Every finding on record at Coronado Care Center

Based on observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items stored in facility's freezer were labeled and dated. This deficient practice is likely to affect 76 residents listed on the resident census list provided by the Administrator on 06/09/25 and could likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 06/09/25 at 11:03 am during observation of the facility's walk in freezer the following items were found open and undated: 1. Two bags of what appeared to be hash browns. 2. Two bags of what appeared to be French fries. B. On 06/09/25 at 11:05 am during an interview with the Dietary Manager (DM), he confirmed the items were not labeled and dated. DM stated that doesn't meet his expectations and everything in the fridge/freezer should be labeled and dated.

Based on observation and interview, the facility failed to ensure the hallway was accessible for residents. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 06/09/25 at 8:10 am a random observation of the [NAME] Wing revealed the following: 1. A medication cart on the right side of the hallway near room [ROOM NUMBER]. 2. A shower chair on the left side of the hallway near room [ROOM NUMBER]. B. On 06/09/25 at 8:18 am during an interview with the Restorative Nursing Aide (RNA), she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway, so residents had a clear path. C. On 06/10/25 at 8:46 am a random observation of South Wing revealed the following: 1. A medication cart on the right side of the hallway near room [ROOM NUMBER]. 2. A medication cart on the left side of the hallway near room [ROOM NUMBER]. D. On 06/10/25 at 8:48 am during an interview with Certified Medication Aide (CMA) #1, she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway.

Based on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are: R #22 A. On 06/12/25 at 10:34 am during an observation of R #22's room revealed R #22 was asleep in her recliner. The call light laid on top of the bed where she could not reach it. B. On 06/12/25 at 10:36 am during an interview with Hospice Nurse (HN) #1, she confirmed the call light was not within R #22's reach and the call light should have been. R #56 C. On 06/11/25 at 8:58 am during an observation of R #56's room, revealed R #56 was asleep in his recliner. The call light laid on top of the bed where he could not reach it. D. On 06/11/25 at 9:05 am during an interview with Certified Nurse Assistant (CNA) #2, she confirmed the call light was not within R 56's reach and the call light should have been.

Based on observation, record review and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed 3 medication errors out of 29 opportunities for 3 (R #39, R #43, R #76) of 4 (R #36, R #39, R #43, R #76) residents reviewed during medication administration. This resulted in a medication error rate of 10.34%. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 06/12/25 at 9:40 am, during an observation of Certified Medication Aide (CMA) #1 revealed the following: 1. CMA #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #76. 2. CMA #1 then failed to sanitize her hands before beginning her medication pass for R #39. 3. CMA #1 then failed to put gloves on (don) gloves to open a capsule for R #43. B. On 06/12/25 at 10:15 am during an interview with CMA #1, she confirmed she should have sanitized her hands before beginning the medication pass for R #39. She confirmed she should have sanitized all vital sign equipment before taking R #76's vitals and in between each resident afterwards. She confirmed she should have donned (put on gloves) gloves before she opened the capsule to pour the medication in the medicine cup for R #43. C. On 06/12/25 at 10:25 am during an interview with the Director of Nursing (DON), she confirmed she would expect all nursing staff to perform hand hygiene before and after each medication pass for each resident. She confirmed she would expect all nursing staff to sanitize the vital machines before and after use with each resident. She confirmed she would expect all nursing staff to don (put on gloves) gloves before touching any medications for any of the residents. D. Record review of the Medication-Administration policy (not dated), provided by the Administrator (ADM) on 06/12/25, under the heading Procedure point number 2, wash hands before and after medication administration. E. Review of CDC guidelines Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2008, Section 4.c., stated staff should ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis, such as after use on each patient or once daily or once weekly.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 5 (R #2, R #23, R #54, R #56 and R #75) of 5 (R #2, R #23, R #54, R #56 and R #75) residents reviewed when staff failed to: 1. Update R #2's care plan to include the use of a trapeze bar (a short horizontal bar that is suspended from two ropes) for mobility. 2. Update R #23's and R #54's plan of care to include hospice (care and services for people nearing the end of life). 3. Update R #56's care plan to remove the use of a communication board (a tool used to help people with limited language skills or who are nonverbal to communicate) with word cards. 4. Update R #75's plan of care to include advanced directive. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #2 A. On 06/10/25 at 1:46 pm, an observation of R #2's room revealed a trapeze bar at the head of R #2's bed. B. Record review of R #2's face sheet revealed he was originally admitted to the facility on [DATE] with the following diagnoses. 1. Unsteadiness on Feet, 2. Unspecified Lack Of Coordination, 3. Muscle Weakness, 4. Multiple Sclerosis (a chronic disease that affects the brain and spinal cord), 5. Myoneural Disorder (conditions affecting where nerves and muscles communicate). C. Record review of R #2's care plan dated 06/28/24 revealed no interventions for the use of a trapeze bar. D. On 06/10/25 at 1:48 pm during an interview with R #2, he stated he uses the bar to help with repositioning himself while in bed. E. On 06/12/25 at 12:32 pm during an interview with the Director of Nursing (DON), she confirmed R #2's care plan was not revised to include the use of a trapeze bar and should have been. R #23 F. Record review of R #23's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Cerebral aneurysm (a weak spot on an artery in the brain that fills with blood), 4. Chronic heart failure (an ongoing inability to pump enough blood through the body causing an insufficiency of oxygen). G. Record review of R #23's care plan dated 05/01/25 revealed a focus area indicated R #23 has a terminal diagnosis of COPD and has the following interventions listed: 1. Adjust provision of ADLS (activities of daily living) to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate dated 02/28/24. 2. Assess resident coping strategies and respect resident wishes dated 02/28/24. 3. Consult with physician and Social Services to have hospice care for resident in the facility dated 02/28/24. 4. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion dated 02/28/24. 5. Encourage support system of family and friends dated 02/28/24. 6. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free dated 02/28/24. 7. Keep lighting low and familiar objects near dated 02/28/24. 8. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain dated 02/28/24. 9. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met dated 02/28/24. 10. Work with nursing staff to provide maximum comfort for the resident dated 02/28/24. H. On 06/13/25 at 12:53 pm, during an interview with the Assistant Director of Nursing (ADON) #2, she stated R #23 was previously on hospice and was taken off hospice in 2024. ADON #2 stated that all interventions listed in R #23's care plan for hospice are over one year old. ADON #2 confirmed there are no current interventions included in R #23's care plan for hospice. R #54 I. Record review of R #54's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic kidney disease (kidneys are damaged and gradually lose ability to filter blood effectively), 2. Unspecified heart failure (condition where the heart cannot pump enough blood to meet the body's needs), 3. Gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining), 4. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others). J. Record review of R #54's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 05/20/25, revealed R #54 is on hospice. K. Record review of R #54's comprehensive care plan last revised on 05/23/25, revealed no mention of hospice care. L. On 06/13/25 at 12:53 pm, during an interview with ADON #2, she confirmed that R #54 is on hospice and hospice is not included R #54's care plan. ADON #2 stated her expectation is for a resident's care plan to be revised to include hospice if or when it becomes relevant to the resident. R #56 M. Record review of R #56's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Cognitive Communication Deficit (difficulties in communication arising from impairments in mental processes), 2. Dementia (a decline in mental ability severe enough to interfere with daily life). N. Record review of R #56's care plan dated 03/13/24 revealed a focus for cognitive communication deficit with the following approaches: 1. Ask simple questions that require short answers 2. Listen attentively and allow time to communicate 3. Use communication board with word cards 4. Speak slowing and clearly while facing resident 5. Use gestures an body movements. O. On 06/11/25 an observation of R #56 room revealed there was no communication board with word cards available for use. P. On 06/12/25 at 3:48 pm during an interview with Certified Nursing assistant (CNA) #3, she confirmed R #56 communicates by answering yes or no questions. She stated R #56 also uses nonverbal communication that require staff to pay attention to his body movements. CNA #3 confirmed R #56 does not have a communication board with word cards available. Q. On 06/13/25 at 12:32 pm during an interview with the Director of Nursing (DON), she stated R #56 does not have a communication board. The DON stated that the facility attempted to use a communication board and word cards with R #56, but it was ineffective. The DON could not remember the date of this trial. The DON confirmed the care plan should have been revised and was not. R #75 R. Record review of R #75's admission record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Spinal Stenosis, cervical region (narrowing of one or more spaces within the spinal canal), 2. Type 2 diabetes mellitus with hyperglycemia (blood sugar levels rise significantly), 3. Depression, unspecified, 4. Chronic diastolic (congestive) heart failure. S. Record review of R #75's order dated 05/29/25, revealed an order for an advance directive of (do not resuscitate: DNR; lifesaving measures are not desired) code status in place. T. Record review of R #75's care plan dated 06/03/25 revealed R #75 was missing the advance directive for a DNR on his care plan. U. Record review of R #75's New Mexico Orders for Scope and Treatment (MOST) form dated 05/29/25 revealed R #75 has an advance directive of DNR code status in place. V. On 05/29/25 at 12:20 pm during an interview with the DON, she confirmed the facility failed to revise the care plan for R #75 after confirming his advance directive DNR code status.

