, and received her next shower on 6/13/18, 10 days later. Resident #24 was not provided a shower on 6/16/18 and 6/20/18 and her next shower was on 6/22/18, 9 days later. Resident #24 received a shower on 6/29/18, refused a shower on 7/30/18, did not receive a shower on 7/4/18, and her next shower was on 7/7/18, 8 days later. Additionally, there was no documentation Resident #24 was reapproached or offered a shower the next day when she refused showers. On 7/12/18 at 10:28 AM, the DNS state the oral care and the showers should be completed as scheduled. 5. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/1/18, documented Resident #17 had a moderate cognitive impairment. The MDS assessment documented he was totally dependent on 2 staff members for all cares except eating and for personal hygiene he was dependent on assistance from 1 person. The MDS assessment documented he had a bilateral range of motion impairment to his upper and lower extremities. The care plan area addressing Resident #17's ADL care, revised 4/4/08, documented Resident #17 required the assistance of 1 staff member for bed mobility, bathing, personal hygiene, and dressing. The 5/1/18 through 7/11/18 the ADL Record documented Resident #17 was to be provided oral care twice daily. The ADL Record documented staff did not provide assistance with oral care 35 out of 143 opportunities. On 7/11/18 at 5:00 PM, the DNS stated oral care should be completed twice daily. 6. Resident #20 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/7/18, documented Resident #20 had a severe cognitive impairment. The MDS assessment documented she was totally dependent or required extensive assistance of 1 to 2 staff members for all cares except eating. The care plan area addressing Resident #20's ADL care, revised 11/12/12, documented Resident #20 required 1 staff member's assistance with personal hygiene and dressing. The 5/1/18 through 7/11/18 ADL Report documented Resident #20 was to be provided oral care twice daily. The ADL Report documented staff did not provide Resident #20 assistance with oral care 32 out of 143 opportunities. On 7/11/18 at 5:00 PM, the DNS stated oral care should be completed twice daily. 7. Resident #159 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/23/17, documented Resident #159 had a moderate cognitive impairment. The MDS assessment documented he required physical help of one staff member with bathing. The care plan area addressing Resident #159's ADL care, revised 8/18/17, documented Resident #159 required 1 staff member's assistance with bathing and his bath days were on Tuesdays and Thursdays. The 1/1/18 through 2/12/18 ADL Report documented Resident #159 was to be provided showers Tuesdays and Thursdays. The ADL documentation showed Resident #159 received a shower on 1/16/18 and he refused a shower on 1/18/18 and his next shower was on 1/23/18, 6 days later. Resident #159 received a shower on 2/1/18 and did not receive showers on 2/6/18 and 2/8/18, and was discharged from the facility on 2/11/18, 10 days later. Additionally, there was no documentation Resident #159 was reapproached or offered a shower the following day if he refused. On 7/13/18 at 11:12 AM, the DNS stated the facility had a shower schedule by room numbers that determined the days residents received showers. The DNS stated residents with the Tuesday and Thursday scheduled would go 5 days between showers and if showers were missed then potentially longer. The DNS stated residents should receive showers on shower days and if residents missed their shower days then staff should offer showers the next day. The DNS stated CNAs knew which showers needed completed by the residents' names populating into the computer system. The DNS stated if a resident's shower was not completed there was not an alert in the system to notify staff that showers were not completed.

Based on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 3 of 18 sampled residents (#20, #30, and #41) reviewed for standards of practice. Resident #20 was harmed when she developed new wounds without consistent weekly wound assessments, measurements, treatments, and consistent care plan revisions. Resident #30 had the potential for harm when neurological assessments were incomplete after an unwitnessed fall. Resident #41 had the potential for harm when he received a nebulizer treatment without supervision. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include: 1. Resident #20 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/7/18, documented Resident #20 had a severe cognitive impairment. The MDS assessment documented she was totally dependent or required extensive assistance of 1 to 2 staff members with all cares except eating. The MDS assessment documented Resident #20 had skin tears. A previous quarterly MDS assessment, dated 2/4/18, documented she did not have skin tears or wounds. The care plan area addressing Resident #20's skin impairments, initiated 5/9/18, documented Resident #20 experienced skin impairments such as complications related to areas of injury to her left lower extremity abrasion, initiated 7/9/18. The care plan documented staff were to monitor and document the location, size, and treatment of [REDACTED]. The care plan area addressing Resident #20's wound infection to the left lower leg, initiated 7/9/18, documented Resident #20 experienced signs and symptoms of wound infection. The care plan documented staff were to monitor and record the amount, color, and odor of wound drainage and provide treatments per physician orders. The Braden Scale, dated 5/6/18, documented Resident #20 was at risk for developing pressure ulcers. a. Weekly Skin Monitoring of the wound on the back of Resident #20's left lower leg was to be completed weekly until the skin impairment resolved. The monitoring was to assess the healing progression of the wound. Resident #20's Weekly Skin Alternation Reports documented she developed multiple wounds which were not sufficiently monitored and the documentation was not consistent, as follows: * A Weekly Skin Alteration Report, dated 2/3/18, documented Resident #20 had a 6 cm triangular shaped skin tear on the front of her right lower leg, first observed 1/26/18. * A Weekly Skin Alteration Report, dated 4/30/18, documented Resident #20 had a 10 cm 1/2 moon shaped skin tear on the back of her left lower leg, first observed 4/30/18. * A Weekly Skin Alteration Report, dated 5/9/18, documented Resident #20 had an 8 cm by 3 cm skin tear on the back of her left lower leg, first observed 4/30/18. The report documented Resident #20's pain settled down as soon as her dressing change was completed. The report documented the half-moon shaped skin tear to the left lower leg was dark red with bruising. * A Weekly Skin Alteration Report, dated 5/16/18, documented Resident #20 had a 7.5 cm by 3 cm skin tear on the back of her left lower leg, first observed 4/30/18. The report documented Resident #20's pain settled down as soon as her dressing change was completed. The report documented the skin tear was improving with less redness and bruising. * A Weekly Skin Alteration Report, dated 5/23/18, documented Resident #20 had a 7 cm by 5 cm skin tear on the back of her left lower leg, first observed 4/30/18. The report documented Resident #20's pain resolved once the treatment was completed. The report documented the skin tear was healing slowly. The report documented the covering skin appeared to have sloughed off (shedding of dead tissue from surrounding living tissue) leaving healthy tissue. * A Weekly Skin Alteration Report, dated 5/30/18, documented Resident #20 had a 6.8 cm by 5 cm skin tear on the front of her left lower leg, first observed 4/30/18. The report documented Resident #20 only complained of pain during dressing changes. The report documented the skin tear was healing slowly. The report documented Resident #20 was on antibiotics for [MEDICAL CONDITION] and the redness had decreased. * A Weekly Skin Alteration Report, dated 6/6/18, documented Resident #20 had a 5.8 cm skin tear of red granulation tissue with white slough throughout on the back of her right lower leg, first observed 4/30/18. The report documented Resident #20's pain resolved with the completion of the dressing changes. The report documented the wound was showing signs of improvement and staff were to continue with Santyl per physician's orders [REDACTED]. * A Weekly Skin Alteration Report, dated 6/13/18, documented Resident #20 had a 6 cm by 2.5 cm skin tear on the back of her left lower leg, first observed 4/30/18. The report documented Resident #20's pain resolved with the completion of the dressing changes. The report documented the wound was healing slowly and to continue with physician's orders [REDACTED]. The monitoring was not completed for the weeks of 6/18/18 and 6/25/18. A Weekly Skin Alteration Report, dated 7/6/18, documented Resident #20 had three wounds on her left lower leg, first observed on 4/40/18. She had one wound on the anterior (front) of her left lower leg 5 cm by 3.5 cm, a 4 cm by 2.5 cm wound on the posterior (back) of her left lower leg, and a 0.7 cm by 0.7 cm wound on her lateral (side) left lower leg. The report documented slough (dead tissue, usually cream or yellow in color) was present on the anterior and posterior wounds with odor, purulent (pus) discharge, signs and symptoms of infection, and the wound progression had deteriorated. b. Resident #20's 5/1/18 through 7/11/18 TAR documented treatments were administered. Resident #20 was missing the following treatments: * Staff was to cover steri strips to the left leg with [MEDICATION NAME] or [MEDICATION NAME] lite every 3 days until resolved for a skin tear, ordered 5/14/18 and discontinued 6/4/18. The treatment was not completed on 5/14/18, 5/23/18, and 6/4/18. *Staff was to clean wound on the side of Resident #20's left leg with wound cleanser and apply Santyl to the wound bed and cover with foam dressing every other day, ordered 6/7/18 until 6/11/18. The treatment was not completed on 6/8/18. * Staff was to complete the wound care order of [MEDICATION NAME] gel to wound bed with an island dressing every 2 days, ordered 6/12/18 and discontinued 7/6/18. The treatment was not completed on 6/16/18, 6/20/18, and 6/22/18. c. Resident #20 developed an infection in her wounds: * A Patient Infection Report, dated 6/1/18, documented Resident #20 developed [MEDICAL CONDITION] (potentially serious bacterial skin infection) with heat, redness, swelling, serous (clear, thin, watery) drainage at the site, and was on antibiotic therapy. * A Patient Infection Report, dated 7/6/18, documented Resident #20 developed [MEDICAL CONDITION] with heat, redness, swelling, presence of pus at the wound site, and was on antibiotic therapy related to wound infection of the lower leg and signs and symptoms of infections. d. Resident #20's [MEDICATION NAME] (elastic tubular compression bandage) were observed bunched up on her legs as follows: * On 7/10/18 at 2:17 PM, Resident #20 was observed in bed with [MEDICATION NAME] on both legs. The [MEDICATION NAME] were rolled down and bunched on her right leg leaving an indentation where the bunching was localized. CNA #7 and CNA #6 were present and did not notice the bunched [MEDICATION NAME] and did not correct the stockings. * On 7/10/18 at 6:36 PM, Resident #20 was observed sitting in her wheelchair in the hallway. Resident #20 had her pants hiked up her legs to her knee and her left leg was red and irritated looking. Resident #20's right leg looked purple in color and the [MEDICATION NAME] remained bunched up and the front of her right leg was scratched. * On 7/10/18 at 6:43 PM, LPN #4 assessed Resident #20's right and left leg. Resident #20's [MEDICATION NAME] on her right leg was bunched up and the front of her leg was scratched and bleeding. LPN #4 stated she needed to remove Resident #20's [MEDICATION NAME] on her right leg because it was bunched up and the [MEDICATION NAME] caused an indentation into her leg. LPN #4 stated the nursing staff were responsible for placing and removing the [MEDICATION NAME] on Resident #20. LPN #4 stated nursing staff monitored Resident #20's [MEDICATION NAME] for functionality and the CNAs should report to nursing if the stockings were bunched and correct the stockings to prevent pressure points. * On 7/11/18 at 9:14 AM, the DNS and the Clinical Resource Nurse stated they did not know if the Weekly Skin Alteration Reports were documenting the same wounds. The DNS stated a nurse had spoken with her about Resident #20's [MEDICATION NAME] bunching up. The DNS stated she did not know the [MEDICATION NAME] was bunched up from 2:00 PM till 6:00 PM and the surveyor had notified the LPN about the bunching. * On 7/11/18 at 10:47 AM, Resident #20 was observed in bed with her [MEDICATION NAME] bunched on her right leg leaving an indentation where the bunching was localized. The Clinical Resource RN corrected the bunched [MEDICATION NAME]. * On 7/11/18 at 1:30 PM, LPN #1 stated Resident #20 did not have all three wounds on her left leg from the beginning. LPN #1 stated the wound on the back of her leg was from the tape of the bandages. * On 7/11/18 at 1:54 PM, Resident #20 was observed being assisted into bed by CNA #2 and CNA #4 with a Hoyer lift and the [MEDICATION NAME] on her right leg was bunched up. CNA #2 and CNA #4 assisted Resident #20 into bed for a nap and change her soiled briefs. While CNA #2 and CNA #4 assisted her with cares and rolled her from side-to-side she moaned out and continued to moan out throughout the process. The two CNAs were changing her attends and CNA #2 changed her gloves after performing pericare, and did not perform hand hygiene between glove changes. CNA #4 removed her gloves after completing pericare, removed the soiled trash bag, replaced the liner, and left with room without performing hand hygiene. On 7/11/18 at 1:54 PM Resident #20's roommate stated Resident #20 was in pain often at night and when staff interacted with her during cares. Resident #20's roommate stated Resident #20 scratched herself because she was in pain. On 7/11/18 at 1:59 PM, CNA #2 stated she should have performed hand hygiene between glove changes but forgot. On 7/11/18 at 2:06 PM, LPN #1 stated Resident #20's [MEDICATION NAME] on her right leg was bunched up and an indentation was present on the right and left leg. LPN #1 began the process of the dressing change of the two bandages on Resident #20's left leg. LPN #1 asked CNA #7 to assist her with the dressing change by holding Resident #20's leg in place. LPN #1 removed Resident #20's [MEDICATION NAME] from her left leg and removed the soiled bandages. While Resident #20's bandages were removed she grimaced in pain and cried, Owww. LPN #1 began cleansing the wounds with cleanser and removed her gloves once she completed the process. LPN #1 did not perform hand hygiene before placing new gloves on her hands. While Resident #20's wound was being cleansed she was crying out, Quit it. Get your dam. Resident #20 was pulling her leg back and trying to get her leg out of CNA #7 hands. LPN #1 removed a tube of Santyl from her pocket and opened the tube and applied and spread the ointment to the wound base using the end of the tube. While LPN #1 spread the ointment on Resident #20's wounds base she continued to cry and pull her leg back. Resident #20 was covering her face with her blanket and crying. LPN #1 asked Resident #20 if the dressing change was that bad and Resident #20 shook her head yes. On 7/11/18 at 2:20 PM, LPN #1 stated Resident #20 did not receive routine pain medications and this dressing change was the worst interaction she had seen Resident #20 experience. LPN #1 stated she had not offered PRN pain medications prior to the dressing change and she would next time. LPN #1 stated she should have washed her hands between moving from dirty to clean in the dressing change process. On 7/11/18 at 2:37 PM, LPN #5 adjusted Resident #20's [MEDICATION NAME] and Resident #20 cringed while her leg was being touched. Resident #20's clinical records did not contain orders or care plan directions for her [MEDICATION NAME] for nursing staff of when to remove and apply the [MEDICATION NAME] and check the skin under the stocking. On 7/11/18 at 5:00 PM, the DNS stated the facility was aware of concerns with wound management and had a contract agency set up to manage wounds. The DNS stated the measurements on the wounds should be completed weekly and she could not find the measurements for the missing dates. The DNS stated the treatments should be completed per physician's orders [REDACTED].#20's leg got infected because she picked at the wound and removed the bandages. Resident #20's clinical records did not contain documentation she removed her bandages or picked at her wounds. The DNS stated during wound care nurses should perform hand hygiene, apply gloves, remove soiled bandages and cleanse the wounds, perform hand hygiene and apply fresh glove. The DNS stated the nurse should use a Q-tip to apply the ointment onto the wound base and apply new bandages onto the wounds. The DNS stated the nurses should wash their hands after the process was completed. 2. Resident #41 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #41's quarterly MDS assessment, dated 5/7/18, documented her cognition was moderately impaired and she required extensive assistance from two staff members for most ADLs. On 7/9/18 at 2:34 PM, Resident #41 was observed in bed, eyes closed, head of bed elevated about 45 degrees, and with a face mask on (aerosol mask) attached to a nebulizer cup which was connected to a tube to the nebulizer machine. The nebulizer cup was observed to be empty, no mist was coming out, and the nebulizer machine was on. The strap of the face mask on the left side was observed touching Resident #41's left eye. On 7/9/18 at 2:40 PM, LPN #6 said she administered the nebulization treatment to Resident #41 about 10 minutes earlier. The LPN said she did not stay with Resident #41 while she was on nebulization treatment because she knew Resident #41 would not remove the face mask. If she knew a resident would remove the face mask she would then frequently check on the resident to make sure the face mask was still on their face. On 7/9/18 at 2:54 PM, RN #2 said the nurse should stay with the resident during nebulization until the treatment was completed unless there was a self-administration order and assessment completed. 3. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented Resident #30 was severely cognitively impaired, had a history of [REDACTED]. A history and physical dated 3/9/18, documented Resident #30 was admitted to the hospital for an intercranial hemorrhage following a fall, prior to admission to the facility. The facility's Fall Response and Management policy, dated 11/28/17, documented, an unwitnessed fall would require the following actions: * Evaluate the resident for injury. * Monitor neurological assessments per physician's orders [REDACTED]. * Follow-Up and Monitoring - Evaluate the residents condition for at least 72 hours post fall. A Post Fall Investigation Report dated 4/13/18, documented Resident #30 had an unwitnessed fall from his Geri chair. He was found on the floor, on his left side. He denied pain. A Neurological Record initiated 4/13/18, documented Resident #30's vital signs were not documented on 4/13/18 at 9:45 PM, 10:15 PM, or 10:45 PM. On 4/14/18 at 5:15 AM, a neurological assessment was not completed. On 4/15/18 at 9:15 AM, a neurological assessment was not documented. On 4/15/18 at 1:15 PM and 5:15 PM, no vital signs or neurological assessments were documented. On 7/11/18 at 3:10 PM, the DNS stated she was aware there were problems with neurological checks being completed for falls. She stated she expected her staff to know when neurological checks were required and how to complete them.

Based on staff interview and record review it was determined the facility failed to ensure residents consistently received necessary treatment to promote healing of pressure ulcers and prevent infection from developing. This was true for 1 of 8 residents (#1) reviewed for pressure ulcers. This deficient practice caused harm to Resident #1 when he developed an infection to his pressure ulcer, required debridement, and use of antibiotics. Findings include: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses, including muscle weakness and unstageable pressure ulcer. A Hospital Admitting report, dated 12/25/17, documented Resident #1 was sent to the hospital due to fever and was discovered to [MEDICAL CONDITION] (blood infection) due to urinary tract infection. The physical examination documented mildly [DIAGNOSES REDACTED]tous (abnormal redness) 1 centimeter (cm) irritated area on the left. Lateral foot metatarsal area has a boggy ecchymotic (blood underneath the skin greater than 1 cm) area on the left heel. Right heel appears relatively unremarkable . An Initial Nursing Evaluation, dated 1/3/18, completed upon Resident #1's return from the hospital, documented a 4 x (by) 4 cm SDTI to the left heel, and it was black in color. Resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 1/3/18, documented he was at moderate risk for developing pressure ulcers. Resident #1's Care Plan, initiated on 1/15/18, documented he had an SDTI to his left heel. Interventions were: staff to apply Prevalon (pressure relief) boots at all times as resident allows, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, encourage good nutrition and hydration to promote healthier skin, keep skin clean and dry, use lotion on dry skin and wound as ordered. Resident #1's quarterly MDS assessment, dated 3/22/18, documented he was moderately cognitively impaired and required extensive assistance of two staff members for all cares except for eating and personal hygiene. The MDS assessment documented Resident #1 had one unstageable pressure ulcer with SDTI and had no infection. Resident #1's quarterly MDS assessment, dated 6/22/18, documented he had one unstageable pressure ulcer and an infection of the foot. Resident #1's Weekly Pressure Ulcer Report (WPUR), Nursing Notes (NN), Physician Notes, Wound Clinic Notes (WCN), and Laboratory Results documented a pressure ulcer on his left heel as follows: * 1/3/18 WPUR - 4 x 4 cm, stage - SDTI, noted upon admission, black in color, firm, redness surrounding wound, blanches around wound, non blanchable to 4 x 4 SDTI. Prevalon boots on at all times. * 1/23/18 NN - wound RN (registered nurse) stated no changes to Resident #1's left heel, remains black in color, will continue to follow weekly. * 1/30/18 NN - wound RN stated no changes to Resident's #1 left heel, remains black in color. * (MONTH) (YEAR)'s TAR - documented Prevalon boots were on at all times, * 2/6/18 Nursing Practitioner's Notes - documented Resident #1 was referred to the wound clinic for evaluation and treatment of [REDACTED]. * 2/8/18, WCN - 3.71 x 3.54 x 0 cm pressure ulcer not healed, orders included to apply Iodosorb gel to wound bed or paint with [MEDICATION NAME] and cover with foam. Refer to vascular for evaluation and treatment, offloading at all times, avoid prolonged standing in one place and return in one week. * 2/12/18, NN - Resident #1 went to the wound clinic on 2/8/12, order to apply Iodosorb gel topically to left heel then cover with [MEDICATION NAME] or foam dressing, refer to vascular for evaluation and treatment. * 2/16/18 WCN - 4 x 4.8 cm, orders included [MEDICATION NAME] to wound bed, change dressings 2-3 times per week, cover wound with appropriate dressing to manage exudate (drainage) and secure dressing in place, offloading at all times and return in one week. * 2/16/18 Physician's Notes - The appearance of the ulcer and the lack of significant arterial insufficiency suggest that this is a pressure ulcer .we will evaluate further with arterial duplex study. Patient will return for follow-up in 4 weeks. * 2/16/18 NN - dressing to left heel changed, * 2/23/18 NN - heel not as moist, more dry, * 2/27/18 at 2:38 PM, NN - left heel SDTI with no significant change noted, * 2/26/18 WPUR - 4 x 4 cm, stage - SDTI, Iodosorb Gel 0.9% daily as ordered by the wound clinic, float heels and apply boots continuously. * 2/27/18 at 7:15 PM, NN - resident refused to go to speech therapy due to pain left hand and wound on left heel. * (MONTH) (YEAR) TAR - documented Resident #1's left heel was offloaded, and was treated with Iodosorb Gel 0.9% and covered with [MEDICATION NAME] dressing from 2/13/18 to 2/27/18. * 3/1/18 WCN - 3.8 x 4.5 x 0 cm, scant serous (thin, watery) exudates, 76% - 100% eschar, [MEDICATION NAME] to wound bed, cover with ABD dressing (highly absorbent dressing that provides padding and protection for wounds), no foam, and wrap with gauze, change dressings daily, offloading boots at all times, return appointment in 3 weeks. There was no documentation found on Resident #1's clinical record that he was sent back to the Wound clinic after the three week period. * 3/2/18 at 2:39 PM, NN - new order obtained to left heel, cleanse left heel with wound cleanser pat dry and paint wound bed to left heel with [MEDICATION NAME], cover with ABD, no foam and wrap with gauze change daily, continue to offload, boots at all times. * 3/5/18 WPUR - new orders received from wound clinic: Cleanse left heel daily with wound cleanser, pat dry, apply [MEDICATION NAME] to wound bed, cover with ABD pad (no foam) and wrap with gauze. * 3/6/18 at 2:35 PM, NN - pressure wound to left heel continues to be black in color, hard, 75-100 %eschar. On 3/11/18 to 3/15/18, Resident #1 was admitted to the hospital due to [MEDICAL CONDITION] (high potassium in the blood). * 3/15/18 NN - resident was readmitted to the facility, 5 x 6 cm, unstageable pressure ulcer * 3/15/18 WPUR - 5 x 6, SDTI, black and hard, unstageable pressure ulcer to left heel 2 cm larger upon readmission from the hospital. * 3/22/10 WPUR - 5 x 6 cm, SDTI, Prevalon boots, and float heels along with repositioning. * 3/22/18 Physician Notes - treatment options were discussed with the family to improve healing of the pressure ulcer, and that the primary cause of the ulcer was pressure due to Resident's #1's limited mobility, and occlusion of the posterior tibial artery was a factor in the delayed healing. It was in the opinion of the family Resident #1 would not want aggressive procedures. * 3/27/18 NN - Family conference held recently w(ith) wishes for comfort care and no further hospitalization s . * (MONTH) (YEAR) TAR - documented Resident #1's left leg was offloaded using Prevalon boots from 3/1/18 to 3/10/18 and staff were to clean the left heel with wound cleanser, apply [MEDICATION NAME] swab and cover wound with primary dressing using ABD pad, and then apply secondary dressing using Kerlix. This order was discontinued on 3/10/18 when Resident #1 was sent to the hospital, and was readmitted to the facility again on 3/15/18. There was no documentation Resident #1 received treatment on his left heel from 3/16/18 through 3/19/18. * 4/2/18 WPUR - 5/6 cm, unstageable, float heels and repositioned resident, * 4/9/18 WPUR - no measurement, covered with 100% eschar (dark, crusty or leathery dead tissue), Prevalon boots and floating heels for pressure relief. Foam dressing covering wound for added protection. No signs and symptoms of infection. Per the wound clinic order dated 3/1/18 no foam was to be used to cover the wound. * 4/16/18 WPUR - 3.8 x 3 cm, unstageable, covered with hard black eschar, no change on treatment. * 4/23/18 WPUR - 3.8 x 3 cm, unstageable, no change on treatment. Complained of pain with dressing, * 4/30/18 WPUR - 3.8 x 3 cm, unstageable, had some pain with dressing, 100% eschar, * (MONTH) (YEAR) TAR - did not include documentation Resident #1's left heel wound treatment was completed on 4/2/18, 4/12/18 and 4/13/18. The TAR did not include documentation Prevalon boots were applied to the resident. * 5/7/18 WPUR - 3.8 x 3 cm, unstageable, with black hard eschar, complained of pain during treatment. * 5/14/18 WPUR - 3.8 x 3 cm, unstageable with hard black eschar * 5/21/18 WPUR - 3.8 x 3 cm, unstageable with hard black eschar, denied pain during treatment * 5/28/18 WPUR - 3.5 x 4.4 cm, unstageable, eschar is starting to lift at edges, faint odor noted during treatment. * (MONTH) (YEAR) TAR - did not include documentation Resident #1's wound treatment was completed on 5/4/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18 and 5/23/18. The TAR did not include Prevalon boots was applied to the resident. * 6/4/18 WPUR - 3.8 x 3.8 cm, unstageable, eschar is lifting slightly at the edges. * 6/11/18 Physician Notes - .He has been followed by wound care clinic in the past but no recent evaluations are documented .Currently he is DNR (do not resuscitate) with comfort measures only. I discussed minimizing his scheduled medications to only those absolutely necessary to providing him comfort but he states he would like to continue those as well as seek treatment for [REDACTED]. * 6/11/18 WPUR - no measurement, wound developed an increasing odor, will refer to the wound clinic. * 6/14/18 WCN - 3.6 x 4 x 0, small serous exudates with strong odor, eschar 76 - 100%, surgical abridgement done, wound treatment orders included: cleanse wound and peri-wound with Dakins solution, barrier ointment to protect surrounding skin, 1/4 Dakins moistened gauze to wound bed, cover with ABD/Kerlix, change dressing twice a day and as necessary, offloading at all times. * 6/15/18 Laboratory result - light growth of Coagulase Positive Staphylococcus (bacterial infection). * 6/19/18 Nutrition progress note - followed by the wound clinic, due to personal wishes Resident #1 would not be started on any further supplements/additional foods for healing/weight maintenance. * 6/20/18 WPUR - 3.6 x 4 cm, unstageable, eschar patch is smaller, less odor this week, wound was positive for [MEDICAL CONDITION] (MRSA), Dakins wet to dry 2 x a day. * 6/21/18 WCN - 3.03 x 2.88 x 0.5 cm, small serous exudates with mild odor, 76-100% eschar, treatment the same. * 6/27/18 WPUR - no measurement, no eschar present, skin blanches around wound, complained of pain when pressure is applied with or without Prevalon boots. * 6/28/18 WCN - 2.83 x 2.74 x 0.5 cm, small amount of exudate with mild odor, wound orders included cleanse wound with Dakins solution, barrier ointment to protect surrounding skin, 1/4 Dakins moistened gauze to wound bed, and cover with ABD pad and Kerlix, change dressings BID/PRN * (MONTH) (YEAR) MAR - Resident #1 started on [MEDICATION NAME] Tablet 100 milligrams (mg) one tablet every 12 hours, and [MEDICATION NAME] clavulanate 875-125 mg tablet twice a day for 2 weeks. * (MONTH) (YEAR) TAR - Did not include documentation Resident #1's left heel wound treatment was completed on 6/8/18, 6/9/18, 6/10/18, 6/15/18, 6/16/18, 6/17/18. On 6/18/18 TAR documented the frequency of wound treatment was changed to twice a day. Resident #1's left heel dressing was done once a day instead of twice a day on 6/18/18, 6/19/18, and 6/23/18, and no wound treatment was documented on 6/27/18. The TAR did not include documentation Resident #1's left leg was offloaded. The 6/14/18 WCN orders documented Resident #1's dressing was to be changed twice a day and as needed. The order was included on the TAR on 6/18/18, 4 days later. * 7/4/18, WPUR - 6 x 6 x 1 cm, stage 3 * 7/8/18, WPUR - 6 x 6 x 1 cm, stage 3, wound bed with new onset of eschar noted. On 7/12/18 at 3:02 PM, RN #2 reviewed Resident #1's record and said the nurse could have completed the treatments and forgot to document them. The facility failed to consistently implement the wound dressing orders and follow the wound clinic order to bring Resident #1 back in 3 weeks after his appointment on 3/1/18. Resident #1 was seen again by the Wound Clinic on 6/14/18 when increasing odor was noted from his left heel. Resident #1 was harmed when the SDTI to his left heel deteriorated, became infected, required surgical debridement, and required the use of oral antibiotics.

