Every finding on record at Coeur d Alene Health of Cascadia

Based on observation, interview, review of the food code, and facility policy review, the facility failed to ensure food was dated as to when it expired, food was sealed, frozen food was appropriately thawed, and failed to ensure towels used to clean countertops were not heavily stained for one of one kitchen with the potential to affect 73 out of 80 resident consuming oral food. This failure had the potential to lead to food borne illnesses. Findings include: During an observation on 05/04/26 at 8:09 AM, there were three frozen meat logs sticking out of a container in a sink, with water running over one of the logs. Two of the logs were extended out of the container, not fully submerged and no water running over them. The walk-in refrigerator was observed with undated and unlabeled items. On the left side of the walk-in, there was a container of undated baked beans, a container of unsealed and undated hot dogs, a container of undated cooked ground hamburger, a container of undated canned diced peaches, and a container of undated sliced onions. By 8:29 AM, the meat remained thawing in the same manner. During an interview on 05/04/26 at 8:23 AM, the Dietary Manager (DM) confirmed the thawing of the frozen meat in the sink and stated he was unaware the meat needed to be fully submerged. He stated the items included two pork roast logs and one beef log. The DM confirmed the food items in the walk-in were undated and the hot dogs were unsealed. He confirmed they should have been dated and sealed. During an observation in the kitchen on 05/06/26 at 11:12 AM, the staff were using towels that had the appearance of being excessively stained throughout. The towels were used for cleaning the counter tops. During an interview on 05/06/26 at 3:00 PM, with the Director of Nursing (DON), Administrator, and the Registered Dietitian (RD), the Administrator stated the DM was ultimately responsible for ensuring all foods were dated and sealed. They stated they were aware of issues concerning the kitchen. The RD confirmed the towels used during meal preparation appeared dirty and deeply stained. Review of the facility's policy titled, Food Safety & Storage, dated 11/28/17, revealed under labeling and rotation 1. Opened and repackaged food must be labeled with contents and use-by-date.3. Ready-to-eat food held longer than 24 hours must be labeled with preparation and use-by dates. Review of the 2022 Food Code, located at https://www.fda.gov/media/164194/download?attachment, dated 01/18/23, Chapter 3-26, revealed revealed Safety food shall be thawed: (A) Under refrigeration.(B) Completely submerged under running water.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food was not served in disposable dishes for residents receiving cake. The facility also failed to ensure residents seated at the same table ate at the same time for one of one resident (Resident (R)75) reviewed for dignity in dining out of a total sample of 29 residents. This failure had the potential to cause R75 to feel less dignified.Findings include:1.Review of R75's undated admission Record, located in the electronic medical record (EMR) Profile tab, revealed R75 was admitted to the facility on [DATE] with diagnoses including gastroparesis, other specified eating disorder, unspecified protein-calorie malnutrition. Review of R75's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/26, located in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R51 was cognitively intact. During an observation on 05/05/26 at 12:00 PM revealed R75 was seated at a table in the main dining room. At this time, a Certified Nurse Aide (CNA) 2 was observed delivering food to the other residents seated at the table with R75. CNA2 was then observed talking with R75 after she failed to receive her meal. Continued observation on 05/05/26 revealed R75 was served at 12:26 PM after her table mates were observed to be finished eating. R75 then took her meal to her room to eat. During an observation on 05/05/26 at 5:10 PM revealed R75 was seated at a table in the main dining room.Other members of the table were served at 5:11 PM, R75 received her food at 5:27 PM with no explanation given for the delay. During an interview on 05/05/26 at 1:17, R75 stated, I ordered a standard always available item to eat like I always do and it was late again. it sucks, because everyone is done eating before I get mine, and it happens frequently. During an interview on 05/05/26 at 1:34 PM, CNA2 confirmed that R75 was served her meal after her tablemates had finished eating their meals. CNA2 stated, I told her it would be 15-20 minutes for her to get her food. The kitchen had run out of chicken and the supply truck had just arrived. During an interview on 05/07/26 at 1:08 PM, the Director of Nursing (DON) stated I expect all residents seated together should be served together. During an interview on 05/06/26 at 3:35 PM the Registered Dietitian stated that, Residents at the same time should be served relatively at the same time. 5-10 minutes apart at the most. The kitchen should have had the chicken on hand to serve since it is listed as always available. Review of the facility policy Dignity dated 09/12/25, revealed, Policy: Each resident has the right to be treated with dignity and respect. Procedure: All residents will be treated with dignity and respect. 2. Promoting resident independence and dignity while dining, such as avoiding: Daily use of disposable cutlery and dishware. Review of the facility policy Meal Service dated 09/12/25, revealed, Policy: .The dining environment is designed to promote quality of life by providing a pleasant, dignified atmosphere and will reflect regulatory requirements under 42 CFR 5483.60, including infection control, resident right and the safe preparation and delivery of food and fluids. Dining Environment and Service Protocols:. 4. Residents seated together shall be served in a timely and coordinated manner to promote dignity social engagement and homelike dining experience. 2. During an observation in the kitchen on 05/06/26 at 9:14 AM, [NAME] (C) 4 cut up the pineapple upside down cake and portioned it out on clear disposable lids. She was observed to have prepared 60 servings of cake. C4 stated the Dietary Manager (DM) told her to use the disposable dishes and confirmed they were lids. She stated they had too many and they didn't fit anything, so they needed to use them up. During an interview on 05/06/26 at 11:45 AM, the Registered Dietitian (RD) confirmed the DM was gone and was no longer working in the facility. During an interview on 05/06/26 at 3:00 PM, with the Director of Nursing (DON), Administrator, and the RD, the RD confirmed they were using the disposable lids. They stated it was another ordering concern they had with the DM and that they should have been using the custard dishes. During an interview on 05/06/26 at 5:03 PM, R75 stated the disposable dishes happened a lot and that the lids served with the cake kind of sucked. She stated a couple of them needed a real dish to soak the cake with milk, making it easier to consume with their chewing difficulties. R75 stated they could not do that with the disposable lid. Review of the facility's policy titled, Food Preparation for meals, menus, and food, revised 09/16/25, revealed 14. Food must be served attractively, garnished as appropriate, and on suitable dishware. Review of the facility's policy titled, Dignity, dated 09/12/25, revealed 2. Promoting resident independence and dignity while dining, such as avoiding: a. Daily use of disposable cutlery and dishware.

Based on observation, menu and recipe review, interview, and facility policy review, the facility failed to ensure the menu, menu extension, and recipes were followed for six of 29 sample residents (Resident (R) 11, R91, R71, R75, R79, and R81) reviewed for menu compliance in one of one kitchen. This failure had the potential to affect nutritional adequacy for 73 of 80 residents consuming oral food. Findings include: During a resident group interview on 05/05/26 at 2:00 PM, with R11, R91, R71, R75, R79, and R81, they stated they did not always get what they were supposed to get. R75 and R71 stated they sometimes only received lettuce as the salad. They stated they used to receive large salads with fruit in it. 1.Review of the week four Spring/Summer menu provided by the facility, for Tuesday dinner meal, revealed: beef shepherd's pie, dinner roll, veggies & dip, and seasonal fruit. Review of the menu extensions revealed the veggies consisted of carrots. During observation of the dining room on 05/05/26 at 5:04 PM, the posted menu outside of the dining rooms revealed shepherd's pie, veggie and dip, roll, and seasonal fruit. During the dining room meal observation from 5:04 PM- 5:30 PM, 10 out of 16 residents who ordered the main dish received a small portion of corn with the shepherd's pie. There were no veggies or dips served. One unidentified resident who ordered the pizza received the lettuce salad with no other ingredients. [NAME] (C) 3 was observed on duty. R75 confirmed they only received lettuce as the salad and that they didn't always get salad dressing. She stated dietary employees had attitudes when they asked for condiments. During an interview on 05/06/26 at 11:31 AM, C3 stated they did not have the menu items for dinner the night before. She stated they only had 1/2 bag of baby carrots. She stated they usually served carrots and celery for the vegetable cup. She confirmed they substituted corn for the vegetable cup. During an interview on 05/06/26 at 3:43 PM, the Registered Dietitian (RD) confirmed the replacement vegetable for the carrots should have been another high Vitamin A food item. She stated she was not aware of the substitution beforehand and that corn was not an appropriate substitute. 2. Review of the week four Spring/Summer menu provided by the facility, for Wednesday lunch meal, revealed: ham and potato casserole, garden salad, choice of dressing, and pineapple upside down cake. Review of the undated Ham & Potato Casserole recipe provided by the facility revealed the following ingredients: potatoes, fresh peeled and diced; butter; ham, baked; onion, fresh, chopped; flour, all-purpose; milk, 2% fat; salt; pepper, black, ground; cheese, cheddar, shredded; and breadcrumbs, seasoned. -The procedure revealed: 1. place peeled, diced potatoes in a large pot and cover with water. Bring to a boil. Reduce heat to medium-low and simmer until 10-15 minutes.3. Cut ham into bite size pieces. 4. When the potatoes are nearly done, melt first listed butter in a skillet over medium heat. Add ham and onion, cook and stir until the onion has softened and turned translucent.6. Sprinkle ham and onion mixture over the potatoes evenly.9. Pour cheddar cheese sauce over ham and potatoes. Sprinkle with breadcrumbs. Review of the Garden Salad recipe provided by the facility revealed the following ingredients: lettuce, choice of leaves; salad ingredients, choice of; salad garnish, as needed; and salad dressing, choice of. -The procedure revealed: .2. Select various salad toppings which may include some of the following suggestions; asparagus, artichokes, avocado, bean sprouts, garbanzo beans, broccoli, carrots, cauliflower, celery, cucumbers, green onions, sweet peppers, mushrooms, green peas, radishes, tomatoes, water chestnuts, or zucchini. 3. Consider a garnish such as alfalfa sprouts, bacon, cheese, croutons, hard cooked eggs, olives, onion rings (fresh or fried) parsley, sunflower seeds, dried fruits, etc. During an observation of the kitchen on 05/06/26 at 9:16 AM, the staff were preparing the lunch meal. C1 cut up the ham into diced pieces and placed it in a large hard plastic container. At 9:30 AM, the staff cut up romaine lettuce. A box of scalloped potatoes was on the steam table, near the stove. At 9:36 AM, C2 cut up tomatoes. There were shredded cheese, Kosher salt, pepper, and butter close to the stove for sauce preparation for the main dish. At 9:52 AM, C4 finished adding the ingredients to the sauce mixture and placed the remaining salt and pepper back onto the shelf. C2 finished portioning out the salads with lettuce and diced tomatoes. He placed them into the walk-in refrigerator. At 10:57 AM, the staff pulled out the prepared au gratin potatoes from the oven. C2 added the cold diced ham into the potatoes, and then he added the prepared sauce into the potatoes and mixed throughout. There were no onions or breadcrumbs observed in the preparation. At 11:00 AM, staff announced that the Dietary Manager (DM) was no longer working at the facility and that he was not coming back. The casserole was placed back into the oven. During an observation on 05/06/26 at 12:30 PM, a test tray was added to the cart. Staff started to pass trays at 1:00 PM on the hall. A test tray was evaluated, alongside the RD. The salad contained lettuce and diced tomatoes, alone. When asked what should be in the salad, she mentioned she needed to review the recipe. During an interview on 05/06/26 at 3:00 PM, with the Director of Nursing (DON), Administrator, and the RD, the Administrator stated they were aware of the staff not following the menu about two months ago. The Administrator stated there was a time in which the RD was mostly remote through March and that staffing was inconsistent during that time. The DON confirmed she also observed the staff serving lettuce for the salad in the dining room for dinner meal, the night before. The DON confirmed the corn was observed with the meal. The RD confirmed the menu items were not followed and confirmed the recipe was not followed for the ham and potato casserole. They confirmed recipes were available for the staff in the kitchen. Review of the facility's policy titled, Menu Development, Substitutions & Implementation, revision date 08/01/23, revealed Menus shall be developed and implemented to meet the nutritional, cultural, and personal preferences of residents in accordance with federal regulations. Review of the facility's policy titled, Food Preparation for meals, menus, and food, revised 09/16/25, revealed Preparation must follow standardized recipes.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure food was palatable to include proper temperature during food preparation and holding during meal service for nine of 29 sample residents (Resident (R) 14, R9, R6, R75, R11, R91, R71, R79, and R81) reviewed for food palatability. This failure had the potential to affect resident oral intake resulting in potential weight loss. Findings include: 1.a. Review of R14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/26 and located under the MDS tab of the electronic medical record (EMR) revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R14 was cognitively intact. During an interview on 05/04/26 at 4:16 PM, R14 stated the food was poor quality and cold at times. b. Review of R9's admission MDS with an ARD of 02/24/26 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 which indicated R9 was cognitively intact. During an interview on 05/05/26 at 9:11 AM, R9 stated the food was cold. c. Review of R6's annual MDS with an ARD of 02/16/26 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 which indicated R6 was cognitively intact. During an interview on 05/04/26 at 10:14 AM, R6 stated the food was nasty, and the food was either undercooked or overcooked. d. Review of 75's quarterly MDS with an ARD of 04/22/26 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 which indicated R75 was cognitively intact. During an interview on 05/04/26 at 5:04 PM, R75 stated the food was poor quality, overcooked, and not receiving the food she was supposed to receive. e. During a resident group interview on 05/05/26 at 2:00 PM, with R11, R91, R71, R75, R79, and R81, revealed that the food was cold a lot of times. They stated this was an issue for meals being served in both resident rooms and in the dining room. They stated they had their own stock of seasoning, to help season the food. R75 and R71 stated they sometimes only received lettuce as the salad. They stated they used to receive large salads with fruit in it. During an interview and observation of the kitchen on 05/06/26 at 8:11 AM, [NAME] (C) 2 stated he had not been told anything about the hot plate warmer. It was observed to be cool to touch. He confirmed it was not on. 2. During an observation in the kitchen on 05/06/26 at 11:12 AM, the steam table had five wells (two with no water and three with 1-2 inches of water). At 11:35 AM, C2 placed the spaghetti sauce, and ground hamburger meat onto the steam table, in shallow pans. These items were not temped prior to placing them on the steam table. He placed cold spaghetti noodles in a shallow pan, placed hot water on top, and placed it on the steam table. He did not take the temperature of the item. At 11:38 AM, C2 took the hamburger patties out of the oven and placed the shallow pan onto the steam table. He did not take the temperatures of the beef patties prior to placing them on the steam table. At 11:45 AM, the French fries were placed onto the steam table. The Registered Dietitian (RD) was interviewed and confirmed the DM was gone and was no longer working in the facility. The thermometer was observed alongside the temperature logbook, throughout food preparation. At 11:57 AM, several cold items were observed out at room temperature, which included glasses of milk, juice, cake with whipped topping, and yogurt. At 12:04 PM, C2 got the thermometer beside the temperature logbook and proceeded to take food temperatures. The ham and potato casserole was 184 degrees F (Fahrenheit), the hamburger patties were 131 degrees F, the spaghetti noodles were 129 degrees F, and the ground beef was 148 degrees F. C2 stated he may have to put back into the oven. C2 proceeded to reheat the items. At 12:13 PM, the RD was asked about the availability of only one thermometer. She stated they usually had more than one. At 12:13 PM, the noodles and hamburger were taken out and placed back onto the steam table, after being reheated. During an interview on 05/06/26 at 12:26 PM, when asked what the temperatures needed to be for a test tray, the RD stated she did not rely on the temperature and instead relied on how warm the food tasted. During an observation on 05/06/26 at 12:30 PM, a test tray was added to the cart (three section enclosed cart). At 12:51 PM, the staff in the kitchen located and opened the package to a second thermometer. At 12:52 PM, the steam table was rechecked for temperatures. C2 took the temperatures. The spaghetti noodles were 122 degrees F, and the ground beef was 136 degrees F. At 12:58 PM, the cart was finished and left the kitchen. Staff started to pass trays at 1:00 PM on the hall. A test tray was evaluated, alongside the RD. The cake with whipped topping was 61 degrees F, the orange juice was 54 degrees F, the salad was 57 degrees F, the ham and potato casserole was 124 degrees F. After tasting the casserole, the RD stated, It could be warmer. During an interview on 05/06/26 at 3:00 PM, with the Director of Nursing (DON), Administrator, and the RD, they stated they were aware of issues concerning the kitchen. Regarding the food temperatures, the Administrator stated they discussed the food often. The Administrator stated the steam table was new and she was not aware of the low water in the wells. They stated they did not know the plate warmer was not in use and that it should have been. The RD confirmed the cold foods were out at room temperature during meal service. Review of the facility's policy titled, Food Preparation for meals, menus, and food, revised 09/16/25, revealed Food shall be stored, prepared, and held using methods that preserve nutritional value and palatability to the extent possible. Cold.foods must be held at 41 degrees F or below; hot.foods must be maintained at 135 degrees F or above.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure medical record accuracy to include an updated order to match the Portable Medical Orders (POST) form for one of 29 sample residents (Resident (R) 10) reviewed for advanced directives. This failure had the potential to lead to inaccurate code status guidance. Findings include: Review of R10's admission Record located under the Profile tab of the electronic medical record (EMR) revealed admission on [DATE] and the advanced directive as Do Not Resuscitate [DNR]. Review of R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R10 was cognitively intact. During an observation on [DATE], there were POST books located at the nursing stations. Review of R10's hospital transfer orders, date of service [DATE] and provided by the facility, revealed Code Status: DNR. Review of the Order Summary Report, located under the Orders tab of the EMR, dated [DATE], revealed Do Not Resuscitate. Review of the POST, dated [DATE] and located under the Documents tab of the EMR, revealed Yes: CPR [Cardiopulmonary Resuscitation]. Review of the care plan, revised [DATE] and located under the Care Plan tab of the EMR, revealed [resident] has a Full Code POST in place. During an interview on [DATE] at 1:07 PM, Licensed Practical Nurse (LPN) 2 stated during an emergency she would look at the POST form and POST book. LPN2 reviewed the POST book at the nursing station for R10, and the POST form was accurate to reflect full code. During an interview on [DATE] at 1:25 PM, the Registered Nurse (RN) 1/ Resident Care Manager stated the DNR was on the transfer orders, and he would have usually gotten the DNR paperwork. He stated R10's POST reflected Full Code. He stated the order should have been changed when the POST was completed. He stated medical records, uploaded them, and completed the audits. At 1:42 PM, RN1 stated the care plan was changed appropriately but it was missed in the audit process. During an interview on [DATE] at 1:34 PM, Medical Records (MR) stated she was the one who reviewed the POST and made sure it matched the orders. She stated everything matched up originally. She stated she was unsure how this got missed. During an interview on [DATE] at 2:22 PM, with the Administrator and Director of Nursing (DON), the DON stated during an emergency, they looked at the POST or the POST book for the code status. They stated they were made aware the order was not updated to match the POST. Review of the facility's policy titled, Advance Directives and Advance Care Planning, dated [DATE], revealed DNR orders may be revoked at any time but must be documented in the Resident's chart.

Based on observation, review of the Food, Drug, Administration (FDA) Food Code, and staff interview it was determined the facility failed to provide employee hand hygiene, beard masks, and a cleaned and sanitized kitchen. This was true for 57 of 76 residents who received food prepared by the facilities kitchen. This deficient practice created the potential for harm by placing residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include:1. The FDA Food Code Section 2-301.14 When to Wash documented food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils . (H) before donning gloves to initiate a task that involves working with food.On 11/11/25 from 4:50 PM to 6:00 PM, the following observations were recorded: -At 4:55 PM, Kitchen Aide #1 was observed wiping his nose with his fingers and then emptied out the clean silverware from a dish container into a silverware container, where he wrapped the silverware into the resident's tray napkins before placing them on resident's dinner trays.-At 5:10 PM, [NAME] #1 was observed putting gloves on without performing hand hygiene.-From 5:15 pm through 5:45 PM, Kitchen Aide #1 touched his face or bare arms 24 times without washing his hands.On 11/11/25 at 6:08 PM, [NAME] #1 stated she had not performed enough hand hygiene during meal service and should have washed her hands between tasks and glove changes.On 11/11/25 at 6:09 PM, Kitchen Aide #1 was unable to answer when hand hygiene should be performed.2. The FDA Food Code Section 2-402.11 Effectiveness documented: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens.On 11/11/25 at 4:55 PM, Kitchen Aide #1 was observed wrapping silverware into the resident's tray napkins, which were later observed being placed on the resident's dinner trays.On 11/11/25 from 4:50 PM to 6:02 PM, the DM was observed prepping food for resident dinner without wearing a beard covering. On 11/11/25 at 6:03 PM, the DM stated beard covers should be worn in the kitchen, and both he and Kitchen Aide #1 were not wearing one. 3. The FDA Food Code Section 4-501.114 Manual Chemical Sanitization - Temperature, pH, and Concentration documented sanitizing solution should have a concentration as indicated by the manufacturer's use directions included in the labeling.On 11/11/25 between 5:00 PM and 5:25 PM, the DM and [NAME] #1 were observed using a food thermometer to temp food and then placing the thermometer into a sanitation bucket on the floor under the dish storage shelves multiple times throughout the dinner tray line service. On 11/11/25 at 6:10 PM, the DM measured the sanitizing solution at 100 parts per million (ppm) and stated the sanitation bucket should be at least 200 ppm according to the use instructions of the chemical sanitizer if used to sanitize kitchen surfaces or the thermometer.4. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned. On 11/11/25 at 4:55 PM, a food particle was left in an immersion blender container, upside down with the other clean immersion blender containers.On 11/11/25 at 5:10 PM, The DM stated dishes are cleaned and sanitized after use, and he did not know why a container with a food particle was stored among the clean containers.5. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented: Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. On 11/11/25 at 5:00 PM, a coating of dust was observed on the lower shelves where clean dishes were stored. A layer of dust was observed on the pipes along the kitchen wall above food preparation areas.On 11/11/25 at 5:15 PM, the Dietary Manager (DM) stated the kitchen is cleaned daily, with a deep clean at least weekly. He could not answer why there was dust on the shelves or the pipes.