Based on record review, observation and interview, the facility failed to keep residents free from physical restraints for 1 (R #8) of 1 (R #8) resident observed during random observations. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's (a progressive brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out even the simplest tasks), 2. Dementia (a general term for a decline in mental ability severe enough to interfere with daily life), 3. Depression (persistent feeling of sadness, loss of interest in activities, and changes in appetite, sleep, and energy levels), 4. Cognitive communication deficit (a communication problem stemming from impairments in thinking skills, rather than language or speech difficulties themselves), 5. Unsteadiness on feet, 6. Psychotic disorder with hallucinations (characterized by experiencing sensory perceptions that aren't real, such as hearing voices or seeing things that aren't present). B. Record review of R #8's care plan dated 03/01/23 revealed the following approaches for risk of elopement safety awareness: 1. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. 2. Provide structured activities. 3. Educate the resident and family of the risks. 4. Engage resident in activities of choice. 5. Report to medical provider. 6. Supervise closely and make regular rounds when the resident is in her room. C. On 06/09/25 at 12:00 pm, during an observation of R #8, she was in the dining room, sitting in her wheelchair. R #8 made three attempts to wheel herself out of the dining room. D. On 06/09/25 at 12:15 pm, a follow up observation with R #8 revealed her sitting in a recliner with the foot part extended. R #8 was attempting to get out of the recliner. E. On 06/09/25 at 12:16 pm, during an interview with Certified Nursing Assistant (CNA) #3 she stated that R #8 was a wanderer so the recliner was used as a way to keep her safely in one place. CNA #3 confirmed that R #8 cannot get out of the recliner without assistance.

Based on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #23) of 1 (R #23) resident reviewed for MDS assessment timing. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are: A. Record review of R #23's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Cerebral aneurysm (a weak spot on an artery in the brain that fills with blood), 4. Chronic heart failure (an ongoing inability to pump enough blood through the body causing an insufficiency of oxygen). B. On 06/10/25 at 8:55 am, during an interview with R #23 she stated that she is on hospice (care and services for people nearing the end of life). C. Record review of R #23's MDS dated [DATE], revealed R #23 is not on hospice. D. Record review of R #23's electronic health record (EHR) revealed the following: 1. R #23's current clinical census showed Hospice Medicaid was started on 05/01/25. 2. An order dated 05/08/25 for hospice service to start effective 05/01/25. 3. A Significant Change MDS dated [DATE] revealed as In Progress indicated the assessment was started but not completed. E. On 06/13/25 at 12:30 pm, during an interview with the MDS Coordinator, she stated that she expects all Significant Change MDS assessments to be completed within 14 days and confirmed that R #23's was not.

Based on observation and interviews, the facility failed to maintain proper infection prevention practices for 3 (R #39, R #43, and R #76) of 4 (R #36, R #39, R #43, and R #76) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 06/12/25 at 9:40 am, during an observation of Certified Medication Aide (CMA) #1 revealed the following: 1. CMA #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #76. 2. CMA #1 then failed to sanitize her hands before beginning her medication pass for R #39. 3. CMA #1 then failed to put gloves on (don) gloves to open a capsule for R #43. B. On 06/12/25 at 10:15 am, during an interview with CMA#1, she confirmed she should have sanitized her hands before beginning the medication pass for R #39. She confirmed she should have sanitized all vital sign equipment before taking R #76's vitals and in between each resident afterwards. She confirmed she should have donned (put on gloves) her gloves before she opened the capsule to pour the medication in the medicine cup for R # 43. C. On 06/12/25 at 10:25 am, during an interview with the Director of Nursing (DON), she stated she would expect all nursing staff to perform hand hygiene before and after each medication pass for each resident. She confirmed she would expect all nursing staff to perform hand hygiene before and after each medication pass for each resident. She confirmed she would expect all nursing staff to sanitize the vital machines before and after use with each resident. She confirmed she would expect all nursing staff to don (put on gloves) gloves before touching any medication for any of the residents.

Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #48) of 1 (R #48) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE]. B. Record review of R #48's physician orders dated [DATE] revealed R #48 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status. C. Record review of R #48's care plan dated [DATE] revealed R #48 was a DNR for her advanced directive code status. D. Record review of R #48's EHR revealed the record did not contain an advanced directive form, the New Mexico Orders for Scope and Treatment (MOST). E. On [DATE] at 12:45 pm during an interview with the Director of Nursing (DON), she confirmed R #48's advanced directive code status, the New Mexico Orders for Scope and Treatment (MOST) was not uploaded into R #48's EHR nor was it available in physical form for nursing staff and should have been.

Based on record review and interview, the facility failed to provide documentation confirming one Nurse Aide (NA), employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 68 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: A. Record review of NA #1's personnel record revealed the following: - The NA's hire date was 12/01/23; - The record did not contain a Certified Nursing Assistant (CNA) License. - NA #1 was employed full time as of 05/17/24. - NA #1 completed the CNA training but did not complete the CNA state licensure exam. B. On 05/17/24, at 10:40 AM, during an interview with the Director of Nursing (DON), she stated NA #1 did not obtain her CNA license within four months of her hire date. The DON stated the NA completed the training but did not test in time DON further stated that NA #1 was working full time at the facility.

Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the dry storage area were stored properly. 2. Ensure all food items in the walk-in refrigerator were labeled and dated. 3. Ensure all food items in the freezer were sealed appropriately. This deficient practice is likely to affect all 75 residents identified on the resident census list provided by the Director of Nursing on 05/13/2024. These deficient practices are likely to expose residents to food borne illnesses. The findings are: Dry Storage Area: A. Observation on 05/13/2024 at 12:35 pm, during initial observation of the facility's food storage area, revealed one case of a 10 pound box of grape juice stored on the bare floor. B. On 05/13/24 at 12:51 pm during an interview with the Dietary Manager (DM), he confirmed the items were on the bare floor. The DM stated there should not be any boxes on the bare floor, and all items should be stored on the shelves. The DM further stated that all kitchen staff were responsible to make sure nothing was on the floors. Walk-In Refrigerator: C. On 05/13/24 at 12:35 pm, an initial observation of the facility's walk-in refrigerator revealed the following: 1. One small pan of orange fluff salad not labeled or dated. 2. One single tomato wrapped in saran wrap with no date. 3. One 2 quart plastic container of apple sauce not labeled or dated. 4. One case of 2 oz. sour cream packets no date. 5. One pack of flour tortillas open to air and not labeled and dated. 6. Two packs of corn tortillas not labeled or dated. 7. Two 2 quart pitchers of juice not labeled or dated. D. On 05/13/2024 at 12:51 pm during an interview with the DM, he confirmed the findings and stated all items should be labeled and dated. The DM stated all kitchen staff were responsible for labeling and dating all items. Facility Freezer: E. On 05/13/24 at 5:52 pm, observation of the facility freezer revealed the following: 1. One box of beef patties open to air and not sealed. 2. One box of cookie dough open to air and not sealed. 3. One box of Salisbury steak patties open to air and not sealed. F. On 05/13/24 at 12:51 pm during an interview with the DM, he confirmed the items should be sealed and not open to air to avoid freezer burn. He further stated the expectation was for staff to close the boxes after removing the food item.