Based on observation, staff and resident interview, and review of residents' clinical records, it was determined the facility failed to ensure a method for evaluating the effectiveness of residents' pain management plans was in place. This was true for 1 of 2 residents (#20) sampled for pain. Resident #20 was harmed when she experienced increased pain during cares and a dressing change and the facility did not identify and treat it. Findings include: Resident #20 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/7/18, documented Resident #20 had a severe cognitive impairment. The MDS assessment documented she was totally dependent or required extensive assistance from 1 to 2 staff members for all cares except eating. The MDS assessment documented she was interviewed about pain and did not have the presence of pain. The care plan area addressing Resident #20's acute and chronic pain related to arthritis, initiated 11/12/12, documented staff were to administer medications as ordered and anticipate Resident #20 for pain relief and respond to her complaints of pain. The care plan area addressing Resident #20's wound infection to the left lower leg, initiated 7/9/18, documented Resident #20 experienced signs and symptoms of a wound infection. Resident #20's physician's orders [REDACTED].>* Tylenol 650 mg by mouth every 4 hours as needed for pain, ordered 9/2/16. * Pain Monitor using verbal and non-verbal 0-10 scale every shift, ordered 8/26/17. Resident #20 did not have orders for scheduled pain medications. The Weekly Skin Alteration Reports and Patient Infection Reports documented the following: * Weekly Skin Alteration Reports, dated 5/9/18, 5/16/18, 5/23/18, and 6/13/18, documented Resident #20 had a skin tear to the back of her left lower leg, first observed 4/30/18. The reports documented Resident #20's pain settled down as soon as her dressing changes were completed. * A Weekly Skin Alteration Report, dated 5/30/18, documented Resident #20 had a skin tear on the front of her left lower leg, first observed 4/30/18. The report documented Resident #20's only complained of pain during dressing changes. * A Patient Infection Report, dated 6/1/18, documented Resident #20 developed [MEDICAL CONDITION] (potentially serious bacterial skin infection) with heat, redness, swelling, serous (clear, thin, watery) drainage at the site, and was on antibiotic therapy. * A Weekly Skin Alteration Report, dated 6/6/18, documented Resident #20 had a skin tear of red granulation tissue with white slough (dead tissue, usually cream or yellow in color) throughout on the back of her right lower leg, first observed 4/30/18. The report documented Resident #20's pain resolved with the completion of the dressing changes. * A Weekly Skin Alteration Report, dated 7/6/18, documented Resident #20 had three wounds on her left lower leg, first observed on 4/40/18. She had one wound on the anterior (front) of her left lower leg 5 cm by 3.5 cm, a 4 cm by 2.5 cm wound on the posterior (back) of her left lower leg, and a 0.7 cm by 0.7 cm wound on her lateral (side) left lower leg. The report documented slough was present on the anterior and posterior wounds with odor, purulent (pus) discharge, signs and symptoms of infection, and the wound progression had deteriorated. * A Patient Infection Report, dated 7/6/18, documented Resident #20 developed [MEDICAL CONDITION] with heat, redness, swelling, presence of pus at the wound site, and was on antibiotic therapy related to wound infection of the lower leg and signs and symptoms of infections. Resident #20's [MEDICATION NAME] (elastic tubular compression bandages) were observed bunched up on her legs as follows: * On 7/10/18 at 2:17 PM, Resident #20 was observed in bed with [MEDICATION NAME] on both legs. The [MEDICATION NAME] were rolled down and bunched on her right leg leaving an indentation where the bunching was localized. CNA #7 and CNA #6 did not notice the bunched [MEDICATION NAME] and did not correct the stockings. * On 7/10/18 at 6:36 PM, Resident #20 was observed sitting in her wheelchair in the hallway. Resident #20 had her pants hiked up her legs to her knee and her left leg was red and irritated looking. Resident #20's right leg looked purple in color and the [MEDICATION NAME] remained bunched up and the front of her right leg was scratched. * On 7/10/18 at 6:43 PM, LPN #4 assessed Resident #20's right and left leg. Resident #20's [MEDICATION NAME] on her right leg was bunched up and front of her leg was scratched and bleeding. LPN #4 stated she needed to remove Resident #20's [MEDICATION NAME] on her right leg because it was bunched up and the [MEDICATION NAME] caused an indentation into her leg. LPN #4 stated the nursing staff were responsible for placing and removing the [MEDICATION NAME] on Resident #20. LPN #4 stated nursing staff monitored Resident #20's [MEDICATION NAME] for functionality and the CNAs should report to nursing if the stockings were bunched and correct the stockings to prevent pressure points. * On 7/11/18 at 10:47 AM, Resident #20 was observed in bed with her [MEDICATION NAME] bunched on her right leg leaving an indentation where the bunching was localized. The Clinical Resource Nurse corrected the bunched [MEDICATION NAME]. * On 7/11/18 at 1:54 PM, Resident #20 was observed being assisted into bed by CNA #2 and CNA #4 with a Hoyer lift and her [MEDICATION NAME] on her right leg was bunched up. CNA #2 and CNA #4 assisted Resident #20 into bed for a nap and change her soiled briefs. While CNA #2 and CNA #4 assisted her with cares and rolled her from side-to-side she moaned out and continued to moan out throughout the process. On 7/11/18 at 1:54 PM Resident #20's roommate stated Resident #20 was in pain often at night and when staff interacted with her during cares. Resident #20's roommate stated Resident #20 scratched herself because she was in pain. Resident #20's roommate stated a baby doll occupied Resident #20's hands so she did not scratch herself due to pain. On 7/11/18 at 2:06 PM, LPN #1 stated Resident #20's [MEDICATION NAME] were bunched up and an indentation was present on the right and left leg. LPN #1 began the process of the dressing change of the two bandages on Resident #20's left leg. LPN #1 asked CNA #7 to assist her with the dressing change by holding Resident #20's leg in place. LPN #1 removed Resident #20's [MEDICATION NAME] from her left leg and removed the soiled bandages. While Resident #20's bandages were removed she grimaced in pain and cried, Owww. LPN #1 began cleansing the wounds with cleanser and removed her gloves once she completed the process. LPN #1 did not perform hand hygiene before placing new gloves on her hands. While Resident #20's wound was being cleansed she was crying out, Quit it. Get your damn. Resident #20 was pulling her leg back and trying to get her leg out of CNA #7 hands. LPN #1 removed a tube of Santyl from her pocket and opened the tube and applied and spread the ointment to the wound base using the end of the tube. While LPN #1 spread the ointment on Resident #20's wounds base she continued to cry and pull her leg back. Resident #20 was covering her face with her blanket and crying. LPN #1 asked Resident #20 if the dressing change was that bad and Resident #20 shook her head yes. On 7/11/18 at 2:20 PM, LPN #1 stated Resident #20 did not receive routine pain medications and this dressing change was the worst interaction she had seen Resident #20 experience. LPN #1 stated she had not offered PRN pain medications prior to the dressing change and she would next time. On 7/11/18 at 2:37 PM, LPN #5 adjusted Resident #20's [MEDICATION NAME] and Resident #20 cringed while her leg was being touched. On 7/11/18 at 5:07 PM, the DNS stated nursing staff were to ensure residents were not in pain and that residents were comfortable. The DNS stated nurses should offer PRN pain medications prior to dressing changes and if a resident demonstrated and/or verbalized pain during the dressing change the staff should stop. The DNS stated Resident #20 was not receiving scheduled pain medications and she did not receive a PRN pain medication dose on 7/11/18, prior to or during the dressing change.

Based on observation, record review, and staff interview, it was determined the facility failed to: *Ensure a resident received necessary emergency medical treatment and services after sustaining multiple second and third degree burns; *Recognize and evaluate a resident for fracture who had unusual movement in a previously immobile arm, and increased reporting of pain to the arm; *Provide appropriate and timely treatment for [REDACTED]. *Ensure residents with [MEDICAL CONDITION] had TED (Therapeutic Embolic Device) hose in place as well as geri sleeves for bruising as indicated by Physician Orders; and *Implement a care plan for falls upon admission for a resident with a known fall history. Resident #1 was harmed when she was not sent to the Emergency Department for evaluation of multiple second and third [MEDICAL CONDITION] is indicated in the facility's burn policy and was not seen by a physician for 6 days following the incident. Resident #4 was harmed when he was not evaluated for a fracture following an increase in abnormal movement and pain to the effected arm and received delayed and inappropriate treatment for [REDACTED]. This was true for 4 of the 15 (#'s 1, 4, 8 and 10) sampled residents reviewed for Quality Care issues. Findings include: 1. The facility's Health [MEDICAL CONDITION] dated 04/28/09, documented in part: "First and second degree Burns ...3. Immerse in cool water or apply cool moist saline packs as soon as possible. ...5. If second degree burn, immerse area in cool water or apply moist saline compresses immediately until the employee no longer feels a burning sensation when the area is exposed to air. Irrigate gently to remove all loose dirt and skin. ...6. Apply dry sterile dressing or apply a thin layer of Silvadone (silver [MEDICATION NAME]) with a dry, sterile dressing to reduce inflammation... Third degree burns/Extensive Burns ...13. Refer extensive second [MEDICAL CONDITION] third [MEDICAL CONDITION] medical care immediately... ...14. Arrange for immediate emergency transportation and medical care for any extensive third degree burn. ...15. Do Not remove clothing that adheres to burned tissue. ...20. Do NOT apply any medications to burns." Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's Quarterly MDS assessment dated [DATE], documented the resident: -Had a BIMS of 12, indicating the resident was cognitively intact; -Required extensive assistance of one person for bed mobility and transfer; -Was frequently incontinent of urine; and -Had a fall since admission with no injury. The resident's Care Plan included a focus area documented on 6/17/13, "(Resident) had an actual fall with No injury r/t (related to) Unsteady gait, Poor Balance, [MEDICAL CONDITION]." Goals dated 9/19/13, documented: "(Resident) will resume usual activities without further incident through the review date." Interventions dated 6/17/13, documented: "-Continue skilled therapies for strengthening;-Encourage to use call light for assistance; -Monitor/document/report PRN (as needed) x 72h (every 72 hours) to MD (Medical Doctor) for s/sx (signs and symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation; and -Neuro-checks per policy and procedure." The Resident's Incident Investigation Directives Post Fall documented on 11/20/13: -2:20 AM, "Call light was on, CNA entered room (and) found resident on floor beside bed. (sic) Was laying on LT (left) side, with legs under bed. Resident states she rolled out of bed. Denies trying to get out of bed. Interventions included: -Change air mattree (sic) w/th (mattress with the) bolsters; -Neuro (72 hours crossed out); and -Moniter (sic) pain 72 (hours)" The resident's interdisciplinary progress notes documented: -1/4/14 at 3:44 AM: "At 0205 (2:05 AM), resident found on the floor between bed and window wall. Skin on back is reddened but blanchable. No apparent other injuries from fall. When moving resident she did touch her upper left arm on the heater. No red spot noted at this time but will continue to monitor that area for possible burn. ROM (range of motion) within normal limits for resident. Neuro checks within normal limits for resident. BP (blood pressure) elevated but is gradually coming back down. Will continue neuro checks and monitoring per protocol x72hrs (hours)." -1/4/14 at 3:50 AM, "When resident returned to bed with assist, complained of pain in left foot. Aide removed sock to check foot. Found denuded spots on great toe and second toe. Areas white, dry except around edge where skin pulled off by sock. Toes reddened, irritated. Great toe nail black. Areas cleaned, covered with [MEDICATION NAME] and [MEDICATION NAME], held in place with gauze for protection for the rest of the night. Will request proper tx (treatment) orders." -1/4/14 at 9:38 AM, "L (left) great toe from nail to top of foot about 2inches (sic) is white with top layer of skin missing, great toenail is purple and intact. 2nd toe around knuckle missing skin with purple center and white around edges (sic). 3rd toe knuckle area has fluid filled blister, skin intat (sic). Top of foot is red and tender to touch. (MD) notified, new orders to apply [MEDICATION NAME] cream, non stick [MEDICATION NAME], wrap in gauze, change 1 x (time) daily. Will monitor for s/s (signs and symptoms) of infection, swelling, redness, pain, fever, s/s of healing as well." 1/6/14 at 11:09 AM, "IDT review of event on 1/4/14 at 0205 (2:05 AM). Resident was seen asleep in bed at 0150. At approximately 0205, CNA smelled something burning and found resident with pillow and blanket behind her laying against base board heater. First Aide(sic) initiated. Resident received [MEDICAL CONDITION] left toes and back. She has a swollen left ankle. x-ray was negative for fracture. See assessments dated 01/05/14. Resident's pain is controlled with [MEDICATION NAME]. Treatment initiated with blister to rt (right) scapula resolved. Family and MD notified. Bed was moved away from heater. All beds against base board heaters were turned away and contractor will move all base board heaters to the center walls away from the beds. Will monitor and treat until resolved." The resident's Physician Telephone Orders include: -1/4/14:"Paint blister to RT (right) scapula area w/ (with) betadyn. Let air dry. Cover w/ island drsg (dressing). Change QD (every day); Paint blister to lateral left back, flank w/ betadyn. Let air dry. Cover w/ island drsg. Change QD; -1/4/14 Clense (L) mid back blister w/ gauze. Swab blister w/ [MEDICATION NAME]. Cover w/ non-adherent pad change drsg (dressing) daily. If blister sloughs follow w/ drsg treatment for [REDACTED]. -1/8/14 Clense (L) foot w/ NS (Normal saline). Pat dry w/ gauze apply [MEDICATION NAME]. Air dry. Weave interdry cloth between toes. Apply exudry to large area of top of foot. Secure w/ kerlix. Change daily and prn (as needed)." A facility Incident Investigation Directives Post Fall was undated, documented the following: "Summary of Event: CNA heard someone calling for help. Search rooms and found (resident) had rolled off the back side of her bed onto the baseboard heater. LN (licensed nurse) assessment identified open areas, first aide provided and MD notified for orders.... Immediate Interventions: -Bed turned away from heater and window to provide distance. -Wound treatment initiated. -Pravalon Boot to left foot and keen wedge to float both heels. -1/4 rails bilaterally to assist with bed mobility. -Foot cradle to elevate bedding. -Monitoring for increase pain and medicate as ordered. -Continue with air mattress and off load area's affected. -Neuro's initiated Investigation and Conclusion: Upon completion of a thorough investigation including resident interviews, observation, and record reviews it is determined that (resident) moves around in her bed. At approximately 0130 she was provided cares and repositioned in the middle of her bed with her call light. Around 0150 the LPN observed (resident) curled in a fetal position on her bed with her call light. (Resident) states she rolled out of her bed by the window and became stuck between the bed and the wall heater. She states that it was hot and she called for help. One CNA reports that she heard someone call for help, but then did not hear anything more. She went to the nurse's station to see if anyone else had heard anything. simultaneously, another CNA was at the time clock checking out for lunch at 0205 when he smelled something burning. The two CNA's heard (resident) call out and found her lying on the floor on her right side with a blanket and pillow between her and the baseboard heater. They moved the bed away from (resident) and called for the LN. The blanket and pillow had scorched marks. The resident gown and socks did not have any evidence of burning. The LN assessed (the resident) with the following: -left great toe nail appeared busied with the top missing and white like dry patch (sic) -2nd toe had denuded area -left lower back with reddened blanchable area -no blisters noted at this time MD was notified and wounds treated as indicated At approximately 0600, two LN's completed an additional skin check [MEDICAL CONDITION] as following (sic): -left great toe and left 2nd toe open areas -blisters to left 3rd and 4th toes -blister to left rear iliac crest and right scapula -open blister to left lower mid back and mid spine area. MD was updated and orders received. (The resident) complained of left ankle pain. X-ray ordered and results were negative. In Conclusion, it is determined that (the resident) received a variety [MEDICAL CONDITION] she rolled out of bed and onto the baseboard heater. Plans to Prevent Reoccurrence: -All beds next to base board heaters were turned to provide more distance. -Contractor is moving all base board heaters from under the window and way from the resident beds." On 01/10/14 the physician progress notes [REDACTED]. "..now they are applying [MEDICATION NAME] to her burns, letting it air dry between her toes, applying Exu-Dry to the large area on the top of her foot and wrap with Kerlix with acetic acid soaks to the left foot daily for 10 minutes. On her back wound they are cleansing it with normal saline, patting it dry, applying [MEDICATION NAME] and Accudry and an Exu-Dry, secured with Long Island dressing, changed daily and p.r.n. She does have a foot cradle in place and a Keen wedge... PHYSICAL EXAMINATION:... The top of the left great toe including the entire top of the toe has a third-degree burn. There is yellow eschar present in the wound base. There is also a burn on the DIP (Distal interphalangeal joint) ... ASSESSMENT: 1. Fall with 2nd and 3rd [MEDICAL CONDITION] the back and left foot due to contact with floorboard heater." On 2/10/14 the Physician ordered a wound clinic referral. NOTE: The resident experienced a delay in treatment when she was not immediately sent to the emergency room (ER) as indicated by the facility's Burn Policy points 13 and 14. Although the facility was in contact with the physician by telephone, the resident was not evaluated by the physician until six days after the burn occurred. On 2/12/14 at 3:30 PM, The DON and DDCO were questioned regarding the resident's treatment. They were unable to answer questions at that time, but took notes and said they would research the issue. On 2/13/14 at 3:30 PM, the DON and DDCO were questioned regarding care of the resident following the fall which resulted in burns. When asked why the resident was not transferred to a local ER the DON said, "Her pain was controlled, we initiated treatment and x-ray for her complaints about her ankle. We were in communication with (the resident's physician) throughout the day. She said that there was nothing the ER would have done that we couldn't do here... (Resident's Physician) wasn't here, but she did not appear to [MEDICAL CONDITION] first. At first it was only redness, then as the day went on the third [MEDICAL CONDITION]. You can see that we were on the phone getting physician telephone orders through the day." Additional information was received from the facility on 2/18/14 at 3:17 PM. However the information provided did not resolve the concern. 2. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's (R#4) Significant Change of Condition (SCOC) MDS assessment, dated 10/16/13, coded: -Unable to complete BIMS, assessed by staff with severely impaired cognition. -Non-verbal, able to understand simple, basic, direct information. -Dependent on 2 persons for transfers and dressing. -Did not ambulate. -Pain present, treated with routine pain medication. No PRN medication medications needed. No non-medication pain relief measures used. -Resident unable to rate pain per pain scale, but was not noted with non-verbal signs of pain. Resident #4's most recent SCOC DS, dated 1/16/14, coded: -Unable to complete BIMS, assessed by staff with severely impaired cognition. -Non-verbal, able to understand simple, basic, direct information. -Dependent on 2 persons for transfers and dressing. -Did not ambulate. -Incontinent of bowel. -Foley catheter in place for urine. -Pain present. Both routine and PRN pain medications needed, as well as non-medication pain interventions. -Non-verbal sounds, facial expressions, and protective body movements indicating pain present noted. On 12/23/13, time documented as, "AM," a facility "Stop and Watch Early Warning Tool" documented R #4 was experiencing increased pain. The form was signed by CNA #3, and documented as given to LN #4. LN #4 signed acknowledgement of the document on 12/23/13 at 9:30 AM. Resident #4's Nurse's Progress Notes documented: -12/23/13 at 10:36 AM. Health Status Change (SBAR) (Situation, Background, Assessment, and Request). Situation: Res has a [DIAGNOSES REDACTED]. Background: Res is having more movement with his L upper extremity. Also, res is having increasing pain at L upper extremity. Res is on routine Tylenol 650 mg (milligrams) tid (three times daily), also he has a prn (as needed) dose of Tylenol 650 q (every) 6 hours prn. The routine dose of Tylenol is helpful. Assessment:...No skin issues noted to LUE (left upper extremity)...Request: Please advise." -12/23/13 at 5:33 PM. "New orders received for [MEDICATION NAME]." -12/24/13 at 11:58 PM, "zero signs of pain or discomfort." -12/25/13 at 9:31 AM. "X-Ray ordered of L shoulder, L clavicle to rule out fracture. Assessment of resident reveals guarding to L shoulder ROM. Very faint old yellow bruises on upper arm, appear to be 1-2 weeks old. Pt (patient) with contracted left arm, held to body, when moved he grabs our hand/arm with his right hand and grimaces. (Physician) notified. X-ray to be obtained today to r/o (rule out) fx (fracture), as well as pt has pain medications to be used as needed that control pain per nursing staff report." -12/25/13 at 11:01 AM, "Notified by radiology tech that there is some type of fracture on this resident...Report on fax machine states 'acute proximal left humeral fracture', calls out to (physician), left two messages 11:17 at this time..." -12/25/13 at 11:08 AM, "Late entry for 12/24...It was brought to my attention by CNA that he (R #4) was guarding his left arm. I assessed arm and upper arm is tender and when arm is raised he tries to swing at me with his right arm. Alerted the nurse who said it has been addressed and also notified the charge nurse..." NOTE: There was no entry from either the LN caring for R #4, or from the charge nurse, regarding this report on 12/24/13. -12/25/13 at 11:12 AM. Called to residents (sic) room to assess left arm again, today a yellow discolored area was noted to left upper arm above the elbow and area is still very tender and again tried to swing with his other arm at this nurse. Floor nurse and charge nurse notified." -12/25/13 at 2:22 PM, "When I arrived I was informed of resident having a change in his pain medication due to arm being painful. When I questioned staff they told me it had been this way since it was noted on Monday (12/23/13). When I went to see it I noticed a faint bruise on outer back upper arm. Supervisor was called by CNA to look at it and that was when an X-ray was ordered..." -12/25/13 at 11:36 PM, "...pain pill given at this time to help relieve pain with next change and cares, has left arm and sling in place..." -12/26/13 at 2:50 PM, "It was noted at noon today that resident appeared to be in pain. On evaluation of pain MD was called and [MEDICATION NAME] 50 (milligrams) (by mouth) was increased to TID from BID (twice daily)..." 12/27/13 at 11:08 AM, "...No signs of pain at this time noted...Tightens up when anyone touches left arm..." -12/27/13 at 3:56 PM, "...Resident also with DX (diagnosis) of Left Humerus fx 12/25/13. Sling and swathe (sic) in place, pain medications adjusted to maintain comfort. (Physician) rounded on resident today, no new orders. Resident is pending appointment with ortho(pedic doctor)..." NOTE: This was the first documented physician's examination since the onset of pain and passive mobility changes on 12/23/13, and the [DIAGNOSES REDACTED]. 12/31/13 at 3:18 PM. "Pt returned from...(ortho) with illegible progress note and order. Multiple attempts made to contact office for clarification made without success r/t holiday. Contacted on call ortho for clarification...but wasn't able to clarify order..." On 12/25/13, an "Addendum: Final X-Ray Report" in R #4's medical record documented Exam Type as, "Portable Shoulder Left." Findings documented, in part, "Acute Proximal humeral fracture noted." The addendum documented, "There is minimal [MEDICAL CONDITION]." On 12/25/13 at 12:37 PM, a physician's orders [REDACTED]." Resident #4's MAR for December 2013 documented a "Pain Rating Scale at the Start of Each Shift" (Scale of 0 to 10, with 0 being no pain and 10 being the worst pain ever felt), as follows: -Days: Score of "0" 12/1/13 - 12/24/13. Score of 10 on 12/25/13, score of 8 12/26/13 - 12/28/13. -Evenings: Score of "0" 12/1/13 - 12/24/13. Score of 9 on 12/25/13 and 12/26/13, score of 4 on 12/28/13. -Nights: Scores of "0" the entire month. NOTE: Please see interviews and notes below, identifying pain as early as 12/23/13. Resident #4's MAR for December 2013 documented an order for [REDACTED]. A facility "Unusual Occurrence" report for the above fracture, dated 12/25/13, documented, in part: -"Summary of event: On 12/25/13 during cares, resident noted to guard left arm. Licensed nurse examined and noted some faint yellow bruising and swelling, grimacing with gentle touch. Physician notified, x-ray obtained with evidence of acute proximal left humeral fracture." -"Investigation & Conclusion: Upon completion of a thorough investigation including interviews, record review, and observation it is determined that on the morning of 12/23/13 (Resident #4) exhibited guarding and pain with morning cares...