Based on grievance review and staff interview, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 2 of 2 residents (Resident #9 and #3) whose records were reviewed for neglect and 1 of 1 resident (Resident #5) reviewed for abuse. The facility's failure to properly investigate grievances alleging neglect and abuse created the potential for physical harm, pain, and emotional distress. Findings include:1.Resident #9 was admitted to the facility on [DATE] with diagnoses including quadriplegia (complete immobility due to severe disability), respiratory failure, and depression. Resident #9 's care plan revised 4/9/25, documented he was dependent on staff for all activities of daily living, including incontinence care. A grievance form dated 9/10/25, documented Resident #9 submitted a grievance requesting that CNA #1 no longer provide care, he documented that CNA #1 left him wet for 4 hours. Resident #9 reported CNA #1 repeatedly turned off his call light, stated she would return, but did not provide timely care. Resident #9 described similar past episodes with CNA #1. On 9/11/25, CNA #1 provided a statement she often had difficulty finding a second staff member to assist with Resident #9's care. On 9/11/25, the facility documented Resident #9's interview confirming CNA #1 failed to return in a timely manner after multiple call light responses. CNA #1 was educated on timely care, use of her radio to obtain assistance, and a verbal corrective action was issued. On 11/12/25 at 3:00 PM, the CNO confirmed Resident #9 was left without incontinence care for 4 hours after his initial request. On 11/12/25 at 3:07 PM, the CEO acknowledged the grievance should have been investigated as neglect. 2.Resident #5 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including dementia and diabetes. And I&A report dated 9/18/25 documented CNA #1 was heard by a staff yelling at Resident #5. Resident #5 was severely cognitively impaired. The incident was reported to the CNO and CNA #1 was immediately suspended pending investigation. The I&A documented the following staff were interviewed: - Staff #1: reported when working with CNA #1 on 9/18/25, CNA #1 made the following comments to Resident #5 I can't deal with you. Go to your room. You are getting louder and louder. You are doing this for attention. - Staff #2: reported CNA#1 can be short with the residents when pressed with time. -Ancillary Staff #1: reported while talking to RCM #1, Resident #5 was in the hallway singing as she does at her baseline. CNA #1 was heard yelling at Resident #5 to be quiet and Just stop!, loud enough to interrupt her conversation with RCM #1. The I&A investigation documented CNA #1 can use verbal tones and words that could be perceived as condescending, stern, or scolding; however witnesses did not perceive the interactions between CNA #1 and Resident #5 to be abusive. The investigation concluded the facility was unable to substantiate harm, abuse, or neglect related to allegation of verbal abuse. On 11/12/25 at 2:55 PM, the CNO with the CEO present, stated CNA #1 was probably stern when speaking with Resident #1, but it was not yelling. The CNO stated CNA #1 was kind of loud with her voice and others could perceive it as yelling. The CNO was then asked, if another person would talk to her I can't deal with you. Go to your room. You are getting louder and louder. You are doing this for attention on that of tone of voice, like loud voice, how would you feel? The CNO stated she would not appreciate that kind of tone of voice and probably she would file a complaint. 3. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], and 9/15/25 with multiple diagnoses including a broken right and left arm, cognitive communication deficit, muscle weakness, and altered mental status. Resident #3's care plan, initiated on 7/23/25, and revised on 10/14/25, documented she was incontinent with bowel and bladder, and to check and change every two hours. A grievance report dated 10/2/25 at 3:00 PM, documented Resident #3 was left in a stool filled brief all day. Resident #3 had attempted to get a CNA to change her, but the CNA never returned. The facility's response dated 10/3/25 documented a care conference was completed along with multiple conversations with Resident #3, her spouse, and the ombudsman. Facility staff were interviewed, and based on the facility's investigation, Resident #3 was moved to a new room. The facility did not identify why Resident #3 was not changed as she requested. A Care Conference Review, dated 10/14/25, documented Resident #3 had increased sadness and frustration related to the cares provided. The report also documented the Interdisciplinary Team (IDT) addressed nursing concerns and care related issues with Resident #3, [the facility] committed to ongoing staff education and support to resolve matters. It was also documented that Resident #3 had multiple concerns and was moved to a new room. On 11/12/25 at 3:11 PM, the CNO acknowledged the grievance should have been investigated as neglect.

Based on incident and accident (I&A) review, record review, and staff interview it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 2 residents, (Resident #79) whose records were reviewed for falls. This resulted in actual harm to Resident #79. Findings include: The Centers for Medicare and Medicaid Services (CMS) State Operation Manual (SOM), Appendix PP, revised 8/8/24, defined 'Avoidable Accident' as an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Resident #79 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness and abnormalities of gait and mobility. Resident #79's care plan, dated 12/4/24, documented he was assessed to be at risk for falls due to impaired mobility and required extensive assistance with chair to bed transfers. The care plan also directed staff to provide one-person extensive assist with bed mobility and direct supervision while toileting. An I&A report, dated 2/21/25, documented Resident #79 had a fall with injury on 2/16/25 at 12:45 PM and a second fall with injury on 2/16/25 at 5:45 PM. A post fall investigation, dated 2/16/25 at 12:45 PM, documented his first unwitnessed fall occurred while transferring from the toilet to his wheelchair. During that fall he obtained a skin tear measuring 0.4 cm x 0.04 cm. The report also documented Resident #79 verbalized having a 1 out of 10 pain level. Section G of the report documented the removal of Resident #79's wheelchair from within reach as an intervention and cleansing the skin tear. On review of Resident #79's care plan dated 12/4/24, no interventions were implemented to prevent further falls. The I&A report, dated on 2/16/25 at 5:45 PM, documented Resident #79 had a second unwitnessed fall with injury while transferring. During that fall he obtained a laceration to the back of his head. The report did not include the measurements of the laceration. A post fall investigation, dated 2/16/25, documented Resident #79's pain level to be a 10 out of 10 with facial grimacing and yelling inconsolably. The investigation documented the Licensed Nurse observed a rapid decline in his vital signs and called 911 to transfer Resident #79 to the hospital for further evaluation and treatment. The post fall investigation did not include documentation of the severity of Resident #79's injuries after his transfer to the hospital. On 3/19/25 at 3:08 PM, the DON stated the facility failed to train staff to update care plans and implement interventions post falls on the weekends.

Based on observation, CDC recommendation review, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and transmission of infection. Findings include: 1. The facility's Work Practices-Cleaning Policy, updated 1/1/18, documented multiple use resident care, such as resident lifts, items are properly cleaned/disinfected between each resident use. The following issue was observed: -On 3/18/25 at 4:55 PM, CNA #1 and LPN #2 were observed using a resident lift to transfer a resident, afterwards CNA #1 returned the lift to the hallway and was not observed cleaning or disinfecting the lift after use. -On 3/18/25 at 5:00 PM, CNA #1 stated that they are not required to clean or disinfect the lifts between resident use. -On 3/18/25 at 5:20 PM, the Infection Prevention (IP) Nurse and DON both confirmed the resident lifts should be cleaned/disinfected between resident use. 2. The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, documented hand hygiene should be performed: -Immediately before touching a patient. -Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. -Before moving from work on a soiled body site to a clean body site on the same patient. -After touching a patient or patient's surroundings. -After contact with blood, body fluids, or contaminated surfaces. -Immediately after glove removal. The following was observed for hand hygiene and personal protective equipment (PPE): On 3/19/25 at 7:15 AM, LPN #1 was observed entering resident #71's room to administer her medication. No hand hygiene was observed before entering her room and after exiting her room. LPN #1 returned to her medication cart without performing hand hygiene and prepared the next resident's medications. On 3/19/25 at 8:34 AM, Resident #42 was observed to be on droplet transmission precautions for influenza. LPN #1 was observed preparing medications for Resident #42. LPN #1 was not observed performing hand hygiene before or after preparing the medications or before putting on gloves, gown, a second surgical mask, and face shield. LPN #1 was observed entering Resident #42's room and positioned the medication cart in the open doorway with the drawers facing inside the room, then she obtained her vital signs using a vital signs tower. Resident #42 was noted to have a productive cough throughout the observation. LPN #1 was observed administering Resident #42's medications by handing her a cup of her medications and then a cup of water. LPN #1 was observed returning to the medication cart positioned in the doorway, then leaning against the cart allowing the PPE gown to press against the front of the cart while she reached for disinfecting wipes. She was observed using disinfectant wipes on the vital signs tower, then removed her gown and put it in the garbage, removed her face shield and hung it on the outside doorknob, removed her gloves and disposed of them, and washed her hands with soap and water in the sink inside Resident #42's room. LPN #1 was observed pushing the medication cart away from the doorway without disinfecting the surface and left Resident #42's room. She then removed the outer of two surgical masks and disposed of it, then donned a new surgical mask over the one she was already wearing and then used disinfecting wipes to clean a small exposed area on top of the medication cart, but not cleaning the drawer fronts her gown had touched or any of the equipment on top of the medication cart. LPN #1 was not observed to perform hand hygiene and then began preparing medications for another resident. On 3/19/25 at 9:00 AM, LPN #1 confirmed she should have sanitized her hands between residents and stated she did not get any updated guidance on droplet transmission based precautions from the facility. On 3/18/25 at 5:30 PM, the DON stated the facility had not provided staff in-service training specifically dedicated to proper use of PPE for the current influenza outbreak. She further confirmed that she nor her team have performed any official staff observations to ensure quality control for hand hygiene or PPE use.

Based on record review, resident interview, and staff interview, it was determined the facility failed to ensure residents received physical therapy services as ordered by their physician. This was true for 5 of 18 residents (#19, #33, #37, #67, and #182) whose records were reviewed for rehabilitative services. This failure created the potential for all residents who required physical therapy services to experience decline in their physical functioning and ability to perform activities of daily living (ADL's) when these services were not provided consistently. Findings include: 1. Resident #19 was readmitted to the facility on [DATE], for surgical aftercare, and had multiple diagnoses including muscle weakness, and difficulty walking. A physician order, dated 3/4/25, documented Resident #19 was to have physical therapy evaluation and treatment. Resident #19's care plan, dated 1/15/25, documented physical therapy evaluation and treat as ordered. A Physical Therapy Evaluation and Treatment Plan, dated 3/4/25, documented Resident #19 was to have physical therapy 3 times a week for 8 weeks. Resident #19's record documented 2 out of 24 physical therapy sessions were provided with no documentation of resident refusals. 2. Resident #33 was readmitted to the facility on [DATE] with multiple diagnoses including, abnormality of gait and mobility, muscle weakness, and lack of coordination. A physician order, dated 11/14/24, documented Resident #33 was to have a physical therapy evaluation and treatment. Resident #33's care plan, dated 11/4/24, documented physical therapy evaluation and treatment. A Physical Therapy Evaluation and Treatment Plan, dated 11/4/24, documented Resident #33 was to have physical therapy 3 times a week for 8 weeks. Resident #33's record documented 7 out of 24 physical therapy sessions were provided with documentation of three resident refusals. 3. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia, muscle weakness, and contracture of the joint. A physician order, dated 1/24/25, documented Resident #37 was to have a physical therapy evaluation and treatment. Resident #37's care plan, dated 1/24/23, documented physical therapy evaluation and treatment. A Physical Therapy Evaluation and Treatment Plan, dated 1/24/25, documented Resident #37 was to have physical therapy 6 times a week for 4 weeks. Resident #37's record documented 0 out of 24 physical therapy sessions were provided with no documentation of resident refusals. 48402 4. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, abnormalities of gait and mobility, and cognitive communication deficit. On 3/17/25 at 10:06 AM, Resident #67 stated she had not received physical therapy as ordered. A physician order, dated 2/17/25, documented Resident #67 was to have physical therapy evaluation and treatment. Resident #67's care plan, dated 2/17/25, documented physical therapy as ordered. A Physical Therapy Evaluation and Treatment Plan, dated 2/18/25, documented Resident #67 was to have physical therapy 5 times a week for 8 weeks. On review of Resident #67's record 16 out of 20 physical therapy sessions were provided before she discharged . 5. Resident #182 was admitted to the facility on [DATE], with multiple diagnoses including difficulty walking and absence of left leg below the knee. A physician order, dated 2/24/25, documented Resident #182 was to have a physical therapy evaluation and treatment. Resident #182's care plan, dated 2/24/25, documented physical therapy as ordered. A Physical Therapy Evaluation and Treatment Plan, dated 2/25/25, documented Resident #182 was to have Physical Therapy 5 times a week for 8 weeks. On review of Resident #182's record 9 out of 19 physical therapy sessions were provided with no documentation of resident refusal. On 3/20/25 at 8:42 AM, the Physical Therapy Director stated residents were not receiving therapy services according to the therapy evaluations due to insufficient staffing.

Based on record review and staff interview, it was determined the facility failed to ensure a resident's representative was notified when they experienced a change in condition. This was true for 1 of 2 residents (Resident #64) whose records were reviewed for notifications. This failure placed Resident #64 at risk when his family was not able to advocate for his needs. Findings include: Resident #64 was admitted to the facility on [DATE] for care following a traumatic brain injury with multiple diagnoses including a tracheostomy, respirator dependence, and acute respiratory failure. On 1/24/25 at 3:35 PM, a physician verbal order, received by a respiratory therapist, documented, if resident decannulates and [respiratory therapist] cannot get it back in, do not send to the [emergency room ] to have it replaced, may leave trach out. A respiratory therapy note, dated 2/1/25, documented at approximately 11:00 AM, Resident #64 was found to be decannulated and the respiratory therapist (RT) attempted to insert a trach but was unable to do so. The physician was notified and staff continued to monitor Resident #64. On 3/20/25 at 11:54 AM, the DON stated, according to the documentation on 2/1/25, Resident #64's family was not notified when he experienced a change in condition.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS- standardized assessment tool used in nursing facilities to assess residents' health and functional status) assessments included correct information. This was true for 3 of 18 residents (#11, #20, and #44) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #11 was initially admitted to the facility on [DATE], with multiple diagnoses including depression, delusional disorder, and dementia. Resident #11's PASRR Level II dated 12/6/24, documented she had a diagnosis of depression, schizophrenia (mental disorder involving chronic or recurrent psychosis), and dementia. Resident #11's significant change in status MDS assessment, dated 12/12/24, under A1500 in section A, documented, No, for the question, Is the resident currently considered by the state PASRR Level II process to have serious mental illness and/or intellectual disability or a related condition? However, Resident #11's record also showed a PASRR Level II dated 12/6/24, which documented schizophrenia, depression, and dementia diagnoses. 2. Resident #20 was initially admitted to the facility on [DATE] with a diagnosis of schizophrenia, bipolar disorder (a mood disorder), obsessive-compulsive disorder (OCD), and anxiety. Resident #20's admission MDS assessment, dated 10/27/22, under A1500 in section A, documented, No, for the question, Is the resident currently considered by the state PASRR Level II process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II, dated 8/12/22, in her record which documented she had a diagnosis of schizophrenia, OCD, bipolar disorder, and depression. 3. Resident #44 was admitted to the facility on [DATE] with the diagnoses autism, schizophrenia, depression, and anxiety. Resident #44's annual MDS assessment, dated 11/24/24, under A1500 in section A, documented, No, for the question, Is the resident currently considered by the state PASRR Level II process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II, dated 2/28/24, in her record which documented she had a diagnosis of autism, schizophrenia, depression, and anxiety. On 3/19/25 at 3:34 PM, the MDS Coordinator confirmed Resident's #11, #20, and #44's MDS assessments were incorrectly coded indicating the residents did not have a serious mental health illness.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 3 of 18 residents (Resident #60, #64, #182) whose care plans were reviewed. This placed residents at risk for adverse outcomes when care plans were not revised to reflect their updated needs. Findings include: The facility's Care Plan policy, revised on 10/15/22, documented a qualified person would monitor the resident's condition and effectiveness of the care plan interventions and revise the care plan quarterly, annually, and with a significant change in condition. 1. Resident #60 was readmitted to the facility on [DATE], with multiple diagnoses including congestive heart failure and chest pain. A hospital discharge summary, dated 3/13/25, documented Resident #60 was seen for an exacerbation for acute congestive heart failure. Resident # 60's Care Plan, dated 11/9/24, did not include revision or implementation of new interventions related to his congestive heart failure. On 3/19/25 at 11:46 AM, on review of Resident #60's records, the Director of Nursing (DON) stated the facility had room for improvement with care planning. 2. Resident #182 was admitted to the facility on [DATE], with multiple diagnoses including nicotine dependency. A smoking evaluation, dated 2/24/25, documented Resident #182 was able to smoke independently. On review of resident #182's care plan, initiated 2/24/25, no documentation was located related to his smoking needs. On 3/19/25 at 6:00 PM, the DON stated, Resident #182's care plan did not reflect his current smoking status. 48401 3. Resident #64 was admitted to the facility on [DATE], following a traumatic brain injury with multiple diagnoses including a tracheostomy (surgically created opening in the windpipe that provides an alternative airway for breathing), respirator dependence, and acute respiratory failure. On 1/24/25 at 3:35 PM, a physician verbal order, received by a respiratory therapist, documented, if resident decannulates and [respiratory therapist] cannot get it back in, do not send to the [emergency room ] to have it replaced, may leave trach out. A respiratory therapy note, dated 2/1/25, documented at approximately 11:00 AM, Resident #64 was found to be decannulated and the respiratory therapist (RT) attempted to insert a trach but was unable to do so. The physician was notified and staff continued to monitor Resident #64. Resident #64's care plan, revised on 3/16/25, documented the following: [Resident #64] has a Tracheostomy and potential for: Alteration in respiratory status and high risk for accidental self decannulation related to: thickened, dried secretions or mucous plugs, inability to protect airway need for tracheostomy, prior history of self-decannulation, confusion/agitation. On 3/20/25 at 11:28 AM, the Staff Development Coordinator Nurse (SDC) stated Resident #64 was decannulated on 2/1/25, and the care plan should have been updated to reflect that his tracheostomy had been removed.

Based on record review and staff interview, it was determined the facility failed to ensure bathing was provided to residents who required assistance. This was true for 1 of 6 residents, (Resident #60) whose records were reviewed for bathing. This failure had the potential for embarrassment and compromised skin integrity due to lack of hygiene. Findings include: Resident #60 was admitted on [DATE], with multiple diagnoses including generalized muscle weakness, difficulty walking, and need for assistance with personal care. The facility's shower schedule, undated, documented Resident #60 was scheduled to receive a shower on Wednesday and Saturday evenings. Resident #60's care plan, revised on 11/4/24, documented he required assistance with bathing. The care plan also documented if he refused to bathe, the licensed nurse should be notified. Resident #60's bathing record from February-March 2025 was reviewed documenting the following: -2/1/25-2/16/25, no documentation a shower was offered or refused -2/17/25, a shower was refused -2/18/25-2/19/25, no documentation a shower was offered or refused -2/20/25, a shower was refused -2/21/25-3/6/25, no documentation a shower was offered or refused -3/7/25, he received a shower -3/8/25-3/16/25, no documentation a shower was offered or refused -3/17/24, he received a shower A request of documentation for bathing refusals was made and not provided. On 3/19/25 at 4:24 PM, the DON stated Resident #60 did not receive his shower opportunities as scheduled.

Based on record review and staff interview, it was determined the facility failed to ensure quality care was provided to 1 of 18 residents whose bowel records were reviewed. This was true for Resident #49 when his physician orders were not followed placing him at increased risk for harm. Findings include: Resident #49 was admitted on [DATE] with multiple diagnoses including quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function), respirator dependence, and a personal history of constipation and gastrointestinal hemorrhage. Resident #49's record documented the following physician orders, dated 5/21/24: -Milk of Magnesia (MOM) Suspension 1200 MG/15 ML, Give 30 ML orally as needed for no bowel movement (BM) for two (2) days. Give 1 dose. 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 Dulcolax suppository. Complete bowel assessment and notify physician if no results. Resident #49's bowel movement records and medication administration records (MAR) for February-March 2025 were reviewed and documented the following: -A BM on Sunday 2/9/25 with the next recorded BM on Friday 2/14/25, no as needed medications were administered. -A BM on Saturday 2/15/25 with the next recorded BM on Friday 2/21/25, no as needed medications were administered. -A BM on Saturday 2/22/25 with the next recorded BM on Wednesday 2/26/25, no as needed medications were administered. -A BM on Friday 2/28/25 with the next recorded BM on Tuesday 3/4/25, no as needed medications were administered. -A BM on Tuesday 3/4/25 with the next recorded BM on Monday 3/10/25, no as needed medications were administered. -A BM on Tuesday 3/12/25 with the next recorded BM on Tuesday 3/18/25, no as needed medications were administered. On 3/19/25 at 5:48 PM, the DON stated Resident #49 did not receive BM medications as ordered and could not explain why they failed to be administered.