Based on interview and observation, the facility failed to: 1. Ensure the facility had enough food to serve all residents the meal on the menu. 2. Ensure staff served residents a second portion of meal if requested. This deficient practice is likely to affect all residents who eat at the facility. If the facility fails to provide adequate food to meet the nutritional needs of the residents then residents are likely to lose weight and not get their nutritional needs met. The findings are: Ensure the facility had enough food to serve all residents the meal on the menu. A. Record review of Residents Council minutes, dated May 2024, revealed the residents discussed the Dietary Department ran out of food and coffee often. B. On 05/13/24 at 5:49 pm, during a dining observation, revealed staff served some of the residents meals without the vegetables. Further observation revealed the facility ran out of vegetables for the meal. C. On 05/13/24 at 5:50 during an interview, Certified Nurse Aide (CNA) #2 stated the facility ran out of vegetables for the dinner meal, so some residents did not receive vegetables on their plate. CNA #2 stated some of those residents wanted to receive vegetables with their meal. D. On 05/15/24 at 9:23 am, during an interview, R #25 stated the facility ran out of food often. R #25 could not say how often they ran out of food, but she stated it was at least twice a week or more. E. On 05/15/24 at 9:30 am, during an interview with R #54, she stated the facility ran out of coffee, and there were many meals the facility did not provide coffee. The resident stated this often occurred in the morning and the evening. R #54 stated the residents would like to get coffee with their meals when they requested it. R #54 further stated staff told her that they do not always make more then one pot of coffee so it did not get wasted. Ensure staff served residents a second portion of meal if requested. F. On 05/15/24 at 9:23 am, during an interview, R #25 stated residents seldom received a second serving when they requested it. R #25 further stated the staff would say the kitchen did not have enough for seconds. G. On 05/15/24 at 9:33 am, during an interview with R #57, she stated she asked for second portions, but staff tell the residents there was not any second portions available. She further stated the residents are often left hungry. H. On 05/15/24 at 9:35 am, during an interview with R# 58, she stated staff tell them to wait until they serve everyone before they can have seconds. R #58 stated the kitchen runs out of food, and the residents are not able to get a second portion. I. On 05/16/24 at 5:08 pm during a dining observation, staff served residents small portion of egg salad, and residents asked for a second helping. Staff told the residents there was not any second portions, because they ran out of the egg salad. J. On 05/16/24 at 5:10 pm during an interview and observation, the Dietary Aide (DA) stated they ran out of egg salad and were waiting for the kitchen to bring more. The DA left the dining room, and staff did not bring any more egg salad for the residents. K. On 05/16/24 at 5:39 pm during interview, R #37 stated she requested an extra serving of egg salad, and the DA told her there was not enough food for another serving.

Based on record review and interview, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #13) of 1 (R #13) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents. The findings are: A. Record review of R #13's most recent PASRR, dated 12/27/21, revealed the following: - Individual information: Staff documented schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) as a pertinent diagnoses. - Identification of mental illness (MI) evaluation criteria: Staff documented No, the resident did not have a diagnosis or suspected mental illness in Section C1. The criteria listed schizophrenia as a MI, but staff did not enter the diagnosis of schizophrenia. B. Record review of R # 13's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/26/24, revealed R #13 had a diagnosis of schizophrenia. C. On 05/16/24 at 4:20 PM during interview with Admissions Coordinator (AC), she confirmed the PASRR for R # 13 was incorrect, because it did not acknowledge R #1's diagnosis of schizophrenia in Section C1. She stated the PASRR was completed by the discharging hospital, and facility staff should have reviewed it prior to admission. D. On 05/17/24 at 9:13 AM during interview with the Social Services Director, she stated the PASRR for R #13 was incorrect, because staff should have documented in Section C1 that the resident had a diagnosis of schizophrenia.

Based on interview and record review, the facility failed to ensure residents were invited to attend care plan meetings for 2 (R #23 and R #30) of 2 (R #23 and R #30) residents reviewed for participation in care planning. If residents are not able to participate in their care plan development, then residents could likely not get the care and treatment they want or need. The findings are: R #23 A. Record review of R #23's face sheet revealed R #23 was admitted into the facility on [DATE]. B. On 05/13/24 at 4:18 pm, during an interview with R #23, she stated she did not attend the last care plan meeting that was scheduled. R #23 stated it was important to her to attend her own meetings. She stated she previously talked with the Social Services Director (SSD) and explained to her that she wanted to be involved in her care and her meetings. C. Record review of R #23's Care Plan Conference (a document the facility uses to record details of a care plan meeting including attendees), dated 04/24/24, revealed R #23 did not attend her care plan meeting because she was napping and has not been sleeping well so nursing requested not to wake her. The meeting was held without the resident present. D. On 05/17/24 at 9:10 am, during an interview with the SSD she stated R #23 did not attend her care plan meeting. The SSD confirmed she knew it was important for R #23 to attend her meetings and stated this meeting should have been rescheduled until R #23 was able to attend. R #30 E. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE]. F. On 05/13/24 at 2:41 pm, during an interview with R #30 he said, I've never been invited to one of those [care plan meeting]. G. Record review of R #30's Electronic Health Record revealed the record did not contain documentation to show staff held a care plan meeting for the resident. H. On 05/17/24 at 9:10 am, during an interview with the SSD, she stated she could not produce a Care Plan Conference form to show a care plan meeting for R #30 occurred. The SSD stated Care Plan Conference forms should be kept in the resident's Electronic Health Record, but R #30's Electronic Health Record did not contain Care Plan Conference documentation. The SSD stated she was responsible to complete the Care Plan Conference forms for the residents' records.