(Doctor) notified and [MEDICATION NAME] was added for pain management; there were no behaviors of agitation noted...On 12/24/13 (R #4) appeared to have pain managed with the use of [MEDICATION NAME], no grimacing was noted. ...On the morning of 12/25/13, (R #4) showed evidence of additional faint yellow bruising and some swelling to his left arm. The licensed nurse contacted the physician and an x-ray was obtained. X-ray confirms acute proximal left humeral fracture...on the morning of 12/23/13 the CNA assigned to care for (R#4)...approached (R #4) to untie his gown, he groaned and used his right hand to hold his left elbow. When asked if he hurt he indicated yes. The CNA notified the nurse...Investigation indicates...arm was fractured between the evening of 12/22/13 and the morning of 12/23/13." -The last 2 pages of the report were entitled, "Compilation of Interviews (CI) held on 12/30/13, 01/01/14, and 01/02/14." The pages contained bulleted summaries of staff interviews related to this event. Interview statements documented, in part: 12/25/13: -LN #6's statement included a nursing progress note ..."A typed interview from LN #6, dated 1/1/14 at 4:30 PM further documented, "I notified (Physician's Name) on 12/26/13 that (R #4's) pain was not controlled, and received a new pain order...(R #4) was resting after pain medication was adjusted." -A hand-written statement from CNA #7 documented, "I was told on the beging (sic) of my evening shift either on Saturday or Sunday (12/21/13 or 12/22/13) that his arm was sensitive and he was pulling away his arm and crying out...I was also informed that he was going to have an X-Ray and after finding out this, I made sure when he was getting his shirt off or changing him we were careful." -LN #12 documented, "Called to room Tue (Tuesday, 12/24/13) to assess resident's pain - arm was very tender with faint yellow bruise. Mentioned to nurse (LN #4) response was, "It's old and has been taken care of...Wed (12/25/13) called back to room by same aide (CNA #3) due to arm still sore. Reassessed old bruising noted today and more swelling, had (LN #6) look and call RN supervisor to room and we discussed x-ray to (rule out fracture)." (NOTE: This was 2 days after R #4 was initially noted with symptoms of pain, guarding, and increased passive range of motion in an extremity which had been contracted and immobile for over [AGE] years.) LN #12's typed statement, dated 1/1/14, a week later, documented regarding the 12/25/13 reassessment of R #4, "...the bruise was larger and darker in color, as if the bruise was coming from the inside out." -CNA # 13 documented, "Monday, Dec(ember) 23 rd when I arrived on shift, (CNA #7) informed me that days told her (R #4) was having arm pain (and) was getting X-Rays. That evening (at) about 6:30, while changing his shirt, he pushed our hand away (and) held his left arm, so we stopped removing the shirt." On 1/1/14, a typed statement from this CNA further documented, "We were able to get his shirt off after we lay resident down. We removed his shirt by taking his good arm out of the sleeve first, then over the head, then slid it off the left arm. Resident appeared in less pain once he was laid down. We were able to roll on his right resident side, but he grimaced when we rolled him to his left side..." -On 12/26/13 at 11:20 AM, a hand-written statement from LN #4 documented, "(CNA # 3) reported to this nurse that res(ident's) left arm was more moveable, and that he had pain with this. I assessed res(ident) (left) arm no skin issues were noted. I reported this to (LN # 9)...I typed up an SBAR report, and faxed this to (Physician's name). I checked back with (LN #9) and she had received new orders...for [MEDICATION NAME]. I initiated the first dose...promptly. The pain med was helpful." -On 12/26/13, at an unknown time, a hand-written statement from LN #9 documented, "On Monday 12/24/13 I received a faxed order for [MEDICATION NAME] regarding pain for (R #4). The fax was non-specific about where the pain (R #4) was having so I thought it was generalized discomfort. I wasn't notified of pain until I received this fax. Tuesday 12/24/13 I was notified of a faded green/yellow bruise on his arm which 'looked old'..." -On 12/26/13, unknown time, a hand-written statement from CNA #10 documented, "Tuesday the 24th...(CNA #3) let me know there was something wrong with his arm. I asked what was wrong with it and she took me into his room and kind of showed me. I saw that his arm just above the elbow was fat and on the top of his shoulder there was a dime-sized yellowish bruise...I got (CNA #3) and (Unknown staff person) to help me get him into bed and dressed...(R #4) did get mad and tried to grab at me when we were putting his shirt on." -On 12/27/13 at an unknown time, a hand-written document identified as a "phone interview" with CNA #3 documented, "About 7:00 - 7:10 AM went in room to get resident ready. (The DNS clarified during interview this statement referred to the morning of 12/23/13.) Res grabbed arm (and) grimaced. Thought it was weird that arm more moveable (and) he was definitely in pain. Reported to (LN #4) (and) asked if there were changes with res...Nurse said no, no changes (and) that we'd watch (and) see what was happening. Went back in room and got res up (with second) aide. Res responded to (other unknown staff member) in Spanish yes I hurt. He continued to appear in pain during the shift, nurse said something about (doctor) knowing." -On 1/1/14, a typed statement from LN # 15 documented, in part, "On 12/23/13, at approximately 10:30 AM...(LN #4)...reported to me that CNAs were saying (R #4's) Left arm ([MEDICAL CONDITION] affected side) was more mobile and showing increased pain...I said an SBAR to (physician's name) sounds like a great idea,,,I asked (LN #4) late afternoon if we had received new orders as I was walking by and she said yes...approximately 8:50 PM...(CNA #7) said (R #4) is in a lot of pain, and we couldn't take his shirt off, he was guarding his arm and staff was waiting on x-rays. I told her I did not know anything about x-ray ordered and for her to check with the nurse because he needed to be medicated for pain so they could get his shirt off. Also to ask the nurse about x-ray orders because if he was in that much pain an x-ray might be a good idea...On 12/25/13 at 6:54 AM I received a call from (LN # 20) reporting...(R #4's) pain, he had old yellow bruising, and swelling to the arm and she could not find any documentation on what had been done...I then asked her if an x-ray had been done, she stated no there weren't any x-ray orders. I asked her what he was receiving for pain and she said [MEDICATION NAME]. I asked her please make sure (physician) was notified and an x-ray needed to be done that morning...at (12:21 PM) I received a call from (LN #14)...and she informed me (R #4) had a fracture to his left arm...I let her know to check with skilled therapy if a sling was available to immobilize arm. If not to try our vendors...I also asked her to pad under sling/armpit and make sure staff was checking skin Q shift and medicating (R #4) appropriately for pain...At approximately 3:30 PM (LN # 14) called me again to inform me (vendor) had delivered a sling but no one had a swathe (sic) available...contacted...(retailer)...stated they were sold out...at approximately 5 PM...proceeded to (another retailer)...but they were closed...I called the facility and asked the RN to use ace wrap/gauze or a sheet to create one so his arm would be positioned appropriately. 12/26/13 I looked at resident chart to review orders and x-ray results with 'Acute proximal humeral fracture' noted...I asked (LN #6) on hall how (R #4) was and she stated he was still in pain. I asked her to contact (physician) to make more pain medication adjustments to maintain resident comfort..." NOTE: Approximately 44.5 hours had transpired since R #4 was first noted with pain and passive ROM changes and the time the facility obtained an x-ray. Once the resident was diagnosed with [REDACTED]. There was no documentation the physician was notified of this delay, nor that the facility was having difficulty obtaining the ordered supplies. On 12/27/13, a Physician's Progress Note from Resident #4's primary care physician documented, "The patient was seen today in followup of some left shoulder pain. I had initially been notified on 12/23/13, that the patient seemed to be having some increased pain to his left shoulder. He has had multiple [MEDICAL CONDITION] so he is hemiparetic on that side, but was having problems with some increased discomfort. There was noted to be no signs of injury or reports injury from the staff. (NOTE: The physician's note did not address whether they physician was aware of the sudden changes in the resident's passive mobility with his affected arm, or address this change as a possible sign of injury.)...at that time, I ordered some [MEDICATION NAME] to see if he could tolerate that would help. The patient does have a history of becoming over sedated with [MEDICATION NAME] and other narcotic pain medications, In any case. I was called again on 12/25/13 indicating that the [MEDICATION NAME] was not helping and he was having significantly worse pain and it seemed to be quite problematic (NOTE: The physician's note did not indicate awareness of the increased pain and combativeness noted in the nurse's notes from 12/24/13.)...An x-ray was obtained on 12/25/13, that showed acute proximal humeral fracture.." On 12/31/13, a Physician's Progress Note, identified by the facility as the progress note from R #4's orthopedic consultation documented, "(Recommend) sling for (left) arm." NOTE: This notation was made 6 days after R #4's x-ray results were available, and 8 days after R #4 was originally noted with increased pain and passive movement in his affected extremity. On 2/12/13 at 12:45 PM, the DNS and DDCO were asked about R #4's arm fracture, in terms of his increased pain, and the delay between the onset of pain and diagnosis. The DNS stated the physician was notified of the resident's new onset of symptoms on 12/23/13, and ordered [MEDICATION NAME] for the resident's pain. The DNS was unable to state whether or not Resident #4's mobility changes were considered as a symptom, along with his increased pain. The DNS stated she was unsure when the resident had first been evaluated by a physician after the onset of these symptoms, but it could have been that the physician visit at the facility on 12/27/13 was the first time a physician examined the resident after the fracture was discovered. The DNS stated a resident with a new fracture would only be sent out to the hospital or physician's office if the physician ordered it. The DNS was asked about continued reports from the CNAs of the resident continuing to experience pain throughout 12/23/13, 12/24/13, and 12/25/13 when the fracture was diagnosed . The DNS stated the CNAs were expected to report changes to the nursing staff, and the nurse should handle it. The DNS stated she thought the nurses had handled the situation, given their assessments at the time. The DNS was asked if the physician had been notified of the delay in getting the sling and swath placed, so those treatment choices could be re-evaluated. The DNS stated once the physician ordered the sling and swath, the facility staff had proceeded to get them in place. The DNS was asked if the physician had been notified the facility had been unable to locate a swath, and had used an alternate material instead. The DNS stated she would look into it. On 2/13/15 at 10:50 AM, the DNS and DDCO approached the surveyor for further follow-up. The DNS and DDCO stated they had spoken to the resident's physician that morning, and the physician stated at the time the symptoms of pain appeared, and even when the fracture was diagnosed , it was not felt the resident needed to be evaluated further outside the facility, until an orthopedic appointment could be made. The DNS and DDCO also stated the physician had been unaware of the substitution of another material for the swath until the resident was examined on 12/27/13, but was not concerned the substitution had been made. Resident #4 was harmed when he sustained a fracture in the facility, which was not diagnosed for at least 2 days after the onset of increased pain and mobility changes. Resident #4 continued to experience pain and distress during cares throughout this time. Further, once the fracture was diagnosed , there was a delay of several hours before the supplies for treatment, as ordered by the physician, could be obtained. On 2/13/13 at 6:30 PM, the Administrator, DNS, and DDCO were informed of the surveyor's concerns. The facility offered no further information. 3. Resident #10 was admitted to the facility on [DATE] wi

Based on observation, record review, policy review and interviews with staff, residents, and resident families, it was determined the facility failed to implement interventions to prevent the development of pressure sores. This was true for 4 of 5 residents (#s 1, 2, 3, and 4) sampled for pressure sores. *Resident #2 was harmed when she developed an re-current unstageable pressure ulcer on her coccyx while a resident in the facility; *Resident #4 had the potential for more than minimal harm when he developed a Stage II pressure ulcer to his chest and a Stage I pressure ulcer to the left under arm related to the use of a sling after he fractured his arm in the facility; and * Resident #'s 1 and 3 had the potential for more than minimal harm when skin protection interventions were not implemented per their plans of care. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 8/21/13, documented the resident: -Had a BIMS of 1, indicating severe cognitive impairment; -Required extensive assistance of one person for bed mobility, transfer, toilet use, personal hygiene and bathing; -Was frequently incontinent of urine; -Had no pressure ulcer and no risk of pressure ulcers; and -Had moisture related skin problems. The resident's Annual MDS assessment dated , 11/21/13, documented the resident: -Had a BIMS of 1, indicating that she was severely impaired; -Required extensive assistance of one person for bed mobility, transfer, toilet use, personal hygiene and bathing; -Was frequently incontinent of urine; -Had 2 stage 1 pressure ulcers and had no other skin problems. The resident's Braden Scale documented on 12/1/13 a score of 17, indicating she was at risk for pressure ulcers. The resident's Non-Pressure Ulcer Investigation on 1/10/14 documented that an open area was found on her coccyx. It documented in part, "Was called to room due to area on coccyx. Checked area (and) instructed staff to apply barrier cream and then reported to supervisor (sic). Recommendations included: -Treat (and) monitor; -Refer to wound clinic; -Change Q1 hr (every 1 hour) waking; and -Change Q2hr (every 2 hours) Noc (night shift)." The resident's Interdisciplinary Progress Notes documented: -On 1/10/14 at 6:50 AM, "Was called to room to check area on coccyx. On inspection noted open area. Area was on coccyx and open. Had staff apply barrier cream to area and instructed them to turn and change positions frequently. Then reported to night shift supervisor about the area." -On 1/10/14 at 1:35 PM, "After talking with Supervisor cleaned area and applied Poly mom AG (sic) and a coccyx dressing after Measured and seen by DON and assessed by her. On seeing the area at this time noted the area was larger than first thought." NOTE: See Wound Care Flowsheets below for measurements. -On 1/13/14 at 9:00 AM, "Weekly Pressure Ulcer BWAT (Bates-Jensen Wound Assessment Tool) Report completed. Site information: Coccyx - Pressure: Length = 4.8 (cm), Width = 4.5 (cm), - Stage Unstageable. Date of initial observation: 01/10/2014. BWAT score = 34.0. Continues with Tx (treatment) per MD (Medical Doctor) order for PU (pressure ulcer) on coccyx. Denies pain with Tx. White/Yellow slough noted to base of wound. No s/sx (signs or symptoms) infection. Scant amount of serous drainage on old dressing noted. will monitor. Improvement noted this week See assessment for more details." -On 1/13/14 at 10:37 AM, "IDT review of event on 1/10/14 at 0630 (6:30 AM) and 1200 (1200 PM). Resident was found with open area to coccyx and buttocks when given cares at 0630. New orders for treatment initiated. Resident dribbles urine constantly. She has a positive U/A (urinalysis) with C&S (culture and sensitivity) pending. Resident set up to change q1 hour during waking and q2 hours during the night..." On 1/17/14 the resident's Physicians Progress note documented in part, "...she was noted to have some ulcers on her bilateral buttocks. The patient does have advanced dementia with [MEDICAL CONDITION]. She is becoming more immobile and it appears that she had not been turned as a possibility or possibly sat in her chair longer. Most likely it was from her lying in bed in moisture and she has now developed very serious bilateral buttock wounds on the upper buttocks/sacrum. I wanted to evaluate these and write some wound care instructions. The plan is also for her to see the Wound Clinic since it has been very sudden and dramatic onset. The patient is quite debilitated. She is dependent on activities. The patient herself is not able to give me any information...Assessment: 1. New onset bilateral decubitus on the buttocks. 2. Urinary and bladder incontinence. 3. [MEDICAL CONDITION] with immobility. 4. Dementia." The resident's Wound Care Flowsheets document the following for her coccyx pressure wound: -1/10/14, 4.3 x 4cm, unstageable; -1/13/14, 4.8 x 4.5cm, Butterfly shape, unstageable; -1/20/14, 3.7 x 2.5cm, Irregular shape, unstageable; -1/27/14, 3.0 x 2.3cm, Irregular shape, unstageable; and -2/3/14, 1.7 x 2.0cm, Round/oval shape, unstageable. The resident's Care Plan included a Focus area for impaired skin prior to the development of her pressure ulcers and was initiated on 9/26/13. The resident Goals documented, "to keep toes free from pressure wounds on feet bilat (sic). Interventions documented, in part: "-[MEDICATION NAME] to buttocks with toileting, initiated 8/12/13; -Geri Sleeves when up, initiated 7/1/13; -Use foot cradle while in bed to keep pressure off of toes on feet bilat (bilaterally), initiated 9/26/13; and -Use Keen Wedge to float heels, initiated 9/3/13." Note: a Keen Wedge is a triangular foam device that is placed in the residents bed to elevate the feet and float the heels. The resident's Care Plan included a Focus area dated 2/5/14 for her skin problems: "(Resident) has a pressure wound to her buttocks, and a bruise to the top of her left hand." The Goals are documented as, "Keep toes free from pressure wounds on feet bilat, and Wound to buttocks/coccyx will resolve by the review date 1/13/14." Interventions documented, in part: "-Air flow pad to be used with air mattress for lifting patient up in bed, initiated 1/14/14; -Air mattress to help protect skin, initiated 1/10/14; -Calmosptine to buttocks with toileting, initiated 8/12/12; -Geri sleeves when up, initiated 7/1/13; -Hourly incontinence care to reduce moisture during day, initiated 1/13/14; -Noc shift to provide Q2 hour incontinence care, initiated 1/13/14; -Turn Q2 hours to offload coccyx wound, initiated 2/10/14; -Use foot cradle while in bed to keep pressure off of toes on feet bilat, initiated 9/26/13; -Pt (Patient) not to wear shoes until further evaluation/assessment. Pt to wear socks only, initiated 1/10/14; -Use Keen Wedge to float heels, initiated 9/3/13; and -Wound clinic referral for buttocks, initiated 1/13/14." The resident's physician's orders [REDACTED]. -On 11/17/13, "[MEDICATION NAME] to buttocks after each incont (incontinent) episode. DX (diagnosis): open area to (r) (right) buttocks; -On 1/12/14, Turn Q2 HRS (every 2 hours) and prn (as needed), float heels while in bed, avoid supine position; Wound clinic referral, Air bed per protocol; -On 1/21/14, Cleanse coccyx area w/ wc (sic). Pat dry w/ gauze. Apply [MEDICATION NAME] gel to open areas, apply skin prep around wound, cover with mepon (sic) of dressing, change daily. Roho cushion to w/c (wheel chair); -On 1/17/14, Prevalon Boots to BLE while in bed; and -On 2/4/14, Continue (with) santyl dsg (dressing) (change) to sup (sic) and inf (sic) buttocks q (every) day. Turn pt Q 2 (hours) while in bed. Avoid sitting for prolong times (sic)." Note: a Roho cushion is a brand of pressure relieving cushion that fits in a wheelchair. Prevalon boots are a brand of boot that is designed to lift the foot off the mattress reducing pressure on the heel. On 2/10/14, the resident was observed to be lying flat in bed, positioned on her left side under her covers. She was wearing a sweater with the pull alarm attached to her pillow and her sweater. The resident was wearing non-skid socks and her heels were not floated. She was lying on a pressure reducing mattress. She was observed in this same position at the following times: 11:00 AM, 1:35 PM, 2:30 PM, 3:00 PM, and 4:10 PM. On 2/10/14 at 3:00 PM and 4:10 PM, the resident was observed to be awake and non communicative while in her bed. On 2/11/14, the resident was observed in her wheelchair with a Roho cushion at: 8:10 AM, 8:20 AM, 9:45 AM, 10:40 AM, 12:10 PM, 12:35 PM, 12:37 PM, and 1:05 PM. On 2/11/14 at 2:20 PM, the resident was observed to be in bed positioned on her left side under multiple blankets. Her heels were not floated and were in contact with the mattress. NOTE: During the period of 2/10-2/12/14, the resident was not observed wearing Prevalon boots and did not have her heels floated while she was in bed. She remained in bed 2/10/14 for the entire day, despite being wakeful in the afternoon, and was not observed to be repositioned. Additionally, the resident was observed to spend several hours up in her wheelchar on 2/11/13 from 8:10 AM through 1:05 PM. There was no foot cradle or Keen Wedge observed in her bed from 2/10/14-2/13/14. On 2/12/14 at 3:20 PM, the DON and DDCO were questioned regarding the resident's care. The DDCO said, "We'll look into it and see." When asked why the pressure ulcer on her buttocks was unstageable, the DON said, "When there is any slough on it anywhere, it is unstageable." On 2/13/14 at approximately 3:30 PM, the DON and DDCO were re-interviewed regarding the resident's care. When asked what the facility had done to prevent the resident's pressure ulcers, the DON stated the following timeline: "On 9/6/13 a pressure reducing mattress and gel cushion for the wheelchair were implemented, on 11/17/13 the [MEDICATION NAME] for incontinence after incontinent care to the peri region was implemented, on 12/9/13 we tried bowel movement scheduled for incontinence, on 12/20/13 she started wearing pullup briefs. She was repositioned before 1/10/14 but not on a schedule; it was not documented. Her Braden on 12/1/13 was 17 so she was at low risk." The DON and DDCO stated they believed a primary reason for her pressure ulcer development was related to moisture, not immobility. The DON said, "She has [MEDICAL CONDITION] and (Resident's Physician) feels that her disease is progressing and so she will continue to get worse." The DDCO said, "It is getting better more quickly with antifungals and incontinence products." When asked if they had looked into additional incontinence products as they suspected the ulcer was a result of moisture skin damage, the DDCO said, "We could look into it; we have all kinds of products here." When asked about the resident's Care Plan to wear Prevalon boots, the DON said, "The boots were discontinued." The DDCO said, "The care plan wasn't updated for the Keen Wedge or Prevalon Boots." The DON and DDCO were informed of the surveyor's multiple observations of the resident remaining in bed on her left side for much of 2/10/14; they stated they would look into that issue. On 2/12/14 at 5:30 PM, the Executive Director, DON, DDCO, and DDCO corporate supervisor were notified of the concern. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. 2. Resident #1's Quarterly MDS assessment dated [DATE], documented the resident: -Had a BIMS of 12, indicating the resident was cognitively intact; and -Required extensive assistance of one person for bed mobility and transfer. The resident's Care Plan included a focus area documented on 1/4/14, "(Resident) has an actual skin impairment to her left toes, left flank area, (related to) scapula, and lower to left (sic) spine to mid spine related to burns." Goals documented: "(Resident) will heal without signs or symptoms of infection by next (sic) review date." Interventions documented: "-Pravalon boot on left foot at all times." On 2/10/14 at 2/11/14 and 2/12/14, The resident was observed to be in bed multiple times with no Pravalon boot in place. On 2/13/2014 at 3:30 PM the DON and DDCO were interviewed regarding the resident's care. When asked why the resident was not observed wearing the Pravalon boot as the care plan indicated the DON said, "It should be there; it wasn't? It was on on Saturday. It was not on yesterday when we checked so we put it back on." When questioned how the facility ensures that the resident's receive interventions care planned the DON said,"The Kardex with each ADL (activity of daily living); The CNA's have access to it. These boots are washable. We think that it got sent for laundry and not returned." 