Based on observation, resident interview, staff interview, and record review, it was determined the facility failed to ensure residents are free from pain. This was true for 1 of 2 residents, (Resident #60) whose records were reviewed for pain management. This failure placed Resident #60 at risk of psychosocial harm and functional decline related to unrelieved pain, and not being offered effective pain management. Findings include: Resident #60 was readmitted to the facility on [DATE], after a short hospital stay, with multiple diagnoses including malignant neoplasm of the stomach (stomach cancer) and cognitive communication deficit. On 3/17/25 at 8:18 AM, Resident #60 was observed lying on his bed with no sheets on his right-side verbalizing 9 out of 10 abdominal pain and guarding his abdomen. When asked, Resident #60 stated he had already asked for pain medication. On 3/17/25 at 8:20 AM, LPN #3 entered the room and asked Resident #60 how he was feeling. Resident #60 verbalized having 8 out of 10 abdominal pain. She acknowledged his pain and left the room without conducting an assessment. On 3/17/25 at 2:20 PM, Resident #60 was observed in bed guarding his abdomen and stated he still had an 8 out of 10 pain. He also stated no one had provided pain management interventions or pharmacological interventions. When asked to describe his pain he stated I can't describe it. It just hurts and no one has given me anything. On 3/17/25 at 2:30 PM, Resident #60 was observed requesting pain medication. On 3/17/25 at 2:39 PM, LPN #2 entered the room with pain medication and administered it to Resident #60. On 3/17/25 at 2:57 PM, When asked if resident had received any non-pharmacological or pharmacological interventions to manage his pain since the morning request for medication at 9:18 AM, LPN #3 stated, I don't believe so, but I did notify the provider. A physician order, dated 3/13/24, documented Hydrocodone-Acetaminophen oral tablet 7.5-325 MG, give 1 tablet by mouth every 8 hours as needed for pain. Non-pharmacological interventions should be attempted prior to medication administration. On review of Resident #60's record, 9 out of 11 pain evaluations documented a pain level of 7 or higher. On 3/19/25 at 3:57 PM, the DON stated Resident #60 used to have a scheduled pain medication, but the order was not reinstated when he returned from the hospital.

Based on record review and staff interview, it was determined the facility failed to ensure a registered nurse (RN) was on-site for 8 consecutive hours a day, 7 days a week, to provide care to the residents. This was true for 2 of 21 days reviewed for sufficient staffing. This failure placed all residents at risk for harm if their routine and/or emergency needs could not be met without the care of a registered nurse. Findings include: The nursing staff hours worked were reviewed from 2/23/25-3/15/25. This review documented the facility did not provide 8 consecutive hours of registered nurse coverage on 2/24/25 and 3/3/25. On 3/20/25 at 1:22 PM, the Administrator confirmed those two dates did not have an RN on-site for 8 consecutive hours.

Based on observation, record review, and staff interview it was determined the facility failed to ensure nurse staffing data was completed accurately, posted daily, and the records were maintained for a minimum of 18 months. This failed practice had the potential to affect the 76 residents residing in the facility, their representatives, and any visitors who would like to review staffing data and census information. Findings include: The facility's daily nurse staffing data posting records were reviewed for 10/1/24-3/20/25 and documented the following: Missing dates: October 2024: 9, 12, 13, 19, 20, 26, 27 November 2024: 2. 3. 9, 10, 16, 17, 23, 24, 30 December 2024: 1, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31 January 2025 : 1, 5, 11, 12, 18, 19, 25, 26 February 2025: 1, 2, 8, 9, 15, 16, 22, 23, 27 March 2025: 1, 2, 8, 9, 15 Incomplete data: October: 4, 17 December: 24 January: 2, 3, 4, 20, 21 February: 6, 7, 13, 14, 18 On 3/16/25 at 12:45 PM, the facility's daily nurse staffing data posting was observed. The data posting was dated 3/14/25. On 3/20/25 at 1:08 PM, the Administrator stated he was unsure why the nurse staffing data was not completed accurately and was not posted and retained as required.

Based on observation, policy review, United States Food and Drug Administration (FDA) food code review, and staff interview, it was determined the facility failed to ensure sanitation of nutrition rooms and equipment. This failure had the potential to affect all residents who consumed food or ice from the nutrition rooms and increased the risk for transmission of food born illnesses. Findings include: The facility's Sanitizing Stationary Food Service Equipment and Food Contact Surfaces policy, dated 1/1/18, documented the facility will provide proper cleaning and sanitation of food service equipment to minimize the growth of microorganisms that may result in food contamination. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils, documented: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned: (4) In equipment such as ice bins and beverages, dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverages and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. On 3/20/25 at 2:50 PM, during a nutrition room inspection 1 out of 2 ice bins were observed to have a thick, slimy layer with different shades of pink surrounding the ice dispensing tray. Also observed were plastic containers of food with no indication of use by date and thickened cocktail cranberry juice with no indication of when it was open or when it should be disposed. On 3/20/25 at 2:55 PM, the Dietary Manager stated the ice bin in the nutrition room was not in sanitary conditions and he was unsure who was responsible for cleaning it. He also stated the food items in the refrigerator were unclear when they were opened or when they should be disposed.

Based on observation, policy review, resident interview, food test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This was true for 4 of 4 residents (#1, #9, #19 and #35) reviewed for food concerns, and had the potential to affect all residents in the facility who ate food from the kitchen. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The facility's policy for Food: Quality and Palatability, dated 9/2017, documented: * Food was prepared by methods that conserve nutritive value, flavor, and appearance. * Food was palatable, attractive, and served at a safe and appetizing temperature. * Food and liquids/beverages were prepared in a manner, form, and texture that met the needs of the residents. The facility's policy for Food Preparation, dated 11/28/17, documented food was prepared by methods that conserve nutritive value, flavor and appearance. The documented procedures included: * Food was stored, prepared, and held by methods that preserved the nutritive value of the food to the extent possible. * Food was prepared according to standardized, yield adjusted recipes by trained staff to produce a palatable and attractive meal. * Food temperatures were kept at the appropriate levels to maintain flavor and palatability. These policies were not followed. On 1/22/20 at 10:37 AM, during the Resident Group interview, Resident #4 said yuck when asked about the food. Resident #4 said the facility served too much starch, bread, and noodles, the food was not always hot, and the facility needed to redo their menus and get some new stuff on there. Resident #9 said the facility served cold eggs and rotten milk, and the residents needed more fresh fruit. Residents were interviewed individually regarding the food served at the facility, and they responded as follows: * On 1/21/20 at 3:41 PM, Resident #9 said the food was usually cold. * On 1/22/20 at 1:11 PM, Resident #35 said the food was often not hot. * On 1/22/20 at 1:49 PM, Resident #1 said he did not like the food, he would not serve it to my cat, and it did not taste good. * On 1/22/20 at 2:51 PM, Resident #19 said she did not like the food and the flavor was bad. On 1/23/20 at 12:44 PM, a test tray was evaluated during the lunch meal at the end of the 400 hall, which was the farthest from the kitchen. Dietary Supervisor #2 (DS #2) took the meal tray out of the insulated food cart, and it was evaluated by two surveyors along with DS #2. The meal included sweet potatoes which had a temperature of 128 degrees F (Fahrenheit), the chicken was 133 degrees F, brussel sprouts were 113 degrees F, and a glass of red juice was 50 degrees F. DS #2 said the sweet potatoes tasted good and could be warmer; the brussel sprouts could use some butter or salt and could be hotter; and the chicken was good, but it had cooled down and could use more seasoning. A surveyor said the brussel sprouts were overcooked and had lost their bright green color, and DS #2 agreed. DS #2 said the cake was good and it could use a little more powdered sugar. DS #2 said perhaps the facility should switch to 2 carts for 300 and 400 halls instead of 1 cart for both. The facility did not ensure food served to the residents was palatable in regards to temperature and flavors.

Based on record review, review of medication error reports, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This affected 1 of 5 residents (Resident #24) reviewed for medication administration. Resident #24 was harmed when she received another resident's medication, including an antipsychotic medication and insulin, and required interventions throughout the night to mitigate the risks of a high risk medication and was transported to the hospital for further evaluation. Findings include: According to the manufacturer website, accessed on 7/24/19, [MEDICATION NAME] is a long-acting insulin used to treat adults with type 2 diabetes to control high blood sugar in which the effect starts in 1 to 2 hours and peaks in 6 hours. The website stated the most common side effects are low blood sugar which can be serious and life threatening. Other side effects include trouble breathing, a fast hearbeat, sweating, and extreme drowsiness or confusion. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, completed on 5/5/19, documented Resident #24's cognition was severely impaired, she was dependent for care, and had communication problems. There was no documentation in the MDS assessment to indicate Resident #24 required insulin injections. A progress note, dated 2/12/19 at 10:17 PM, documented Resident #24 received medication in error by the evening shift nurse and the physician was notified. The physician gave orders to monitor Resident #24's status in the facility. The note documented the medications Resident #24 received in error were [MEDICATION NAME] 12.5 mg (an antipsychotic medication), [MEDICATION NAME] 20 mg (to treat high cholesterol) and [MEDICATION NAME] 13 units. The physician returned the call on 2/12/19 at 10:48 PM and instructed staff to monitor Resident #24's medical status in the facility. The physician gave orders to provide nutrition of Resident #24's preference, as tolerated, to keep her blood glucose (sugar) within normal limits. The physician also gave orders to implement the facility's hypoglycemic (low blood glucose) protocol if needed, check Resident #24's blood glucose hourly, monitor her neurological status and vital signs, and to monitor her for any side effects of the medications given in error. A late progress note documented at 6:20 AM on 2/13/19, for 2/12/19 10:00 PM, documented Resident #24 was assessed at baseline on 2/12/19 at 10:00 PM, and was being fed a strawberry nutritional drink and strawberry yogurt. Her blood glucose reading was within the normal range at 114 mg/dl (milligrams per deciliter). A progress note, dated 2/13/19 at 3:00 AM, documented Resident #24's status was unchanged and she continued to receive nutritional drinks and yogurt. A progress note, dated 2/13/19 at 5:20 AM, documented when the nurse entered Resident #24's room to check her blood glucose level Resident #24 had vomited a large amount of liquid on her chest and left shoulder, the head of her bed was in the high position, and her lungs had rhonchi (rattling lung sounds) throughout both upper lobes. Resident #24's temperature was 100.4 degrees Fahrenheit and her pulse was irregular at 118 per minute (normal resting heart rate for adults ranges from 60 to 100 beats per minute). Resident #24's respiration was high at 24 breaths per minute (normal for an adult at rest is 12 to 20 breaths per minute). Resident #24's oxygen blood saturation level was low at 76% on room air (normal readings range from 95 to 100 percent and below 90% is considered low) and oxygen was applied at 2 liters per minute. The note documented a Physician Assistant was notified and orders were received for a stat (immediate) chest x-ray. The note documented Resident #24's daughter was contacted and requested she be transferred to the hospital. 911 was called and Resident #24 was transferred to the hospital via ambulance on 2/13/19 at 6:10 AM. The assessment did not include documentation of Resident #24's blood glucose level. Resident #24 was discharged from the hospital on [DATE] and admitted back to the facility. The facility's medication incident report for Resident #24, initiated on 2/12/19 and and completed on 3/1/19, documented the medication error was related to Resident #24 being moved to a different room and the the name of the resident who previously occupied the room, remained on the outside of the door. The nurse administered the previous resident's medication to Resident #24. The facility did have a picture of each resident on the MAR for reference to prevent medication errors. On 7/10/19 at 1:11 PM, the CNO stated she was not employed at the facility when the medication error occurred. She said the facility tracked medication errors in its Quality Assurance program.

Based on staff interview and record review, it was determined the facility failed to ensure the physician was notified timely of a residents' low BG levels and of falls that resulted in head injury. This was true for 1 of 8 residents (Resident #10) whose records were reviewed. Resident #10 was harmed when she experienced a cognitive decline after experiencing multiple unwitnessed falls and multiple low BG levels and the physician was not notified and/or not notified timely. This failed practice harmed Resident #10 when the resident experienced a decline in condition and the physician was not notified in order for the physician to make treatment/care decisions. Findings include: The facility's Resident Change of Condition policy and procedure, dated 11/28/17, documented when the staff recognize a significant change in status the nurse should communicate with the physician to meet the residents' needs. The policy documented the facility was to immediately inform the resident, confer with the physician, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. The policy defined a change of condition to include deteriorating mobility, falls, and behavior changes. Resident #10 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Mental Health Progress Note, dated 10/2/18, documented Resident #10's thought process was intact, and her associations were logical. The note documented she had normal thought content and no hallucinations. The note documented she was oriented to situation, place, and person and her memory was intact. A quarterly MDS assessment, dated 10/18/18, documented Resident #10 was cognitively intact and required supervision while walking in her room or the corridor. The MDS assessment documented Resident #10 required extensive assistance of one staff member with bed mobility, transfers, toileting, and locomotion on and off the unit. The MDS documented Resident #10 experienced one fall without injury since the prior assessment. Resident #10's (MONTH) (YEAR) recapitulated physician's orders [REDACTED]. - Monitor BGs twice daily and notify the physician if BG was less than 60 or greater than 500 mg/dl, ordered 6/14/18. - [MEDICATION NAME] (Insulin [MEDICATION NAME]) 12 units subcutaneously at lunch and dinner for diabetes, ordered 6/14/18. - Tresiba (Insulin Degludec) 50 units subcutaneously in the morning for diabetes, ordered 7/25/18 and discontinued 12/4/18. - Tresiba (Insulin Degludec) 45 units subcutaneously at bedtime for diabetes, ordered 7/25/18, and discontinued 12/4/18. - Tresiba (Insulin Degludec) 45 units subcutaneously in the morning for diabetes, ordered 12/4/18. - Tresiba (Insulin Degludec) 40 units subcutaneously at bedtime for diabetes, ordered 12/4/18. a. Resident #10's 11/1/18 through 12/13/18 MAR, documented she had 4 BG levels less than 60 mg/dl. A physician order [REDACTED]. The notification documented she was provided glucose gel and her BG level raised to 81 mg/dl. The notification documented she had a low oral intake at dinner and her pre-dinner BG level was 129 mg/dl. Resident #10 was provided her evening doses of [MEDICATION NAME] and Tresiba when her BG was 44 mg/dl. The notification documented Resident #10's morning BG levels were normally below 100 mg/dl with an HS snack provided. The request asked the physician review her BG levels and consider reducing her [MEDICATION NAME] and Tresiba. The request was documented as faxed to the physician on 11/7/18, time not noted. The physician did not respond to the request. The physician reviewed the low BG level and her insulin was adjusted on 12/4/18 (28 days) after the request. b. Resident #10's clinical record documented she experienced six falls between 11/11/18 and 12/4/18, and the physician was not notified of falls and/ or not notified timely when she had a change in cognition. Examples include: i. Resident #10's clinical record included a Post Fall Investigation report, dated 11/29/18. It documented she experienced a fall on 11/11/18. Resident #10's clinical record did not contain documentation the physician was notified of the fall on 11/11/18. ii. An I&A Report, dated 11/12/18 at 7:40 PM, documented Resident #10 experienced an unwitnessed fall in her room tripping over the legs of her front wheeled walker. The I&A documented she hit her head on the floor. A physician order [REDACTED].#10 had an unwitnessed fall in her room and she stated she fell on her back and hit her head. The notification documented she had no hematoma noted and neurological assessments were started. The request was faxed on 11/12/18, untimed. The physician responded and signed the request on 11/27/18, 15 days later. iii. An I&A Report, dated 11/13/18 at 11:50 PM, documented Resident #10 experienced an unwitnessed fall from bed. She was found kneeling next to her bed and denied hitting her head. The I&A documented she had a 5 cm by 3 cm bruise on the pad of her left hand near her thumb. The I&A documented she was able to remember her full name and date of birth but was unable to remember her location. The I&A documented she was attempting to go to the bathroom and she got dizzy and fell to the floor. A physician order [REDACTED].#10 was found on the floor kneeling by her bed, by an aide . The notification documented Resident #10 denied hitting her head and she had injured her hand. The notification documented neurological assessments were started per protocol. The request was faxed on 11/14/18 at 9:05 AM. The physician responded to the request on 11/27/18, 14 days later. The physician responded with an order for [REDACTED].>iv. Resident #10's clinical record documented she experienced a fall on 11/14/18 in a Progress Note, dated 11/16/18 at 2:55 AM and on a Post Fall Investigation report, dated 11/19/18. Resident #10's clinical record did not contain documentation the physician was notified of the fall on 11/14/18. v. An I&A Report, dated 11/19/18 at 10:20 AM, documented Resident #10 experienced an unwitnessed fall from her chair in her room. She was found lying on her stomach with her head on her arms. The I&A documented Resident #10 was trying to find her apartment and fell out of her chair. A physician order [REDACTED].#10 experienced an unwitnessed fall and was found on the floor lying face down. The request documented Resident #10 had increased confusion, and lethargy, and she was not requesting assistance. The request documented the nursing staff asked the provider see Resident #10 due to her recent falls on 11/13, 11/14, and 11/19. The request did not include a date of when the notification was faxed to the provider. The physician did not respond to the request. A Progress Note, dated 11/20/18 at 5:20 AM, documented Resident #10 was confused and was yelling out 'help me.' The progress note documented she had weakness and needed verbal reminders to use her walker, and her gait was unsteady at this time. The note documented she complained of pain to the back left-side of her head from when she fell . The note documented Resident #10 verbalized she was having trouble saying, what she wanted to say, and she had slow thought processes. Resident #10 complained of head pain on 11/20/18 and neurological assessments were not completed for another 28 hours after she complained of the head pain. The Progress Notes, dated 11/21/18 at 3:00 AM, 10:40 AM, and 9:52 PM, documented Resident #10 was alert to herself with confusion and she was having increased confusion over the past week, and difficulty expressing her words. One of the notes documented she was afraid of her call light and was asking where the small boy was. A Progress Note, dated 11/22/18, documented Resident #10 was alert to herself with confusion. A Progress Note, dated 11/23/18, documented Resident #10 was alert to herself with confusion. The note documented she called out several times and when staff asked her what she needed, she had a hard time saying what she needed. A Progress Note, dated 11/27/18 at 6:59 AM, documented Resident #10 frequently calling out. The note documented she was more confused over the past few weeks resulting in falls. The note documented her mental health provider noticed an overall decline in Resident #10's cognition. The note documented Resident #10 required more time to complete sentences and experienced an increased difficulty completing sentences. A Progress Note, dated 12/3/18, documented Resident #10 was confused and stated she did not want a snack because she was late for her airplane. vi. A Progress Note, dated 12/4/18 at 11:35 PM, documented during Residents #10's HS medication pass she was assisted to the bathroom and had to be lowered to the floor. The note documented she had lower leg weakness and she was assessed following the assisted fall. The note documented Resident #10's vital signs were WNL except for her BG which was 53 mg/dl. A physician order [REDACTED].#10 experienced an assisted fall when she was in the bathroom. The notification documented her legs were weak and they gave out on her. The request documented the nursing staff assessed her BG level and it was 53 mg/dl. The provider did not respond to the request. A Progress Note, dated 12/5/18, documented Resident #10 was making inconsistent statements to staff and had a cognitive decline over the past two weeks. The note documented Resident #10 was not herself, and experienced periods of restlessness where staff was unable to redirect her and/or she was sleeping more. On 12/14/18 at 10:55 AM, the DNS with the Administrator present, stated when a resident fell the staff was to complete an incident report and initiate neurological assessments if the fall was unwitnessed, and if the resident hit their head or suspected a head injury. The DNS stated when Resident #10 complained of head pain on 11/20/18, and had slow thought processes, the staff should have notified the physician. Resident #10 experienced a decline in her cognitive and physical ability between 10/2/18 and 12/14/18. The facility failed to notify the physician in a manner and time in which he could respond to the change in the resident's condition.