Based on observation, record review, and interview, the facility failed to ensure a resident who was admitted with an indwelling Foley (name of device) catheter (a thin, sterile tube inserted into the bladder to drain urine) was assessed for the removal of the catheter for 1 (R #46) of 1 (R #46) sampled residents with an indwelling urinary catheter. This failed practice is likely to cause R #46 to not regain bladder control, to develop bladder incontinence, or to develop a bladder infection. The findings are: A. Record review of R #46's face sheet revealed the resident was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of the sacral region (the portion of the spine between the lower back and the tailbone), Stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone). B. Record review of R #46's wound reports, dated April and May 2024, revealed R #46's pressure injury was stable (had not changed since admission on 03/29/24.) C. Record review of R #46's physician orders revealed an order, dated 04/23/24, for a Foley catheter: Continue Foley catheter due to pressure wound of coccyx. D. Record review of R #46's progress notes, dated 05/01/24 and entered by the Nurse practitioner (NP), stated R #46 was alert, oriented, and able to follow commands. The note also stated R #46 did not have incontinence (loss of bladder control). E. On 05/14/24 at 10:50 am, R #46 lay in bed with a Foley catheter drainage bag (bag attached to end of tube inserted into the bladder that collects urine as it drains) attached to the bed frame. The catheter tubing and drainage bag contained light yellow, translucent urine with no foul odors. F. On 05/14/24 at 10:59 am during an interview, R #46 stated she did not want the Foley catheter in place, and she did not know why the facility staff did not removed it. R #46 also stated she utilized a bedside commode as needed. G. On 05/16/24 at 2:21 pm during an interview, LPN #1 stated R #46 came into the facility with the Foley catheter. LPN #1 stated she did not see a diagnosis in the resident's record that related to the Foley catheter use. She further stated she was not aware if staff attempted a trial to discontinue the resident's catheter (remove the catheter) since R #46 was admitted to the facility. H. On 05/16/24 at 6:17 pm during an interview with the Director of Nursing (DON), she stated the reason for R #46's Foley catheter was to promote wound healing. I. On 05/17/24 during an interview with the facility NP, she stated R #46's Foley catheter was left in place so the wound on her backside (a Stage 4 pressure injury) did not get infected or soiled. She further stated the catheter was to be left in place until the wound reached a healing stage. She stated typically staff attempted a trial void (the Foley catheter is removed and if the person is able to void within 8 hours of removal then the catheter is discontinued) with a resident as soon as possible. J. On 05/17/24 at 9:10 am during an interview with the Medical Director (MD), she stated if a resident was cognitively aware, could use their call light to call for assistance, and could use the bedside commode (such as R #46) then her expectation would be for staff to attempt to discontinue the catheter as soon as possible, especially if the resident stated she no longer wanted the catheter. She stated it was also her expectation that facility staff inform her of the resident's wish to discontinue the catheter, but staff did not make her aware of R #46's request to have the catheter removed. K. On 05/17/24 at 9:37 am during an interview with ADON/Wound Care Nurse, she stated R #46's wound remained the same, and R #46 did not express pain with dressing changes or when up to her chair or bedside commode, indicating R #46 was able to sustain transfers and bedside toileting without experiencing pain caused by the pressure injury.

Based on observation, record review, and interview, the facility failed to provide an adaptive eating device (a tool that helped a person with a disability do a certain task) for 1 (R #35) of 1 (R #35) residents reviewed during dining observation. If residents are not provided adaptive eating devices as needed, then residents might be unable to consume their meals and beverages and likely to have weight loss, malnutrition, and dehydration. The findings are: A. Record review of R #35's Physician's orders, dated 05/13/24, revealed the resident was to use a plate guard for meals as tolerated for improved self-feeding skills. B. Record review of R #35's meal ticket, dated 05/13/24, revealed it did not direct staff to provide adaptive feeding equipment for the resident. C. On 05/13/24 at 5:09 pm during a dining observation, R #35 ate her meal without an adaptive eating device. At 5:36 pm, Certified Nursing Assistant (CNA) #2 put a plate guard (a curved piece of material that fits around the rim of a plate to prevent food from falling off) on R #35's plate. D. On 05/13/24 at 5:40 pm, CNA #2 stated R #35 had an order for a plate guard, and she should have served the resident's meal with a plate guard on the plate.