3. Facility policy for the Application of Removable, Performed Splints, dated 10/31/06 documented: -"Splinting is used primarily to immobilize broken bones...in nonemergency situations, a nurse would assess the extremity and apply the splint according to a physician's orders [REDACTED]. -"Verify the order for: a. For proper application, if other than manufacturer's instructions. b. Schedule of application..." -"During the time frame that the resident is wearing the splint, observe the area distal to the splint for: a. Complaints of pain and/or signs (and) symptoms of non-verbal pain b. Rubbing c. Pressure d. Changes in skin condition 1) Color-Redness, cyanosis...ecchymosis 2) Swelling/[MEDICAL CONDITION] 3) Rash/excoriation... 4) Odor... g. Proper alignment and positioning of the splint..." Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 12/25/13, an "Addendum: Final X-Ray Report" in Resident #4's medical record documented Exam Type as, "Portable Shoulder Left." Findings documented, in part, "Acute Proximal humeral fracture noted." The addendum documented, "There is minimal [MEDICAL CONDITION]." On 12/25/13 at 12:37 PM, a physician's orders [REDACTED]." NOTE: Please see F309 as it pertains to pain and delay of treatment and F323 as it pertains to fractures. Resident #4's Nursing Progress Notes documented: -12/28/13 at 5:22 PM. "small dime-sized, unopened blister on center chest from left arm brace resting on chest..." -12/29/13 at 9:08 PM."Pt has blister on chest still intact...readjusted sheet that is placed over blister..." -12/30/13 at 6:24 PM. "Blister swabbed with [MEDICATION NAME] as ordered. Also sling padded. Skin checked under sling with no skin issues noted. No (signs and symptoms) of infection at blister site..." -12/31/13 at 10:18 AM. "IDT review of event on 12/28/13...Resident found with blister to upper left chest from seam of sling. Resident has a history of fragile skin, pressure ulcers, and diabetes..." -12/31/13 at 4:37 PM. "New orders (received) for blister (treatment) including loose fitting [MEDICATION NAME] for LUE and tank top on at all times. Remove for bathing." Resident #4's most recent Significant Change of Condition MDS, dated [DATE], coded: -Unable to complete BIMS, assessed by staff with severely impaired cognition; -Non-verbal, able to understand simple, basic, direct information; -Dependent on 2 persons for transfers and dressing; and -At high risk for the development of pressure ulcers, with no pressure ulcers present. Resident # 4's MAR for December 2013 documented, "Sling (and) Swath 24/7", beginning 12/25/13. NOTE: It was not clear from this entry where the sling and swath were to be applied. There were no instructions as to how the sling was to be positioned, nor instructions to check the skin near or under the sling and swath. It was not clear from this entry on the MAR indicated [REDACTED]. Resident #4's TAR for December 2013 documented: -"(L) arm sling on at all times, monitor strap sites (every) shift." Start date documented as 12/25/13. -"Circulation (check) to L arm (and) hand (every) shift." Start date documented as 12/25/13. -"Check skin under sling (every) shift (and) prn." Start date documented as 12/30/13. NOTE: This treatment was started 2 days after the resident was noted with a blister on his chest from the sling. Resident #4's Braden Pressure Sore Risk Category was identified on 10/20/13 as Moderate Risk. On 1/20/14, the category was identified as High Risk. Resident #4's care plan documented: Focus area of, "...actual impairment to skin integrity diabetic ulcer, abrasions to arm, back r/t end stage disease process, immobility, hx of pressure ulcers, and a recent decline in health." Date initiated 1/20/14, revised on 2/21/14. -Goal of, "Diabetic ulcer will not decline through the next review date." Initiated on 1/20/14, revised on 2/6/14. (NOTE: There were no goals identified in terms of the resident's pressure ulcer risk, even in light of his increased Braden risk category, and a stage II pressure ulcer discovered on his chest on 12/28/13.) -Interventions included: *"Cleanse skin under L(eft) wrist brace daily and PRN." Date initiated 1/20/14, revised on 1/21/14. *"Pt to have blue "comfy" splint applied to L wrist/hand with finger separator between fingers and velcroed onto the splint. Place light blue "donut-like" cushion around pt's wrist at his chest to reduce pressure between hand and chest." Date initiated: 4/22/13. On 2/10/14 at 10:00 AM, the resident was observed lying in his bed, in his room. An air mattress and black Prevalon boots were in place. The resident was wearing a hospital gown, tied behind his neck but otherwise draped over the resident and unsecured down the back. There were geri-sleeves on his arms. His left arm was contracted so as to lay across his chest. His right arm was laying along his right side, with a soft blue trough-shaped sling laying beneath his arm and pillows beneath the sling. There was a blanket draped over a foot cradle at the foot of his bed. On 2/12/14 between 12:45 and 2:45 PM, the DNS and DDCO were interviewed about Resident #4's skin breakdown. The DNS stated the blister on R #4's chest came from the resident's sling positioning his left hand so as to rest on his chest, and caused the hand to rub against his chest. The DNS stated the physician's orders [REDACTED]. When asked what the facility had done to ensure the skin surrounding the sling and swath was checked regularly, the DNS referred to the directions on the resident's TAR for instructions to manage the sling. When questioned, the DNS stated the area where the chest blister developed would have been an area the nursing staff were able to visualize, even with the sling and swath in place undisturbed. The DNS stated once the blister was discovered, the facility padded the area to prevent further recurrence. The DNS was unable to describe why the area was not padded before the blister developed. On 2/13/14 at 6:30 PM, the Administrator, DNS, and DDCO were informed of the surveyor's concerns. The facility offered no further information. 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE], documented: *BIMS: "13" cognition intact. *Risk of Pressure Ulcers: "Yes" The resident's Braden Scale, dated 12/5/13, documented; *Risk for developing pressure ulcers: "High Risk." The resident's Patient Nursing Evaluation dated 12/5/13 documented: *E. Other Skin Risk Factors 1. Extrinisic risk Factors(check all that apply). 1A. "Requires staff assist to move to relieve pressure over any one site." 1B. "Bed/chair bound." 1C. "Requires special mattress/chair cushion." The resident's Care plan documented (date?): *Focus: "(Resident's name) has actual impairment to skin abrasion to buttocks, blemish to right ear, r/t (related to) fragile skin, Hx. (history) PU(pressure ulcer) stage 2, immobility, bedpan removal." Date initiated: 3/7/13. Revision on: 1/29/14 *Interventions: -"Air mattress to prevent skin breakdown." Date initiated: 2/10/14. -"Float heels at all times while in bed." Date initiated: 3/7/13. *Focus: "(Resident's name) has an open blister to her rt. (right) upper medial gluteal fold." Date initiated: 11/6/13 *Interventions: -"Off load rt. gluteal fold." Date initiated: 11/6/13 On 2/10/13 at 1:15 pm, CNA #24 provided cares for the resident. When cares were completed, the CNA positioned a pillow at the side of the resident's left leg, and under the back of the legs. The left heel was directly on the bed. The resident was on her back. On 2/11/14 at 9:22 am, the surveyor observed the resident was on her back in the bed with the head of her bed elevated. There was a pillow behind her legs. The left foot, lateral side, was directly on the bed. The right foot was crossed over the ankle of the left foot. The resident was asked about the positioning of the pillows, and stated, "I have the pillows because of the knee, not the heels." The resident was asked if she ever got out of bed, and she stated, "No, its too hard with the Hoyer (mechanical lift), it makes my joints hurt. They get me up to take me to the shower one time a week." The resident was asked if she always laid on her back, and she replied, "I always lay on my back because I can't lay on my shoulders. Oh, I will flip onto my side, then the other sometimes." On 2/11/14 at 10:50 am, the resident was on her back with the head of her bed elevated. The left foot, lateral side, was directly on the bed, and the right leg was crossed over the left ankle. The resident was asked if she had been on her back since the 9:22 am observation, she stated, "Yes, but I shift my hips a little bit." There was a pillow positioned beside the right side of the resident, right arm resting on the pillow. On 2/11/14 at 12:05 pm, the resident's position was unchanged. On 2/11/14 at 2:05 pm , the surveyor observed the resident was on her back, the head of her bed was elevated. The resident's left foot, lateral side, was directly on the pillow that was under the lower legs, with the right foot crossed at the left ankle. Multiple sores were noted to the lateral side of the left foot, and the skin was visibly reddened along the lateral side of the foot. The resident was asked how long the visible sores on the lateral aspect of the foot had been present, she stated, "A couple weeks, they don't know what they are. They have been washing them and taking care of them." When the resident was asked if they were painful , she replied, "Nope, they are not painful at all." On 2/11/14 at 2:55 pm the resident's position was observed unchanged. On 2/12/14 1:40 pm, the resident was observed lying with the lateral side of the left foot directly on the bed. The right foot was crossed over the left foot at the left ankle. On 2/12/14 at 3:45 pm, the resident's lateral side of the left foot was observed directly on the bed. There was a pillow on the left side supporting the left knee. CNA#25 was in the room and had provided cares for the resident. CNA#25 was asked if there were any special cares they were to provide to the resident's heels to prevent skin problems The CNA replied, "We put lotion on them, the nurse would know if there is anything else." On 2/13/14 at 9:15 am, the resident's lateral side of the left foot was observed directly on the pillow which was under the lower legs. The right foot was crossed over the left lower leg. The resident stated, "I just woke up." On 2/13/14 at 10:07 am the DON and DDCO were interviewed about the concerns with the resident. When asked how off loading of the gluteal fold was being provided, the DON stated, "They are supposed to have pillows for positioning." The DON and DDCO were informed of the observations of the left foot not being floated, the reddened lateral left foot and the pillows beside the resident, the DDCO stated, "You obviously have a lot of observations but we will see what we can do." On 2/13/14 at 12:45 pm the surveyor observed the resident's skin with the Facility NP (Nurse Practitioner.) The resident's feet were floated on a "Keen" wedge pillow, no redness was visible, small dark areas were present. The NP stated the left foot, and heel areas were not Stage 2 pressure ulcers. "Not sure what they are, they are like blood blisters. We are sending her to a dermatologist." The NP observed the dark areas to both feet and fingers. The observations, and concerns were explained to the NP. The resident was asked how the new pillow was under her legs, the resident stated, "This feels great. It's very comfortable." On 2/13/14 at 1:20 pm, the surveyor told the DON that the resident's feet were observed with the NP, and the feet looked much better. The DON stated, "Oh, good I am glad." On 2/13/14 at 6:15 pm, the Administrator, DON and DDCO were informed of the finding. No additional information was provided.

Based on observation, record review, family, resident and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent falls with injuries, fractures, and burns for 3 of 15 (#'s 1, 8, and 4) sampled residents. *Resident #1 was harmed when the facility failed to implement interventions to reduce hazards and risks when the resident with a history of falls, fell on a heater which was near her bed and was harmed when she sustained multiple second and third degree burns. *Resident #8 was harmed when the resident slid off the bed onto the floor, resulting in a fracture to the right lower leg. *Resident #4, who was dependent for the provision of care, was harmed when he sustained a fracture to the upper left arm. Also, the facility failed to initiate a timely and thorough investigation when staff noted a sudden increase of passive range of motion on an extremity which had been non-moveable for a number of years. Additionally, the facility failed to ensure the environment remain free from accident hazards when side rails were implemented without being evaluated for safety for 3 of 3 sampled residents (#'s 1, 4, and 5). This had the potential to harm the residents due to the risk of limb entrapment in the side rails. 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. Resident #1's Quarterly MDS assessment dated [DATE], documented the resident: -Had a BIMS of 12, indicating the resident was cognitively intact; -Required extensive assistance of one person for bed mobility and transfer; -Was frequently incontinent of urine; and -Had a fall since admission with no injury. The resident's Care Plan included the focus area documented on 6/17/13, "(Resident) had an actual fall with No injury r/t (related to) Unsteady gait, Poor Balance, recent CVA." Goals dated 9/19/13, documented: "(Resident) will resume usual activities without further incident through the review date." Interventions dated 6/17/13, documented: -"Continue skilled therapies for strengthening;-Encourage to use call light for assistance; -Monitor/document/report PRN (as needed) x 72h (every 72 hours) to MD (Medical Doctor) for s/sx (signs and symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation; and -Neuro-checks per policy and procedure." The resident's Care Plan included the Focus area dated 11/25/12, documented "(Resident) has potential impairment to skin integrity r/t (related to) fragile skin/hx. (sic) of coccyx impairment." Goals dated 11/25/12, documented: "Staff will have interventions in place to prevent altered skin integrity. Resident will not develop any new areas of skin breakdown through next review date." Revision dated 6/11/13. An intevention dated 11/25/12-"(Resident) needs air mattress to protect the skin while in bed." The Resident's Incident Investigation Directives Post Fall documented on 11/20/13: *2:20 AM, "Call light was on, CNA entered room (and) found resident on floor beside bed. (sic) Was laying on LT (left) side, with legs under bed. Resident states she rolled out of bed. Denies trying to get out of bed. Interventions included: -Change air mattree (sic) w/th (sic) bolsters; -Neuro (72 hours crossed out); and -Moniter (sic) pain 72 (hours)" Note: Bolsters were not added to the resident's Care Plan even though the above document stated it would be included as an intervention. The resident's interdisciplinary progress notes documented: *1/4/14 at 3:44 AM: "At 0205 (2:05 AM), resident found on the floor between bed and window wall. Skin on back is reddened but blanchable. No apparent other injuries from fall. When moving resident she did touch her upper left arm on the heater. No red spot noted at this time but will continue to monitor that area for possible burn. ROM (range of motion) within normal limits for resident. Neuro checks within normal limits for resident. BP (blood pressure) elevated but is gradually coming back down. Will continue neuro checks and monitoring per protocol x72hrs (hours)." *1/4/14 at 3:50 AM, "When resident returned to bed with assist, complained of pain in left foot. Aide(sic) removed sock to check foot. Found denuded spots on great toe and second toe. Areas white, dry except around edge where skin pulled off by sock. Toes reddened, irritated. Great toe nail black. Areas cleaned, covered with telfa and bactroban, held in place with gauze for protection for the rest of the night. Will request proper tx (treatment) orders." *1/6/14 at 11:09 AM, "IDT review of event on 1/4/14 at 0205. Resident was seen asleep in bed at 0150 (1:50 AM). At approximately 0205, CNA smelled something burning and found resident with pillow and blanket behind her laying against base board heater. First Aide (sic) initiated. Resident received several burns to left toes and back. She has a swollen left ankle. X-ray was negative for fracture. See assessments dated 01/05/14. Resident's pain is controlled with Norco. Treatment initiated with blister to rt (right) scapula resolved. Family and MD notified. Bed was moved away from heater. All beds against base board heaters were turned away and contractor will move all base board heaters to the center walls away from the beds. Will monitor and treat until resolved." A undated Facility Incident Investigation Directives Post Fall documented the following: "Summary of Event: CNA heard someone calling for help. Search rooms and found (resident) had rolled off the back side of her bed onto the baseboard heater. LN (licensed nurse) assessment identified open areas, first aide (sec) provided and MD notified for orders.... Immediate Interventions: -Bed turned away from heater and window to provide distance. -Wound treatment initiated. -Pravalon Boot to left foot and keen wedge to float both heels. -1/4 rails bilaterally to assist with bed mobility. -Foot cradle to elevate bedding. -Monitoring for increase pain and medicate as ordered. -Continue with air mattress and off load areas affected. -Neuro's initiated Investigation and Conclusion: Upon completion of a thorough investigation including resident interviews, observation, and record reviews it is determined that (the resident) moves around in her bed. At approximately 0130 she was provided cares and repositioned in the middle of her bed with her call light. Around 0150 the LPN (Licensed Practical Nurse) observed (the resident) curled in a fetal position on her bed with her call light. (Resident) states she rolled out of her bed by the window and became stuck between the bed and the wall heater. She states that it was hot and she called for help. One CNA reports that she heard someone call for help, but then did not hear anything more. She went to the nurse's station to see if anyone else had heard anything. Simultaneously, another CNA was at the time clock checking out for lunch at 0205 when he smelled something burning. The two CNA's heard (the resident) call out and found her lying on the floor on her right side with a blanket and pillow between her and the baseboard heater. They moved the bed away from (resident) and called for the LN. The blanket and pillow had scorched marks. The resident gown and socks did not have any evidence of burning. The LN assessed (the resident) with the following: -left great toe nail appeared busied with the top missing and white like dry patch (sic) -2nd toe had denuded area -left lower back with reddened blanchable area -no blisters noted at this time MD was notified and wounds treated as indicated At approximately 0600, two LN's completed an additional skin check with burns advancing as following (sic): -left great toe and left 2nd toe open areas -blisters to left 3rd and 4th toes -blister to left rear iliac crest and right scapula -open blister to left lower mid back and mid spine area. MD was updated and orders received. (The resident) complained of left ankle pain. X-ray ordered and results were negative. In Conclusion, it is determined that (the resident) received a variety of burns after she rolled out of bed and onto the baseboard heater. Plans to Prevent Reoccurrence: -All beds next to base board heaters were turned to provide more distance. -Contractor is moving all base board heaters from under the window and way from the resident beds." Note: The resident's Facility Incident Investigation Directives Post Fall form did not document bolsters were on the bed at the time of the 1/4/14 fall. The bolsters were to be added as an intervention following a fall from bed on 11/20/13, but was not found on the resident's care plan. Refer to F309 for information related to a delay in treatment. On 2/12/14 at 3:30 PM the DON and DDCO were interviewed regarding the space between the bed and heater. The DON said, "The bed wasn't that close to the heater. The night stand could have fit between the bed and the heater." The DDCO said, "We moved the furniture then, because the fall and burn happened. It was the blanket and pillow that got scorched." b. Resident #1 was observed multiple times from 1/10 thru 1/13/14 in a bed with a left side rail up. On 2/10/14 at 11:05 AM, The resident was observed to be lying sideways on the mattress with her head resting against the left side rail. The call light attached to a pillow near residents neck with her pillows near resident arms. The head of the bed was elevated at approximately 80 degrees. When the resident asked about comfort levels she said, "I'm not comfortable because my head is on something right there." When the resident was asked how she happened to be positioned this way she replied, "I don't know." The resident stated she would like to be repositioned in bed. The surveyors notified staff and four staff members including the DON came into room, repositioned resident and provided cares. On 2/10/14 at 11:20 AM, CNA #18 was asked when the last time the resident was turned or observed and she said, "She turns herself, she is all over that bed." On 2/13/14 at 3:30 PM, the DON and DDCO were interviewed and asked for side rail safety assessment documentation for the resident. A "Bed Safety Evaluation" document was provided which was signed and dated on 1/4/14. When asked if there was another form which addressed safety of bed rails specifically, the DDCO stated the form provided was the only form used. The DDCO said, "The form we use is to assess for mobility but not for safety. That has not been documented. She has foam bolsters as part of her mattress. They are attached under the cover so they can not be easily or mistakenly removed." 