Based on staff interview and record review, it was determined the facility failed to ensure the physician was notified timely of a residents' low BG levels and of falls that resulted in head injury. This was true for 1 of 8 residents (Resident #10) whose records were reviewed. Resident #10 was harmed when she experienced a cognitive decline after experiencing multiple unwitnessed falls and multiple low BG levels and the physician was not notified and/or not notified timely. This failed practice harmed Resident #10 when the resident experienced a decline in condition and the physician was not notified in order for the physician to make treatment/care decisions. Findings include: The facility's Resident Change of Condition policy and procedure, dated 11/28/17, documented when the staff recognize a significant change in status the nurse should communicate with the physician to meet the residents' needs. The policy documented the facility was to immediately inform the resident, confer with the physician, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. The policy defined a change of condition to include deteriorating mobility, falls, and behavior changes. Resident #10 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Mental Health Progress Note, dated 10/2/18, documented Resident #10's thought process was intact, and her associations were logical. The note documented she had normal thought content and no hallucinations. The note documented she was oriented to situation, place, and person and her memory was intact. A quarterly MDS assessment, dated 10/18/18, documented Resident #10 was cognitively intact and required supervision while walking in her room or the corridor. The MDS assessment documented Resident #10 required extensive assistance of one staff member with bed mobility, transfers, toileting, and locomotion on and off the unit. The MDS documented Resident #10 experienced one fall without injury since the prior assessment. Resident #10's (MONTH) (YEAR) recapitulated physician's orders [REDACTED]. - Monitor BGs twice daily and notify the physician if BG was less than 60 or greater than 500 mg/dl, ordered 6/14/18. - [MEDICATION NAME] (Insulin [MEDICATION NAME]) 12 units subcutaneously at lunch and dinner for diabetes, ordered 6/14/18. - Tresiba (Insulin Degludec) 50 units subcutaneously in the morning for diabetes, ordered 7/25/18 and discontinued 12/4/18. - Tresiba (Insulin Degludec) 45 units subcutaneously at bedtime for diabetes, ordered 7/25/18, and discontinued 12/4/18. - Tresiba (Insulin Degludec) 45 units subcutaneously in the morning for diabetes, ordered 12/4/18. - Tresiba (Insulin Degludec) 40 units subcutaneously at bedtime for diabetes, ordered 12/4/18. a. Resident #10's 11/1/18 through 12/13/18 MAR, documented she had 4 BG levels less than 60 mg/dl. A physician order [REDACTED]. The notification documented she was provided glucose gel and her BG level raised to 81 mg/dl. The notification documented she had a low oral intake at dinner and her pre-dinner BG level was 129 mg/dl. Resident #10 was provided her evening doses of [MEDICATION NAME] and Tresiba when her BG was 44 mg/dl. The notification documented Resident #10's morning BG levels were normally below 100 mg/dl with an HS snack provided. The request asked the physician review her BG levels and consider reducing her [MEDICATION NAME] and Tresiba. The request was documented as faxed to the physician on 11/7/18, time not noted. The physician did not respond to the request. The physician reviewed the low BG level and her insulin was adjusted on 12/4/18 (28 days) after the request. b. Resident #10's clinical record documented she experienced six falls between 11/11/18 and 12/4/18, and the physician was not notified of falls and/ or not notified timely when she had a change in cognition. Examples include: i. Resident #10's clinical record included a Post Fall Investigation report, dated 11/29/18. It documented she experienced a fall on 11/11/18. Resident #10's clinical record did not contain documentation the physician was notified of the fall on 11/11/18. ii. An I&A Report, dated 11/12/18 at 7:40 PM, documented Resident #10 experienced an unwitnessed fall in her room tripping over the legs of her front wheeled walker. The I&A documented she hit her head on the floor. A physician order [REDACTED].#10 had an unwitnessed fall in her room and she stated she fell on her back and hit her head. The notification documented she had no hematoma noted and neurological assessments were started. The request was faxed on 11/12/18, untimed. The physician responded and signed the request on 11/27/18, 15 days later. iii. An I&A Report, dated 11/13/18 at 11:50 PM, documented Resident #10 experienced an unwitnessed fall from bed. She was found kneeling next to her bed and denied hitting her head. The I&A documented she had a 5 cm by 3 cm bruise on the pad of her left hand near her thumb. The I&A documented she was able to remember her full name and date of birth but was unable to remember her location. The I&A documented she was attempting to go to the bathroom and she got dizzy and fell to the floor. A physician order [REDACTED].#10 was found on the floor kneeling by her bed, by an aide . The notification documented Resident #10 denied hitting her head and she had injured her hand. The notification documented neurological assessments were started per protocol. The request was faxed on 11/14/18 at 9:05 AM. The physician responded to the request on 11/27/18, 14 days later. The physician responded with an order for [REDACTED].>iv. Resident #10's clinical record documented she experienced a fall on 11/14/18 in a Progress Note, dated 11/16/18 at 2:55 AM and on a Post Fall Investigation report, dated 11/19/18. Resident #10's clinical record did not contain documentation the physician was notified of the fall on 11/14/18. v. An I&A Report, dated 11/19/18 at 10:20 AM, documented Resident #10 experienced an unwitnessed fall from her chair in her room. She was found lying on her stomach with her head on her arms. The I&A documented Resident #10 was trying to find her apartment and fell out of her chair. A physician order [REDACTED].#10 experienced an unwitnessed fall and was found on the floor lying face down. The request documented Resident #10 had increased confusion, and lethargy, and she was not requesting assistance. The request documented the nursing staff asked the provider see Resident #10 due to her recent falls on 11/13, 11/14, and 11/19. The request did not include a date of when the notification was faxed to the provider. The physician did not respond to the request. A Progress Note, dated 11/20/18 at 5:20 AM, documented Resident #10 was confused and was yelling out 'help me.' The progress note documented she had weakness and needed verbal reminders to use her walker, and her gait was unsteady at this time. The note documented she complained of pain to the back left-side of her head from when she fell . The note documented Resident #10 verbalized she was having trouble saying, what she wanted to say, and she had slow thought processes. Resident #10 complained of head pain on 11/20/18 and neurological assessments were not completed for another 28 hours after she complained of the head pain. The Progress Notes, dated 11/21/18 at 3:00 AM, 10:40 AM, and 9:52 PM, documented Resident #10 was alert to herself with confusion and she was having increased confusion over the past week, and difficulty expressing her words. One of the notes documented she was afraid of her call light and was asking where the small boy was. A Progress Note, dated 11/22/18, documented Resident #10 was alert to herself with confusion. A Progress Note, dated 11/23/18, documented Resident #10 was alert to herself with confusion. The note documented she called out several times and when staff asked her what she needed, she had a hard time saying what she needed. A Progress Note, dated 11/27/18 at 6:59 AM, documented Resident #10 frequently calling out. The note documented she was more confused over the past few weeks resulting in falls. The note documented her mental health provider noticed an overall decline in Resident #10's cognition. The note documented Resident #10 required more time to complete sentences and experienced an increased difficulty completing sentences. A Progress Note, dated 12/3/18, documented Resident #10 was confused and stated she did not want a snack because she was late for her airplane. vi. A Progress Note, dated 12/4/18 at 11:35 PM, documented during Residents #10's HS medication pass she was assisted to the bathroom and had to be lowered to the floor. The note documented she had lower leg weakness and she was assessed following the assisted fall. The note documented Resident #10's vital signs were WNL except for her BG which was 53 mg/dl. A physician order [REDACTED].#10 experienced an assisted fall when she was in the bathroom. The notification documented her legs were weak and they gave out on her. The request documented the nursing staff assessed her BG level and it was 53 mg/dl. The provider did not respond to the request. A Progress Note, dated 12/5/18, documented Resident #10 was making inconsistent statements to staff and had a cognitive decline over the past two weeks. The note documented Resident #10 was not herself, and experienced periods of restlessness where staff was unable to redirect her and/or she was sleeping more. On 12/14/18 at 10:55 AM, the DNS with the Administrator present, stated when a resident fell the staff was to complete an incident report and initiate neurological assessments if the fall was unwitnessed, and if the resident hit their head or suspected a head injury. The DNS stated when Resident #10 complained of head pain on 11/20/18, and had slow thought processes, the staff should have notified the physician. Resident #10 experienced a decline in her cognitive and physical ability between 10/2/18 and 12/14/18. The facility failed to notify the physician in a manner and time in which he could respond to the change in the resident's condition.

Based on observation, staff interview, resident and family interview, review of facility policies, record review, and review of facility incident reports, it was determined the facility failed to prevent the development and worsening of pressure ulcers. This was true for 2 of 5 residents (#1 and #24) reviewed for pressure ulcers. These failures resulted in harm when Resident #24 developed a blister on her heel that deteriorated and became an unstageable pressure ulcer and when Resident #1 developed a pressure ulcer on her coccyx. Findings include: The facility's policy Prevention and treatment of [REDACTED]. * Residents at risk for developing pressure ulcers were identified using the Braden Scale (an assessment tool widely adopted to assess a person's risk for development of a pressure ulcer). * Pressure ulcer and other wound/skin interventions were created in cooperation with the interdisciplinary team and were implemented to identify, avoid, or decrease the risk of pressure ulcers. * Based on the resident's assessment, clinical status, preferences and needs, routine care may include but is not limited to: redistributing pressure (e.g. repositioning, protecting/offloading heels), minimizing contact with moisture, providing appropriate pressure-redistributing surfaces that are non-irritating, and maintaining/improving nutrition and hydration. * New or existing pressure ulcers and non-pressure related wounds were treated according to the principles of wound healing. * The interdisciplinary team and resident/family cooperated to create goals and interventions to improve wound healing and/or prevent further skin breakdown. 1. Resident #24 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Weekly Skin Integrity Review, dated 7/26/18, documented Resident #24's skin was intact. Resident #24's Braden Scale for Predicting Pressure Sore Risk, dated 7/30/18 at 9:00 AM, documented Resident #24 was at moderate risk for pressure ulcers. Resident #24's admission MDS assessment, dated 8/2/18, documented the following: * Moderate cognitive impairment. * Extensive assistance of 2 persons required for bed mobility and dressing. * Extensive assistance of 1 person with transfers and personal hygiene. * A wheelchair was in use. * Risk for developing pressure ulcers. * One unhealed Stage I pressure ulcer. * Pressure reducing device for chair and bed. According to the Hopkins Medicine website, accessed 10/2/18, pressure ulcers are classified by stages as defined by the National Pressure Ulcer Advisory Panel. A Stage I pressure ulcer is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Resident #24's (MONTH) (YEAR) physician orders, dated 8/8/18, included Opti-foam (a type of dressing) to the right heel every day, a wound nurse consult, and Prevalon boots (pressure reducing) to be in place when in bed every shift. A Physician order [REDACTED].#24's physician. The form documented Resident #24 had a 7 cm by 3 cm bruised, non-blanchable blister on the bottom of her right heel. An order was requested for Skin Prep (a protective film or barrier) to be applied to both heels every day, and application of Opti-foam to the right heel each day. The request also included Prevalon boots for Resident #24 and a wound nurse consult. A Nurse Practitioner signed the document on 8/8/18 at 5:52 PM. Resident #24's current care plan documented the following: * A new skin event of Stage II right heel pressure ulcer on 8/8/18. A Stage II pressure ulcer, defined by the Hopkins Medicine website accessed on 10/2/18, is partial thickness loss of the skin presenting as a shallow open ulcer with a red/pink wound bed, without dead tissue, or may present as a blister. * Pressure reduction in place to bed and chair, initiated on 8/8/18. * Follow facility protocol for wound care, initiated on 8/8/18. * Treatment per physician's orders [REDACTED]. * Notify charge nurse of skin impairment, initiated on 8/8/18. * Heel boots on when up in chair, initiated on 8/27/18. * Heel lift when in bed, initiated on 8/27/18. * Refer to wound nurse as needed, initiated on 8/27/18. An Incident Report, dated 8/8/18, documented a 7 cm by 3 cm bruised, non-blanchable blister on Resident #24's right heel was reported by the CNA to the nurse. Skin Prep and an Opti-foam dressing were applied, and a fax was sent to the physician. Resident #24's record included Weekly Pressure Ulcer BWAT Reports. The weekly reports included inconsistent documentation of the Stage II pressure ulcer identified on Resident #24's right heel. The reports also documented how the ulcer worsened from a Stage II to an Unstageable pressure ulcer during a 30 day period from 8/8/18 to 9/7/18. Examples include: - On 8/8/18 at 10:59 AM, the report documented the Stage II pressure ulcer on the right heel measured 7 cm by 3 cm. A foam dressing was in place and the right heel was elevated off the bed. - On 8/16/18 at 11:25 AM, the report documented the Stage II pressure ulcer on the right heel measured 0.5 cm by 0.5 cm. The nurse documented the wound appeared unchanged and daily dressing changes continued. The wound size had changed and decreased by 6.5 cm and 2.5 cm from the previous measurements, 8 days before. - On 8/23/18 at 4:27 PM, the report documented the Stage II pressure ulcer on the right heel measured 0.5 cm by 0.5 cm. The nurse documented the wound was slightly improved, a foam dressing was in place, and Prevalon boots were in place to both feet. However, the measurements were unchanged from the report 7 days earlier on 8/16/18. - On 8/31/18 at 10:19 AM, the report documented the Stage II pressure ulcer on the right heel measured 7 cm by 3 cm. The blister was flat and dark tissue was present and a foam pad was in place. The wound had increased in size by 6.5 cm and 2.5 cm in 8 days. - On 9/6/18 at 1:29 PM, the report documented the Stage II pressure ulcer on the right heel measured 7 cm by 5 cm. The nurse documented the wound appeared the same as the previous week, a dark scab was present, and a foam dressing was in place. However, the wound had increased in length by 2 cm and a scab was present. - On 9/7/18 at 10:39 AM, the report documented a suspected deep tissue injury pressure area on the right heel that measured 4.1 cm by 6.1 cm. Resident #24 experienced pain during wound treatment. A foam dressing was applied and the heels were floated on a pad. A deep tissue injury according to the Hopkins Medicine website, accessed on 10/2/18, was a localized skin or blister area purple or maroon in color due to the damaged underlying soft tissue from pressure or shear. The area may be painful, mushy, or boggy. - On 9/12/18 at 4:44 PM, the report documented an unstageable pressure ulcer on the right heel that measured 5 cm by 5 cm. The nurse documented the wound was smaller in size with eschar (black dead tissue). A foam dressing was in place and Skin Prep was applied to both heels. On 9/10/18 at 2:24 PM, Resident #24's family member said Resident #24 had really dry skin on her feet, the skin was turning black during the past couple of weeks, and she had an infection on her heel. Resident #24's family member said her feet were not that way when she was in the hospital prior to coming to the facility. On 9/10/18 at 2:39 PM, Resident #24's family member said the facility told her there was a sore on Resident #24's heel and did not say why the sore appeared. Resident #24's family member said the sore on her heel was not present in the hospital. On 9/12/18 at 3:40 PM, a large purple/black area was observed on Resident #24's right heel and an Opti-foam dressing was in place. The Wound Nurse (RN #1), said when Resident #24 came to the facility from another facility her skin was intact. RN #1 said Resident #24 was not on an air mattress and the pad was placed after the ulcer developed on her right heel. On 9/12/18 at 3:44 PM, the DNS said there was a deep tissue injury on Resident #24's heel and it developed in the facility. The DNS said Resident #24 was at moderate risk for skin breakdown on admission. The DNS said every 2-hour turning was initiated for Resident #24 upon admission, but there was no place to document it was done. The DNS said the normal standard of care was to initiate measures on the 48-hour care plan, such as a pressure reduction mattress. The DNS said the heel lift pad was initiated on the care plan after the pressure ulcer developed on Resident #24's heel. The DNS said on 8/8/18, Resident #24's pressure sore was noted as a blister that was believed to be caused by the wheelchair. On 9/14/18 at 9:41 AM, RN #1 the wound nurse, stated on Resident #24's Weekly Pressure Ulcer BWAT Reports, dated 8/16/18 and 8/23/18, she meant to document the right heel wound measured 5.0 cm by 5.0 cm, not 0.5 cm by 0.5 cm. Resident #24 developed an avoidable pressure ulcer on her right heel at the facility, and it worsened from a Stage II to unstageable. 2. Resident #1 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's care plan, revised 8/8/18, documented she had a history of [REDACTED]. The care plan did not address Resident #1's pressure ulcer to the coccyx found on 8/25/18. Resident #1's quarterly MDS assessment, dated 8/9/18, documented Resident #1 was moderately cognitively impaired and required 2 person extensive assistance with bed mobility and transfers. The MDS assessment documented Resident #1 was at risk for pressure ulcers and had no unhealed pressure ulcers. An Incident Report, identified as a late entry on 8/27/18 for an incident on 8/25/18 at 11:30 AM, documented during cares the CNAs found an open area to Resident #1's coccyx. The open area measured 2 cm x 0.5 cm and depth of 0.5 cm with no odor or drainage. The report documented RN #2 cleansed the area and applied an Opti-foam dressing to the open area. Nurse's progress notes from 8/25/18 to 9/3/18, and 9/7/18 to 9/10/18, did not include documentation of the Stage II pressure ulcer to Resident #1's coccyx. Weekly Pressure Ulcer BWAT Reports, from 8/31/18 to 9/12/18, had inconsistent documentation of when the Stage II pressure ulcer to Resident #1's coccyx was identified. Examples include: - On 8/31/18 at 9:59 AM, RN #1 the wound nurse, documented Resident #1 had a Stage II pressure ulcer to her coccyx that measured 3 cm x 1 cm with 0 cm in depth. The report documented the initial observation of the pressure ulcer was dated 8/29/18. The report documented there was a foam dressing on the coccyx area and the dressing was clean, dry, and intact. - On 9/4/18 at 1:30 PM, RN #2 documented Resident #1 had an initial observation of a Stage II pressure ulcer on 9/4/18. The pressure ulcer was on Resident #1's coccyx and measured 3 cm x 3 cm with a depth of 0.1 cm. The pressure ulcer had a scant amount of serosanguineous (yellow in color with small amounts of blood) drainage. - On 9/6/18 at 1:24 PM, RN #1 documented Resident #1 had a Stage II pressure ulcer to her coccyx which was initially observed on 8/8/18. The pressure ulcer measured 3.0 cm x 4.0 cm with a depth of 0 cm. RN #1 documented a foam dressing had a scant amount of serosanguineous drainage when removed from the coccyx. - On 9/12/18 at 5:01 PM, the report documented Resident #1 had a Stage II pressure ulcer to her coccyx which was initially observed on 8/31/18. The pressure ulcer measured 0.3 cm x 0.3 cm with a depth of 0 cm and no drainage. The 4 Weekly Pressure Ulcer BWAT Reports documented 4 different dates of when the Stage II pressure ulcer was initially observed or identified. An Incident Investigation Report, dated 9/4/18, documented on 8/25/18, staff noted 2 open areas to Resident #1's coccyx. The report documented both areas were superficial and small in area. The investigation report documented nursing staff were cleaning and dressing the wound as ordered and Resident #1 had a cushion for her wheelchair, which she spent large amounts of time sitting in. Resident #1's (MONTH) (YEAR) and (MONTH) (YEAR) weekly skin checks on the TAR were blank. A Nutrition Progress Note, dated 9/11/18 at 10:19 AM, documented Resident #1 had no skin issues. On 9/10/18 at 11:53 AM, Resident #1 was observed sitting in her electric wheelchair. Resident #1 stated she had an open area to her coccyx area. Resident #1's electric wheelchair did not have a cushion. Resident #1 stated she had never had a cushion for her wheelchair. Resident #1 stated she gets up by 9:00 AM and laid back down by 2:00 PM every day. On 9/10/18 at 3:00 PM, Resident #1 was observed in her room laying on her back on an air mattress bed. On 9/11/18 at 9:57 AM, Resident #1 was observed sitting in her electric wheelchair without a cushion. On 9/12/18 at 1:59 PM, RN #1 was observed assessing Resident #1's open area to her coccyx. RN #1 stated to Resident #1 the dressing to her coccyx had fallen off and needed to be replaced. RN #1 stated the wound was healing well and needed a dressing to protect the fragile healing skin for another week. On 9/12/18 at 2:01 PM, LPN #2 was observed applying an adhesive dressing. LPN #2 stated the open area to Resident #1's coccyx area was approximately 1 cm x 1 cm in size. On 9/13/18 at 4:10 PM, the DNS and the Clinical Resource Nurse stated the facility had a delay in treatment for [REDACTED]. The DNS stated the nurses should have documented daily in the nurses' progress notes, updated the care plan, and transcribed the physician's orders [REDACTED].#1's wound. The DNS stated if the TAR was left blank that meant the treatment was not done. The DNS was unable to explain why the initial observation dates were different on the Weekly Pressure Ulcer BWAT Reports and the reports were based on the pressure ulcer found on 8/25/18.