Based on record review, observation, and interview the facility failed to 1) Develop a comprehensive care plan and 2) Implement a comprehensive care plan for 4 (R #2, 30, 31 and 41) of 4 (R #2, 30, 31 and 41) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being. the findings are: Findings for R #2 A. Record review of facility face sheet for R #2 admitted on [DATE] revealed admission diagnoses which included: Heart Disease (conditions that affect the heart's function and blood flow), Kidney Failure (kidneys no longer function well on their own), Reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), Obesity (overweight), Hernia (organ or tissue bulges through a weak spot in the abdominal wall), Vitamin D Deficiency (low vitamin D levels), Fracture (bone break), Muscle Atrophy (loss or thinning of muscle), Dependence On Wheelchair, Hypothyroidism (low thyroid levels), Hyperlipidemia (high cholesterol), Dysphagia (trouble swallowing), Multiple Sclerosis (central nervous disease), Weakness, Need For Assistance With Personal Care, Pressure Ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin), Fracture Of Right Tibia (broken leg bone), Fracture Of Right Fibula (broken leg bone), Cognitive Communication Deficit (trouble thinking and speaking). B. Record review of R #2's weights revealed on 12/02/2022, the resident weighed 242 lbs and on 05/04/2023, the resident weighed 204.6 pounds which is a -15.45 % weight loss.: C. Record review of R #2's Care Plan dated 04/21/23 revealed that it did not address weight loss. D. Record review of Progress notes for R #2 revealed the following: 04/27/2023 at 14:08 (2:08 pm) Nutrition Note Text: Name: (name of R #2) RD (Registered Dietician) following Rsd (resident) d/t (due to) wound and severe weight loss. Rsd is currently 201.5 lbs and within ideal range of 171-209 lbs and 99.8% of ideal weight, BMI (a measure of body fat: 24.5. Ht: 76 Severe weight loss of 69.8 lbs, 25.7% in 2 months. Diet order: Regular/Pureed; Supplements: Liquacel BID (2 times a day). Appetite: Poor/Fair, 25-50%; Nutrition Diagnosis: Inadequate oral intake related to increased nutrient needs as evidenced by wound and severe weight loss.; Recommendations: Ensure TID (3 times a day) d/t poor/fair appetite, recent severe weight loss and wounds.; RD following monthly/PRN. 05/4/2023 at 16:16 (4:16 pm) Nutrition Note Text: Name: (name of R #2) RD following Rsd d/t wound and severe weight loss. Rsd is currently 204.6 lbs and within ideal range of 171-209 lbs and 107.7% of ideal weight, BMI: 24.9. Ht: 76 . Severe weight loss of 67 lbs, 24.6% in 3 months. Diet order: Regular/Pureed Supplements: Liquacel BID/Ensure TID; Appetite: Poor/Fair, 25-50%; Nutrition Diagnosis: Inadequate oral intake related to increased nutrient needs as evidenced by wound and severe weight loss.; Recommendations: Ensure TID added 4/28(/23) for this wt loss, rsd with beneficial gain of 3.1 lbs, 1.5% in 1 mo., continue POC (Plan of Care) at this time. RD following monthly/PRN (as needed). E. On 05/11/23 at 5:47 pm, during an interview with the DON, she confirmed that a nutritional weight loss plan was not developed for R #2 after his significant weight loss. Findings for R #30 F On 05/08/23 during a record review of R #30's facility face sheet revealed admitting diagnoses for admission of 07/29/21 and included: Non-st elevation (nstemi) myocardial infarction (heart attack). Unspecified ectropion of left lower eyelid (watery eyes without proper drainage). Chronic pain (arthritis right knee). Other seasonal allergic rhinitis (allergies to environment). Mixed hyperlipidemia (fat in the blood). Major depressive disorder (sadness,or disinterest in things previously interested in). Anxiety (feeling of panic, doom, fast heart rate). Restless legs syndrome (inability to be still and rest, feeling like you must move your legs). Essential hypertension (high blood pressure not due to another condition). Atherosclerotic heart disease of native coronary artery without angina pectoris (hardening of the arteries, without pain). Old myocardial infarction (previous heart attacks). Chronic obstructive pulmonary disease (difficulty breathing) low back pain. Unsteadiness on feet(dizziness, lack of balance). Weakness (lack of strength or energy). Other malaise (feeling sick, lack of energy), other fatigue (tiredness, not improved with rest). Dependence on supplemental oxygen (requirement of more oxygen than room air for tissue health). Personal history of COVID-19. Dysphagia (difficulty swallowing for unknown reason). G. Record review of the facility provided smoker list (not dated) on 05/08/23 indicated R #30 was an independent smoker. H. Record review of R #30's initial care plan dated 05/08/23 identified the resident as a/an independent smoker. I. On 05/10/23 at 9:15 am, during an interview with R #30, she (R #30) stated she was/is a smoker. J. Record review of Minimum Data Set (MDS) for R #30 revealed the resident was not evaluated for smoking. K. Record review of smoker policy dated 12/2017, revealed: Nursing Policy and Procedure Subject Smoking. Policy: It is the policy of this home that :*All residents who smoke will be supervised. L. Record review of facility Smoking by Residents policy, dated 03/2022 revealed: Purpose . Policy . IV. Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas. V. Residents who are not able to smoke independently and safely will be accompanied by Facility Staff while smoking. Procedure I. Smokers shall be identified at the time of admission. A. Residents will be provided with a copy of this policy during admission process a. All smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by OBRA (Omnubus Budget Reconciliation Act of 1987) assessment time frames. b. If necessary, a referral to PT/OT (Physical Therapy/Occupational Therapy) to access for the necessary eye-hand coordination and cognitive skills for safe smoking may be required. II. The IDT (Interdisciplinary Team) shall create a Smoking Care Plan for the resident. X. All smoking sessions will be supervised by facility Staff members. M. On 05/10/23 at 9:30 am, during an interview with the Minimum Data Set (MDS) Coordinator/Care Plan Coordinator (CPC) about R #30's independent smoker status, she brought up the computer information and said, yes she is listed as an independent smoker and has a care plan for independent smoking, but she doesn't smoke. That is a mistake on the smoker list and care plan. R #30 is not a smoker, she (R 30) only went out to smoke once that I know of. When asked why she (R #30) was smoking, she (R #30) stated, I don't know, another resident gave me one and I smoked it. She is not a smoker. N. The MDS/CPC acknowledged the conflict of provided information documented for R #30, including R #30's interview, R #30 being on the smoker list, (undated), the care plan dated 05/08/2023), and the facility provided policy and procedure (dated 12/2017 and 03/2020) which stated, all smoking sessions will be supervised by facility Staff members. O. On 05/10/23 at 11:30 am during an interview the MDS/CPC she stated, I just spoke with the Director of Nursing about (name of R #30) and she (R #30) is not a smoker, she does not need a care plan for smoking, or to be on the smoker list. That will be corrected at our next IDT meeting. They happen in the morning and at night. That is when we update the resident information Findings R #31 P. Record review of current facility face sheet dated 07/04/22 for R #31 revealed admitting diagnoses which included: Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Muscle Weakness, Hypothyroidism (low hormone), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Bipolar Disorder (mood swings), Major Depressive Disorder (feeling of sadness), Anxiety Disorder (feeling of fear), Post-Traumatic Stress Disorder (disorder caused by trauma), Mild Cognitive Impairment (memory loss), Polyneuropathy (nerve pain), Hypertension (High Blood Pressure), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastritis (intestinal swelling), Radiculopathy, Lumbosacral Region (pinched nerve in lower back), Urinary Incontinence, Hallucinations (seeing or hearing things not there), and Morbid Obesity Due To Excess Calories. Q. On 05/09/23 at 10:26 am, during an observation R #31 appeared agitated (yelling out and talking over other residents) while at the resident council meeting. R. Record review of current care plan initiated on 03/01/23 revealed no care plan related to R #31's PTSD diagnosis. S. Record review of previous care plan dated 01/18/23 revealed a care plan which addressed PTSD diagnosis within the psychotropic drug use plan. T. On 05/16/23 at 10:45, during an Interview with DON, she stated that R #31 did not have a current care plan to address active PTSD diagnosis. Findings for R #41 U. Record review of facility face sheet for R #41 revealed admitting diagnoses which included: cerebral infarction (stroke) COPD (chronic lung disease which causes shortness of breath), cognitive communication deficit (difficulty thinking and making self understood) depression (sadness or loss of interest), dysarthria (weakened speech muscles), and anxiety (a feeling of panic or doom, difficulty concentrating). V. Record review of facility (undated) Smokers list provided by the facility revealed Smoking Hours for Supervised Smokers were as follows: 0800 (am), 1000 (am), 2 (pm) and 6 (pm) W. Record review of R # 41's care plan for nursing dated 03/15/23 indicated R #41, needs supervision while smoking. The care plan also indicated, Encourage resident to wear smoking apron while smoking to prevent injuries, and to smoke with supervision. X. Record review of R # 41's activity care plan dated 05/09/23 indicated that he is an independent smoker. Y. Record review of smoker policies provided by the facility dated 12/2017, and 03/2022 stated: 1. All residents will be supervised by staff during smoking. 2. Resident was observed smoking, outside facility set smoking hours. AA. On 05/10/23 at 9:45 am, during an observation of R #41 revealed he was out on the patio smoking. He was unaccompanied, and there were no staff members outside supervising smoking. BB. On 05/10/23 at 9:47 am, during an interview R #41 stated, I am an independent smoker and I don't want to wear an apron. 47333 47636

Based on observation, record review and interview, the facility failed to store food under sanitary conditions by not ensuring (1) Food items stored in facilities dry storage were labeled and dated, (2) Food items in the dry storage area were stored in the correct locations, and (3) expired foods were either used or discarded prior to expiration date. These deficient practices are likely to affect all 61 residents residing in the facility, and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On [DATE] at 9:55 am during the initial tour of the facility kitchen the following was observed: 1. Two- 1.5 gallon Tupperware container of cereal was labeled use by [DATE] and was still on the shelf. 2. One- 1.5 gallon Tupperware container of cereal was labeled use by [DATE] and was still on the shelf. 3. One large metal mixing bowl with a powdery substance was wrapped in plastic wrap, unlabeled and stored on the shelf. 4. One undated package of gelatin was wrapped in plastic and stored on the shelf. 5. One undated box of brownie mix was stored on shelf. 6. Two undated bags of Frito were stored on the shelf. 7. Several boxes of food products were sitting on the bare floor. B. During observation of the lunch meal [DATE] at 12:12 pm the following was observed: 1. The food traveled the entire length of the facility from the kitchen to the dining area in an unheated wire cart. 2. There were not any posted menus in the dining area. C. During observation of the dining area at lunch on [DATE] at 12:26 pm the following was observed: 1. Food arriving to the dining area was over 15 minutes late. 2. Menus were not posted in the dining area. 3. A resident did not want the food on the menu and ordered an alternative. The alternative menu took 25 minutes to arrive for the resident's meal. D. On [DATE] at 8:10 am, during an interview the Director of Dietary Services (DDS) stated that the facility had ordered hot boxes (insulated food transport carts), however they had not come in yet, as well as the menu displays which had not been placed up for resident viewing. He acknowledged that the equipment used to serve meals impedes the entry and exit of the right side door use. E. On [DATE] at 8:30 am, during an interview the Director of Dietary Services (DDS) stated that menus had been made for both the south and main dining areas and sent out to the nurses stations, but could not say as to why they had not been displayed. DDS stated that the meals are made in the kitchen then transported on open wire carts to the main dining room and placed on a steam table. The meals are then plated from the steam table and sent out to the residents. Room trays are made from the steam tables and the plate is then placed on the open wire cart and domed (insulated plate topper). He stated that several are made and then sent out to the residents rooms. He stated that the plates did not have a bottom insulated base to go along with the dome tops. When given the scenario of the earlier observation and the times that the plates sat on the cart; he acknowledged that the plates could have lost significant heat. F. On [DATE] at 12:49 pm during a subsequent visit to the kitchen and interview with the dietary manager he confirmed the above findings and stated that, all food items should be labeled and dated and nothing should be set on the bare floor. G. Record review of the facility's Food Storage policy dated ,d+[DATE] revealed: Purpose: To establish guidelines for storing, thawing, and preparing food. Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. XIII. Dry Storage Guidelines F. Foods should be stored off the floor. G. Any opened products should be placed in storage containers with tight fitting lids. H. Label and date storage products.