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS), dated [DATE], documented: *BIMS: 3- severely impaired cognition; *Bed mobility: 3-2 extensive assistance, one person; and *Transfer: 3-2 extensive assistance, one person. The resident's Quarterly MDS, dated [DATE], documented: *BIMS: 1- severely impaired cognition; *Bed mobility: 4-2 total dependence, one person; and *Transfer: 3-3 extensive assistance, two person. NOTE: The resident had a decline in Bed mobility and Transfer, from the Annual MDS and the Quarterly MDS. The resident's Care Plan documented: *Focus: "(Resident's name) has an ADL(activity of daily living) self care performance deficit r/t (related to) disease process deterioration in ADL's, declining ability to make decisions." Date initiated: 2/19/13 *Interventions: -Bed mobility: "(Resident's name) requires 2 staff participation to reposition and turn in bed." Date initated: 2/19/13. -Transfer: "(Resident's name) requires 2 pr (person) sera-lift (mechanical device used to transfer residents) for transfers." Date initiated: 2/19/13. The resident's Post-Fall Investigation, event date 9/6/13 at 4:00 pm, documented: *Fall location: "Next to transfer surface." *Verbal Fall description: "aide assisting resident up from bed into w/c (wheelchair) - sat resident up on side of bed to hook up sit to stand (mechanical device used to transfer residents)- resident started to slide off side of bed so aide lowered resident to the floor." *Resident and equipment (check all that apply): "slipped." *Signature Licensed Nurse Completing Investigation: Was left blank. *Date of completion: Was left blank. The CNA written statement, dated 9/8/13, documented: "I was hooking up (Resident's name) up (sic) to the sit-to-stand while she was sitting on her bed. She started to slide off of her bed before I could finish getting her hooked up. I tried to hold her up while her room mate, (Resident's name), put her call light on & (Resident's roommate) tried to open the door to her room but couldn't turn the handle. I ended up sitting (resident's name) on the floor. When I did that, I noticed that her feet were on the sit to stand, kind of wrapped around the base of it. She did not complain of pain in her ankle or foot at that time. This happened on 9-6-13." The resident's IDT (Interdisciplinary) progress notes documented: -9/6/14 7:24 pm: "At 1600 (4:00 pm), when assisting resident to get up from bed to w/c for dinner, resident started sliding off side of air bed. Aide lowered resident to floor to prevent fall, then called for assist. Resident assisted up to w/c with 3 assist. Resident noted to have a 1.5 cm diameter skin tear to right forearm where she bumped her arm against bottom of sit-to stand. ST (skin tear) cleaned, flap reappointed, steri-strips applied. Will monitor for s/s (signs and symptoms) infection until healed." -9/7/13 2:27 am: "Resident resting in bed at this time. No apparent problems from fall. No complaints of pain." -9/7/13 5:29 pm: "Resident alert. Up in w/c for evening meal. No apparent problems from fall." -9/8/13 10:30 am: "At appx. (approximately) 0800 (8:00 AM) staff notified nurse resident had a swollen and bruised R (right) ankle, nurse notified supervisor, MD notified. Order for X-ray received. At appx 1030 (10:30 AM) xray taken, awaiting results." -9/8/13 1:04 pm: "Final Xray report received, results as follows. IMPRESSION: Mild DJD (degenerative joint disease). Acute distal fibula (lateral malleolar) fracture. Medial malleolar hairline fracture VS (versus) pseudo-finding. Follow up Xray suggested for further assessment." -9/8/13 3:33 pm: "Dr. (name) notified of X-ray results. Order rec'd and noted for PT (physical therapy) to eval(uate) for a splint or boot, NWB (nonweight bearing) for 6 weeks. Make appt (appointment) with ortho, Elevate extremity and apply ice to affected area PRN (as needed.)" -9/9/13 9:34 am "IDT review of event on 9-6-13 at 1600. Resident slid out of bed onto floor when CNA was assisting her in the sit to stand for a transfer. Resident was sitting on her air mattress and slid off. Resident developed a bruise to her rt. ankle which became painful and warm. Xray showed a fracture to the lateral fibula. Ice applied, ortho to see resident., Hoyer transfers, non-wt bearing for 6 weeks, bed rest until eval(uated). Staff education on new care plan restrictions. Monitor for increase pain. MD and family notified. Will assess air mattress setting." -9/11/13 2:26 pm: "Resident had MD visit and returned with a cast on RLE (right lower extremity.) resident does not appear to be in discomfort with cast in place." The resident's Physical Therapy Evaluation dated 10/28/13, documented: *Physical therapy treatment Diagnosis: [REDACTED]." *Additional Medical [DIAGNOSES REDACTED]. (fracture)." *Prior level of function: "Pt. (patient) was min A (minimal assist) for bed mob(ility)., transfers, & gait (with) FWW (front wheel walker) x 20 (feet) CGA(contact guard assist) w/c mob(ility) short distances in the facility." *Reason for Referral: "Pt. fell & fx. (right) ankle on 9/8/13 & was NWB until 10/24/13, cast removed. MD order for activity as tolerated." *Evaluations Functional Outcome Scores: -Bed mobility: Prior level: "4.0" min -occasional assist (25% or less time or effort to complete); Evaluation score: "1.7" NTD (near total dependence). -Transfers: Prior level: "4.0" min; Evaluation score: "1.7" NTD. -Gait: Prior level: "4.0" min; Evaluation score: "1.0" CD (complete dependence). -Distance: Prior level: "20(feet)"; Evaluation score: "0 (feet)". -Wheelchair Mobility: Prior level: "4.5" CGA; Evaluation score: "1.0" CD. The resident's Physical Therapy Discharge summary dated 11/19/13, documented: -Summary statement: "Pt. has made small gains (with) bed mob(ility) & sit (to)stand/transfer ability but progress has plateaued so pt. will be set up on RNA (Restorative Nurse Aide) program for maintenance." -Discharge summary: - Bed mobility: "2.5-3.0" moderate to maximum assist. -Transfers: "1.7 (with) sara lift (with staff)" -Gait (parallel) bars: "stand 2.0 x 10 seconds." maximum constant assist. W/C mobility: "1.7" NTD. NOTE: The resident required Physical therapy for decline in ADL's after the resident received a right ankle fracture on 9/6/13. Physical therapy scores documented decline in functional abilities when bed mobility, transfers, gait, and w/c mobility were compared to prior level and discharge level after treatment of [REDACTED]. On 2/12/14 at 1:15 pm CNA #5 was observed providing care for the resident. When the surveyor asked the CNA about transferring the resident, the CNA stated, "she used to be just a two person assist for transfers." The surveyor then asked if the resident's transfer assistance had changed since she had a fracture in September. The CNA stated, "Yeah, I think since then she has been a sara (lift transfer)." The CNA was asked about the air mattress; specifically if the LN or CNA's were responsible for turning the mattress on or off, or if they stay on all the time. The CNA stated, "They stay on all the time." The CNA was asked if the staff turned them off when getting residents in and out of bed. The CNA stated, "They stay on, I have one resident (Resident's name) that I turn it off, but the others, they stay on." On 2/13/14 at 10:07 a.m., the DON and DDCO were interviewed concerning the resident's fall on 9/6/13. They were asked if they could explain why the CNA was transferring the resident by herself, whether or not there concerns with the bed, specifically whether it was supposed to be on or off during a transfer, and what was the outcome of the IDT note written on 9/9 pertaining to the assessment of checking the air mattress setting. The DON stated she was "unsure" and would look into it. No further information was provided. On 2/13/14 at 6:15 pm the Administrator, DON, and DDCO were informed of the findings. On 2/14/14 at 12:00 pm, at the Exit conference, the DCHO provided documentation of the resident's RNA program. No further information was provided on the use of the bed, or why 1 CNA was performing the transfer when the care planned intervention documented a 2 person transfer. 3. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's Significant Change of Condition (SCOC) MDS assessment, dated, 10/16/13, coded: -Unable to complete BIMS, assessed by staff with severely impaired cognition; -Non-verbal, able to understand simple, basic, direct information; -Dependent on 2 persons for transfers and dressing; -Did not ambulate; -Pain present, treated with routine pain medication. No PRN medications needed. No non-medication pain relief measures used. -Resident unable to rate pain per pain scale, but was not noted with non-verbal signs of pain. Resident #4's most recent SCOC MDS, dated [DATE], coded: -Foley catheter in place for urine. -Pain present. Both routine and PRN pain medications needed, as well as non-medication pain interventions. -Non-verbal sounds, facial expressions, and protective body movements indicating pain present noted. On 12/23/13, time documented as, "AM," a facility "Stop and Watch Early Warning Tool" documented Resident #4 was experiencing increased pain. The form was signed by CNA #3, and documented as given to LN #4. LN #4 signed acknowledgement of the document on 12/23/13 at 9:30 AM. On 12/25/13, a facility "Non-Pressure Ulcer Investigation" form documented: (NOTE: The form documented check boxes for several types of "Skin Issues," such as blister, burn, abrasion, bruise, etc., including an option of "other." None of the boxes on this form were marked.) -"Resident Statement as to Cause, if able:" documented: "(Patient) bed bound 20 (plus) years, Hoyer transfer. Bruising appears somewhat linear - hit against bed rail; position incorrect in Hoyer; struggles during clothing changes are three possible eitiologies (related to left upper arm) bruising. One LPN (name) states she gives insulin in that (left) upper arm..." (NOTE: Resident was unable to state the cause of the injury.) -The form documented the resident had poor skin turgor, and was using geri-gloves, chair bolsters, hand splints, quarter side rails, and required Hoyer lift transfers at the time the bruises were discovered. -The resident was documented as "Total Dependence" for transfers. On 12/25/13, an "Addendum: Final X-Ray Report" in the medical record documented Exam Type as, "Portable Shoulder Left." Findings documented, in part, "Acute Proximal humeral fracture noted." The addendum documented, "There is minimal osteoporosis." A facility "Unusual Occrrence" report for the above fracture, dated 12/25/13, documented, in part: -"Summary of event: On 12/25/13 during cares, resident noted to guard left arm. Licensed nurse examined and noted some faint yellow bruising and swelling, grimacing with gentle touch. Physician notified, x-ray obtained with evidence of acute proximal left humeral fracture." -"Investigation & Conclusion: Upon completion of a thorough investigation...it is determined that on the morning of 12/23/13 (Resident #4) exhibited guarding and pain with morning cares...On the morning of 12/25/13...an x-ray was obtained. X-ray confirmes acute proximal left humeral fracture...there is no evidence that (Resident #4) had a fall, hit his arm on anything in the environment, had an inappropriate hoyer transfer, or had any other accident...on 12/22/13, two CNA's provided cares...They report that his t-shirt fits so snuggly, so they pulled down the arm of the shirt then lifted his elbow to remove his t-shirt...Investigation indicates...arm was fractured between the evening of 12/22/13 and the morning of 12/23/13. Evidence shows that the fracture was consistent with internal rotation during cares, either during the removal of his shirt or during turning/repositioning while in bed. No specific event was identified. (Resident #4) has significant tone/contractures in his left arm related to his CVA and DJD." -"Plan to Prevent Recurrence...CNA staff re-educated and skills checked on donning/doffing shirts and repositioning for residents with [DIAGNOSES REDACTED] impairments." -The last 2 pages of the report were entitled, "Compilation of Interviews (CI) held on 12/30/13, 01/01/14, and 01/02/14." The pages contained bulleted summaries of staff interviews related to this event. NOTE: The summaries on these pages were of interviews conducted between 5-7 days after the fracture was diagnosed , and 8-10 days after the inital onset of pain and ROM changes. The summaries did not include statements from the CNA identified to have originally reported the event. The summaries did not identify which CNAs were in the room providing cares when the resident's T-shirt was identified as being too tight, nor describe the technique the CNAs used to remove his shirt in light of this awareness. The content of the interviews for several staff members was attached. Interview statements documented, in part: -12/25/13, CNA #11 documented, "Lots of times when I come on duty he has to (sic) small of shirts on..." -12/25/13, a statement from CNA #7 documented, "I was told on the beging (sic) of my evening shift either on Saturday or Sunday (12/21/13 or 12/22/13) that his arm was sensitive and he was pulling away his arm and crying out. The last time I saw him before I was told this, he showed no signs of being hurt..." This statement was summarized in the CI as, "Worked with resident on 12/21/13 and 12/22/13. No pain or discomfort noted. NOTE: The statement from this CNA identified a possible change in the time frame of Resident #4's injury, to 24-48 hours earlier than the facility had concluded. There was no documented evidence this was investigated. The summarized statement on the CI was not reflective of the CNA's hand-written statement. Resident #4's Care Plan documented: -Focus of, "(R #4) has a fracture of left humerus and dislocated Femoral head fracture to Right leg r/t Severe demineralization of bones, severe osteopeni, Hx of chronic fractures and degenerative changes to bilateral hips/pelvis." Date Initiated 12/28/12, revised on 1/21/14. -Interventions included: *"Family requires resident stay in clean hospital gown (every shift) and not be dressed in personal clothing any more." Date initiated 1/21/14. -"Indwelling catheter for comfort to minimize pain caused with mobility and repositioning." Date initiated 2/21/14. -"Resident to remain bed bound per family request to minimze pain and/or further injury from transfer and frequent repositioning." Date initiated 1/21/14. Physician's Progress Notes documented: 12/27/13. (NOTE: This is the first time the resident was examined by a physician since the onset of his pain and mobility changes on 12/23/13, and his [DIAGNOSES REDACTED].) "...I had initially been notified on 12/23/13, that the paitent seemed to be having some increased pain to his left shoulder...There was noted to be no signs of injury or reports of injury from the staff,,,I was called again on 12/25/13 indicating that the Ultram was not helping and he was having significantly worse pain...An x-ray was obtained on 12/25/13, that showed acute proximal humeral fracture...I did have the nurses go back to see him when he started complaining of the pain and we will try to find out when the fracture actually occurred..." -1/17/14. "...he is quite immobile with his history of stroke and it is somewhat difficult to get his clothes off and on without hurting his arm... He is not eating or drinking very well. He gets a little bit sedated with medications so appears to be somewhat dehydrated today..." -1/24/14. "...On 1/19/14, the staff noted that he had some protrusion of the right hip with deformity and seemed to have some pain. An x-ray was obtained which showed a displaced fracture of the right femoral neck...it was felt that the hip fracture was old and nothing new...The patient had a Foley catheter placed for his dignity as well as for the fact that to move him causes severe pain and this needs to be in place for his pain control and quality of life..." Resident #4's interdisciplinary Progress Notes documented: -12/25/13 at 12:20 PM. "Family notified, (daughter) was in bed ill. She did return the call and is quite angry about this, does not appear to be rationale (sic)..." -12/25/13 at 6:08 PM. "Called (daughter) to give her status update...discussed there is an ongoing investigation...Discussed tight fitting clothing, family will be happy to bring in loose clothing... NOTE: This is the first documentation the resident's family was informed his shirts were too tight, and the first documented request for looser clothing. -1/1/14 at 10:40 AM. "...is not eating and drinking as usual. Continues to appear in some pain due to fx..." 1/3/14 at 1:53 PM. "...T-shirt cut off due to being too painful to put on, use hospital gowns instead..." -1/19/14 at 3:32 AM. "CNAs were providing incontinuence care and noticed a hard area to res(ident's) buttocks that they have not noticed before...Rt side of buttocks was noted to have a bony protrusion. Res noted to have facial grimacing upon palpation...obtained order for STAT portable x-ray..." -1/19/14 at 9:47 AM. "Res sent to (acute care hospital) via ambulance..." -1/19/14 at 12:23 PM. "Pt back from ER...R hip fx is chronic in nature r/t severe osteoporosis, demineralization, osteopenia. Both hips are severely compromised r/t these finding (sic)..." -1/20/14 at 12:43 PM. "...(daughter) notes plan to eliminate option of placing tops/bottoms on res as she will be taking his clothes home today. Notes that MD at hospital indicated to drape gowns over res...Does not want res to get up for all three meals anymore..." A facility Unusual Occurrence report dated 1/19/14, summarized the event as above and further documented, as part of the Plan to Prevent Recurrence, "Staff is educated on new diagnosed disease process, fracture care, hip precautions, and updates to care plan for fracture prevention." On 2/11/14 at 1:20 PM, during an interview, the resident's representative stated: -They understood the hip fracture to be pathological, but continued to have concerns regarding the arm fracture. -The facility said the root cause of the arm fracture was tight-fitting T-shirts. The facility had not asked the family, either before or after the arm fracture, to provide larger T-shirts. -The facility had been unable to explain how they had ruled out whether someone had twisted, pulled, or forcibly lifted the resident's arm. -The resident's shirts were removed only after the facility placed metal fasteners on the backs of his shirts, because they were concerned the fasteners would cause skin breakdown. On 2/12/14 between 12:45 PM and 2:45 PM, the DNS and DDCO were asked about Resident #4's fractures. -The DNS initially stated the root cause of R #4's arm fracture was determined to be severe osteopenia. However, the DNS agreed the facility did not know about this [DIAGNOSES REDACTED]. -The DNS stated the facility had not informed the family of the need for larger shirts prior to the fracture, as it had not been identified as an issue before that time. -The DNS was unable to address whether or not other possible causes of the fracture - such as side rails or the mechanical lift - had been ruled out as causes, since those items were identified in the original incident report. NOTE: The facility was twice asked to produce a side rail safety assessment for Resident #4, but ultimately did not provide that document. On 2/13/15 at 10:50 AM, the DNS and DDCO met again with the surveyor. They stated: -While the nurse who wrote the original incident report mentioned the mechanical lift and the side rails as possible contributing factors, the facility felt they could rule those out because the first symptom which presented was pain, and there was no evidence of trauma. NOTE: They were unable to explain how the bruising which developed on the arm, or the sudden change in mobility of the arm, were not evidence of trauma. -During interviews, the staff stated the resident's T-shirts had been too tight, but they would never "force" to get one on. -They reported the orthopedic physician had stated, after the hip fracture was discovered on 1/19/14, the resident could sustain a fracture from something as simple as rolling over in bed. -However, the DNS and DDCO also stated there was no way the fracture could have come from anyone pulling on, twisting, or lifting his arm. They were unable to offer another explanation as to how the fracture may have occurred. -Even though the original incident report identified the resident as bed-bound, the DNS stated, "He was not that fragile at the time of the arm fracture. He was still getting up to the dining room for meals and everything." Resident #4 was harmed when he sustained a left humeral fracture while a resident in the facility. There was a 2 day delay between the onset of pain, and the [DIAGNOSES REDACTED]. In fact, the statements obtained during the investigation suggested the fr

Based on observation, staff and resident interviews and record review, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop multiple avoidable ulcers for 3 of 3 sample residents, (#1, #2 & #6) reviewed for pressure ulcers. Resident #1 was harmed when interventions were not put in place to prevent multiple Stage III and IV pressure ulcers which resulted in hospitalization for treatment of [REDACTED]. In addition, Resident #2 was assessed as being at risk for pressure ulcers, had multiple reddened areas present on admission, but skin assessments were not documented for those areas. Ankle/Foot orthotics with the potential to cause skin breakdown for Resident #2 were not care planned. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged to a hospital for wound care on 7/26/11, and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission MDS, dated [DATE], documented no cognitive impairment present. The MDS also documented the resident was at risk for pressure ulcers, but no pressure ulcers were present at the time of assessment. The next MDS assessment was a quarterly assessment, dated 6/17/11. The MDS documented the presence of 4 Stage IV pressure ulcers, defined, in part, as full thickness tissue loss with exposed bone, tendon or muscle. A 4/18/11 Pressure Ulcer Investigation In-House Acquired form documented the presence of a Stage III pressure ulcer on the left buttock which measured 1.5 x 1.5 cm. The form summarized the wound development, in part, as "...up in chair for majority of day per her choice & wishes to smoke." A Care Plan Update form, dated 4/18/11, listed "Pressure reduction W/C (wheelchair) cushion" as a new approach to address the pressure ulcer development. Resident Weekly Skin Check Sheet entry on 6/5/11 documented the buttocks wound was resolving without complications, and no other skin issues were present at that time. A 6/3/11 Pressure Ulcer Investigation In-House Acquired form documented the presence of an unstageable pressure ulcer on the right lateral foot which measured 1.0 x 1.0 cm. A Condition Change Form in the Resident Progress Notes, dated 6/3/11, stated the resident was repositioned frequently for pressure relief in bed, and that the area may have been related to her shoes or electric wheelchair use. A 6/7/11 progress note stated the resident was compliant with the use of a manual wheelchair. The weekly Pressure Ulcer Condition Report for 6/7/11 documented in "Week 1" a 4 x 3 cm Stage IV wound soft black eschar was observed on the right plantar area of the foot. A Nursing Home Visit report from the resident's primary physician, dated 6/8/11, stated "Right lateral foot ulcer with friction blister on the bottom of the foot." The plan for treatment included discontinuation of the resident's tennis shoe, foot elevation and assessment of the Prevalon boot to rule it out as a source of pressure. The resident was described as being at high risk for complications and non-wound healing. Resident Weekly Skin Check Sheet entry on 6/12/11 documented the presence of 2 [MEDICAL CONDITION] on the right foot. On 6/12/11, a Resident Progress Notes entry stated a blood blister was observed to the plantar area of the right foot. Weekly Pressure Ulcer Condition Report form documented a pressure ulcer to the outer right foot, first observed 6/6/11, measuring 1.2 x 1 cm. On 6/7/11, the wound was described as a Stage II partial thickness wound with distinct edges, no exudate, of light brown color. By week 4, 6/28/11, the wound was described as 2.5 x 1.5 cm, with necrotic tissue and "Black tissue present in middle of wound." Note: It was unclear why the plantar wound was not documented in skin monitoring reports prior to 6/7/11 when it had developed into a Stage IV wound. Daily Monitoring Pressure Ulcers form documented the resident went to the wound clinic on 6/16/11 for the foot pressure ulcer. Wound Care Progress Reports from the wound clinic, dated 6/24/11, documented the following: "Followup regarding right midfoot pressure ulcers...The patient has continued with Prevalon boot although still getting pressure...removal of the [MEDICATION NAME] and slough and eschar revealing areas of ulceration approximately on the midfoot described ulceration 2.2 cm, on the plantar foot area 2.0 x 1.4 cm." The [DIAGNOSES REDACTED]." A Resident Progress Notes entry on 7/5/11 described the wound as deteriorating with possible skin infection. The note stated the resident had a follow-up wound clinic appointment the following day. The wound clinic note from 7/7/11 stated "The right medial foot and right plantar foot have actually bridged into one...4.5 x 2.5 cm and 2.4 x 1 cm. There is odor with debridement." The [DIAGNOSES REDACTED]." An antibiotic, Bactrim-DS, one tablet twice daily by mouth for 10 days, was started. The 7/18/11 wound clinic Progress Report stated the resident had been started on an IV (intravenous) antibiotic secondary to the wound infection. The report also stated "She is no longer in her power chair, as that was the etiology of pressure." The [DIAGNOSES REDACTED]." On 7/22/11 the wound clinic Progress note stated both wounds were "with tendon exposure post debridement." The resident continued on antibiotics for wound infection. A 7/26/11 Resident Progress Note documented the resident was discharged to a local hospital for "more aggressive" treatment to the right foot wounds. A hospital Wound Care Consultation report, dated 7/27/11, documented in part, "...acquired an ulceration on her right lateral 5th metatarsal secondary to pressure from her wheelchair pedal." The report also documented, "A 3-phase bone scan was obtained, which was positive for osteo[DIAGNOSES REDACTED]. The patient subsequently was transferred to a long-term acute care facility for aggressive care for limb salvage efforts, which include IV antibiotics, adequate offloading, hyperbaric oxygen therapy, and planned serial debridements." The culture results in the report documented the resident's wound was positive for multiple organisms, including [MEDICAL CONDITION]-sensitive Staphylococcus aureus. The resident's "Skin Integrity Impairment - Potential" care plan, dated 3/17/11, included a goal to be free of skin breakdown with goal date 6/17/11. With the exception of the 4/18/11 care plan update of the pressure relieving cushion to the wheelchair in response to the buttocks ulcer, there were no additional updates to the original plan. Resident #1 was interviewed on 9/6/11 at 10:40 a.m. The resident was asked about the brace and wrap on her right foot/leg. She stated there was a sore on her foot, maybe from her shoe or wheelchair pedal. It was "black on the bottom" when they found it, and the wound clinic had to take it off. The resident further stated she had been hospitalized for [REDACTED]. At 10:50 a.m., a technician obtained a bedside x-ray of the resident's foot. The resident stated it was to see if the osteo[DIAGNOSES REDACTED] was better. The results of the x-ray were not available in the resident's record for review during the remainder of the survey. On 9/8/11 at 9:20 a.m., the treatment nurse changed the resident's dressing. The wound was observed to be approximately 2 x 1 cm, without visible drainage and with a pink wound bed. On 9/8/11 at 8:30 a.m., the DON was informed of the findings in regard to the pressure ulcers for Resident #1. The details of the findings were shared and the DON stated there might not be any further information to clarify or dispute the surveyor findings. He stated he would follow up with staff for any further information. On 9/9/11, the DON provided the Pressure Ulcer Investigation In-House Acquired forms referenced above. No further information was provided. Resident #1 experienced harm when multiple pressure ulcers developed, one of which was not documented until it was a Stage IV. The right foot wounds deteriorated, became infected and required hospitalization for treatment to save the limb. 2. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The resident's 8/2/11 quarterly MDS assessment and 5/5/11 annual MDS assessment coded: * Extensive assistance of 2 staff for bed mobility. * Extensive assistance of 2 staff for transfers. * Extensive assistance of 2 staff for toileting. Resident #6's 5/5/11 annual assessment documented no pressure ulcers were present. The 8/2/11 MDS assessment documented a Stage IV pressure ulcer that was 01.6 by 1.0 (centimeters or inches not identified) with necrotic tissue (black, brown tissue that adheres to the wound bed). Resident #6's 8/22/11 Braden scale for predicting pressure sore risk of 13 documented he was at moderate risk to develop pressure ulcers. a. A Weekly Pressure Ulcer Condition Report (WPUCR) documented he developed a Stage IV pressure ulcer, in the facility, on the heel which measured 2.0 x 1.5 cm. The form documented the wound was first observed on 6/21/11. Weekly skin checks from 6/23/11 through 8/2/11 documented the following: Stage IV on his heel (right or left not identified) less than 2 cm undermining necrotic tissue on 75% to 100 % of the wound no drainage minimal swelling around the wound. The wound surface was covered with 100% epithelization on all assessments except 7/26/11 and 8/2 11 when epithelization covered less than 25% of the wound. Size 6/23/11 and 6/28/11 - 2 cm (length) by 1.5 cm 7/12/11 - 1.2 cm by 1.7 cm 7/19/11 - 2.0 cm by 1 .0 cm 7/26/11 - 1.2 cm by 1.6 by 1.0 cm 8/2/11 - 1.6 by 1.0 cm 8/4/11 - Resolved Note: The form did not include an assessment for the week of 7/4/11. A Condition Change Form (CCF) dated 6/21/11 documented a reddened area of 1.5 cm by 2.0 cm to the left heel. A Post-Event Investigation/Interviews form (PEII), dated 6/22/11 documented the wound may have been caused by, "Friction of the boot." The Interdisciplinary team documented on a CCF Resident #6 had a blister to his left heel and multiple skin issues. The CCF documented, "Wears heel lift boots but possibly not the best fit for him for position will check fit and change to Prevalon boots...." The Resident's 9/11 Physician Order's (POS) included a 6/22/11 order for Prevalon boots and to "Make sure boots are on correctly." Resident #6's Comprehensive Care Plan Report (CP) documented in the problem section, "Skin/Tissue Integrity impaired." The Approach section included to encourage the resident to get out of bed (5/12/05), Keen flotation wedge to elevate heels (4/17/07), foot cradle (5/27/09), Prevalon boots at all times (6/22/11). The CP did not document heel lift boots had been used. On 9/9/11 at 9:20 a.m. the DON stated the Care Plan had been revised to include Prevalon boots as an intervention for the ulcer to the heel. When the surveyor informed him the WPUR did not identify which heel the wound was on he stated the left heel was documented in the resident's medical record. When asked about the statement the heel lift boots were "not the best fit" he stated the boots were changed to Prevalon boots. When the surveyor asked if the pressure ulcer was avoidable he stated Resident #6 had fragile skin. b. A Post-Event Investigation/Interviews dated 8/5/11, documented bilateral open areas to Resident #6's buttock. A CCF dated 8/5/11 included in the investigation documented open areas to the resident's lower buttock. The CCF documented an area on the right cheek was 1.5 cm by 0.5 cm. The left buttock was documented as, "Red irregular area with 4 sm (small) open area throughout." Note: The documentation did not include a measurement of the wound on the left buttock. The PEII documented the open areas to the buttocks may have occurred due to improper peri-care, not being cleaned adequately, shearing when positioned, or pressure from sitting in his wheelchair too long. A CCF documented the IDT reviewed the wound and documented, "Observed with incont (incontinent) brief with bunching and causing irritation to the area bilat (bilaterally). Res. (Resident) has severe incont and fragile skin to this area." A 8/10/11 POS documented the area on the left and right buttocks were to be cleaned with (illegible) and PolyMem (bandage) was to be applied to sites. A physician visit on 8/17/11 documented, "I was notified that he had a area to his right groin that was a little irritated." The physician visit did not include any information regarding the resident's left or right tuberosity. Resident #6's 9/11 POS (recapitulation) included an order for [REDACTED]. His medical chart included a "Weekly Non - Pressure Skin Condition Report" (WNPSCR) that documented a wound was observed on 8/5/11 to the right groin. The form documented the area was 2.5 cm by 1 cm with partial thickness pale red/pink with a scant amount of serous drainage without odor. On 8/16/11 the form documented the wound was 4.5 cm by 2.5 cm with red color (lacks evidence of healing), drainage had increased to a small amount and progress was documented as deteriorated. Resident #6's progress notes documented: 8/6/11 at 9:25 a.m. - 4.0 by 2.0 (cm/inches not specified) area on the right inner groin with the skin off 8/8/11 at 7:00 p.m. - No signs or symptoms of infection to bilateral buttocks 8/9/11 at 1:10 p.m. - Area to right groin is 2.5 by 1.5 (cm/inches not specified) 8/16/11 at 8:15 a.m. -Increase in size to right groin to 4.5 by 2.5 depth of .2 and light drainage documented 8/23/11 at 12:30 p.m. - Area to right groin 4.5 by 2.5 with less than 0.(illegible) depth... will continue to monitor area NOTE: The resident's medical record did not include any WNPSCR or WPUCR's for the right ischial tuberosity pressure ulcer after 8/16/11. WPUCR provided for the left ischial tuberosity documented on 8/23/11, 8/30/11 and 9/6/11: Stage II Less than 2 cm undermining White/grey non-viable necrotic tissue Serosanguineous, thin, watery, pale red/pink, small amount Minimal swelling and firmness around the wound [MEDICATION NAME] less than 25% of the wound was covered The skin surrounding the wound was white or gray on 8/23/11 and 8/30/11. On 9/6/11 the skin was bright red and/or blanched to touch. Size 8/23/11 - 4.5 cm by 2.5 cm 8/30/11 - 5.5 cm by 2.8 cm 9/6/11 - 5 cm by 2.5 cm Note: The location of the wounds documented as the groin, were the left and right ischial tuberosity. The WPUCR did not identify the date of the first observations of the wound. On 9/8/11 at 11:40 a.m. a surveyor viewed the wound on Resident #6's left ischial tuberosity. The surveyor observed a 5-6 cm x 2.5 cm area on the left ischial tuberosity with yellow slough. There was slight tunneling noted. LN #1 identified the pressure ulcer as a Stage III (Previous WPUCR identified a Stage II). During the observation the surveyor observed the right ischial tuberosity to have lighter pigmentation (an indication of a previous wound). During the observation LN#1 referred to the "back groin." The surveyor clarified LN #1 was referring to the ischial tuberosity. Resident #6's Comprehensive Care Plan Updates included: monitor placement of incontinence brief (8/9/11), repositioned every 1-2 hours from side to side while in bed (8/5/11), clean wound and use barrier cream every shift, last person up and first one down for meals (8/5/11), keep off left ischial, physical and occupational therapy evaluation for wheelchair off loading, wound clinic as ordered (9/8/11). During an observation on 9/6/11 at 1:20 p.m. Resident #6 was observed to be sitting in the dining room after finishing his mid-day meal. There were no more than 6 other residents in the dining room. At 1:30 p.m. he was observed sitting in his wheelchair outside of his room. At 1:50 p.m. Resident #6 was taken to his room and assisted to lay down. On 9/7/11 at 10:00 a.m. CNA #8 stated Resident #6 got up for the mid-day meal between 11:30 and noon. He was laid down when people were out of the dining room. CNA #8 stated he was not the first one to lay down as he required 2 people to transfer him and usually only 1 CNA was available. The other CNAs remained in the dining room or assisted residents who only require 1 person to transfer. On 9/12/11 CNA #9 stated Resident #6 required a Hoyer lift to transfer him to bed. CNA #9 stated it varied when Resident #6 got up for meals as they started at one end of the hall, "And work from that end." CNA #9 stated the same method was used for laying Resident #6 down after a meal. On 9/9/11 at 9:20 a.m. the DON stated the wounds were from Resident #6 being incontinent and wearing attends. He stated the medical chart documented the wounds were to the left and right ischial tuberosity. The surveyor stated the CP included to encourage Resident #6 to get out of bed. The DON stated that should have been revised as a CP revision was implemented to have Resident #6 remain in bed and be the last one to get up for meals and the first one to lay down after meals. The surveyor informed the DON of the observation and the interview verifying the CP revision was not implemented. The DON was informed documentation did not identify location of the pressure ulcers accurately or consistently. The DON stated the medical chart documented the correct location of the pressure ulcers. On 9/13/11 the surveyor requested documentation of assessments for pressure ulcers to the right ischial tuberosity. At 12:45 p.m. the DON stated LN #1 stated the assessments had been completed but he could not find the documentation. Resident #6 experienced harm when multiple pressure ulcers of at least stage III developed, one of which progressed to a Stage IV from the use of a heel boot that did not fit correctly. The resident also developed wounds to the left and right ischial tuberosities from improper peri-care. The care plan intervention to reduce pressure to that area was not implemented. The wound to the left ischial tuberosity progressed to a Stage III. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's 9/1/11 admission nursing note, documented the resident was alert and able to make her needs known. Resident #2's admission Patient Nursing Evaluation (PNE), dated 9/1/110, documented the resident scored a 15 on the Braden scale for Predicting Pressure Ulcers, indicating the resident was at risk for skin breakdown. The 9/1/11 PNE also documented that Resident #2 required staff assistance to move and relieve pressure over any one site, had devices causing pressure (The devices were not identified), and had functional limitation of ROM. The Skin Inspection section of the PNE, documented the resident had multiple bruises and brown skin discoloration. In addition, the Skin Inspection documented the following: * Left heel, dark red, blanches * Right inner ankle 3x2 cm (centimeter) red, blanches * Left upper thigh red, 2 1/2 cm x .25 cm, peri area red The 9/1/11 PNE, documented Resident #2 typically arose at 7:00 am and went back to bed at 9:00 am and did not take naps. The resident required extensive assistance with all ADLS, was continent during the day but not at night, and received 100% of her nutrition through tube feedings. Resident #2's interim Care Plan, initiated on 9/2/11, addressed only impaired thought process, self-care deficit, and functional incontinence. Other than a generic statement to monitor the resident's skin for redness, and report issues to the nurse, the 9/2/11 Care Plan did not address the resident specific issues identified on the 9/1/11 PNE, or identify that the resident was at risk for skin breakdown (SAR). In addition, the resident was observed on 9/7/11 at 7:30 am to have AFOs placed on her feet (see observation note below). The interim Care Plan did not address the AFOs, when they were to be on/off, or what precautions should be taken to monitor for and prevent skin breakdown. Nursing staff did complete Skin at Risk Checks ([DIAGNOSES REDACTED]) 24 hours after admission, 48 hours after admission, and 72 hours after admission. The 9/2/11 Resident Weekly Skin Check sheet documented, "Blister (left) hip (and) right thigh old. 2330 (?) open, pt (patient) states irritation from attends. (No) new issues." The 9/3/11 Resident Weekly Skin Check sheet documented, "No new issues from admit" A Skin Inspection Anatomy Diagram sheet, dated 9/4/11, documented, "Left hip, blister like lesion - non intact (sic) - 2 X 2 cm denuded area ... Resident has a [DEVICE] ([MEDICAL CONDITION] tube) well healed left lower quad(rant). Also noted a well healed [MEDICAL CONDITION] stoma." Note: Neither these notes, nor nursing notes, dated 9/1/11 through 9/7/11, addressed the other skin issues identified on the 9/1/11 PNE or the AFOs that the resident wore. In addition, there was no documentation in Resident #2's medical record that the physician was notified of the resident's skin breakdown until 9/6/11, including the open area on the resident's left hip and there was no nursing documentation indicating the resident received care and services for the skin issues until 9/6/11, five days after the resident was admitted to the facility. Resident #2's medical record did indicate that treatment was finally inititated and a generic care plan for actual skin breakdown was put into place on 9/6/11: * A 9/6/11 Condition Change Report, attached to a Resident Progress Notes, documented, "admitted with blister (left) hip. Area 3X3 top skin off. Will care plan do tx (treatment) as per standing orders." The Condition Change report indicated that the resident's attending physician was notified of the issue. However, neither the 9/6/11 Condition Change Report, nor the nursing notes documented when the physician was notified or the physician's response. *A Physician Telephone Order (TO), dated 9/6/11, listed the following orders from the standing order sheet," 1) Clean area NS (normal saline) (left) hip, 2) Apply Opsite (dressing) to area for protection, 3) Change prn (as needed) and 2 - 3 days, 4) DC (discontinue) when resolved. " The TO was transcribed to the TAR on 9/6/11. There was no evidence of skin care/wound treatment orders on the TAR previous to the 9/6/11 order. * A Care Plan Update form, dated 9/6/11, documented, "Skin integrity r/t (related to) blister to (left) hip," The Approach column listed, "Monitor site, report all red/open areas to nurse" * A Skin Integrity Impairment - Actual, Resident Care System Problem Complex Master File List (SIMFL), dated 9/6/11, was also added to the interim Care Plan. The SIMFL listed generic approaches such as turn from side to side, change position while in wheel chair, elevate lower limbs while in bed, and pressure reduction cushion to bedside chair and/or wheel chair. However, the Care Plan still did not list specific approaches for the pressure ulcer/blister on the resident's left hip, or specific approaches for the resident's AFO, or specific approaches for the other [MEDICAL CONDITION] listed on the PNE. The SIMFL documented that the turning from side to side and the changing position while in w/c should be added to the C.N.A. Flow sheet. During an observation on 9/7/11 at 7:15 am, C.N.A. #6 entered Resident #2's room to assist the resident to get up for the day. Prior to starting the resident's care, C.N.A. #6 stated she had not taken care of the resident before, went to the resident's closet to look for a C.N.A. Flow (care) Sheet but did not find one. The C.N.A. then went to the nurses station to obtain the flow sheet. C.N.A. #6 returned to the resident's room with the flow sheet and proceeded to change the resident's incontinent briefs, provided peri care, and then waited for C.N.A. #5 to assist her to dress the resident and transfer her out of bed. When C.N.A. #5 arrived, he obtained two AFOs from beside the resident's bed and attempted to put them on. After two attempts to put the AFOs on, Resident #2 told the C.N.A. that something was wrong, the AFOs were not going on correctly. C.N.A. #5 checked the padding on the AFOs and looked at them to see what feet they went on. After two more attempts the AFOs were in place, but the resident stated they were on the wrong feet. C.N.A. #5 removed the AFOs from the wrong feet and put them on the right feet. They were placed over long stockings and still were difficult to correctly place on the resident. It took C.N.A. #5 a few attempts to finally push the AFOs into place and for the resident to verbally state they were on correctly. Note: The AFOs were not marked regarding which foot they went on and, because of the resident's foot deformities, they both looked very similar. In addition, the AFOs were not listed on the C.N.A. Flow Sheet, nor was repositioning and/or turning the resident listed. On 9/9/11, at 8:55 am, the DON accompanied the surveyor to the resident's room to observe the resident's skin condition. The reddened area on the resident's left buttock, observed by the surveyor on 9/7/11, was still present but partially faded. The lesion on the resident's right inner thigh was faded and almost invisible. Three red [MEDICAL CONDITION] were observed on the resident's outer right foot. These [MEDICAL CONDITION] were blanchable but very beefy red in color. They were located over the bony cuboid process on the side of the foot and over knuckles on the 4th and 5th metatarsals. After the 8:55 am observation on 9/9/11, the DON was asked about care plans and nursing documentation regarding the skin issues identified on Resident #2's 9/1/11 PNE. The DON stated he would review the resident's chart and see if there was additional documentation. At the time of the interview, the DON did provide a note written on the Resident Progress Notes by LN nursing staff on 9/7/11, and a 9/7/11 entry on the Resident Weekly Skin Check Sheet. The Resident's Weekly Skin Check Sheet documented, "Blister yet to (left) hip. No other red areas. Feet cold to touch, red all areas all blanchable. (Illegible) inner ankle red, but blanchable. Some excoriation to [DEVICE] site."The note written on the Resident Progress Notes documented the same information found on the 9/7/11 Weekly Skin Check sheet, and added, " Resident wears AFO (on) bilateral feet, will request an order from (resident's physician) for (Occupational Therapy), correct fit of AFO and positioning for power chair. No other areas noted at this time. Will also request (treatment) for stoma site ... slightly pink to buttock area, skin barrier cream applied ... will continue to observe." On 9/9/11 at 10:15 am, the DON, Administrator, and the Regional Nurse Consultant were advised of the on-going concerns regarding the lack of care planning and the lack of documentation between the resident's admission on 9/1/11 and 9/6/11. The facility provided no further documentation or information that resolved the concerns.

Based on record review and staff interview it was determined the facility failed to ensure appropriate treatment to prevent urinary tract infection for 1 of 15 sample residents (#15). Resident #15 was harmed when antibiotic therapy was ordered and not given for a urinary tract infection. The resident required hospitalization and treatment for [REDACTED]. Resident #15 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. A Condition Change Form in the Resident Progress Notes dated 3/29/11 documented a fax had been sent to the physician on that date with the reported pharmacist concern that the [MEDICATION NAME] ordered for the resident's UTI (urinary tract infection) had too many side effects and was requesting a change in antibiotic to [MEDICATION NAME]. Medication Administration Records (MAR) for 3/11 documented [MEDICATION NAME] 500 mg (milligrams) by mouth every 12 hours for 10 days was given both morning and evening. The medication was written as discontinued due to "allergy" on 3/29/11. Another form in the MAR indicated [REDACTED]. The medication was initialed as given on 3/29/11, 3/30/11 and 3/31/11. Note: The documentation showed the resident received 2 doses of [MEDICATION NAME] and a once daily dose of [MEDICATION NAME] on 3/29/11. The 4/11 MAR indicated [REDACTED]. Resident Progress Notes for 4/20/11 described the resident as "continues to babble," spitting out pills and food, vomiting and remaining in bed. A Condition Change Form in the Resident Progress Notes dated 4/20/11 documented a fax had been sent to the physician on that date at 1:50 p.m. reporting that a urine dip test had been done. Resident Progress Notes for 4/20/11 at 8:40 a.m. documented a urine sample had been sent to the hospital. An un-timed entry documented a call had been placed to one physician's office with no return call, and a fax had been sent to the primary care physician with the results of the urinalysis. A Condition Change Form in the Resident Progress Notes, dated 4/21/11, documented a call had been placed to the physician on that date, no time, and stating new orders had been received. The MAR for 4/11 documented [MEDICATION NAME] 250 mg by mouth every 12 hours for 7 days was given at 2:00 p.m. on 4/21/11. All other columns were blank and the medication was marked discontinued on 4/28/11. On 4/21/11, the resident was transported to the hospital by ambulance at 1:05 p.m. according to the nurse's note written on 4/21/11 at 1:05 p.m. A report from the hospital dated 4/24/11, documented the discharge [DIAGNOSES REDACTED]. Moderate dehydration..." The report went on to state, "...On April 20, 2011, UA was performed and a urinary tract infection was the diagnosis. The patient was started on [MEDICATION NAME], but actually they were not able to start this medication because it was not refilled, and the following day, the patient's symptoms continued, the reason why the patient was transferred to the ER (emergency room )." A 4/24/11 entry documented the resident had returned to the facility alert and oriented. Antibiotic treatment with [MEDICATION NAME] 250 mg twice daily for the UTI was ordered and given through 4/30/11. The stop date for the medication was 5/7/11. A Condition Change Form in the Resident Progress Notes dated 5/15/11 documented a call had been placed to the physician on that date at 1:30 p.m. stating a urine dip had been done which was positive for leukocytes, trace blood and asked the physician if it should be sent for culture and sensitivity testing. The MAR for 5/11 documented [MEDICATION NAME] 250 mg by mouth every 12 hours for 10 days was given from 5/24/11 through 6/2/11. Resident Progress Notes for 6/2/11 at 8:40 a.m. documented a urine dip had been done and was positive for leukocytes, trace blood and protein. No other note for 6/2/11 or 6/3/11 was present in the record. Resident Progress Notes for 6/4/11 documented the resident refused all medications and dinner. The 6/6/11 Condition Change Form documented the UA results were sent to the physician via fax. On 6/7/11 the resident reportedly complained of nausea and dizziness and vomited a small amount. Later in the day on 6/7/11, the resident was described in the notes as being verbally aggressive toward her roommate. The roommate was moved to another room. A Condition Change Form in the Resident Progress Notes dated 7/25/11 documented a call had been placed to the physician on that date, no time listed, stating a urine dip had been done which was positive for blood and trace [MEDICATION NAME], and asked the physician to "please advise." The note described the resident as grunting/moaning all shift, refusing all meals and medications. A Condition Change Form in the Resident Progress Notes, dated 7/26/11, documented a call had been placed to the physician on that date at 11:15 a.m. requesting the physician to order a culture and sensitivity if indicated based on the urine dip reported the previous day. The note stated the resident had lab work scheduled for the following day. The note described the resident as restless, hollering agitated with cares, refusing all food and fluids and pain medications. Resident Progress Notes for 7/26/11 at 6:25 p.m. documented the resident refused all food/ fluids and medications. The resident was described as "non-responsive" then moaning and refusing cares. Resident Progress Notes for 7/27/11 at 6:30 a.m. documented the resident refused all fluids and [MEDICATION NAME]. The resident was described as "Doesn't respond to voice/touch." then moaning and refusing cares. "Oral mucosa is parched." An additional Resident Progress Note, dated 7/27/11 at 1:00 p.m., described the resident in the same condition and stated the physician was notified. and would be in at 4:00 p.m. On 7/30/11 a Condition Change Form documented new orders had been received based on the culture results. A note that the resident received the first dose of antibiotic was present. A hospital laboratory culture and sensitivity report for the urine specimen collected 7/26/11 documented the resident had [MEDICATION NAME] resistant [MEDICATION NAME] Faecium (VRE) in the urine. A hand written note on the lab report listed 2 physicians had been contacted of the results on 7/29/11. The MAR for 8/11 documented Linezolid 600 mg one tablet by mouth twice daily for 10 days for UTI was started 7/30/11 and marked as discontinued 8/9/11. Resident Progress notes did not document contact precautions had been put in place until an 8/5/11 12:55 p.m. note which stated the resident, "cont(inued) on contact prec(autions) r/t (related to) VRE." The resident's Isolation Precautions Care Plan was dated 8/4/11 and documented contact isolation measures for VRE were put in place on that date. Note: According to this documentation, the resident was not placed on isolation for the VRE until 5 days after the infection was confirmed and the physician notified. Resident Progress Note dated 8/6/11 at 4:45 a.m. documented a urine sample had been collected and sent to the laboratory. A hospital laboratory report, dated 8/6/11, documented the specimen contained [DIAGNOSES REDACTED] and Escherichia coli bacteria (E coli). An attached laboratory report dated 8/7/11 contained the culture report, and had a hand written note, with a signature which closely matched the prescribing physician's on other documents in the resident's record. The note stated, "extend Linezolid by 4 days for total of 14 days." As previously stated, the 8/11 MAR indicated [REDACTED]. No other MAR indicated [REDACTED]. Resident Progress Note entries stopped on 8/9/11 at 1:15 p.m. The entry described the resident as having a good day. The next entry was dated 8/16/11 at 5:30 p.m. and documented the resident's readmission from the hospital. An 8/11/11 hospital discharge summary report documented the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. coli, recent history of [MEDICATION NAME]-resistant [MEDICATION NAME] urinary tract infection." The resident's condition upon arrival to the emergency room was documented as, "The patient presented to the emergency room with a change in mental status, worse than her usual baseline dementia, and was apparently unresponsive at the time. She was noted in the ER to have a urinary tract infection and signs and symptoms of [MEDICAL CONDITION]." The DON confirmed by telephone the morning of 9/16/11, the facility had no documentation of the physician order [REDACTED]. The resident had a history of [REDACTED]. Resident #15 was harmed when the facility failed to ensure antibiotic treatment for [REDACTED].