Based on observation, staff interview, policy review, and record review, it was determined the facility failed to provide adequate supervision to meet residents' needs. This was true for 1 of 2 residents (Resident #33) reviewed for supervision and accidents. Resident #33 was harmed when she fell and sustained a fractured forearm when staff failed to implement interventions and provide adequate supervision. Findings include: The facility's Fall Response and Management policy, dated 11/28/17, documented if there was no injury staff were to obtain vital signs including postural (orthostatic) vital sign measurement. Document the fall in the resident's medical record and implement immediate interventions to prevent a repeat fall. The policy further stated if there was an unwitnessed fall or resident injury staff were to obtain an x-ray if a fracture was suspected and monitor neurological assessments. Staff were also to complete a post-fall investigation and event report and revise the care plan as appropriate, and document the incident or injury in the resident's medical record. This policy was not followed. Resident #33 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 8/13/18, documented Resident #33 had moderate cognitive impairment, required supervision with ambulation, had limited ROM (range of motion) impairment to her lower extremities, and had experienced 2 or more non-injury falls. A Fall Risk Assessment Tool, dated 8/20/18, documented Resident #33 had a history of [REDACTED]. The Fall Risk Assessment scored Resident #33 a 7 out of 10 and was considered a risk for falling. The ADL care plan, dated 5/31/18, documented Resident #33 was independent with ambulation and transfers. Resident #33's care plan documented Resident #33 had a history of [REDACTED]. The care plan interventions were documented as follows: * Assist to steady/assist resident as needed due to impaired balance with right arm sling in place, dated 9/12/18. * Encourage resident to wear nonskid socks and/or shoes when ambulating, revised 6/1/18. * Fall risk assessment Quarterly and as needed, revised 6/1/18. * INFO: resident ambulates independently, revised 6/1/18. * Have commonly used items within easy reach, dated 5/17/18. * Request therapy evaluation as appropriate, revised 6/1/18. Resident #33's record included 4 incident reports of 5 falls, witnessed and unwitnessed, with 2 injuries in 2 days. Examples include: a. An Incident Report, dated 8/23/18 at 9:00 AM, documented Resident #33 fell while she was walking at a fast pace. The report documented she hit her forehead and her right wrist was swollen and bruised. A physician's orders [REDACTED]. A Nurse Practitioner progress note, dated 8/23/18 at 12:40 PM, documented Resident #33 had a goose-egg size bump on her forehead and a noticeably swollen and bruised right wrist and they were waiting for x-ray results. A Radiology Report, dated 8/23/18 at 6:07 PM, documented Resident #33 sustained a fractured right wrist. A fax to the physician, dated 8/23/18 at 8:20 PM, documented, .was not able to get a hold of on call provider. X-ray positive for distal radial fracture. Pt (patient) was sent to (name of hospital) ER for medical treatment at 7:00 PM. The ER Report, dated 8/23/18, documented Resident #33 was seen for a wrist fracture from a fall. The discharge instructions from the ER stated to have Resident #33 follow-up with an orthopedic physician and return to the ER if she experienced numbness or tingling of the fingers. A Nurse's progress note, dated 8/23/18 at 10:43 PM, documented Resident #33 returned from the ER with a splint on her right forearm and sling. The nurses' progress notes did not document Resident #33 had a fall, she was assessed by the Nurse Practitioner, x- rays were obtained, and Resident #33 sustained a right wrist fracture and a large bump on her forehead. b. An Incident Report, dated 8/24/18 at 3:00 PM, documented Resident #33 had a witnessed fall in the activity room. She landed on her knees and there was no injury. An Incident Investigation and Conclusion report signed by the DNS on 8/27/18, and signed by the Administrator on 9/5/18, documented Resident #33 had a second fall in 2 days. The report documented the IDT agreed to get an order for [REDACTED]. A physician's orders [REDACTED].#33 was to receive an OT evaluation and treatment 5 times a week. An OT evaluation and plan of care, dated 8/27/18, documented Resident #33 was referred to OT due to new onset of decreased functional mobility, decreased strength, decreased coordination, decreased postural alignment, falls/fall risk, fracture, functional limitation with ambulation, and increased need for assistance from others. Resident #33's care plan did not include OT. The nurses' progress notes did not include documentation Resident #33 had a fall in the activity room on 8/24/18. c. An Incident Report, dated 8/25/18 at 3:50 PM, documented Resident #33 was found sitting on the floor in the dining room. The 3 witness statements documented Resident #33 was found on the floor and they did not witness her fall. A nurses' progress note, dated 8/25/18 at 4:12 PM, documented a volunteer found Resident #33 sitting on the ground in the dining room. Resident #33 stated she was trying to pick up candy off the ground and fell . Resident #33 stated she did not hit their head. The progress note also documented there were no injuries and Resident #33's vital signs were stable. An Incident Investigation and Conclusion report signed by the DNS on 8/27/18, and signed by the Administrator on 9/5/18, documented since Resident #33 had a third fall in three days, staff were to encourage her to use a wheelchair for the rest of the day, as she was scheduled to be evaluated by OT on Monday, 8/27/18. The report also documented Resident #33 agreed to use the wheelchair for a brief time and she was educated to ask for staff assistance to get items off the floor. Resident #33's clinical record did not include neurological evaluations for the fall on 8/25/18 at 4:12 PM. d. An Incident Report, dated 8/25/18 at 5:20 PM, documented Resident #33 was found on the ground near the entryway of the dining room. No injuries occurred, and Resident #33 was helped into a wheelchair and pushed to the table. Staff were helping with dinner and Resident #33 attempted to get up from the wheelchair and the wheelchair rolled back, Resident #33 fell on her bottom. The report documented no injuries occurred, and Resident #33 did not hit her head. An Incident Investigation and Conclusion report signed by the DNS on 8/27/18, and signed by the Administrator on 9/5/18, documented: * Resident #33's sister stated she would like to have Resident #33 use a walker or a cane due to the high number of recent falls. *A cane or walker would be counter indicated, as Resident #33 could not bear weight on her right wrist. * Staff encouraged Resident #33 to use the wheelchair until she was evaluated by OT. * The IDT felt Resident #33 continued to be appropriate for independent ambulation despite recent falls. * Resident #33 would have a difficult time remembering to stay in a wheelchair due to her cognition. * Resident #33 continued to remain in areas of high visibility most of the time. * Resident #33 was independent with transfers and bed mobility. * An OT evaluation was pending. On 9/10/18 at 2:09 PM, Resident #33 stated she fell and broke her arm. Resident #33 was observed with a splint and wrap to her right forearm. She was ambulating around the facility at a hurried pace. On 9/11/18 at 9:00 AM, Resident #33 was observed greeting visitors when entering the facility. She did not have an assistive device for balance and a splint was in place to her right forearm. On 9/13/18 at 5:16 PM, the DNS stated the facility did not complete fall assessments after each fall and the care plan was not updated for Resident #33. The DNS stated the nurses should have documented the 8/23/18 and the 8/24/18 falls in the nurses' progress notes. The DNS was unable to provide documentation for weight bearing status and treatment for [REDACTED]. The DNS was unable to provide evidence of what changes had been made to Resident #33's care plan after each fall. The DNS was unable to provide evidence of increased supervision for Resident #33. On 9/13/18 at 6:12 PM, the Clinical Resource Nurse stated Resident #33 should have had orders for Physical Therapy to evaluate and treat for balance and gait training. On 9/14/18 at 10:25 AM, the DNS stated Resident #33 did not follow up with an orthopedic surgeon because she did not have surgery. She stated the Medical Director was following Resident #33's care for the right wrist fracture. On 9/14/18 at 10:27 AM, the Medical Director stated he was following Resident #33's care for her right wrist fracture. The Medical Director stated he was ordering a follow-up x-ray to determine if the fracture was healing. The Medical Director stated Resident #33 should have been evaluated and treated by Physical Therapy after the fall on 8/23/18.

Based on record review and staff interview, it was determined the facility failed to ensure residents at risk for falls were adequately assessed and interventions were implemented and monitored for efficacy to prevent repeated falls. This was true for 1 of 3 residents sampled for safety and supervision and resulted in harm to Resident #5 when over the course of two months she experienced four falls, one of which resulted in a facial laceration that required sutures. Findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, history of CVA with aphasia, history of bilateral hip replacement, and chronic pai[DIAGNOSES REDACTED]. The most recent Physical Therapy summary, dated 10/7/15, documented the resident had met the following goals: Improved lower extremity muscle performance and completing transfers independently with tactile cues and contact guard assistance. The Summary documented Resident #5 had reached the optimal functional level for her age and therapy treatments would be discontinued, however the document also noted the resident would continue to be at risk for falls without assistance in the facility. A Quarterly MDS assessments, dated 11/27/15, documented the resident required extensive assistance of one staff for transfers, toileting, hygiene, when moving from a seated to standing position, and when transferring between a bed, chair, and/or wheelchair. From November 2015 to January 2016, the facility documented Resident #5 fell on four occasions. Fall Investigation Reports, Nurses Notes, SBAR, Therapy Screens, Therapy Notes, IDT/Fall Committee Notes, and an ER Report documented the following: 1. 11/26/15 - 2:20 pm: Resident #5 did not wait for assistance and fell while self-transferring from a wheelchair to his/her bed. The resident ' s right leg was noted to be externally rotated and, when found, the resident was holding his/her right hip and yell(ing) out in pain. The MD was notified and Resident #5 was transported to the ER, where x-rays documented he/she sustained a contusion of the right hip or thigh. a. Fall prevention interventions in place prior to the fall included placing the resident ' s call light within reach and keeping the bed in its lowest position. b. Post-fall interventions included reminding the resident to ask for assistance with all transfers, 15-minute checks, and a Physical Therapy assessment. This assessment, dated 11/26/15 and performed by a Physical Therapy Assistant rather than a Physical Therapist, documented no current problems, changes in status, or potential risks related to transfers, bed mobility, and balance/postural stability. The PTA documented the resident was recently on PT caseload for similar issue with little improvement. 2. 12/23/15 - 1:00 pm: Resident #5 was found sitting on the floor next to- and still hanging onto the sink with both hands. It appears she pulled herself up to stand at her sink and then either missed her w/c while sitting down or her legs gave out. a. In addition to interventions already in place following the 11/26/15 fall, post fall interventions included encouraging the resident to rest after meals and on 12/28/15 the Fall Committee put into place additional interventions, which included staff staying with the resident when she was at her sink, adding the resident to the facility ' s Adopt-a-Resident program, initiating alert charting, and performing a therapy screening to address balance and transfers. b. A 12/28/15 therapy screen conducted by the Physical Therapy Assitant rather than a Physical Therapist documented the resident had no current problems, changes in status, or potential risks related to transfers, bed mobility, and balance/postural stability. 3. 12/31/15 - 2:00 pm: Staff heard yelling and found Resident #5 lying on her left side on the floor by her sink/bathroom door. The wheelchair with its brakes in the unlocked position was next to the resident, who had sustained a hematoma to her forehead measuring 8.5 cm X 7.5 cm X 1.0 cm; a skin tear to the left elbow measuring 1.9 cm X 1.0 cm; and a small (no measurement provided) abrasion to the left ankle. a. In addition to interventions already in place following the 11/26/15 and 12/23/15 falls, post fall interventions included a Physical Therapy evaluation and anti-rollback brakes to the resident ' s wheelchair. b. A 12/31/15 PT screen conducted by a Physical Therapy Assistant rather than a Physical Therapist documented the resident had no current problems, changes in status, or potential risks related to transfers, bed mobility, and balance/postural stability. The PTA documented, Resident fell while standing at (the) skink. IDT recommendations include self-locking wheelchair. 4. 1/27/16 - 9:00 am: Resident #5 was found lying on the floor behind her bedroom door. The resident pulled herself to a standing position while hanging onto her sink, lost her balance, and fell on to her left side. Resident #5 sustained a 3.0 cm X 1.5 cm laceration to the left side of her head and was transferred to the ER for evaluation and treatment. The ER report documented a 3.5 cm linear laceration to the left side of the resident ' s forehead to her skull and surrounding bruising; the laceration required 3 sutures. a. In addition to interventions already in place following the 11/26/15, 12/23/15, and 12/31/15 falls, post fall interventions included evaluating the resident for an alarmed Velcro seatbelt and a Physical Therapy screening. b. A 1/28/16 PT screen conducted by a Physical Therapy Assistant rather than a Physical Therapist documented no current problems, changes in status, or potential risks related to transfers, bed mobility, and balance/postural stability. The PTA documented, Resident has fallen several times recently. Discussed rehabilitation potential with PT staff, with the concerns being that patient has not benefitted from previous attempts . NOTE: A Physical Therapist Job Description provided by the facility documented, The Physical Therapist assesses the need for, develops, and delivers physical therapy programs to facilitate rehabilitation. Nursing Notes, dated 2/2/16, documented, PT screen and evaluation no treatment indicated. Resident placed on Restorative for (seatbelt) release while in w/c, mobility, and lower extremity ROM to maintain current level of mobility. A physician progress notes [REDACTED].#5 began working with Physical Therapy on standing again. There was no order in the clinical record directing Resident #5 to begin Physical Therapy. On 3/3/16 at 3:30 pm, the Administrator and DNS stated they were not employed at the facility prior to January 2016 and could not, therefore, provide information related to the resident ' s falls prior to the 1/27/16 injury-accident.

Based on record review, and resident and staff interviews, it was determined the facility failed to ensure a resident with a suprapubic catheter received care and services to protect against catheter-related complications. This was true for 1 of 1 (#2) sampled resident reviewed for urinary catheters. Resident #2 was harmed when the facility failed to correctly assess, monitor, and manage care for her suprapubic catheter, which resulted in surgical replacement of the catheter. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS Assessment, dated 4/10/15, and most recent quarterly MDS Assessment, dated 6/3/15, both documented the resident was cognitively intact with a BIMS Score of 15, had an indwelling catheter and required total assistance of 2 people for toileting. Resident #2's Urinary Catheterization Care Plan, implemented 4/4/15, documented the resident had a suprapubic catheter. The June 2015 recapitulated physician's orders [REDACTED].>*4/4/15 - Suprapubic catheter care every shift, discontinued. *4/8/15 - Change suprapubic catheter on the 17th each month on night shift, crossed out and foley catheter handwritten in place of Suprapubic. *4/16/15 - Irrigate catheter as needed, discontinued. The 4/8/15 order to change the resident's foley cather on the 17th of each month during night shift was included on the recapituated July 2015 physician's orders [REDACTED]. *4/5 and 4/6 Progress Notes (PNs) - Suprapubic (SP) catheter was intact, patent and draining amber urine; *4/7 (PN) - SP catheter intact; *4/8 (PN) - Orders received to change SP catheter. *4/11 (PN) - SP catheter patent and draining amber urine; *No documentation for 4/12 to 4/15 regarding the resident's SP catheter; *4/16 N.O. (New Order) - Irrigate foley PRN; *4/17 (PN) - SP catheter changed due to resident report of leakage, monitor for leakage; *4/19 (PN) - Resident reported increased urinary leakage and voiding through urethra. No urine output noted in the catheter bag for two days; assess need for SP replacement; *4/20 (PN) - New order for nonemergent transport to ED for evaluation of SP catheter; *4/20 Emergency Department Note - Complaint of catheter investigated, found to irrigate easily, discharged back to the facility; *4/22 Physician's Progress Note - Requires follow-up with urology for poor SP drainage; *4/25 (PN) - Resident reported ongoing leakage of urine around SP insertion site, dressing was saturated. Continued to void intermittently from urethra and SP catheter insertion site. Resident reported frustration over continuing SP catheter concerns, scheduled for urologist appointment; *4/27 (PN) - SP site dressing wet with urine, continues to have urine through urethra, no urine noted in catheter bag, no redness around SP site, bladder non-distended; *4/29 (PN) - Appointment canceled and rescheduled for 5/7/15, no reason given; *5/3 (PN) - No noted urine output in foley bag. No drainage or redness noted at site. Urologist appointment rescheduled for 5/7. MD notified MD - wants resident urology appointment as soon as possible, phone call to office and message left to schedule appointment earlier in the week if possible; *5/7 (PN) - No urine noted in foley bag. SP catheter intact, appeared to be voiding via urethra. Adult brief changed every 2 hours, urology appointment at 11:00 AM; *5/7 (PN) - Returned from urology office at 11:15 AM, unable to examine resident as paperwork not completed. Facility RN completed paperwork to send back to the urology office with the resident. At 1:45 PM the resident was transported back to the urology office with completed paperwork; *5/7 Urology Report - They changed her suprapubic tube a few days ago but it hasn't drained since. The suprapubic tube was first placed 2 months ago. She has been voiding per urethra and incontinence since then .The suprapubic tube was removed. It was not in far enough. I placed the flexible cystoscope down the tract, however, I was unable to negotiate this into the bladder. I could not pass a wire into the bladder either. The assessment documented, Dislodged suprapubic tube, unfortunately the tract has healed up. She will need to have the suprapubic tube replaced in the operating room. *7/1 Operative Report - SP catheter placed under direction of cystoscopy by urologist; *7/2 (PN) - Resident returned from local hospital status [REDACTED]. The resident's urologist notified and new antibiotic order received.; On 7/30/15 at 2:15 PM, Resident #2 stated the physician told her the SP catheter had not been inserted all the way into the bladder, which caused urine elimination through the urethra. The resident was harmed when the facility failed to correctly insert a SP catheter, which led to leakage of urine around the SP insertion site and intermittent voiding from the urethra. The resident, who experienced difficulty with the SP catheter from 4/9 until it was replaced on 7/1, eventually required surgical replacement of the suprapubic catheter.