Based on observation and interview, the facility failed to maintain a safe and comfortable homelike environment in the dining area. This failure has the potential to affect the 54 residents that choose to eat in the main dining facility. The findings are: A. On 05/08/23 at 12:12 pm during lunch observation in the dining area the following was revealed: 1. The food arrived in the dining area 15 minutes later than the scheduled lunch start time of 12:00 pm. 2. The dining area was very crowded with residents, wheelchairs and walkers making moving around difficult to include entering the dining area, serving and assisting the residents with dining, and exiting the area after the meal was complete. 3. The overcrowding of the area caused high sound levels which made any conversation difficult as it was hard to hear another person. This also caused it to be difficult to get staff attention for assistance. 4. One of the two access doors was blocked by the serving carts and staff making any egress impossible. B. On 05/08/23 at 12:45 pm during an interview with the Corporate Dietary Director, he confirmed that the dining facility was crowded and loud. He went on to state that, they were working on a plan to correct that. C. On 05/09/23 at 10:00 am during the resident council meeting, resident council members brought up the following concerns : 1. The dining area is overcrowded and very loud during meals. 2. Some residents avoid eating meals in the dining area due to the overcrowding and noise levels. D. On 05/09/23 at 12:26 pm during lunch observation in the dining area the following was revealed: 1. The dining area was crowded with residents (54) causing high noise levels and making any conversation difficult. 2. One of two access doors was blocked by serving carts and staff. 3. Dining assistance staff having difficulty maneuvering around room and between residents to deliver meals. 4. One resident got impatient with the noise and yelled out quiet! to the other residents in order to get staff's attention. 5. Four (4) residents having difficulty leaving the area after their meal was complete due to the crowded conditions. Other residents had to move their wheelchairs, walkers and themselves in order for other residents to leave. E. On 05/10/23 at 8:10 am during an interview with the Administrator (ADM), she stated that the fire Marshall had put an occupancy on the room for 90 people, but understood that the area is crowded. She acknowledged that it would be difficult to maneuver through the area with a resident if they had an emergency.

Based on observation, record review, and interview, the facility failed to ensure adequate pain relief for 1 (R #41) of 1 (R #41) resident reviewed for pain. This failure could likely result in unrelieved pain and diminished quality of life for the resident. The findings are: A. On 05/09/23 at 12:45 pm while observing R #41 during a conversation with Licensed Practical Nurse (LPN) #1, as he was exiting the dining room, it was noted that R #41 stopped his motorized wheelchair, was bending forward, and grimacing between words while speaking to LPN #1. (Using a Wong Baker faces pain scale allows medical personnel to visually assess pain with zero 0 being no pain, and ten 10 being the worst imaginable). R #41 appeared to be in discomfort, and had to stop and rest while talking. LPN #1 was asking R #41 if he needed anything at the moment. R # 41 was unable to speak more that a couple of words at a time. LPN #1 stated she, would meet him at his room and see what he could have. B. Record review of R #41's care plan dated 03/15/23 revealed R #41 had diagnoses which included cerebral infarction (stroke), COPD (chronic lung disease which causes shortness of breath), cognitive communication deficit (difficulty thinking and making self understood) depression (sadness or loss of interest), dysarthria (weakened speech muscles), and anxiety (a feeling of panic or doom, difficulty concentrating). 1. The Physician order dated 03/08/23 at 11:44 am reads, Acetaminophen Tablet 325 milligrams. Give 2 tablets by mouth every 4 hours as needed for general discomfort. 2. The MAR lists pain assessment as once a shift. C. Record review of R #41's care plan dated 03/15/23 revealed that R #41 had back pain. The desired outcome was documented as, R #41's pain will be relieved by rest, pain reliever and (name of R #41) will not have an interruption in normal activities due to pain. D. Record review of R #41's care plan revised on 05/09/23 revealed: 1. R #41 is at risk for pain from co-morbidities. (More than one health condition in a person at the same time.) a. administer pain medication as ordered. The order read, Acetaminophen tablet, 325 milligrams. Give two (2) tablets by mouth every four (4) hours as needed for general discomfort. b. evaluate characteristics and frequency/pattern of pain. The ordered frequency of pain assessment was once per shift. c. there is no order or documentation about the characteristics or pattern of pain on the MAR. d. monitor for potential nutritional problem r/t (related to) discomforts or pain. e. evaluate what makes R #41's pain worse. f. maintain adequate level of comfort as evidenced by no s/sx (signs or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort. h. The (MAR), for May 2023, indicated R #41 rated his pain as 8 on 05/02/23, 6on 05/08/23, 9 on 05/09/23, and 8 on 05/10/23 using the facility provided pain scale. i. The facility pain scale on the Medication Record for May 2023 lists the pain scale to be used, as, 0-No Pain, 1-4-Mild Pain, 5-7-Moderate Pain, 8-10-Severe Pain. R #41's May 2023, Medication Administration record (MAR) indicated R #41 rated his pain 5 days out of 10 days (May 1-10, 2023) as 6 or above. i. Review of R # 41's MAR showed Tylenol was given for pain on one shift for the month of May for a pain rating of 8 on 05/10/23 at 8:10 am. E. On 05/10/23 at 2:45 pm during an interview with R #41, he stated that, sometimes he had pain and, would like to try a different medicine if he could. F. On 05/10/23 at 3:30 pm during an interview with Licensed Practical Nurse (LPN) # 1, she stated, no, I don't think (R #41) has adequate pain control. G. Record review of the month of 05/23 MAR, it was indicated that during pain rating for R #41 complained of pain each day with five (5) of the ten (10) days being rated as, 6 or more. The MAR stated to do resident assessment for pain every day, but the physician order stated R #41 could have pain medication every 4 hours as needed.