Based on observation, record review and staff interview, it was determined that the facility failed to put effective interventions in place and/or revise care plans to prevent falls. This was true for 2 of 10 (#s 4 & 6) sampled residents and resulted in harm to Resident #6. *Resident #6 was harmed when he fell from his bed when a CNA rolled him to his side when providing care. Resident #6 was taken to the emergency room of the local hospital for treatment of [REDACTED]. He suffered pain due to injuries received from the fall. *Resident #4 fell 13 times between 7/4/11 & 9/5/11. The facility failed to provide adequate supervision and assistive devices for Resident #4 who was admitted with a fall history and subsequently fell 13 times in an 8 week time frame after. For two of the 13 falls, care planned interventions were not in place. Findings included: 1. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The resident's 8/2/11 quarterly MDS assessment and 5/5/11 annual MDS assessment coded: * Extensive assistance of 2 staff for bed mobility. * Extensive assistance of 2 staff for transfers. * Extensive assistance of 2 staff for toileting. A Bed Safety Evaluation, dated 2/24/11, documented in section 9 Resident #6 could use his right hand during cares if staff placed his hand on the bed rail, however, his left side was "flaccid." A Post - Event Investigation/Interviews (PEII) form, dated 7/2/11, documented at 1:58 p.m., in the "describe event" section, a CNA had rolled the resident to his right side when attempting to clean the resident and thought the resident was able to hang on to the side rails. The bed was in high position and the resident rolled out of the bed onto the floor. The PEII documented the reason the event occurred was because, "...One aide in room doing cares with a resident that is care planned for assist of two." The PEII included the aide failed to follow policy. Note: During the initial tour on 9/9/11 at 8:10 a.m. unit manager #7 stated Resident #6 was to be transferred with a Hoyer lift which required two staff. The Environmental Review section on the PEII had an "X" in the box by improper bed height. The Interdisciplinary Team reviewed the 7/2/11 fall on 7/5/11 on a Condition Change Form (CCF). The CCF documented Resident #6 had rolled out of his bed on to the floor and included the resident had left side hemiparesis and was to be transferred with a Hoyer lift. The CCF documented the resident had injuries to the left great toe with bleeding, a bleeding laceration with a hematoma to the left side of the neck and a bloody nose. A second CCF dated 7/5/11 documented Resident #6 was a large man with poor trunk control and, "Cannot right himself due to [DIAGNOSES REDACTED]." A report from the local hospital emergency room , dated 7/2/11, documented a laceration to the left anterior neck with a surrounding superficial hematoma. The bleeding was controlled and the wound was closed with skin adhesive. An abrasion to the left great toe had a dressing applied. Resident Progress Notes documented the following: 7/2/11 - 3:15 p.m. Condition Change form documented abrasion to the left side of the neck and nose, abrasion to the left great toe nail and a skin tear to the top of the toe. All areas bled. At 3:30 p.m. transported (hospital). Tylenol given and continued with ice to the chin. 8:30 p.m. returned from hospital, bruising and swelling to chin and left side of face. Dressing to left big toe with small amount of drainage. PRN (as needed) Tylenol given. Family requested resident not get up. 7/3/11 - 2:00 a.m. medicated for general discomfort, 2:40 a.m. Left side of jaw and neck, "Black/purple bruises," and swollen, tender to touch. Small abrasion to left side of jaw and the area was iced. A dressing was intact to the left great toe. 7:00 p.m. no complaints of pain noted, neck and bruising noted and iced. Routine Tylenol helpful. 7/4/11 - 4:45 a.m. bruising continues to left side of jaw and neck. 7:00 p.m. bruising to chin, ice applied 7/5/11 2:30 a.m. -bruising to left neck and jaw, resident complaining of pain down left leg when being turned 8/3/11 -Continues to have abrasion to left toe. Progress notes document Resident #6 continued to have an abrasion to his left great toe, for 30 days after he fell on [DATE]. His 8/27/11 Comprehensive Care Plan Report (CP) included a goal for him to be free of falls with injury. The Approach section, dated 7/5/11, (after the recent fall) documented he required 2 staff to assist him when turning in bed. Another goal in his CP was for him to be clean dry and odor free. The approach section, dated 8/12/05 (actual date on CP), included the use of mechanical lift with 2 staff. On 9/9/11 at 9:19 a.m. the DON stated the Care Plan had not included the use of 2 staff for peri-care prior to 7/5/11. The surveyor informed the DON the 5/5/11 MDS assessment, prior to the fall, had identified the resident required 2 to assist with toileting. The DON stated the Care Plan had identified 2 staff for transfers but not for toileting. The facility failed to ensure Resident #6's CP included he required extensive assistance of 2 people to assist him for bed mobility and toileting as determined by his 5/5/11 annual MDS assessment. While being assisted by only one staff, Resident #6 fell to the floor from a high bed and experienced harm requiring medical evaluation and treatment at the emergency room . 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 7/7/11, coded: * BIMS score of 9, indicating moderately impaired cognitive skills for daily decision making * Severe depression * Disorganized thinking * Required extensive assistance of 1 person for bed mobility, transfer, and toileting * fell in the last month before admission to the facility * fell in the last 2-6 months before admission to the facility * fell since admission to the facility Resident #4's CAA documented: * Cognitive Loss/Dementia: "...increase in his confusion recognized by family. Delirium may contribute." * Mood State: "Res(ident) with high mood score of 20/27 for initial MDS. Res with orders for Celexa..." * Falls: "...has had several falls at home and one fall since admit. He is having trouble (with) his memory and tried to do things on his own. Needs encouragement to use call light and wait for assist..." Resident #4's Morris Fall Risk Scale form, dated 6/30/11 at 5:30 pm, documented the resident scored 95 points which placed him at high risk for falls. Note: According to the form, a score of 45 or higher was high risk. The resident's Care Plan documented the problem, dated 7/4/11, "Pot(ential) for trauma. R/T (related to) confusion, weakness, lack of safety awareness as evidenced by hx (history) of falls." Interventions included, "Respond to call light promptly..., Needs to be anticipated by staff, Follow toileting regime/schedule, Assess cause, pattern of previous falls and act upon resolvable factors, Environment assessment for physical clutter..., Non-skid socks at all (times)..., Observe of early signs of agitation or increased anxiety and report to LN, Reassess pain management plan." A Care Plan Update form, dated 7/4/11, documented, "Add to Fall/Trauma...non-skid socks at all (times), 30 minute checks until (after) Fall Committee Review." Documentation from the Post-Event Investigation/Interviews reports, Care Plan and Care Plan Updates, Resident Progress Notes and the Condition Change forms, recorded Resident #4's falls and subsequent interventions from 7/4/11 to 9/5/11: * 7/4 5:40 am - fell from bed to floor, not wearing non-skid socks, pants/floor wet, fell on left arm, no other injuries, Blood pressure (BP) 175/103. Discontinue 30 minute checks, Check every hour for toileting, Monitor arm pain, metoprolol increased. * 7/20 5:25 am - fell from bed to floor, not wearing non-skid socks, bed in low position, resident stated he forgot where he was and was going to check on his car, superficial red mark on back of head. Orthostatic BP's once per shift, non-skid socks when shoes off, continue with neuro checks. NOTE: The resident did not have on the care planned non-skid socks when he fell . * 7/20 5:20 pm - Resident in wheelchair in hallway, wife tried to get him to stand up, before staff could get to him he fell to the floor, may have bumped arm or back on scale, resident confused, wife confused, no one close enough to redirect wife and resident. Room move, wife closer to activities, 1:1 remainder of shift, 30 minute checks, * 7/29 10:50 am - fell to floor, (Note: Documentation did not state where resident was prior to fall), trying to sit in a metal folding chair that was folded and against the wall, no injury, alert but confused. Remove chair. * 7/29 2:00 pm - found on floor at foot of bed, lying on side, no injury noted. * 7/30 no time - fell in hall outside wife's room, (Note: No incident report was filled out for this fall but the fall was documented on the Condition Change form). Change of condition form, dated 8/1, included all interventions for the two falls on 7/29 and the fall on 7/30: Set 1:1 supervision to provide (resident) uninterrupted rest, physician to decrease Norco dose, Speech Language evaluation for cognitive therapy, 1:1 discontinued and "will continue 30 min(ute)" checks, encourage resident to use call light. * 8/2 11:00 am - resident found on floor by bed, was resting after therapy, appears he attempted to get up to locate spouse. Post void residual, continue 30 minute checks-ask for toileting/activities, discontinue 1 hour checks, tether alarm, floor alarm. NOTE: The resident fell 6 times before any type of alarm system was used to prevent his falls. * 8/2 8:00 pm - resident slid to floor from bed, alarm sounded (NOTE: The incident form reported, "floor alarm-will have when it gets to facility"), no injuries noted. Bed against wall per family request. Follow-up with doctor regarding increase INR (International Normalized Ratio) and increase pulse. * 8/13 7:00 pm - resident being led down hall by wife, his pants were starting to fall down and he hit the floor before anyone could get to him, wife unhooked his tether alarm. Change to pressure pad alarm in wheelchair, smaller pants or suspenders. * 8/15 8:30 pm - Resident was attempting to self transfer from wheelchair to bed, alarm was sounding, floor mat pressure alarm in place, resident was on 15 minute checks. Continue 15 minute checks, therapy to check wheelchair cushion, discontinue tether alarm, pressure pad alarm to wheelchair, bed against the wall, offer resident to be assisted to lay down after meals. NOTE: Thirty minute checks were initiated on 7/20 at 5:20 pm. The resident fell 6 more times before he was monitored every 15 minutes. * 8/31 1:30 am - fell from bed to floor, alarm sounded, resident was lowering his body to the mat and leaned over to the side lying position, did not hit his head, this episode of getting out of bed was purposeful, returned to bed with help of 2. Safety precautions were in effect, physicians to review medications, continue of 15 minute checks, continue to review decline. * 9/3 8:50 am - heard alarm go off, found resident sitting on the floor with hs upper body resting on the bed, bed in low position, pillow was also on right side of bed halfway off bed, no injuries noted. Perimeter mattress, 15 minute checks, check on continued use of Wellbutrin, check bowel status (NOTE: The resident's bowel record documented the resident went 3-6 days without a bowel movement in July and August 2011 and no bowel care or limited bowel care medications were administered. See F309), review comfort pattern, in a low bed, pillows used for positioning, will encourage resident to eat in dining room. * 9/5 at 5:30 am - roommate turned on call light, resident lying on floor, denies hitting head, says he fell on right side, floor and bed were dry. "Alarm sounded several times, last at 5:00 am. Now it is unplugged from the mat. CNA reported, "I didn't check him but I saw him in the bed at 5:10 am, he was facing the wall, tucked (into) bed." Analysis of the event documented, "We know the alarm was functioning at 5:00 am. CNA at 5:00 am did not raise bed. She kicked alarm under the bed and reset and put back in place after her work was done. The only conclusion: When alarm was kicked under the bed and then pulled back out it is possible that it accidentally came unplugged. The CNA reset it (at) that time. We did not look (at) it again until his fall 30 minutes later." Perimeter mattress, 15 minute checks, check on bowel pattern/meds, address again regarding Wellbutrin, continue low bed, alarm mat, pillows for positioning. NOTE: The alarm was not checked for function after turning the alarm on, to ensure it would sound. In addition, 15 minute checks were initiated on 8/15 but the resident fell 3 more times since that intervention was initiated. Also, a perimeter mattress was implemented only after the resident fell from his bed to the floor 8 times. Resident #4's Check List form was reviewed for 9/10 and 9/11. The form documented the resident was to be checked every 15 minutes, as stated in the care plan. However, signatures on the form indicated the checks were done every 30 minutes from 2:15 pm until 6:00 am on 9/10/11 and from 8:15 pm to 6:00 am on 9/11/11. On 9/6/11 at 11:25 am, Resident #4 was observed lying in bed with his eyes closed. The curtain was pulled between the resident, who occupied the second bed near the window, and his roommate, who occupied the first bed. Resident #4 was not able to be seen from the hallway. The bed was in the low position, a mat was by the bedside with an alarm hanging on the bed. The head of the bed faced the curtain and the foot of the bed faced the window. The bed was pushed against the wall. The resident was partially covered with a sheet and had on non-skid socks. On 9/7/11 at 7:30 am, the resident was observed in bed. The bed and curtain were in the same configuration as observed on 9/6. The resident had his eyes closed, lying on his left side with the covers off and a hospital gown and attends on. The mat was at the bedside with an alarm hanging on the bed. On 9/8/11 at 9:30 am, RN Unit Manager #4 was interviewed regarding Resident #4's falls. She was asked about the timeliness of interventions when the resident has a history of falls at home and has extensive falls in the facility. She stated the "DON maps it out" and the Performance Improvement meetings make recommendations. On 9/12/11 at 11:50 am, the DON was interviewed regarding Resident #4's falls. The DON stated that 1:1 supervision started on 7/30 at 7:00 pm and continued until 8/1 when the Interdisciplinary Team decided to implement 30 minute checks. The DON stated while the overall goal was to prevent the resident's falls, the facility choose not to implement 1:1 supervision as an intervention to prevent the falls, but implemented interventions to prevent injury to the resident when he fell . The facility failed to initiate appropriate assistive devices when the resident entered the facility with a history of multiple falls and fell within 4 days of admission to the facility. Alarms were not initiated until the resident had fallen 6 times. Supervision for the resident was not increased from 30 minute to 15 minute checks until the resident had 6 more falls. Supervision was not increased to 1:1 when the resident continued to fall after 15 minute checks were implemented. The 15 minute checks were not carried out as the care plan described for 2 days in September, the care planned non-skid socks were not in place as care planned, and an alarm was not checked to verify it was operational after it was turned on. On 9/12/11 at 4:30 pm, the Administrator, DON and RN Consultant were informed of the issue. The facility provided no other information or documentation that resolved the concern.

Based on observation, staff interview, and record review, it was determined the facility failed to prevent the spread of infections in the facility and adjust its infection control processes as appropriate to address known infection risks. The facility failed to develop and implement corrective actions, based on analysis of data collection, despite an increase in infections in the facility. This was evidenced by: 1. Two of three residents sampled for infection control (#s 12 and 15) and one random resident (#22) contracted VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) in their urine while residing in the facility. Resident #15 was harmed when she developed urosepsis and was subsequently hospitalized . 2. One of three residents sampled for infection control (#13), four of 14 sampled residents (#s 4, 7,11, and 12), and seven random residents (#s 18, 25, 26, 27, 33, 34, and 35) developed pneumonia while residing in the facility. 3. Three staff members were observed utilizing improper hand hygiene while providing care to a resident. Findings included: Federal guidance at 42CFR 483.65 Infection Control, defines an outbreak as "the occurrence of more cases of a particular infection than is normally expected, the occurrence of an unusual organism, or the occurrence of unusual antibiotic resistance patterns." 1. According to the CDC, VRE is often spread from person to person by the contaminated hands of caregivers. VRE can get onto a caregiver's hands after they have contact with other people with VRE or after contact with contaminated surfaces. VRE can also be spread directly to people after they touch surfaces that are contaminated with VRE. a. According to notes provided by the Infection Control Nurse (ICN), Resident #15 was discharged to a local hospital on [DATE] and readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED].#15 had VRE in her urine. The ICN verified this resident was dependent on staff for pericare and wore adult incontinence briefs. A Condition Change Form in the Resident Progress Notes, dated 7/25/11, documented a call had been placed to the physician on that date, no time listed, stating a urine dip had been done which was positive for blood and trace [MEDICATION NAME], and asked the physician to "please advise." The note described the resident as grunting/moaning all shift, and refusing all meals and medications. A Condition Change Form in the Resident Progress Notes, dated 7/26/11, documented a call was placed to the physician on that date at 11:15 am, requesting the physician to order a culture and sensitivity if indicated based on the urine dip reported the previous day. The note stated the resident had lab work scheduled for the following day. The note described the resident as restless, hollering, agitated with cares, refusing all food and fluids and pain medications. Resident Progress Notes for 7/26/11 at 6:25 pm documented the resident refused all food/ fluids and medications. The resident was described as "non-responsive" then moaning and refusing cares. Resident Progress Notes for 7/27/11 at 6:30 am documented the resident refused all fluids and [MEDICATION NAME] (antibiotic). The resident was described as "Doesn't respond to voice/touch." then moaning and refusing cares. "Oral mucosa is parched." A 7/27/11 note at 1:00 pm described the resident in the same condition and stated the physician was notified and would be in to the facility at 4:00 pm. On 7/30/11 a Condition Change Form documented new orders had been received based on the culture results. A note that the resident received the first dose of antibiotic was present. A hospital laboratory culture and sensitivity report for the urine specimen collected 7/26/11 documented the resident had [MEDICATION NAME] resistant [MEDICATION NAME] Faecium (VRE) in the urine. A hand written note on the lab report listed 2 physicians had been contacted on 7/29/11. The MAR for 8/11 documented Linezolid 600 mg one tablet by mouth twice daily for 10 days for UTI was started on 7/30/11 and marked as discontinued 8/9/11. The Resident Care Plan did not document contact precautions had been put in place until 8/4/11. NOTE: Contact precautions were not in place for 7 days after physician notification of VRE. A hospital discharge summary report documented the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. coli, recent history of [MEDICATION NAME]-resistant [MEDICATION NAME] urinary tract infection." This hospitalization represented harm to the resident who contracted VRE and did not receive appropriate treatment. There was a delay in providing isolation once the resident was readmitted to the facility on [DATE]. Subsequently, two other residents contracted VRE in the facility. b. According to notes provided by the ICN, Resident #22 was discharged to a local hospital on [DATE] and readmitted after having surgery to remove orthopedic hardware that had become infected. On 7/29/11, a urinalysis with culture and sensitivity was obtained and it documented Resident #22 had VRE in her urine. This resident resided on the same hallway as Resident #15. The ICN verified this resident was dependent on staff for pericare and wore adult incontinence briefs. This resident was moved into the same room as Resident #15 to cohort the two diagnosed cases of VRE on 8/5/11. Residents #s 15 and 22 had resided on the same hallway. NOTE: This move to cohort the two confirmed cases of VRE was not done until 3 days after the second case was confirmed. The ICN documented the facility received the lab report on 8/2/11 that verified Resident #22 had VRE in her urine. The resident was placed in contact isolation and the family and physician were notified on 8/2/11. c. According to notes provided by the ICN, Resident #12 was discharged to a local hospital on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#12 had VRE in her urine. This resident resided on a different hallway than Residents #15 and 22, but had been the roommate to Resident #15 prior to 6/8/11. However, in interviewing the ICN, she stated staff sometimes were asked to help on hallways other than their assigned hallway. The ICN verified this resident was dependent on staff for pericare and wore adult incontinence briefs. NOTE: The ICN documented the facility received the lab report on 8/10/11 which verified that Resident #12 had VRE in her urine. The resident was placed in contact isolation. NOTE: The hospital laboratory that provided the analyses was asked for their procedure and protocol for informing facilities of culture and sensitivity results on 9/14/11 at 11:00 am. A hospital microbiologist informed the surveyor they had no distinct policy for informing facilities of VRE results. The microbiologist stated it normally took 24 hours for the culture to "grow out" and another 24 hours for a panel to develop. She stated if the culture was positive for a multi-drug resistant organisms (MDRO) , the test was always repeated to confirm the results. Therefore, it could be 72 hours for final results to be ready for a facility. The ICN provided copies of a facility "Quickie Inservice" that was presented on 8/1/11 to: * Housekeeping and Laundry staff, on the topic of VRE with regards to Resident #15 and #22. However, the ICN had previously stated she did not have documentation of Resident #22 having VRE at that time. * Pericare, handwashing, and glove use related to urinary tract infections and skin issues. * Handwashing related to urinary tract infections. * Pericare related to urinary tract infections. * VRE (Resident #15's room) NOTE: This inservice contained specific information related to personal protective equipment (PPE) and disinfection of contaminated surfaces. Three "Quickie Inservice's" were provided by the ICN on 8/10/11, on the topic of VRE* With regards to Residents #15, 22, and 12, with specific information related to PPE, double bagging trash and linens, utilizing red barrels, etc. * With regards to VRE and Residents #s 15, 22, and 12. * With regards to urinary tract infections and VRE. The target audience for these inservices was not identified on the forms. A second "Quickie Inservice" was presented by the ICN on MDRO on 8/11/11 for Housekeeping staff and a "Quickie Inservice" was documented as presented to the rehabilitation staff on 8/11/11 on VRE. A "Quickie Inservice" was provided on 8/23/11 on the topic of equipment cleaning, related to not leaving equipment in resident rooms and using bleach wipes between all residents' use. The target audience was not identifed on the form. A CNA competency module for perineal care for the female resident was offered as of 8/8/11. The attendance sheet documented 16 of 35 CNAs completed the activity. In addition, an all staff competency module for handwashing was offered in August 2011, with the earliest date provided by staff completing the module from 8/8/11 to 8/24/11. The ICN also documented an All Staff Meeting on 8/11/11 was devoted to Infection Control. This was documented as attended by 45 of 92 staff, including the Executive Director, DON, ICN, Payroll-Benefits Coordinator, and Supervisor of Medical Records. There were 23 CNAs and 17 licensed nurses documented as not present at this All Staff meeting on Infection Control. Resident #15 was confirmed with VRE on 7/30/11, Resident #22 was confirmed on 8/2/11, and Resident #12 was confirmed on 8/10/11. Although no other cases had been confirmed as of the survey week, the surveyor did observe improper handwashing by 2 CNAs and 1 LN, who also served as the facility treatment nurse, providing wound care (please see below for details), after the inservices had been provided by the ICN. The ICN had no explanation as to how the VRE had spread in the facility, other than the focus of the inservices being on providing proper pericare and utilizing proper hand hygiene when providing care. She also stated she emphasized the importance of handwashing every month and much of the inservices were no different than what she instructed staff on a regular basis. Resident #15 suffered harm when her urinary tract infection resulted in hospitalization and urosepsis. NOTE: Please see F315 as it relates to a delay in treatment for [REDACTED]. 