Based on observation, staff interview and record review, it was determined the facility failed to prevent pressure sores from developing and failed to provide the necessary care to promote healing of a sacral pressure ulcer for 2 of 2 sampled residents (#2, 14), who had a pressure ulcer. Resident #14 was harmed when he developed a stage 4 pressure ulcer six days after admission. Findings included: 1. Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The initial nursing admission, data collection form dated 5/22/13 at 3:10 pm, documented in part, the following: Good Rehabilitation potential, Cardiovascular section: Normal, regular radial pulse, pedal pulses weak bilaterally. There was no documentation of [MEDICAL CONDITION]. Respiratory: Respiration even and unlabored, breath sounds clear, no cough, no oxygen or other special treatments, Skin: Warm and Dry, Multiple bruises, scars, scratch, skin tears noted on the body, no documentation of skin concerns on the feet, Foot Problems and Care: Foot problems were documented as none, open [MEDICAL CONDITION] on the foot and preventative or protective foot care was marked as none. The initial admission assessment did not identify the resident wore a brace on his right foot. The admission care plan dated 5/22/13, documented to turn the resident every 2 hours, float the resident's heels, to assess the resident's footwear for fit and non-skid soles and monitor for [MEDICAL CONDITION]. The initial admission MDS dated [DATE] coded the resident as: *Totally dependent on staff to move in bed and to transfer, *At risk for [MEDICAL CONDITION], *Had [MEDICAL CONDITION], *At risk for the development of pressure ulcers, *Developed a Stage 2 pressure ulcer. Nursing progress notes documented the following: 5/28/13 at 5:30 am-The right heel had an open surface area, with the right heel on the sheet, moisture around the heel, appeared as an opened blister. Resident complained of pain to touch and air. Referred to PT to evaluate right lower extremity brace with a hard plastic frame to evaluate fit and eliminate potential sheer, rubbing or pressure from the brace, 5/29/13 during the night shift with no time recorded-RLE (right lower extremity) remained extensively bruised with swelling above the right knee, foot to mid-thigh. The note further stated the heels were elevated off of the bed. There was an open blister site to the right heel, with no drainage. The resident refused to leave the protective wrap over the wound, 5/29/13 no time recorded-The family was instructed to not put the brace on the resident's right leg as it caused pressure to the right heel. The resident had [MEDICAL CONDITION] and the brace did not fit well. 5/31/13 during the morning with no time recorded-The plastic brace was removed from the room. The Pressure Ulcer Record initial note on 5/29/13 indicated the pressure ulcer was not present on admission. The wound was identified as a Stage 2 pressure ulcer on the right outer heel, measuring 6.4 cm x 5.2 cm x 0.1 cm, with a small amount of serous drainage. Note: The Skin Prevention care plan dated 5/22/13 was not modified until 6/15/13 at which time a foot cradle was added as an intervention. The Pressure Ulcer care plan dated 5/30/13 was not modified until 7/1/13 when the care plan was changed to not allow the resident to sleep on fall mats. The Pressure Ulcer Record documented the following: 6/1/13-The pressure ulcer was a Stage 2 wound, measured at 5.8 cm x 4.2 cm x 0.2 cm, with eschar, 6/1/13-The pressure ulcer was a Stage 2 wound, measured at 4.2 cm x 6 cm x 0.2 cm, with 90% eschar, with moderate serous drainage, 6/10/13-The pressure ulcer was measured at 4.2 cm x 6 cm x 0.2 cm, with 90% eschar, with moderate serous drainage. The wound was not staged, 6/12/13 and 6/19/13-The pressure ulcer was a Stage 4 and measured at 4.5 x 4.2 x 0.2, eschar, with moderate purulent drainage. The resident was seen by the wound care Nurse Practitioner (NP) approximately every 2 weeks for care and treatment of [REDACTED]. The last visit by the wound NP on 9/10/13 documented: 1.8 cm x 0.7 cm x 0.2, 98% granulation 2% slough, 0% necrotic, with a small amount of serosanguinous drainage. Treatment goals were changed to palliative care. A wound care NP evaluated the resident and initiated treatment on 6/17/13 for a right heel pressure ulcer which was described as 4.5 cm width eschar with adjacent area approximately, 2.2 cm length x 2.2 cm with x 0.1 depth. The physical exam by the wound care NP on 6/17/13 documented, 2+ (plus) [MEDICAL CONDITION] from the forefoot to the mid tibia. Note: The Stage 2 pressure ulcer developed within six days of admission and then developed into a Stage 4 pressure ulcer within 14 days of identification. On 9/11/13 at 1:30 pm, the DON and MDS nurse were asked for the PT evaluation which was requested per the nursing note of 5/28/13. They could not find where an evaluation had been done. The DON and MDS nurse were also asked for documentation for [MEDICAL CONDITION] checks of the lower extremities and they reported they could not find the documentation except in the PT notes for the week of 5/24-6/6/13. Note: The following Resident's PT progress notes were not individual notes broken down by day but rather cover the period of time of service for 5/24-6/6/13 and was signed by the Physical Therapist on 6/11/13. The PT progress notes from 5/24-6/6/13 and 6/10/13 documented: The resident was seen on 10 days during this period, Short term goal #2 indicated 2 plus [MEDICAL CONDITION] with a new onset of calcaneal wound possibly due to the brace, Had eschar cap and nursing was aware of it and would call wound care nurse today, Will discontinue goal and let nursing address wound and current [MEDICAL CONDITION]. The Resident's PT assessment summary section for the period of 5/24-6/6/13 documented, "Patient has developed wound on RLE/posterior calcaneous possibly due to AFO (brace) although there is not clear etiology. Since the original 2nd degree blister developed, AFO has been D/C (discontinued) and placed in gym. Wound has exacerbated despite discontinued use of AFO (brace). Wound care nurse addressing currently." On 9/17/13, the facility sent additional information to the survey agency, which included a written and signed note from the Physical Therapist dated 9/16/13. The noted indicated he had evaluated the resident on 5/24/13 and physical therapy discontinued the right AFO (brace) due to an ill fit secondary to lower extremity [MEDICAL CONDITION]. The AFO was removed and placed in the therapy storage. The initial PT evaluation signed 5/24/13 at 4:26 pm documented in part the following: fell with injury. Currently "RLE has a severe contusion with purple hematoma on lateral aspect of thigh distally to mid-calf. Current measurements: 51 cm at midthigh, 42 cm at midpeatella, 37 cm at midcalf. All measurements taken at widest portion. [MEDICAL CONDITION] present, 2 plus [MEDICAL CONDITION], medial right knee [MEDICAL CONDITION] and ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) due to trauma from recent fall, hematoma lateral thigh distally to mid-calf. ROM to right hip, knee, and ankle was identified as impaired. The strength of the right lower extremity could not be assessed due to pain. The assessment did not document [MEDICAL CONDITION] in the feet, that the resident used an AFO, or that it was removed from the resident's room at the time of the evaluation. During an interview with the resident's wife on 9/11/13 at 10:45 am, she said prior to coming to the facility, the resident had a brace for his right lower leg for many years, due to an old gunshot injury. On 9/11/13 Resident #14 was observed at the following times: 9:00 am-The Resident was breathing heavily, had a dry washcloth on his head, was lying on his back on a low bed with a scoop mattress, and blue fall pads on the floor, 10:00 am-CNA staff were completing care. His heels were not floated and his right heel dressing appeared to be loose and coming off, 10:45 am-LN#1 performed a dressing change on his right heel while the resident was lying on his back, 1:20 pm-The Resident was lying on his right side with his legs crossed at mid-shin. His left heel was floated while his right heel rested directly on the mattress, 3:00 pm-The Resident was lying on his back with his left heel floated and a new wrap around dressing on his right heel. His right heel rested directly on the mattress, 4:00 pm-The DON, surveyor, and two CNA's were in the room. The two CNA's had just completed incontinent care and the resident had both heels rested directly on the mattress with two pillows between the resident's legs. The DON asked the CNA's about the resident's buttocks and one CNA said it was getting red, 6:00 pm-The Resident was lying on his left side and both heels were floated. Resident #14 was admitted to the facility without pressure ulcers and without documentation of pedal (foot) [MEDICAL CONDITION] or use of an AFO. Resident #14 was harmed when he developed a stage 4 pressure ulcer six days after admission to the facility. The Resident was observed on four occasions to have his right heel in direct contact with the mattress. 2. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The TAR for June, July and August 2013 indicated Resident #2 was to be repositioned every two hours. The Pressure Ulcer Care Plan dated 6/12/13, with an implementation date of 12/18/12 documented to turn and position the Resident every 2 hours side to side. On 5/20/13 an intervention was added for the Resident to be last up and first down, if she was up at meal time. Note: The resident did not eat regular meals since her primary source of nutrition was tube feeding. Her care plan documented, she was a "recreational" eater of ice cream and mashed potatoes. The NP progress note dated 9/10/13, documented, the wound on the sacrum measured 2.8 cm x 0.4 cm x 0.2 cm with 100% granulation/viable and had a moderate amount of serosanguinous drainage to the old dressing. The periwound was slightly macerated with no [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. On 9/11/13 Resident #2 was observed at the following times: 12:00 pm-The Resident was in her room in her tilt in space wheelchair, 12:30 pm-The Resident was sitting in her wheelchair in the activity room, being fed by the activity director, 2:45 pm-The Resident was sitting in her wheelchair outside on the patio with her daughter, 3:00 pm-The Resident was sitting in her wheelchair in the SRC Dinning/Cedar room where she was playing Bingo, 4:05 pm, 5:30 pm, and 6:00 pm-The Resident was in her room sitting in her tilt in space wheelchair. The Resident, who had a sacral pressure ulcer, was observed to be sitting in a tilt in space wheelchair without being repositioned for 6 hours. This lack of repositioning and relief of pressure on the sacrum buttocks had the potential to lead to further breakdown and worsening of the current wound.

Based on observation, record review, resident group interview and staff interview it was determined the facility failed to provide supervision to ensure Resident #8 and all other residents were safe. Resident #8 who had self injurious behaviors and was known to have MRSA (bacterium infections difficult to treat), was not supervised as needed to prevent Resident #8 from harming himself. Also Resident #8 would wander into other resident's rooms when not supervised. This had the potential for other residents to be exposed to MRSA and was an invasion of their privacy. In addition, 2 of 5 sample residents (#s 5 and 8) were at risk for injuries due to multiples falls when supervision and/or interventions were not provided for individuals known to be a fall risk. Findings included: On 5/22/13 at 12:45 p.m., the facility Administrator and the Regional Vice President of Operations (RVPO) were informed verbally, and in writing, of the immediate danger to all residents and to Resident #8 resulting in the calling of an Immediate Jeopardy. On 5/22/13 at 4:45 p.m., the facility provided an acceptable plan of correction to protect Resident #8, and the other residents. The plan documented, in part, Resident #8 would have staff within arm's length (1 to 1 staff) at all times. Note: The facility was cited F323 on 3/1/12 for failure to provide supervision to a resident that was angering other residents by wandering into their rooms. An Immediate Jeopardy was called on 5/24/12 at the follow up survey (for the 3/1/12 survey) when the facility again did not provide supervision to prevent a resident from wandering into other residents' rooms. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's Initial Social Service History, dated 3/30/13, documented the resident had profound developmental delays and was admitted to the facility for "increased assist with ADL's and trach (tracheostomy) care." Resident #8's 5/1/13 recapitulation orders documented he was to receive Trazodone (antidepressant) 12.5 mg every noon, Trazodone 25 mg at bedtime and Lorazepam (anxiolytic) 0.5 mg as needed for agitation. Resident #8's medical record included laboratory results from the local hospital, dated 4/23/13, Resident #8 tested positive for 3+ Staphylococcus Aureus MRSA at the tracheostomy wound site. On 5/23/13 at 9:20 a.m. the Infection Control Nurse stated Resident #8 did touch his wound where the MRSA was located in his trachea. Resident #8's Tracheostomy Care Plan, dated 4/9/13, did not include that the resident had MRSA at the wound site or interventions to implement to ensure the resident did not expose staff or other residents to the bacterium. On 5/20/13 at 11:00 a.m. the surveyors met with 8 of the residents at the facility. At the meeting 4 of 8 residents stated Resident #8 would walk into their rooms. When asked if it happened recently, one resident stated the behavior was "worse" and a week ago Resident #8 went into his/her bathroom and took off all of his clothes. Another resident reported Resident #8 "pounds his head." The resident stated Resident #8's head was "black" about a week ago from being frustrated and pounding his head. Residents at the meeting stated there was not enough staff to be with Resident #8 at all times and there was, "No way they can take care of (Resident #8) and do their job." On 5/20/13 at 3:25 p.m., Resident #8 was observed asleep on his bed. CNA #6 was sitting beside the bed. CNA #6 stated Resident #8 was not "scheduled" for 1 to 1 but "Can do if he gets rambunctious." CNA #6 then stated that since Resident #8 was asleep he/she should not stay with him any longer. On 5/22/13 at 9:25 a.m., CNA #5 stated that Resident #8 was on 15 minute checks. When asked how the checks were completed, CNA #5 stated that if Resident #8 was in his room the CNA would "go into the room every 15 minutes." When asked about Resident #8's "behaviors", CNA #5 stated the resident had daily behaviors of sitting on the floor in the hallway. CNA #5 stated he/she had observed Resident #8 hit his head on the floor but had never seen the resident hit his head on the wall. When asked what he/she did when the resident hit his head on the floor CNA #5 said he/she would "run to the resident's room and get his pillow or grab a blanket from the linen closet." On 5/22/13 at approximately 10:00 a.m. CNA #7 stated that he/she was told Resident #8 knew sign language, but he/she had tried to communicate with sign language and the resident did not respond. CNA #7 stated he/she did not see how sign language could work if Resident #8 was blind. CNA #7 stated Resident #8 would hit himself and push CNA #7 away. When asked what he/she did when the behaviors happened, CNA #7 stated "I don't know what to do." CNA #7 stated Resident #8 needed 1:1 supervision but there were not enough aides to take care of the other residents and stay with Resident #8. CNA #7 stated Resident #8 disrobed and toileted on the floor in the hallway frequently. CNA #7 stated the other resident's got upset when Resident #8 came into their rooms and there was one resident who really did not like Resident #8. During an observation on 5/22/13 from approximately 9:15 a.m. to 9:25 a.m., Resident #8 was observed to be by himself in the small dining room. He was sitting crossed legged with his legs in a chair. Resident #8 was observed to hit his forehead with his fist 3 times, pause for a few seconds and then hit his forehead with his fist 2 times. Resident #8's Nursing Notes documented 35 incidents, between 3/27/13 and 5/20/13, involving Resident #8 being restless, entering other residents rooms, and or being-self abusive. The following are some of the incidents documented in the nursing notes: 3/28/13 at 10:25 p.m. - Removed pants and briefs and urinated and defecated in hallway ... in MDR (main dining room) and in another residents rooms.....required direct supervision all evening due to wandering into residents room and touching their belongings. During dinner walked up to another residents table and began to eat and drink their food. 3/29/13 at 7:20 p.m. - No adversity noted from head striking wall this a.m. 3/29/13 at 9:30 p.m. - at 2045 (8:45 p.m.) entered another resident's room and attempted to sit on resident. 3/31/13 at 2:20 p.m. - 1:1 as much as possible due to invading other clients rooms without being invited or wanted. Has frightened and/or angered or perturbed clients by appearing in their rooms, awakening them. 4/9/13 - nights - patient slapping himself in head and on face. 4/15/13 - 11:10 p.m. - 15 minute checks ...urinating and defecating in hallways; utilizing bathrooms other than one in his room .....Wanderguard with 15 minute checks instituted. Late entry (not dated) - 4:30 a.m. - Client found in woman's room, staff being alerted by female yelling "ouch"....CNA immediately entered female room and observed client pulling sheet off of female. 4/30/13 - 6:30 p.m. -"CNA came to me stating Resident #8 was sitting on the ground, slapping the ground and then hit his forehead on the ground and proceeded to strike his head..." 5/10/13 - evening shift- amb (ambulating) in others rooms...remains on 15 minute checks. 5/20/13 - nights - Going into other residents rooms. The surveyors requested on 5/19/13 incident reports for the past 6 months. The facility provided the 4/30/13 incident report for a "Skin Tear Investigation" that documented the resident had a self- inflicted head abrasion. The investigations provided did not include any other investigations regarding Resident #8. Resident #8's 3/27/13 Elopement Risk Care Plan goal was, "Resident will not leave facility unattended through next review." The approaches and intervention section included to re-direct resident from doors, observe for exit seeking behaviors, redirection, close supervision of where-abouts in facility and a Wanderguard bracelet on the resident's ankle. Resident #8's "Behavior Care Plan" (BCP) identified the problem as "Withdrawal from interests, insomnia, change in sleep pattern." Hand written at the bottom of the problem section was "slaps self." The approaches and intervention section included diversional activities of listening to the radio, giving hugs and sit with others. The approach section also stated, "will often sit on floor and bang his head. When this behavior observed attempt to stand him up, place in wheelchair, chair or ambulate with him and offer food/fluids. Bicycle helmet attempted he will not use it (dated 5/6/13)." A second BCP, dated 3/27/13, identified self-abusive acts, disrobing, rummaging and wandering. The approach section included the resident liked coffee as a treat, medications as ordered, safety checks as indicated and to to educate resident on potential negative outcomes of non-compliance. Note: The plan did not define if the "safety checks" were to be every fifteen minutes, every 30 minutes etc. The resident's Care Plan for falls, dated 4/9/13, did include 15 minute checks were to be done. The facility did provide documentation of the 15 minute checks from 4/2/13 through 10:00 a.m. on 5/23/13. A third BCP, dated 3/27/13 and 4/1/13 identified screaming, hits, butts heads and reduced social interaction. The goal was to maintain appropriate physical behavior on a daily basis. The approach section included that if Resident #8 was feeling for the wall it may be a pre-curser to head butting the wall..."When ambulating with resident walk on side closest to wall." Resident #8's Activities care plan included in the approach section to walk with the resident throughout the day and to place a pillow near him when on or near hard surfaces. Resident #8's Ambulation/Locomotion care plan included in the approach section, "will often undress himself-when this occurs he may be too hot---redress in cooler clothing or he may need to use bathroom." The resident's 4/9/13 Toileting Care Plan included in the intervention section the resident would "grab your arm and start ambulating to his room." The Care Plan did not include any information regarding the resident urinating or defecating on the floor. On 5/22/13 at approximately 11:00 a.m. the RVPO, Administrator and the DON were informed Resident #8's care plan did not address his behavior of wandering into other resident's rooms such as 1:1 supervision. The surveyors explained since the resident had MRSA and could touch their (other residents') personal items it was an additional concern. They were also informed the intervention to use a pillow when he hit his head was on his Activities care plan and not on his behavior care plan. Both agreed the intervention needed to be on the behavior care plan as that is where staff would look for interventions for the behavior. The Administrator stated in response to the resident wandering, the facility had put stop signs in the doors of the other resident's rooms. The residents did not like the signs and did not use them. The Administrator stated the resident was suppose to be supervised 1:1 "today." When asked when the 1:1 supervision was initiated the Administrator stated about a "week and a half" (ago). The facility failed to provide adequate supervision to ensure Resident #8 was not harmed when he demonstrated self-abusive behaviors of hitting his head. The resident's care plan did not provide adequate interventions for staff to ensure Resident #8 did not harm himself. Additionally, the facility failed to ensure Resident #8 did not invade other residents' right to privacy or expose them to the potential for contracting MRSA when he went into their rooms and touched them or their personal possessions. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS assessment, dated 3/19/13, coded, in part: * Moderate cognitive impairment, * Extensive assistance of 2 people for bed mobility, transfers, and toileting, * Two or more falls without injury Resident #1's medical record documented he had fallen 13 times since his admission on 12/19/12. Four of the thirteen falls documented on the Fall Investigation (FI) form documented issues with the wheelchair (w/c) cushion/seat as follows: *1/26/13 - The w/c slid out from underneath resident causing him to slide to the floor. The FI did not document recommendations from the Fall Committee Review nor did it indicate if the care plan had been revised. NOTE: The resident's 12/19/12 Care Plan was not revised to include an intervention related to the fall on 1/26/13. *1/30/13 - The resident may have been attempting to self-transfer from his wheelchair and slid out of the wheelchair. The FI documented the Care Plan had been revised for, "therapy to evaluate w/c (wheelchair) cushion and positioning." NOTE: Physical therapy (PT) did provide therapy for gait training stability and sit to stand transfers but there was no indication that the w/c cushion was evaluated. *3/18/13 at 4:20 (a.m. or p.m. not documented) - The FI documented, "Pt. (patient) reports w/c cushion is slick." The FI included a plan to re-evaluate the seat cushion and the use of a seat belt. *3/18/13 at 5:20 p.m.- The resident slid out of the wheelchair. The FI documented the Care Plan was updated to include a seatbelt. NOTE: The Care Plan was revised to include the seatbelt, however, there was no documentation PT had evaluated the w/c cushion even though the resident stated the w/c cushion was "slick." Additional FI's documented: *A 12/27/12 FI documented Resident #1 had fallen out of bed when he was trying to reach his call light that he thought was on the floor. On 5/21/13 at 9:57 a.m., Resident #1 was observed with his torso on the bed, and his feet over the side of the bed on the floor, asleep. The call light was on the floor near the head of his bed. The call light was not within the resident's reach. *4/15/13 - Resident #1 "took himself out of/off of the bed." The statement "It can't be prevented at this time" was written in the area for How to Prevent the Event in the Future. The FI documented that after the fall "bed continues in low position with bilateral landing pads in place." NOTE: The Care Plan had not been revised since 3/15/13 and did not include interventions related to the fall on 4/15/13. The facility was informed of the above concern on 5/22/13 at approximately 8:00 p.m. The facility provided no further information. 3. Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's quarterly review MDS assessment, dated 12/7/12, coded, in part: * Intact cognition with a BIMS score of 15; * No behavior issues; * Supervision of 1 person for transfers and locomotion on/off the unit; * Use of a walker; * No balance issues; and, * No falls since the admit/reentry/prior assessment. The resident's quarterly review MDS assessment, dated 2/26/13, coding differed from the 12/7/12 MDS, in part, as follows: * Two or more falls with no injury since prior assessment. Resident #5's Fall Prevention Care Plan, dated 9/4/12, interventions/approaches included: * "Uses FWW (four wheeled walker) or wheelchair," undated with a single line drawn through "uses FWW;" * "Uses SPC (single point cane)" also in handwriting, added 5/7/13; * "Assure adequate lighting." Review of Root Cause Analysis for the resident's Fall/Data Collected at Time of Fall (RCAF/DCTF) documents and Fall Investigation (FI) reports revealed 2 falls without injury, on 2/5/13 and 2/14/13, and a 2/27/13 fall that resulted in a laceration to the head. The RCAF/DCTF and FI reports documented, in part: *2/5/13 at 11:15 p.m. - The resident had an no injury fall in her room. - RCAF/DCTF - "Who was present...(?): Unwitness (sic) Resident vocalized what happened Story consistant (sic) with surroundings." *2/14/13 at 7:45 p.m. - RCAF/DCTF - "What procedure or processes were being conducted prior to and during the event(?): Resident was outside smoking lost her balance while turning (with) walker." - RCAF/DCTF - "Who was present...(?): (a CNA's first name)." - RCAF/DCTF - "What might have caused the event(?): Resident turned to (sic) quickly (with) walker. Poor lighting." - RCAF/DCTF - "How the event might be prevented in the future(?): Resident to use wheelchair to go out to smoke." - FI - "What intervention was implemented after fall? Resident to use w/c (wheelchair) when going out to smoke." - FI - "Conclusion: (Indicate what may have caused the accident)(:) CNA reported resident lost her balance while turning (with) walker." A handwritten statement by the CNA, dated 2/14/13 at 11:04 p.m., documented, "... (Resident's name) was sitting on her 4 wheel walker. I reminded (resident's name) three times to lock her brakes before she stands up. She stood up safely while I was standing two feet away. She took the brakes off and went to turn while holding onto the walker. She lost her balance and fell . ... There was no lighting outside. ..." NOTE: The lack of lighting outside in the smoking area was not addressed in either the RCAF/DCTF or the FI report. *2/27/13 at 7:45 p.m. - RCAF/DCTF - "Staffing(:) ... Was the staff properly oriented(?): No (checked) If no, why: Was not told to use w/c to go outside to smoke. Was the staff properly trained regarding this event(?): No (checked) If no, why...(?): Nurse unaware the orientee was taking her out to smoke." - RCAF/DCTF - "What conditions existed prior to the event(?): "Resident was outside smoking (with) supervision." - RCAF/DCTF - "What procedure or processes were being conducted prior to and during the event(?): New orientee took resident outside to smoke using FWW." - RCAF/DCTF - "Who was present...(?): new orientee (name). - RCAF/DCTF - "What might have caused the event(?): Resident stood up to (sic) fast got dizzy and lost her balance." - RCAF/DCTF - "How the event might be prevented in the future(?): All staff needs (sic) to be aware of the use of the w/c when taking resident outside to smoke." - FI - "What intervention was implemented after fall? New CNA was instructed to use w/c when taking resident out to smoke." - FI - "Supervisor Report 1. Did resident sustain injury: Yes 2. If so, what was the injury and how was it treated: Laceration to the back of her head. 3. ..." A handwritten statement by the CNA, dated 2/27/13 at "approximately 7:30 p.m.," documented, "I had taken (resident's name) and another resident to smoke... When both were finished I went to put the code in to go back inside and (resident's name) stood up to go and stumbled before I could get to her and fell backwards hitting her head and stating she was dizzy. The nurse and another aid (sic) came helped get her up." Nurse's Notes, dated 2/27/13 at 9:00 p.m., documented, "Resident went outside to smoke (with) new CNA. ... Resident leaped up out of chair lost her balance fell hitting the back of her head, noted (with) lg (large) amt (amount) of bleeding. Bleeding stopped (after) pressure applied... Laceration measures 2.5 (by) .3 cm (centimeters). ... Resident state (sic) "I got dizzy when I stood up."..." The facility failed to ensure there was adequate lighting in the smoking area and there was no evidence the facility considered whether or not the lack of lighting was a contributing factor when the resident fell on [DATE]. In addition, the facility failed to ensure all staff knew the resident was to use her w/c, not her FWW, when she was outside smoking on 2/27/13. On 5/22/13 at about 8:35 p.m., the Administrator, DON, and the Consultant were informed of the issues regarding Resident #5's falls. However, no other information or documentation was received from the facility.