Based on record review and interview the following was identified: 1. R#1 had an indwelling Foley Catheter (the Foley is a hollow, flexible tube that is inserted into the bladder through the urethra) with drainage bag that needed to be emptied every shift. 2. Beginning [DATE], nurse aides began documenting that R #1 had dark brown urine when the drainage bag was emptied. 3. Interviews conducted with licensed and registered nurses indicated nurse aides did not communicate to them when R#1's urine was dark brown. 4. Visit note reports from Hospice dated [DATE], [DATE], and [DATE] indicated R #1's urine had a strong, foul odor. The notes indicated dark brown urine draining with thick, mucousy sediment (gritty particles or [MEDICATION(S)] in the urine) in the tubing. 5. R#1 passed away on [DATE]. A private autopsy was performed. 6. Office of the Medical Investigator indicated [CONDITION(S)] (A life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) was the cause of R #1's death and the source was a urinary tract infection ([CONDITION(S)]) (Infection of any part of the urinary system, including kidneys, ureters (One of the two tubes that carry urine from the kidneys to the bladder), bladder (the organ that holds urine until it is ready to be released), and urethra (the tubular passage through which urine is discharged from the bladder to the exterior of the body). This resulted in an Immediate Jeopardy (IJ) being called on [DATE] at 12:10 pm. The facility administrator and Director of Nursing (DON) were notified at this time. A plan of removal was received and accepted on [DATE] at 2:30 pm. Implementation of the Plan of Removal was validated onsite. The Plan of Removal included: 1. Utilizing the plan of care 31 of 44 residents were identified at risk for [CONDITION(S)]'s and 1 of 44 residents identified at risk because of a suprapubic catheter. (A suprapubic catheter is a type of urinary catheter. It empties the bladder through an incision in the belly instead of a tube in the urethra). 2. All care plans were reviewed for the 32 residents at risk. 3. An assessment of resident with suprapubic catheter was completed and entered into the EHR. 4. Inservice was initiated on [DATE] by DON on adequate monitoring and documentation of urine characteristics for residents with catheters and at risk for [CONDITION(S)]'s. Licensed nurses will be responsible for emptying all catheter bags and documenting in the progress notes. Medical Doctor (MD) will be notified immediately of residents symptoms and treatment initiated as indicated. All nursing personnel will be inserviced prior to the beginning of each shift until all staff have been inserviced. 5. Administrator will monitor licensed nurses's foley/suprapubic documentation each morning at morning meeting and inservices if any discrepancies noted. New interventions will be added to the care plan immediately. Based on record review and interview the facility failed to recognize the signs and symptoms of a [CONDITION(S)] for one (R #1) of one (R #1) reviewed for foley catheters and [CONDITION(S)]'s. This failure likely resulted in R #1 becoming septic and dying from a [CONDITION(S)]. The findings are: A. Review of a consumer complaint received by the State Survey Agency on [DATE] indicated a family member of R #1 was concerned about the care and services R #1 had received at the facility. The concerns were specific to neglect in regards to R #1's foley catheter, [CONDITION(S)] and rapid health decline. The complaint indicated R #1 died on [DATE] and the family had an autopsy performed. B. Review of R #1's medical record indicated an admitted [DATE]. R #1's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] D. Review of R #1's care plan dated [DATE] indicated the resident is at risk for [CONDITION(S)]'s. Approaches include: observe for change in mental status, or signs and symptoms of [CONDITION(S)]; observe for decreased urine output, foul smelling urine, blood tinged urine or painful urination. The care plan also indicated R #1 had an indwelling (foley) catheter. Approaches to address the indwelling catheter included: drain foley catheter of urine at the end of each shift, assess drainage. Record the amount, type, color, and odor; report signs or symptoms of [CONDITION(S)] to include foul odor, concentrated urine, and malaise (general feeling of discomfort, illness, or lack of well-being). E. On [DATE] at 12:30 pm during an interview, the DON stated nursing assistants should be documenting urine output for R #1 in the Vitals section of the EHR. 1. Record review of the vital section indicated only one entry for urine. It was dated [DATE]. The note indicates the characteristics of the urine as brown/dark. 2. On [DATE] at 2:00 pm during an interview, the DON stated not all nursing assistants have access to the resident's EHR (Electronic Health Record) and some documentation of urine characteristics for R #1 could be recorded on the facility shower sheets. F. Record review of the facility shower sheets for R #1 provided by the DON for the month of [DATE] indicated the following for urine output: 1. [DATE]- 600 millimeters (ml) of brown urine, 2. [DATE]- 300 ml of brown urine, 3. [DATE]-600 ml of brown urine, 4. [DATE]- 900 ml of brown urine, 5. [DATE]- 400 ml of brown urine, 6. [DATE]-500 ml of brown urine, 7. [DATE]-1000 ml of dark brown urine. 8. [DATE]- 450 ml of brown urine, 9. [DATE] - 950 ml of dark, brown urine, catheter leaking all the time. G. On [DATE] at 11:45 am during an interview, Nursing Assistant (NA) #1 stated she did not have access to R #1's EHR. She stated that she documented on the shower sheets when she emptied the foley drainage bag for R #1. NA #1 stated R #1's urine was consistently brown, similar to chocolate milk. She stated she did not notify nursing of R #1's brown urine. H. On [DATE] at 3:00 pm during an interview, Certified Nursing Assistant (CNA) #1 stated no one had told her to document the urine amount or color in the shower sheets or the EHR. She stated R #1's urine had an odor and was similar to coffee in color. She stated she did not tell any nurse about the color and odor of R #1's urine. I. On [DATE] at 3:10 pm during an interview, NA #2 stated R #1's urine was dark brown. NA #2 stated she told a nurse about the dark brown color and was told it was normal for R#1. NA #2 could not recall which nurse she had spoken to. J. On [DATE] at 12:30 pm during an interview, Registered Nurse (RN) #1 stated she was not aware of R #1's urine color and consistency. She stated no one had brought it to her attention. K. On [DATE] at 1:10 pm during an interview, Licensed Practical Nurse (LPN) #1 stated, no one ever told me (name of R#1) urine was brown. If they had, I would have gone down and completed an assessment. Normal urine color for (name of R #1) was a greenish yellow. J. Record review of facility policy and procedure, entitled Urinary Catheter Care .complications, check the urine for unusual appearance (i.e., color, blood, etc),,,,notify the supervisor of any discharge, odor, bleeding, discolored urine. K. Record review of nursing progress notes for R #1 indicated that on [DATE] at 1:30 pm, RN #1 spoke with R #1's Power of Attorney (POA) regarding R#1's condition to include decreased urine output with dark colored urine. Documentation indicates R#1 was place on Hospice at 7:01 pm on [DATE]. L. Record review of Hospice Visit Report dated [DATE] indicated the following: Strong, foul odor noted upon entering room. Staff report that smell is from urine. Has a catheter in place draining dark brown urine with moderate amount of thick, mucousy sediment noted in tubing. Strong, foul odor noted to urine. M. On [DATE] at 12:45 pm during an interview, Hospice RN #1, who completed the visit on [DATE] stated (name of R #1) did not develop the [CONDITION(S)] overnight, that it had been in process for probably 2 weeks. I have never seen the color and consistency or smelt the odor coming from (name of Resident #1) before. I was shocked. N. Record Review of Hospice Visit Report dated [DATE] indicated the following: 'Upon entrance to patient room a foul smell was immediately noted by this nurse. When ask about the smell, facility nurse replied, it is his catheter. This nurse noted catheter drainage bag with brown/green colored urine present with [MEDICATION(S)] and sediment present. New orders placed for an antibiotic for the [CONDITION(S)]. O. Record Review of Hospice Visit Report dated [DATE] indicated the following: .A foul smell could be smelt as soon as you approached the closed door of the patient's room. Upon entrance to room, this nurse noted catheter drainage bag lying on the floor, unsecured, with brown/green colored urine present with [MEDICATION(S)] and sediment. P. On [DATE] at 11:15 am during an interview, Hospice RN #2 who completed the visits on [DATE] and [DATE] stated, (name of R #1) [CONDITION(S)] was extremely severe and should not have had that smell. She stated the [CONDITION(S)] had to have been ongoing for a couple of weeks. Q. Record review of facility progress notes dated [DATE] at 7:07 pm indicated R #1 was without vital signs and no respirations. R #1 was pronounced deceased at 6:45 pm on [DATE]. R. On [DATE] at 2:00 pm during an interview, Medical Doctor (MD) #1 from the Office of the Medical Investigator, stated R #1 died from [CONDITION(S)]. MD #1 also stated there was no other source of [CONDITION(S)], except for the [CONDITION(S)].