2. During the months of May to September 2011, the facility had 13 cases of facility acquired pneumonia. This included two residents who had facility-acquired pneumonia twice and a resident who was admitted with pneumonia that resolved and developed a second case of facility-acquired pneumonia afterwards. In May 2011, Residents #s 11, 23, and 24 were admitted to the facility with [DIAGNOSES REDACTED].#11 was admitted to the 300 Hallway. Resident #25 was a roommate of Resident #24 and developed facility-acquired pneumonia three weeks after Resident #24's admission. In June 2011, Residents #s 28, 29, 30 and 31 were admitted with [DIAGNOSES REDACTED]. Residents #s 26 and 27 developed facility-acquired pneumonia after residing on the same hallway as Residents #s 23, 24, and 25. In addition, Resident #7 developed facility-acquired pneumonia and resided on the 200 Hallway. In July 2011, Resident #32 was admitted to the facility with the [DIAGNOSES REDACTED]. Resident #7, who had a previous [DIAGNOSES REDACTED]. This resident resided on the 200 Hallway. Resident #33 resided on the 200 Hallway and was diagnosed with [REDACTED]. In August 2011, Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #26, residing on the 100 Hallway, suffered a second episode of pneumonia after symptoms had resolved and had to be treated a second time for facility-acquired pneumonia. Resident #35 who resided on the 300 Hallway, was diagnosed with [REDACTED]. As of September 9, 2011, no new residents had been admitted to the facility with [DIAGNOSES REDACTED]. According to the facility Employee Illness/Infection Log: * May 2011 had 7 employee call ins for respiratory illness * June 2011 had 2 employee call ins for respiratory illness * July 2011 had 3 employee call ins for respiratory illness * August 2011 had 2 employee call ins for respiratory illness * September 2011 had no employee call ins for respiratory illness According to September 2011 MARs for all residents with [DIAGNOSES REDACTED]. According to the "Guidelines for Preventing Health-Care-Associated Pneumonia, 2003," published by the CDC, small-volume medication nebulizers, both in-line and hand-held, should be cleaned, disinfected, rinsed with sterile water (if rinsing is needed), and dried between treatments on the same patient. On 9/12/11 at 3:10 pm, the ICN was asked what the facility policy was for cleaning the small-volume nebulizer equipment for residents. The ICN stated she thought it would include wiping down the equipment with a bleach wipe and drying afterwards, placing it back into a bag. The facility policy for hand-held nebulizers stated the equipment was to be changed once a week or as needed, discarding and replacing if heavily soiled. On 9/12/11 at 3:15 pm, nurses on the three hallways were interviewed by surveyors with regards to the cleaning of hand-held nebulizer equipment. The responses varied but nursing stated the oxygen tubing would be changed weekly. In addition, they stated they would rinse the nebulizer with water and dry before placing back into the plastic bag and would wipe the mouthpiece with a bleach wipe if visibly soiled. Nursing did state the hand-held nebulizers were not to be used on multiple residents, only for individual use. The facility form, "A Guide for Infection Control Nurse-Outbreak Suspected," documented several of the following guidelines: * Review the 24-Hr Change of Condition Report for any patients presenting with symptoms indicating potential outbreaks. * Call an emergency meeting of the center Infection Control Committee to begin analysis and interdepartmental action plan. * Post signs at all entrances alerting visitors to the outbreak and what they are to do when entering the center. * Implement isolation and appropriate transmission based precautions for symptomatic patients. * Validate consistent staffing for symptomatic patients. Ideally staff will care for either ill patients or sick patients. Do not "float" staff between affected and unaffected units. * Provide private rooms for ill patients if available. * Do not move/transfer asymptomatic roommates to unaffected halls/units/rooms, as this may only spread the outbreak. * Housekeeping to increase cleaning frequency of symptomatic patient rooms, affected units and common areas. * Provide education for center staff (include therapy and housekeeping personnel) pertaining to suspected infectious disease/organism/virus, transmission based precautions for symptomatic patients, handwashing and standard precautions. * Monitor staff for symptoms Q (every) shift and implement applicable work restrictions. * Develop a narrative/case study to record the center action plan for containment, notifications and subsequent follow up. On 9/12/11 at 3:10 pm, the ICN was interviewed regarding analysis of the pneumonia outbreak and corrective actions taken. The ICN stated she noticed that when residents were admitted to the facility with pneumonia, that subsequently some of the residents' roommates would contract pneumonia afterwards. The ICN stated if a resident, whether with an admission or facility-acquired [DIAGNOSES REDACTED]. She stated the facility attempted to utilize "fairly" consistent staffing for residents but staff could be called to help with other hallways than their assigned hallway. The ICN again referenced the All Staff meeting in August that was dedicated to the topic of infection control, but this was months after the pneumonia outbreak had begun. The ICN provided policies for cleaning of all resident equipment, including mechanical lifts, showers, and shower chairs. When asked what she felt accounted for the pneumonia outbreak the last several months, the ICN stated it had been a "bad summer for smoke in the air" from wildfires. When asked if she had taken any corrective actions prior to the August All Staff meeting on infection control, prompted by the facility outbreak of VRE, she stated she did hand hygiene monitoring on an ongoing basis but had no specific interventions based on the pneumonia outbreak. The ICN did not provide evidence she called an emergency meeting of the Infection Control Committee to begin analysis and an interdepartmental action plan for the pneumonia outbreak. She did not provide evidence that consistent staffing was utilized for symptomatic residents nor that they were placed in private rooms. On the contrary, several roommates were infected when they were housed with symptomatic residents. There was no indication housekeeping increased the cleaning frequency for affected rooms or hallways during these outbreak months or that specific inservices were provided to staff with regards to the pneumonia outbreak. As the outbreak has continued into September 2011, there was no evidence the severity of the infection had been assessed or corrective actions taken. 3. On 9/8/11 at 10:35 am, two CNAs and one LN were observed providing care to Resident #6 in which all three staff utilized improper hand hygiene. LN #1 was identified as the facility treatment nurse whose responsibilities included wound care. LN #1 was providing wound care to Resident #6 during this observation. LN #1 washed her hands for approximately 6 seconds before rinsing, drying and proceeding to retrieve supplies from her treatment cart. LN #1 then washed her hands a second time, again for less than 6 seconds before rinsing and drying. She then donned clean gloves and touched the resident's call light to alert a CNA she needed assistance. CNA #3 entered the room and also washed her hands less than 6 seconds before she rinsed and dried her hands, and donned clean gloves. LN #1 removed her gloves after removing the dressing on Resident #6's left ischial tuberosity pressure ulcer. LN #1 washed her hands again approximately 6 seconds and donned a new pair of clean gloves. LN #1 cleaned the wound bed and again, washed her hands for less than 6 seconds before rinsing, drying and donning a clean pair of gloves. CNA #3 washed her hands a second time for less than 7 seconds and left the room. CNA #2 entered the room to assist LN #1 with providing pericare and placing a new incontinence brief on the resident. CNA #2 washed her hands less than 6 seconds before rinsing, drying, and donning clean gloves. At this time, LN #1 had finished placing a clean dressing on Resident #6's pressure ulcer and LN #1 washed her hands a fifth time for approximately 6 seconds before rinsing, drying, and donning a clean pair of gloves. Incontinence care, including barrier cream, and a new incontinence brief were provided Resident #6. At this time, CNA #2 washed her hands a second time for less than 6 seconds before rinsing, drying, and donning clean gloves and LN #1 washed her hands for approximately 7 seconds. This was a total of 10 handwashing observations on three staff providing direct care to Resident #6 in which they did not wash their hands for at least 15-20 seconds before rinsing and drying. The facility Hand Hygiene/Handwashing policy documented hands should be rubbed together with vigorous friction for 20 seconds before rinsing. On 9/12/11 at 3:10 pm, the ICN documented her expectation, based on facility training she conducted, was for staff to wash their hands for at least 15-20 seconds before rinsing. The facility failed to conduct data analysis to aid in the determination of the causes of infectious trends in residents. They also failed to implement measures to prevent the transmission of VRE and pneumonia amongst residents. After Resident #15 developed VRE in her urine, it was developed in two other residents in the facility who were also dependent on staff for their pericare. The facility admitted residents with known [DIAGNOSES REDACTED]. The interventions of keeping residents who were exhibiting signs and symptoms in their rooms did not protect their roommates and did not limit the spread of the infection to others in the facility. There was no evidence of an adjustment to facility infection control processes to address known infection risks. In addition, the observation of 3 direct care staff repeatedly utilizing improper hand hygiene, the first line of defense in infection prevention, reinforced the failure of the infection control program. The Administrator, DON, and the Regional Nurse Consultant were informed of these findings on 9/12/11 at 4:30 pm. No further information regarding this matter was received from the facility.

Based on a complaint from the general public, record review, and staff interview, it was determined the facility failed to ensure that 1 of 3 sampled residents (#2) was provided with adequate supervision to prevent falls. This resulted in harm to Resident #2, who was sent to the hospital for treatment of [REDACTED]. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 8/24/10, documented the following: * Moderately impaired cognitive skills for daily decision making * Short-term memory impairment * Partial physical assistance required for balance test * Limited assistance of one staff member required for locomotion on the unit * Wandering behaviors * Unsteady gait * Fall within the preceding 30 days Resident #2's Cognitive Loss/Dementia RAP, dated 8/24/10, documented, "Res(ident) new to (facility) ... Res(ident) demonstrated compromised ST (short term) memory. This compounded likely, d/t (due to) res(ident) HOH (hard of hearing)." The resident's ADL Functional/Rehabilitation Potential RAP, dated 8/25/10, documented, "Resident admitted for general weakness and has end stage renal failure, venous stasis ulcers both great toes and depression. Requires extensive assist (with) ADLs except personal hygiene ... Has orders for OT/PT (Occupational Therapy/Physical Therapy)." Resident #2's Behavior Problems RAP, dated 8/24/10, documented, "Res(ident) noted (8/17) (one time) for wandering. Res(ident) also noted for fall that day, too. No further noted occ(urence) of wandering. Suspect may be r/t (related to) res(ident's) recent confusion." The resident's Falls RAP, dated 8/25/10, documented, "Resident admitted with general weakness and has short term memory loss and at times forgets he needs to wait for assistance to transfer. Has had a fall since admit on 8/17/10 (without) injury. Currently on 30 minute checks and Falling Star (program)." An initial nursing assessment, dated 8/13/10, documented that the resident scored 16 on a falls assessment. The assessment scale documented that residents with scores of 14 or greater were at "high risk" for falls. A Wander/Elopement Risk Evaluation, dated 8/13/10, documented that Resident #2 was not at risk for wandering or elopement, but had tested positive in two areas: "1) Does the resident have impaired decision-making skills that decrease his/her awareness of safety?, (and) 2) Does the resident express a desire to leave the center?" The resident's recapitulated physician's orders [REDACTED]. * "Metoprolol Tartrate, 25 mg, PO BID Dx: HTN (Metoprolol Tartrate, 25 milligrams, by mouth twice daily for hypertension)." Start date: 8/25/10. Potential adverse reactions: fatigue, dizziness, and hypotension. * "Sertraline 50 mg PO QD (daily) (for) depression." Start date: 8/13/10. Potential adverse reactions: Fatigue, dizziness, insomnia, anxiety, agitation, and confusion. * "Arterial pump - use 3 hrs (hours) per day (for) foot wounds." Start date: 8/19/10. * "Lactulose, 30 cc (cubic centimeters) PO BID (for elevated) ammonia." Start date: 9/3/10. Resident #2's Physical Therapy Care Plan, dated 8/14/10, documented the resident had "weakness" and an "unsteady gait." The resident's Potential for Trauma Care Plan, dated 8/13/10, documented, "Pressure pad alarm to bed if continued impulsive self transfer/amb(ulation)." A Care Plan Conference Summary, dated 8/18/10, documented, "Spouse in attendance - res(ident) in therapy. Spouse notes confusion more significant in past week ..." Weekly Physical Therapy Progress Notes for August 2010 documented the following: * 8/14/10 - 8/23/10: "Res(ident) has a (sic) poor vision. Res(ident) is impulsive when doing transfer for sit (to) stand (and stand to sit). Res(ident) able to improve standing balance, but Pt (patient) still has the tendency to lose balance backward when turning (and) standing." * 8/20/10 - 8/27/10: "... level of alertness fluctuates. We are currently trying treatments at various times of day, but no pattern of (increased) alertness noted." * 8/23/10 - 8/30/10: "Pt is very impulsive when doing from sit to stand ..." Resident Progress Notes (NN) documented the following information for Resident #2: * 8/17/10 - 4:45 p.m.: "(At 4:30 p.m.) found him on the floor at PT room. No one was there. He was sitting by his chair. He had small red mark on his back from the chair." * 8/17/10 - 6:00 p.m.: "Res(ident) had fall earlier this shift. Told by CNA that he 'wanted to sit down.' Moments earlier he was (up) by nurse station sitting in w/c (wheelchair) waiting for dinner. Res(ident) is alert and confused per usual status." * 8/18/10 - No time documented: "Res(ident) apparently propelled self in w/c down to therapy gym. Res(ident) attempted to stand from w/c and fell back. Res(ident) now has a small red mark to back. Res(ident) apparently wanted to go to therapy." * 8/18/10 - 12:55 p.m.: "Lifestyle hx (history) competed (with resident's) spouse this day. She acknowledges confusion over last 2 months, but more significant over last week. Notes res(ident) believes he's in a hotel presently." NOTE: A Physician Telephone Order, dated 8/18/10, documented, "D/C (Discontinue) tether alarm. Cont(inue) 30 min(ute) checks." * 8/23/10 - 9:30 p.m.: "Resident returned from dialysis (at 7:30 p.m.). Wife at bedside, wife stated she felt resident was not doing enough walking. Spoke to wife about allowing staff to provide resident cares..." * 8/26/10 - 7:15 p.m.: "Resident alert - wife or family at bedside all shift - resident did get up once without assist - staff walked him from doorway back to toilet - wife concerned that an alarm would make him stop trying to do things so no alarm placed at this time ... arterial pump boots on (for one hour) after evening mealtime..." * 8/27/10 - 8:40 a.m.: "Res(ident) wears arterial pump/boots as ordered." * 8/27/10 - 12:30 p.m.: "Alert. Has periods of (illegible) does not recognize staff now. Arterial pump on for (one hour)." * 8/29/10 - 5:00 p.m.: "Resident had an assisted fall, wife was assisting resident to w/c (when) resident lost his balance. The RNA (Restorative Nurse Aide) and CNA helped the wife catch the resident and he was lowered to the floor." * 8/30/10 - No time documented: "Res(ident) had an assisted fall in the dining room (on 8/29/10). Wife was ambulating resident to the dining room from his room. Res(ident) was standing and wife was attempting to assist res(ident) in to stationary chair. Res(ident) lost balance and was assisted to floor by res(ident's) wife (and) 2 other staff members. Res(ident's) wife has been educated to not ambulate res(ident) (without) staff assistance. Res(ident's) wife cont(inues) to do despite education. Hi risk. Gait belt provided (with) education. Will (follow-up)." * 8/30/10 - No time documented: "Falling Star: Resident last fall 8/29/10 - assisted to floor (with) wife (and) facility staff. Res(ident) requires extensive assist r/t weakness, poor balance (and) cardiopulmonary impairment complicated by ESRD (end stage renal disease) (with) hemodialysis. Res(ident) has hx of falls. Res(ident) does (not) appear to be impulsive currently although had one fall in the past when he attempted to go to therapy (without) assist. Res(ident) (with) impaired sensation to LE (lower extremity) that effects (sic) balance. Res(ident) requires assist for ADLs. Working (with) PT/OT to (increase) function (and) safety. Will continue Falling Star (program) to (increase) (illegible). (Discontinue 30-minute checks by staff). Wife (at) beside daily. Room in high traffic area allows for (increased) supervision." * 8/30/10 - 3:00 p.m.: "This PTA (Physical Therapy Aide) performed family training this (morning), mostly explaining the risks related (to the resident's wife) amb(ulating) her husband (without staff). This remains highly unsafe (and) so we began CNA/walk (and) dine program today." * 8/30/10 - 10:50 p.m.: "Resident out to dialysis returned (at 8:30 p.m.), wife concerned about (increased) confusion ... did appear to have an increase in confussion (sic) and was agitated (with) spouse ..." * 8/31/10 - 5:10 a.m.: "No (complaint of) pain from assist to floor. Got OOB (out of bed) unaided (and) walked down the hall in the NOC (night). Didn't fall. Returned to bed (without) problem (and) went back to sleep. He was pleasant, but confused during cares." * 8/31/10 - No time documented: "Res(ident) (with increased) conf(usion) delusional statements/transient in presentation. MD (Physician) updated and suspects that confusion (and) delusions are situational per unit manager. Res(ident) noted (with increased) attempts to get out of bed (at) NOC. Will initiate 15-minute checks." * 8/31/10 - 1:35 p.m.: "Alert (with) confusion. (No) adverse effects r/t recent fall." * 8/31/10 - 9:30 p.m.: "Resident alert, cont(inues) to self transfer. Alarm in place." * 9/1/10 - 2:45 p.m.: "Pressure alarm in place. Does not use call light for assist." * 9/2/10 - No time documented: "Spoke (with resident's physician) on 8/31/10 (regarding) res(ident's) continued confusion (and) impulsiveness; MD requested nurse speak to res(ident's) wife about possibly starting on low dose Zyprexa; spoke (at) length (with spouse) about risks (and) benefits of med(ication). Explained it would be a low dose, but might help (with) some of the confusion; She declines (at) this time, but will think about it (and) let us know if she changes her mind. She is very fearful of meds, stating, 'One of the meds he started after his heart problem caused his kidney failure,' assured her we would keep her informed of any changes (and) if any new meds are ordered." * 9/5/10 - 10:35 p.m.: "Resident on floor in room, feet towards toilet (and) head outside BR (bathroom) door. Head is bleeding copiously enough to saturate 3 towels. Responds verbally, c/o (complains of) head pain. Moving extremities. Head (and) neck stabilized (with) towels. Transported via ambulance to (nearby hospital) ER (emergency room ) for eval(uation) of posterior head laceration." * 9/6/10 - No time documented: "Res(ident) had a fall when res(ident) attempted to ambulate to bed from bathroom independently. Res has had (increased) loose stools d/t elevated ammonia (and) lactulose use. Res(ident) was toileted routinely, last seen by nurse just before shift (change). Res(ident) was wearing arterial pump boots/slick. Res(ident) PA (pressure alarm) did (not) sound. Question if res(ident) disabled. Res(ident) roommate alerted staff who immediately responded. EMTs were called. Res(ident) was stabilized (with) head injury and taken to ER for tx (treatment). Will evaluate for (increased) supervision when res(ident) returns from hosp(ital). Head laceration to be (treated at hospital)." A Post-Event Investigation/Interviews form, no time or date documented, included the following documentation: * "Called to (resident's room) by roommate. Resident on floor, feet toward toilet (and) head just outside BR door. Copious bleeding noted from posterior head. Arterial pumps still on feet." * "Resident (with) ESRF, DM (diabetes mellitus), dementia. He has limited sensation bilateral feet (and) very poor safety awareness. He got OOB unaided, walking on arterial pump boots (slick plastic). He is on (increased) Lactulose (secondary to increased ammonia) levels (and) apparently felt urgency to toilet. There was BM (stool) in toilet." * "Called to resident's room. Resident laying in bathroom doorway (with) arterial leg pumps still on. Resident bleeding from laceration back of head. Pressure applied to area. Resident able to move all extremities." * "Called to resident room, found resident lying on back, large pool of blood around head, resident stated he was going to the bathroom and fell , resident alert, stated only head was hurting, alarm was not sounding, after resident secure (checked) alarm, wires loose at pad side." * "Roommate ... reports he was in bed (and) heard the fall. He turned on light, got OOB (and) came (into) hallway to seek help." * "(Resident's age) (with) ESRF on ... hemodialysis has (diabetes mellitus) (with) chronic foot ulcerations requiring arterial pump (for three hours per) day. Pump was in place (and) on. Call light in reach. He has (increased ammonia) level (and) 8/25/10 began Lactulose (at hour of sleep). He's had some loose stools (secondary) to Lactulose. He has (little) to (no) safety awareness. For safety he has a pressure alarm in bed. Alarm was ON (and) pressure pad securely placed. Investigation shows alarm did not sound. Lactulose was (increased) 9/3/10. Loose stools were in commode when EMS arrived." A Physician's Clinical Report from the hospital, dated 9/5/10 at 11:31 p.m., documented that Resident #2 had sustained a 2-centimeter scalp laceration "with heavy contamination and requiring extensive irrigation and cleaning," as well as "neck pain, traumatic subarachnoid hemorrhage, cervical strain, (and) contusion (of the) right shoulder." Additionally, the report documented, "Wound explored, cleansed and irrigated extensively with normal saline. Closure of skin (initially attempted closure with 5 skin staples but bleeding continued and staples removed and ... silk simple sutures placed with good hemostasis." On 9/14/10, at 11:05 a.m., the facility's Administrator and DON were interviewed and asked to describe any additional safety precautions the facility put into place following Resident #2's falls on 8/17/10 and 8/29/10; the level of supervision provided to the resident following the discontinuation of the tabs ("tether") alarm on 8/18/10; duration of the 30-minute checks continued per physician order [REDACTED].#2's Care Plan following the falls on 8/17/10 and 8/29/10; and investigation results for the pressure alarm malfunction on 9/5/10. The DON stated the facility was attempting to decrease its use of alarms and that both the 30-minute and 15-minute checks would have been continued at least until the facility's weekly Falling Star program meeting, which the facility held each Monday (8/18/10 was a Wednesday, 8/31/10 was a Tuesday). The DON stated any continuation of the 30-minute and 15-minute checks following the weekly Falling Star meeting would have been documented in the Resident Progress Notes. The DON noted the resident's pressure alarm that did not sound at the time of the 9/5/10 injury accident was "tested " and determined to be operational. Resident #2 was admitted to the facility with a known history of falls and [DIAGNOSES REDACTED]. The resident was assessed as a "high" fall risk, and received scheduled medications with potential side effects that included fatigue, dizziness, hypotension, insomnia, anxiety, agitation, and confusion. Additionally, Resident #2 exhibited increasing confusion and impulsivity, sustained two falls at the facility prior to the injury accident on 9/5/10. The facility implemented increased supervision twice but discontinued that prior to the injury accident on 9/5/10. The resident was equipped with a pressure alarm that malfunctioned at the time of the injury fall. That fall resulted in a scalp laceration, neck pain, traumatic subarachnoid hemorrhage, cervical strain, and contusion of the right shoulder.