Based on observation, staff interview, and record review, it was determined the facility failed to provide necessary care to prevent aspiration for residents at risk for aspiration and aspiration pneumonia. This was true for 1 of 1 residents (#7) sampled for tube feeding. The necessary aspiration precaution to elevate the head of the bed at least 30 degrees at all times during a tube feeding, a standard precaution, was not implemented as ordered by the resident's physician and as care planned. This placed Resident #7 at risk for injury or death and constituted immediate jeopardy (IJ) to the health and safety of Resident #7. In addition, the facility failed to ensure physician ordered and/or care planned interventions were followed and/or implemented for 3 of 7 sample residents (#s 1, 4, and 7) as follows: * Resident #1: There was no evidence of any interventions or that a recheck blood glucose (BG) was done when the resident's BG was low on 12/25/11, or that the resident was reapproached later when he refused BG checks which were to be done daily; * Resident #4: Consultant pharmacist recommended and nurse practioner ordered baseline laboratory testing which was not done prior to initiation of [MEDICATION NAME] (a psychotrophic medication); * Resident #7: There was no evidence of any interventions or that a recheck BG was done when the resident's BG was low on 12/23/11. In addition, a palm protector in the right hand was not implemented as care planned. Findings include: On 2/29/12 at 10:30 a.m., the facility was informed verbally, and in writing, of the immediate danger to Resident #7. On 2/29/12 at 2:15 p.m., the facility provided an acceptable plan of correction to protect Resident #7, who received continuous tube feeding, and 3 other residents, who received intermittent tube feeding and/or hydration, and the IJ was abated. The abatement plan included Resident #7's head of the bed immediately elevated to between 30 and 45 degrees, the DON assessed the resident to rule out adverse effects, and the resident's wall at the head of the bed was marked with two lines to indicate a 30 and a 45 degree angle in line with the top of the bed frame when the bed was in the lowest position. All other tube-fed residents were identified and evaluated by an LN for proper position of the head of their beds and the wall at the head of the bed of each of the residents was marked with two lines to indicate a 30 and a 45 degree angle in line with the top of the bed frame when the bed was in the lowest position. On-duty LN and CNA staff were in-serviced on 2/29/12 regarding the facility's tube feeding policy, including the head of the bed at 30-45 degrees elevation during all tube feedings and for 30 minutes after a tube feeding. The LN staff were also in-serviced regarding monitoring and documentation related to the head of the bed elevation specific to each resident on tube feedings. A plan was in place to educate all other staff regarding the policy prior to their next scheduled shift. A plan was also in place for all tube fed residents to be assessed by the ED/DON/Designee for proper elevation of the head of bed approximately every 2 hours for 8 hours; approximately every 4 hours for 24 hours, every shift for 72 hours, weekly for 4 weeks, then monthly for 3 months with the results to be reported at monthly QA meetings. The first such assessment was documented as done on 2/29/12 at 12 p.m. The findings include: 1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS assessment, dated 2/4/12, documented in part: * Severely impaired cognitive skills; * Total dependence of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; * Feeding tube; * 51 percent or more of total calories received through feeding tube; and * 501 cc (cubic centimeters) per day or more of average fluid intake received through feeding tube. Resident #7's December 2011 recapitulation of Physician order [REDACTED]. * HOB (head of bed) up 30 degrees - 5/12/09; * Glucerna 1.0 at 85 ml/hr for 15 hours at night via pump - 7/15/11; * Glucerna 200 ml [MEDICATION NAME] at 12:00 p.m. and 8:00 p.m. per PEG tube - 7/15/11; * Flush feeding tube with 180 ml water 4 times/day - 2/19/10; * [MEDICATION NAME] 500 mg (milligrams) per PEG tube 2 times/day for diabetes - 5/12/09; * FSBS (finger stick blood sugar) 2 times/day - 5/12/09; and * Place palm protector to right hand - 8/31/09. The resident's January 2012 Physician order [REDACTED]. * Maintain head of bed (HOB) elevated 30-45 degrees at all times - 1/5/12; * Glucerna 1.2 per tube feeding at 55 milliliter per hour (ml/hr ) continuous - 1/5/12; * Flush feeding tube with 300 ml sterile water every 6 hours for 48 hours - 1/4/12; * Flush feeding tube with 200 ml sterile water every 6 hours - 1/5/12; and * Monitor FSBS every 6 hours with sliding scale insulin ([MEDICATION NAME]) as indicated - 1/5/12. The resident's February 2012 Physician order [REDACTED]. It also included the following orders and order date for each: * Glucerna 1.2 per tube feeding pump at 65 ml/hr continuous - 1/26/12; * Flush feeding tube with 300 ml sterile water every 6 hours - 1/25/12; * Monitor FSBS every 6 hours with sliding scale level 1 insulin (regular) coverage as indicated - 1/5/12; and * [MEDICATION NAME] 15 units SQ (per subcutaneous injection) every p.m. a) Note: According to the American [MEDICATION NAME] Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition, (http://www3.us.elsevierhealth.com/ gastro/policy/v108n4p1280.html), the following guidelines should be followed with all enteral nutrition: "To limit the risk of aspiration with [MEDICAL CONDITION] feeding, the following precautions should be taken: raise the head of the patient's bed 30?-45? during feeding..." Resident #7's Admission/Re-Admission Data Collection & Initial Plan of Care, dated 1/4/12, included the goal, "Minimize risk of [MEDICAL CONDITION]/poor nutrition or dehydration." The goal was initiated on 1/6/12 with a goal date of 1/27/12. Interventions included, "...Discuss & Establish a schedule with the resident of...eating...Discuss & Establish food and beverage preferences..." However, none of the interventions included the continuous tube feeding, the water flushes, or elevation of the head of the resident's bed. Resident #7's Actual/Potential for Infection Care Plan, dated 11/19/09, identified the problem, "Actual/Potential for infection r/t (related to): Pneumonia - potential for aspiration (and) PEG (percutaneous endoscopic gastrostomy) tube..." Interventions included, "See ADL care plan" and "See Nutrition care plan." The resident's ADL Care Plan, dated 11/19/09, identified several problems, including self care deficit and impaired mobility. One intervention for these problems was, "HOB up at least 30 (degrees) at all times." A Nutrition care plan per se was not found. However, an untitled Care Plan, dated 11/28/10, identified dysphagia as a problem. Approaches included: "(D)iet per MD/ST order: LCS; puree...TF per RD: Glucerna 85 ml/(hour) x 12 (hours) @ noc 200 ml [MEDICATION NAME] (at ) 2000 et (1200)...flush (with) 180 ml H2O qid...(Diet per physician/speech therapist order: low concentrated sweets; puree...tube feed per registered dietitian: Glucerna at 85 milliliters per hour for 12 hours at night, 200 ml [MEDICATION NAME] at 8:00 p.m. and 12:00 p.m., flush with 180 ml of water four times a day...)" * Note: This care plan was not updated to reflect the current physician orders [REDACTED]. On 2/27/12 at 12:30 p.m., Resident #7 was observed in bed on her back with the head of the bed elevated and a tube feeding of Glucerna 1.2 running at 65 ml/hour via a feeding pump. There were no markings on the bedframe, or elsewhere, to indicate the degrees of elevation). The surveyor used a hard plastic Fiskars brand protactor with a movable center point arm and a paper protractor (a conventional protractor v1.0 printed from the internet at http://www.ossmann.com/protractor/) to measure the elevation of the head of the bed (HOB). The elevation was exactly the same, 30 degrees, on both of the protrators. On 2/28/12 at 9:10 a.m., Resident #7 was observed in bed with the HOB elevated at 30 degrees (the surveyor checked the elevation with the paper protractor) as the Glucerna tube feeding ran at 65 ml/hour via a feeding pump. At 9:20 a.m., CNA #4 was observed in Resident #7's room. When asked when the resident would be gotten out of bed, the CNA stated he usually worked the evening shift and the resident did not get out of bed on that shift. CNA #4 stated he was "filling in" on days and was told to "just be sure to turn her." He stated it was time to turn the resident. The CNA also stated, "She gets gurgly with any movement" and, "Usually in the afternoon she's sick from the tube feeding and throws up a lot. So she doesn't want to get up." CNA #4 said he needed help to turn the resident and he left the room. At 9:25 a.m., CNA #4 and CNA #3 returned to Resident #7's room. One CNA lowered the HOB by approximately 5 degrees, they moved the resident up in bed, checked and changed the resident's incontinence brief, performed incontinence care, repositioned the resident onto her right side, then elevated the HOB to about 35 degrees. At 9:40 a.m., one CNA noted the bottom sheet was soiled. The resident's HOB was lowered by about 10 degrees this time while the CNAs changed the bottom sheet and the draw sheet, positioned the resident onto her right side again, then raised the HOB to about 40 degrees. At that point, the resident made a low groan sound and CNA #4 stated, "That groaning sound that she's making is usually the beginning of her getting sick." On 2/29/12 at 9:35 a.m., Resident #7 was observed in bed tilted toward the right with the tube feeding running per the feeding pump. However, the HOB was only at 15 degrees elevation (the elevation was checked with hard plastic and the papter protractor). The resident was alone in the room. The surveyor went directly to LN #2, who was in the hallway at a medication cart in front of a resident room [ROOM NUMBER] rooms down from Resident #7's room. The LN was asked to accompany the surveyor to Resident #7's room. However, the LN asked if she could give the medications that were on top of the cart first. When the surveyor said no, LN #2 stated that the resident for whom the medications were for would be mad at her. At that time, CNA #3 walked by and she agreed to accompany the surveyor to Resident #7's room. At 9:40 a.m., upon entering the room, CNA #3 was asked about the elevation of Resident #7's HOB. CNA #3 stated, "It's too low." The CNA added, "We just turned her and were waiting for the nurse to come in and put a bandage on her foot." The surveyor placed the paper protractor on the bedframe at the angle between the head and middle section of the frame. The CNA was asked to read the degree of elevation on the protractor. CNA #3 leaned down slightly and said, "I guess it's zero." The CNA was asked to look more closely, which she did and she confirmed 15 degrees. When asked how she would know when the HOB was at 30 degrees elevation, CNA #3 stated, "I guess." At that time, 9:45 a.m., CNA #3 elevated the resident's HOB to 35 degrees per the protractor. Review of Nurse's Notes, Progress Notes, and Care Track (Multi-Shift) notes, dated 1/4/12 at 10:00 p.m. through 2/26/12 at 5:30 a.m., revealed documentation that Resident #7 had episodes of emesis on the following dates: 1/4, 1/5, 1/11 twice, 1/13, 1/14, 1/15 twice, 1/24 twice, 1/25, 1/31, 2/1 2/3 twice, 2/7, 2/8, 2/10, 2/22, and 2/26/12. Note: For at least 10 minutes on 2/29/12, the HOB was only at 15 degrees elevation while an enteral feeding ran continuously via a feeding pump for Resident #7, who was known to have occasional vomiting. This placed the resident at risk for aspiration, aspiration pneumonia, and possible death. b) Resident #7's Hypoglycdmic/Hyperglycemic Reaction Care Plan, dated 11/9/09, identified the problem, "Potential for complications..." Interventions included, "Monitor for s/s (signs and symptoms) of [DIAGNOSES REDACTED]...Treat hypo/hyperglycemic reaction per MD (physician) order(,) FSBS per MD order..." A Physician's Telephone Order, dated 12/21/11, documented an order for [REDACTED]. The December 2011 MAR indicated [REDACTED]'s BG level was low (51). However, review of Progress Notes and Nurse's Notes for December 2011 revealed that no interventions for [DIAGNOSES REDACTED], nor a recheck BG, was documented. c) Resident #7's Admission/Re-Admission Data Collection & Initial Plan of Care, dated 1/4/12, included the goal, "Minimize the risk of skin impairment." The goal was initiated on 1/6/12 with a goal date of 1/27/12. Interventions included, "...Discuss & Establish a schedule with the resident of...grooming, bathing...Discuss & Establish therapy, treatment...schedules with the resident..." None of the interventions, however, included a palm protector to the right hand. The resident's ADL Care Plan, dated 11/19/09, identified several problems, including self care deficit and impaired mobility. One intervention for these problems was, "Palm protector to (right) hand." On 2/28/12 at 9:25 a.m., during morning care by CNA #3 and #4, Resident #7's right hand was uncovered and it was observed that a palm protector was not in place. The resident's right hand was empty. At 11:30 a.m. that morning, Resident #7 was observed in bed and again, a palm protector was not in place to the resident's right hand. LN #1 was in the room and she was asked about the palm protector. LN #1 stated, "Oh, her splint" as she looked around the room for the splint. However, when the LN did not locate the palm protector, she left the room. At 1:30 p.m. that day, the resident was observed without a palm protector in place to the right hand. On 2/29/12 at 5:30 p.m., the Interim DON and MDS nurse were asked about the right hand palm protector for Resident #7. The MDS nurse confirmed that the care plan was current and a palm protector should be in use. No other information was received from the facility 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 10/22/11 Admission and 1/20/12 Quarterly MDS assessments coded: severely impaired cognition, impaired mood, behaviors, and [MEDICAL CONDITION] medication use. The resident's care plan documented: cognitive impairment, self care deficit, potential for side effects related to [MEDICAL CONDITION] drug use, and new symptoms of depression. A 2/8/12 Consultation Report from the facility's pharmacist consultant documented the recommendation, "Please consider initiating [MEDICATION NAME] 125 mg BID (milligrams twice daily). If added, it is recommended to monitor a complete blood count (CBC) and ALT ([MEDICATION NAME] aminotransferase, a blood test to detect liver injury) at baseline and every 6 months thereafter, and a serum [MEDICATION NAME] acid concentration two weeks after initiation of therapy to monitor for potential toxicities." On 2/21/12 the nurse practitioner responded, "I accept the recommendation(s) above, please implement as written." A Physician's Telephone Order form, dated 3/21/12 (NOTE: This appeared to be a transcription error, as the order was written based on the nurse practitioner's 2/21/12 response to the pharmacist's recommendation above), documented: "[MEDICATION NAME] 125 mg PO BID. Serum [MEDICATION NAME] Acid in 2 weeks. CBC (and) ALT (every) 6 months." NOTE: This hand written order did not include the baseline (before starting the medication) laboratory tests. It was not clear whether the first tests were to be done in 6 months or right away, and as of 2/28/12, there was no indication that any blood had been sent for testing. Resident #4 was ordered to have baseline laboratory testing done prior to starting a new [MEDICAL CONDITION] medication. The baseline tests were not completed. 3. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 12/24/11 Annual MDS coded: modified independence with daily decision making, inattention and disorganized thinking which fluctuate, and acute mental status change. The resident's care plan documented: potential for side effects related to [MEDICAL CONDITION] drug use, alteration in thought process, problems communicating, self care deficit, severely impaired decision making, and potential for complications related to diabetes. The resident's February 2012 Physician order [REDACTED]. The resident's Diabetic Flow Records for October 2011 through January 2012 documented daily blood sugar checks within normal limits, with the following exceptions: * 10/6/11 - refused * 10/9/11- none documented; a diagonal line was drawn through the result area. * 10/13/11 - refused * 10/17/11 - none documented; the nurse's initials were in the result area. * 10/18/11 - none documented; the nurse's initials were in the result area. * 11/7/11 - none documented; the nurse's initials were in the result area. * 11/12/11 - none documented; a diagonal line and the word "error" were in the result area. * 12/5/11 - none documented; the nurse's initials were in the result area. The back of the form documented, "refused second poke." There was no further explanation. * 12/14/11 - none documented; the nurse's initials were in the result area. * 12/25/11 - Blood sugar result of 56. There was no documentation regarding what interventions may have been done, and whether or not the blood sugar was rechecked. Nurse's Notes for 11/17/11-2/26/12 were reviewed and did not document anything related to blood sugar checks on the above dates. The DON and Administrator were informed of the findings on 2/29/12 at 7:10 PM. The blood glucose protocol was requested. The DON stated that there was no protocol for what nurses should do when a resident refuses a blood glucose check, or if the result indicates [DIAGNOSES REDACTED].

Based on a complaint from the general public received the BFS on 5/17/12, staff interviews and record review, it was determined the facility failed to ensure adequate supervision and safety for a resident with a known history of wandering into other residents' rooms in a disruptive and intrusive manner. This failed practice had the potential to lead to injury from unsafe wandering practices and resident to resident altercations which constituted immediate jeopardy to 1 of 10 (#4) residents reviewed during the follow-up survey and had the potential to affect all residents of the facility. The complainant stated an identified resident was "not fit to be in that facility" as she wandered (intrusively) around the facility. During the recertification survey, dated 3/1/12, the facility failed to provide adequate supervision and interventions to keep Resident #4 safe, and protect other residents from the resident's intrusive wandering. The recertification survey documented that Resident #4 wandered throughout the facility, entered other residents' rooms and took their belongings. This behavior made other residents and family members angry and frustrated and placed the resident at risk for physical altercations with other residents. The facility's Plan of Correction, with a compliance date of 4/16/12, documented, "Facility seeking alternate placement for Resident #4 (and) safety checks implemented including schedule set up for increased monitoring with 15 min(ute) checks until alternate placement." However, during the follow-up survey, there was no evidence that the 15 minute safety checks were ever initiated and/or continued to occur at the time of the follow-up survey. The resident was allowed to continue to wander intrusively into other residents' rooms due to the lack of adequate supervision. The facility's failed practice was brought to the attention of the Executive Director (Administrator) and DON on 5/23/12, at 4:00 pm, and the facility was provided with specific details of the failure to ensure the safety of the residents. On 5/23/12 at 4:45 pm, the facility presented the survey team with a staff assignment sheet assuring Resident #4 would be supervised 1:1 until her planned discharge on 5/24/12. On 5/24/12 at 1:30 pm, the facility provided a plan of correction which abated the immediate jeopardy. This plan included: Resident #4 placed on 1:1 supervision until discharge; Current residents to be assessed by the SS/Designee by 5/25/12 for wandering and intrusive behavior; Care plans to be updated; DCS/Designee to re-inservice staff by 5/29/12; Residents with intrusive and/or wandering behaviors to be reviewed to ensure interventions are appropriate and current setting is appropriate, if not, alternate placement will be sought. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Quarterly MDS assessment, dated 4/18/12 coded: moderately impaired cognition, physical behavioral symptoms directed toward others, wandering on a daily basis, and psychotropic medication use. Resident #4's current care plan, with the "Next review" date listed as 6/2012 included: * Problem/need of Elopement Risk (onset date of 10/14/11) due to impaired cognition, wandering, (and) independently ambulatory. The approaches included, "(Resident) will wander about facility and into rooms throughout the day. Staff to observe for her where abouts frequently" and "Wanderguard on ankle." * Problem/need of Wandering, verbally abusive, physically abusive...(onset date of 10/14/11) and the "Next review" date listed as 7/2012. The approaches included, "Administer medications as ordered, "Take to quiet private location as necessary. Modify environment, situation, and or treatment to minimize episode..." * Problem/need of difficulty finding own room (No onset date given). Approaches included, "Hang name on door. Decorate with pictures of interest. While awake, staff will supervise to help ensure appropriate interactions with other residents." The resident's current Care Plan was not updated to include the 15 minute monitoring checks referred to in the POC. Resident #4's Care Management Summaries and Nursing Progress Notes, dated after the facility's 4/16/12 compliance date, continued to document disruptive and intrusive wandering behaviors. Between 4/16/12 and 5/23/12 there were 36 separate entries in the Nursing Progress Notes that addressed the resident's continued behavior of wandering into other resident's rooms, taking their belongings, putting their clothes on, eating their snacks. Many of these entries included documentation that Resident #4 required "constant" or "continuous" redirection, became verbally aggressive with staff, and on one occasion Resident #4 became verbally aggressive with another resident when redirected out of that resident's room. For example: - 4/17/12 (Late entry for 4/16/12 days): "...Needs constant redirection to stay in MDR (Main Dining Room) for meals and out of other residents' rooms." - 4/18/12 (1:40 pm): "...Consistently needs redirection out of other residents (sic) room..." - 4/19/12 (1:35 pm): "...Continuous redirection needed to keep out of other res rooms ..." - 4/21/12 (1:30 pm): "Aware (and) wandering t/o (throughout) facility entering other residents' rooms (and) turning on their faucets. Took clothes out of one resident's room (and) put them on. Became combative (and) verbally aggressive with cares and redirection." - 4/23/12 (8:45 pm): "Has been awake and wandering t/o facility entering residents' rooms (and) removing their belongings such as perfume bottles, clothes (and) towels. Found sitting in one resident's room with door shut eating resident's snack foods. Became very angry (and) verbally aggressive with re-direction... " - 4/25/12 (Late entry for 4/24/12 day shift): "...Continuously entering other rooms, esp (especially, room number identified)..." - 5/5/12 (9:10 pm): "... Found entering residents' rooms in SRC (Special Rehabilitation & Care) et (and) 200 hall as well as 100 hall. Redirected with each occurrence... at times became agitated et cursed at staff or the resident whose room she entered... " - 5/6/12 (8:45 pm): "...Found entering rooms on 100, 200, et SRC turning on faucets et removing items from rooms. Removed food from other resident's (sic) trays in MDR..." - 5/15/12 (12:20 pm): "...Entering other residents' room continuously...." - 5/20/12 (1:55 pm): "Resident alert and wandering throughout the shift. At about 7:00 am she wandered into the dining room and tried to sit on one of the stools. She missed and landed on her bottom. She knew she had fallen and thought it was humorous... " - 5/23/12 (Late entry for 5/22/12, day shift): "...Wandered halls, entering other resident's room requiring frequent redirection..." A Care Management Summary, dated 4/17/12, documented the resident was "declining" and having, "... (increased) physical aggression..." The summary also documented the resident was on Seroquel 25 mg by mouth every 8 hours. The Seroquel was increased to 50 mg every 8 hours on 4/17/12. A Care Management Progress Notes, dated 5/1/12, documented, "...Wandering into other rooms cont (continues or continuous.)" A second note, dated 5/8/12, also documented, "Still becomes agitated during redirection. Still wanders into other rooms..." A physician progress notes [REDACTED].#4) has been increasingly combative with the staff, resistant to care, aggressive towards other residents, wandering persistently into other residents (sic) rooms..." A second physician progress notes [REDACTED]. No improvement in her behaviors. She continues constant wandering, wandering into other people's rooms...(Family member) is pondering transferring her to assisted living... will recommend (Name of Assisted Living facility)...considering their ability to deal with wandering demented patients..." On 5/23/12 at 1:45 pm, the LMSW was interviewed. She stated she worked with Resident #4's family member who became the legal guardian for the resident. The facility also worked with the family member regarding transferring the resident to an Assisted Living Facility. The LMSW stated this was arranged and the resident was going to be transferred on 5/24/12. "It was a safety issue for our residents." The LMSW also stated Resident #4 was on 15 minute observational checks following the Annual survey as part of the plan of correction. At 2:55 pm, the Executive Director was interviewed. The surveyor requested the documentation of the 15 minute checks as part of the facility's plan of correction. The Executive Director stated, "Okay, (pause), I'll need to look into that." NOTE: At 3:45 pm, the Executive Director and DON stated they were unable to locate documentation of the 15 minutes checks. The Executive Director stated they may have been thinned from the resident's file and could be in medical records. During an interview with the Executive Director and DON on 5/24/12 at 8:30 am, the DON stated they were, "still trying to locate the 15 minute checks." No documentation of 15 minute checks or consistent close supervision of the resident was provided. Resident #4's medical record and interviews with the Executive Director, DON, and LMSW, detailed that Resident #4 continued to intrusively wander about the facility and into other residents' rooms after the facility's POC compliance date. The facility failed to implement the POC they provided to the Bureau of Facility Standards, which documented Resident #4 would be checked and monitored every 15 minutes to provide for her safety and prevent her from entering other resident's rooms. This placed Resident #4 in immediate jeopardy with the potential of harm related to personal safety (such as falling on the floor when wandering about the facility) and potential altercations with other residents. On 5/24/12 at 4:45 pm, during the exit conference, the Executive Director and DON were again informed of the deficient practice. The Executive Director stated during the exit conference, that Resident #4 was still at the facility but it was anticipated that she would be discharged that day. The Executive Director assured the survey team that Resident #4 would remain on 1:1 supervision until her discharge from the facility.

Based on observation, record review, staff interview, and review of the facility's Skin Care & Wound Management policy and procedures, it was determined the facility failed to ensure residents at risk for pressure ulcers (PU) did not develop avoidable PU. This was true for 1 of 2 residents (#7) reviewed for PU. Resident #7 was harmed when an avoidable stage IV PU (per facility documentation) developed on the right lateral foot, a stage II PU developed on the left buttock, and a stage II PU developed on the coccyx. The facility failed to: a) accurately identify and record the stage of PU; b) consistently implement care planned interventions; c) revise and update the Skin Integrity Care Plan; and d) re-assess, and measure PU (per their own P&P). In addition, the facility administered a [MEDICATION NAME] dressing to left buttock PU without a physician's order. Findings include: Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #7's 5/15/11 annual MDS assessment PU CAT (care area trigger) included the following documentation, "High risk for skin breakdown due to impaired mobility, diabetic, impaired ability to communicate. Skin intact at this time. Continue to monitor skin surfaces with routine cares and clinical assessment per skin sweeps." Resident #7's quarterly MDS assessments, dated 8/13/11, 11/11/11, and 2/4/12, documented, in part: * Severely impaired cognition; * Total dependence on 2 people for transfers/bathing; * At risk for PU; * No venous or arterial ulcers; and * Skin and ulcer treatments with pressure reducing device for chair and bed/turning and repositioning program/nutrition or hydration intervention. The 8/13/11 assessment also documented, in part: * Total dependence on 1 person for bed mobility/dressing/toileting/personal hygiene; * No unhealed PU; and * Skin and ulcer treatments with non-surgical dressing other than to feet and ointments/medications other than to feet. The 11/11/11 assessment differed from the prior one as follows, in part: * Total dependence on 2 people for toileting; * One unhealed PU; and * One stage I PU. The 2/4/12 assessment differed from the prior one as follows, in part: * Total dependence on 2 people for bed mobility/dressing/personal hygiene; and * One unstageable PU with slough or eschar that was present on admission or reentry. Resident #7's clinical record contained Braden Scale-For Predicting Pressure Sore Risk evaluations dated 2/20/11, 11/13/11, and 2/4/12. The Braden Scales evaluated risk factors for sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Severe risk = total score less than 9, high risk = total score of 10-12, moderate risk = total score of 13-14, and mild risk = total score of 15-18. Resident #7's 2/20/11 and 11/13/11 Braden Scale total scores were incorrectly totaled as 18 and 19, respectively. The 2/20/11 scale documented: sensory perception = 3, moisture =2, activity =2, mobility = 2, nutrition = 3, and friction = 1, for a total score of 13 (moderate risk), not 18. And, the 11/13/11 scale documented: sensory perception = 3, moisture =2, activity =2, mobility = 2, nutrition = 3, and friction = 2, for a total score of 14 (moderate risk), not 19. The 2/4/12 total score was 13 (moderate risk). Resident #7's recapitulations of Physician Orders (PO) for September 2011 through February 2012 included the order, "May use house protocols for... pressure sores..." The resident's PO recapitulations for September through December 2011 also included orders to float the heels/feet when in bed and to apply skin prep to the right outer heel every day as [MEDICATION NAME] related to a history of PU. A Physician's Telephone Order (PTO), dated 10/21/11, documented, "Apply skin prep to (R) (right) outer aspect of foot Q (every) day until resolved." A PTO, dated 12/21/11, included the order, "(S)kin prep to (R) medial foot QD (every day) (pressure area)." A Physician Order Request, dated 12/28/11, documented, "...Noted (with) Stage II pressure ulcer to coccyx 2 cm (centimeter) x (by) 3 cm x 0.2 cm. Will cleanse (with) NS (normal saline) (and) cover (with) foam dressing; (change) Q 2 days until resolved." The physician signed the order on 1/5/12. The February 2012 PO recapitulation also included the following orders/order dates: * "Skin prep barrier wipe to coccyx/sacral area Q shift to protect (history of skin breakdown)" - 1/31/12; * "Skin prep bil(ateral) feet Q shift" - 1/11/12; and * "Skin prep resolve stg (stage) II to coccyx Q shift" - 1/31/12. A PTO, dated 2/8/12, documented, "[MEDICATION NAME] to eschar area to (R) ft (foot) BID (2 times a day)." Resident #7's Skin Integrity Care Plan, dated 11/9/09, included the problems: * "At risk r/t (related to) Impaired/decreased mobility...Hx (history): pressure areas on feet/heels." Interventions included, "Float heels...in bed;" * "Open area coccyx." This handwritten problem was not dated but had the goal, "Heal by next review." Interventions included, "Monitor daily (and with) cares. Tx (treatment) per MD (physician) orders;" * "Pressure area to lateral aspect (R) foot." This handwritten problem, also not dated, had the goal, "Heal within 30 days." Interventions were, "Monitor daily. Apply skin barrier daily. (C)ontact MD if worsens." Resident #7's TARs for October through December 2011 included the order for the house protocols for PU and to float heels/feet when in bed. Both of these orders were noted as "INFO (information only)." These TARs also included the order for skin prep to the right outer heel and contained initials documented every day for all 3 months. The October 2011 TAR also included the following entries: * "(H)[MEDICATION NAME] dressing to pressure wound (L) (left) buttock; (change) Q 3 D (and) PRN (as needed)." It was dated 10/12/11. And, note "Resolved 10/23/11." * "Skin prep to outer (R) foot pressure area Q shift until resolved." Note: No documentation of treatment prior to 10/21/11. NOTE: No physician orders were found for: a) the [MEDICATION NAME] dressing to the left buttock pressure wound, or b) to change the skin prep to the outer right foot pressure area from every day to every shift. Resident #7's November 2011 TAR included the entry: * "Skin prep (R) outer foot-pressure area." Note: No documentation of treatment from 11/1 - 11/9/11. The December 2011 TAR included the following entries: * "Skin prep (R) outer foot-pressure area." Note: Documented daily from 12/1 to 12/31/11; * "Skin prep medial aspect (R) foot Q day pressure 12/18/11." Note: Documented daily from 12/18 - 12/31/11; and * "Cleanse ulcer to coccyx (with) NS (and) cover (with) foam dressing; (change) Q 2 days 12/28/11." Note: Documented on 12/28 and 12/30/11. The January 2012 TAR included the following entries: * "Monitor ST (stage) II to coccyx Q shift". Dated 1/4/12. And "Resolved" on 1/27/12;" * "Skin prep resolved stage II to coccyx Q shift." Dated 1/27/12. Note: No documentation on the evening and night shifts on 1/31/12; * "Skin prep bil feet Q shift." Dated 1/11/12. NOTE: The resident was out of the facility for acute care on 1/1-1/4/12. However, this treatment was documented as done on those days. The February 2012 TAR included the following orders: * Skin prep barrier wipe to the coccyx/sacral area every shift; * Skin prep to the bilateral feet every shift; Note: For both of the above, there was no documentation for the day shift on 2/18, 2/19, 2/25, and 2/28/12; * [MEDICATION NAME] to the right foot eschar area 2 times/day and cover dressing. Dated 2/9/12 and included treatment times as "AM" and "PM." No documentation at PM on 2/9, 2/10, and 2/21 and none at AM on 2/18, 2/19, 2/25, and 2/28. Resident #7's clinical record contained Skin Grid-Pressure (SG-P) forms. These forms documented PU details and included body diagrams. One SG-P documented, "left buttock," as follows: * Not present on admission; * Circle drawn at lower back, left of midline, on back side body diagram; * 10/12/11 - stage II, 5.5 cm by 4 cm, not present on admission; * 10/16/11 - stage II, decrease in size to 3 cm by 2 cm; and * 10/23/11 - resolved. Another SG-P documented, "right outer foot," as follows: * Not present on admission; * No markings on any kind of the body/feet diagrams; * 10/21/11 - stage I, 3 by 3 cm, not present on admission, slash mark through wound bed; * 10/28/11 - stage I, 2.5 by 2.5 cm, slash mark through wound bed; * Subsequent weekly entries through 12/2/11, stage I, consistent decrease in size, and eschar in the wound bed; * 12/16/11 - "See new skin grid." Another SG-P documented, "right lateral foot proximal to 5th toe" PU, as follows: * Not present on admission; * Arrow drawn to the side and just below the little toe on the right foot diagram; * 12/16/11 - stage II, 0.8 by 0.5 cm, wound bed not marked, notation "Dry wound bed. (No) drainage" above nurse's signature; * 12/31/11 (15 days later) - stage II, decrease in size, wound bed not marked ; * 1/15/12 (15 days later) - stage II, increase in size to 1.8 by 1.6 cm, eschar in wound bed; * 1/19/12, stage II, same size, wound bed not marked, notation "Resolving (with) eschar over wound" above nurse's signature; * 1/26/12 - unstageable, same size, small amount serous drainage, eschar in wound bed; * 1/27/12 - stage II again, same size, no drainage, eschar in wound bed; * 2/3/12 - unstageable, increase in size to 2 by 1.8 cm with a question mark for depth, no drainage, eschar in wound bed; * 2/14/12 (11 days later) - stage II, 2 by 1.5 by 0.2 cm, no drainage, red granulation tissue in wound bed; and * 2/22/12 (8 days later) - stage II, same size/depth, small amount serous drainage, red granulation tissue in wound bed. Another SG-P documented, "coccyx," as follows: * Not marked to indicate if present or not present on admission; * No markings on any kind of the body/feet diagrams; * 12/28/11 - stage II, 2 by 3 by 0.2 cm, no drainage, red granulation tissues in wound bed; * 12/31/11 - stage II, 1.9 by 3 by 0/1 cm, otherwise the same; * 1/15/12 (15 days later) - decrease in size, otherwise the same; * 1/19/12 - continued decrease in size, otherwise the same; * 1/26/12 - "Resolved." Resident #7's Admission/Re-admission Data Collection & Initial Plan of Care, dated 1/4/12, contained front/back body diagrams and a diagram of the bottom of the right and left foot on page 4. Below the body/foot diagrams on page 4, and continued onto page 5, were areas to document each skin impairment "Site Number" and description. The body diagrams documented the resident had numerous skin impairments, including PU. Many, but not all, of the skin impairment on the body diagrams were numbered. The back body diagram included the following, "ST (stage) II (which was crossed out)(,) mascerated (sic) area 4 x 5.5" with a line drawn to a circle at the coccyx area, and "Pressure ST V (five) 1.5 x 1.5" next to a circle drawn on the lateral (outer) aspect of the right foot just below the little toe. Neither area was numbered. The front body diagram included the following, "#8 Pressure ST I 1. x 1.5" next to a circle drawn at the inner aspect of the right foot, on the side, just below the big toe. All of the "Site Number" and description areas on page 4 and 5 were blank. Review of Progress Notes (PN), Care Track (Multi-Shift) notes (CT-MS), and Nurses Notes (NN), dated from 11/10/11 and timed as noc (night shift) through 2/26/12 at 5:30 a.m., revealed the following documentation: * PN - 12/18/11 at 2:30 p.m. - "Noted (with) beginning of pressure area to (R) medial foot. Blanching area 2.4 cm x 2.5 cm..." * PN - 12/21/11 at 6:45 a.m. - "...notified physician of pressure area (lower) (R) medial foot. Okay for skin prep to area QD..." * NN - 12/28/11 at 12:40 p.m. - "Stage II pressure ulcer noted to coccyx this AM 2 cm x 3 cm x 0.2 cm..." * PN - 1/4/12 at 10:00 p.m. - "...ST I (and) V noted to (R) foot..." * PN - 1/5/12 at noc - "...Bsores (bed sores) to buttocks/coccyx..." * PN - 1/5/12 at 1:30 p.m. - "...Dressing placed on ulcer to coccyx..." * PN - 1/12/12 at 4:05 p.m. - "...Skin prep applied to both feet..." * NN - 1/17/12 at noc - "...Barrier cream to buttocks/coccyx..." * CT-MS - 1/23/12 at noc - "...skin prep applied to pressure areas on feet..." * PN - 1/27/12 at 3:15 p.m. - "...Pressure area on coccyx resolved..." * PN - 2/10/12 at 2:10 p.m. - "[MEDICATION NAME] applied to eschar on (R) foot. Skin prep to coccyx..." * NN - 2/20/12 at 6:00 p.m. - "...Cont(inues) (with) small open area (L) buttock..." Review of Resident #7's Skin Sweep records, dated 10/10/11 through 2/22/12, revealed that a new skin impairment was documented only once. This was on 10/21/11 and included a referral to a SG-P. In addition, a back body diagram for 10/21/11, contained a circle at the coccyx area. All of the other Skin Sweep records documented, "No New Skin Impairment." NOTE: A SG-P for the right medial foot PU was not found in Resident #7's clinical record. In addition, no other documentation regarding the left buttock PU, right lateral foot PU, right medial foot PU, and coccyx PU was found in the resident's clinical record. On 2/27/12 at 12:30 p.m., Resident #7 was observed in bed on her back with the head of the bed elevated to 30 degrees. A pillow and heel mat were under the resident's lower legs. However, the resident's heels were in contact with the heel mat. On 2/28/12 at 9:30 a.m., Resident #7 was observed in bed while CNA #3 and #4 provided morning cares. A pillow and a heel lift mat were noted under the resident's lower legs. However, both of the resident's heels were in contact with the heel lift mat. After the CNAs changed the resident's incontinence brief and repositioned the resident onto her right side, the resident's heels were still in contact with the heel lift mat. When asked if the resident's heels were floated, CNA #3 stated, "No ma'am. She contracts up and it's hard to keep her that way." CNA #3 immediately adjusted the pillow and heel float mat and floated the resident's heels. In addition, when the CNAs changed the resident's incontinence brief, the resident's buttocks/coccyx areas were observed intact without skin impairment. On 2/28/12 at 11:30 a.m., LN #1 pulled back a dressing that was on the side of Resident #7's right lateral foot, just below the little toe. This revealed an oval shaped open area about 2 cm by 1 cm with approximately 75 percent pale yellow slough in the wound bed. LN #1 stated, "It was a PU that healed then scabbed and the scab broke open." On 2/29/12 at 5:00 p.m., the Interim DON (IDON) was asked about Resident #7's PU. The IDON stated he was not very familiar with the resident and referred the surveyor to the wound nurse, LN #5. At 5:30 p.m., LN #5, who was also the MDS and Infection Control Nurse, was interviewed in the IDON's presence. LN #5 stated, "Maybe the coccyx PU and left buttock PU are the same. It's not clear." The LN did not address the right foot PUs. When asked about more than 1 week, and up to 15 days, between SG-P assessments, LN #5 indicated she was not always able to do it on time. LN #5 confirmed Skin Integrity Care Plan in Resident #7's clinical record was the current care plan. However, she acknowledged that it was not up to date. The facility's PU policies and procedures (P&P) were requested. They were received later that evening. Review of the Skin Care & Wound Management P&P, which included 3 Pressure Ulcer Prevention policies (Low Risk, Moderate Risk, and High Risk/Severe); and, 3 Treatment Protocols (Stage I, II, III & IV Pressure Ulcer), revealed the following: All of the Prevention policies included: * "Resident/patient evaluation is completed upon admission, weekly for four (4) weeks, quarterly, and with change in clinical condition to determine pressure ulcer risk. Individualized interventions are implemented as indicated...The Braden Scale is used to evaluate...risk. * "Procedure 1. Develop a care plan for pressure ulcer prevention...2. Monitor for consistent implementation of interventions...3. Evaluate effectiveness of interventions. 4. Modify interventions and goals, as indicated..." Treatment Protocol: Stage I: * "...defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence... * "Procedure...2. Obtain a physician order for [REDACTED]. 6. Document wound measurements and characteristics on the Skin Grid-Pressure...no less than weekly. 7. Verify prevention interventions are in place. 8. Review effectiveness of treatment plan every 2 weeks and revise as needed..." Treatment Protocol: Stage II: * "...defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister... * "Procedure...2. Obtain a physician order for [REDACTED]. 7. Document wound measurements and characteristics on the Skin Grid-Pressure...no less than weekly. 8. Verify prevention interventions are in place. 9. Review effectiveness of treatment plan every 2 weeks and revise as needed..." Treatment Protocol: Stage III & IV: * "...Stage III...defined as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." * "...Stage IV...defined as a full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include (sic) undermining and tunneling." * "Procedure...2. Obtain a physician order for [REDACTED]. 7. Document wound measurements and characteristics on the Skin Grid-Pressure...no less than weekly. 8. Verify prevention interventions are in place. 9. Review effectiveness of treatment plan every 2 weeks and revise as needed..." Resident #7, who had a history of [REDACTED]. The facility failed to: a) accurately identify and record the stage of PU (by definition, a stage II PU does not contain eschar; however, a stage IV PU may); b) consistently implement care planned interventions (float heels); c) revise and update the Skin Integrity Care Plan to include problem/goal dates, resolution dates for PU, and new PU areas/treatments; d) re-assess and measure each PU on a weekly basis (per the facility's own P&P); and e) applied a [MEDICATION NAME] dressing to the left buttock PU without a physician's order. On 3/1/12 at 12:15 p.m., the Administrator and the IDON were informed of the concern for harm to Resident #7 related to PU. No other information was received from the facility.