Based on record review and interview the facility failed to 1) assess for injury, 2) identify injury, and 3) provide timely examination by a physician for 1 (R #40) of 3 (R #s 22, 40, and 43) residents when R #40 continued to complain of pain after he hit his left leg. The deficient practice likely led to R #40 suffering pain and psychosocial harm for 12 days due to fractures of left lower extremity. The findings are: [NAME] Record review of Facility Face Sheet dated 02/11/19 revealed this as an initial admitting date for R #40. The following [DIAGNOSES REDACTED]. B. Record review of Consumer Complaint Summary dated 07/18/19 revealed, On Saturday, (MONTH) the 6th I (FM #2) was contacted by my Grandfather (name of R #40) . He asked that I come to the rest home see him . I immediately got dressed and drove to the rest home. Upon arriving at (name of facility) I met with my Grandfather . He advised me that on (MONTH) 2nd he had hit his leg on the bed rail and it was hurting him severely. I said where does it hurt and had he let the nurses know of his injury. He advised me that the day he banged into the bed rail he went to the nurses station and let the nurse know he had injured his left leg . I proceeded to the nurses station and made contact with (Name of RN #2) who was on duty at the time. I said my Grandfather was in severe pain and he has advised me that he injured his leg on the 2nd of (MONTH) and that the Dr. has still not looked at it. (Name of RN #2) told me the Dr. was aware and she was told to give him Tylenol for pain. I told her it still needs to be looked at as he is crying and is in pain . (There was no documentation to indicate that a pain assessment was completed at this time.) C. Record review of Physician's Progress Notes dated 07/14/19 at 3:14 pm revealed, .Patient states that he has pain to the left leg and ankle. He is not sure if he had any fall or injury and nurse also did not mention any particular injury. He denies any knee pain. He was getting Tylenol BID (twice daily) but without relief . Physical Exam . left ankle - very painful to touch. Also left leg has small superficial abrasions with shiny skin . Pain in left ankle and joints of left foot . Today's Impression: will get X-ray. Will give [MEDICATION NAME] for pain. Tylenol prn (as needed) . also appearance of his left leg is concerning for PAD (Peripheral Artery Disease - circulatory problem in which narrowed arteries reduce blood flow to your limbs), will get Doppler US arterial. D. Record review of Progress Notes dated 07/14/19 at 12:27 am for R #40 revealed, New orders received per (name of physician) yesterday for X-Ray of left ankle (two views) and for a Doppler Ultrasound (test that can be used to estimate the blood flow through your blood vessels) LLE (left lower extremity) for [MEDICAL CONDITION] (swelling) to leg. Also a new order for [MEDICATION NAME] (pain medication) 50mg (milligrams) tab (tablet), 1 tab PO (by mouth) BID (twice a day). (Name), POA (Power of Attorney) and residents son stated that he would like for (name of R #40) to get the X-ray and the Doppler done in one trip. He stated that for (name of R #40) to have to make two different trips would be to hard and painful for him to make. (Name) in Social Services aware of this and said she would set them up for Monday (07/15/19), if possible. E. Record review of X-ray Report dated 07/16/19 for R #40 revealed that the findings of the ankle x-ray included the following: Distal tibia (outer side of shinbone) and distal fibula (outer side of calf bone) fractures; medial (middle) cortical (outer) margin of the tibias is offset 5.5 mm (millimeters); there is arthritic (inflammation of joints) change at the ankle joint; age of fractures is uncertain but appears to be acute (sudden onset) to subacute (rather recent onset). F. Record review of Emergency Center Physician Documentation dated 07/17/19 at 5:26 pm for R #40 revealed that R #40 was seen for a leg fracture, patient from (name of city) for possible left tibia fibula fracture status [REDACTED]. The patient presents with left lower leg pain after patient ran into bed rail on (MONTH) 2nd. The onset was 2 weeks ago. The course/duration of symptoms is constant. Type of injury is a direct blow; location is left leg; character of symptoms is pain and swelling. The findings are: generalized osteopenia which limits evaluation; there is a nondisplaced proximal tibial shaft fracture; nondisplaced (cracked but still aligned) distal tibial and fibular shaft fractures; soft tissue swelling of the ankle; and vascular calcifications (hardened calcium deposits in blood vessels) are noted. Nondisplaced fracture along the inferior patella (lowest part of kneecap) is not excluded. Recommend clinical correlation for local pain. G. Record review of Progress Notes dated 07/17/2019 at 06:50 pm for R #40 revealed, Called (name of hospital) to get an update on resident. Splint was applied to the left leg with fracture. Follow up appointment will need to be made in two weeks. (Name of hospital) is currently working on a ride to get the resident back to (name of facility). Notified DON. No further concerns at this time. H. Record review of Progress Notes dated 07/18/2019 at 12:00 am for R #40 revealed, Returned to facility via EMS (Emergency Medical Services) from (name of hospital). Son and grandson arrived at that time also. Transfer to bed with assist of 4. Ace wrap covering soft brace from toes to above knee. Knee immobilizer (medical device that limits knee movement) in place, informed by son that brace can be off while in bed but must be put prior to transfer to chair . I. Record review of Facility Treatment Administration History dated 07/01/19 - 07/31/19 for Weekly Skin Checks revealed that on Friday, (MONTH) 5th RN #1 documented left shin. (There is no further explanation and all other skin checks for the month of (MONTH) reveal skin was clear). [NAME] Record review of Facility 24 hour West Hall Nurses Reports dated 07/12/19 for R #40 revealed the following: 6 am - 2 pm shift - (Name of RN #3) - left ankle hurting x 10 days 2 pm - 10 pm shift - (Name of RN #1)- wants to see (name of physician) about left foot/ankle K. Record review of R #40 medical record revealed no evidence to indicate that a pain assessment was completed at any time during the 12 days R #40 complained of pain to left lower leg. L. On 10/29/19 at 11:05 am during an interview, Family Member (FM) #1 stated, My father (R #40) hit the bed rail with his left leg and broke it. He stated that R #40 was in constant pain and after 10 days we requested that R #40 be sent out to have x-rays done. M. On 10/30/19 at 10:45 am during an interview, R #40 who was alert to person, place, date and situation, stated that he remembers hitting his leg in July. He stated, It was (MONTH) 2nd and the doctor didn't come check it for about ten or so days. I was in my wheelchair and I hit my leg on the bed rail on my bed. I hit it right smack in the middle of my lower leg. I told the nurse, she put a Band-Aid on a small scratch on it. I called my grandson to come down a few days later because I was in so much pain, and I have a very high tolerance for pain. N. On 11/05/19 at 3:00 pm during an interview, R #40 stated, I hit my leg right in the center of the lower leg and immediately went to the nurse's station. The nurse put a bandage on a scratch that I had gotten. I asked her if she thought the leg was broken, she said no it wasn't broken. The next morning when staff was moving me, they had to hold that leg while they were moving me, it hurt too much. He stated, This happened on (MONTH) 2nd, it was a Tuesday night when I was on my way to Special Dinner. He stated that he let them know he was in a lot of pain and everyone knew, they were extra gentle when they had to move him, but it was still very painful. He stated that the following Thursday he talked to RN #1 about his pain. R #40 further stated that he didn't want to let them get him up because it hurt so much. O. On 11/05/19 at 3:33 pm during an interview with FM #2, he stated, I spoke with (name of RN #1) on Friday, (MONTH) 12th about (Name of R #40')s pain and she said that the doctor was aware and had ordered Tylenol. FM #2 stated that he returned to the facility on (MONTH) 13th and noticed R #40's left foot/ankle was very swollen. He stated that he tried to take the sock off to get a look at it but R #40 cried out in pain asking him to stop. He stated that he was able to get the sock down enough to see that it was very swollen and he took some pictures of it. FM #2 stated that he went to the nurses' station and spoke with RN #2. He stated that RN #2 told him that the doctor would be in today to do rounds. FM #2 stated, I told (Name of RN #2) that I wanted an x-ray done today, I left the facility and returned later that evening with (Name of FM #1) and we spoke to (Name of RN #2) again who advised us that the doctor had prescribed [MEDICATION NAME] for the pain and also ordered an x-ray and doppler ultrasound of his leg. We had a family meeting on 7/23/19 after (Name of R #40) finally had x-rays that showed his leg was broken in 4-5 places. FM #2 stated that (Name of Physician #1) attended the meeting over the phone and (name of Physician #1) stated that he had not been informed that the leg was so severe. FM #2 stated, (Name of R #40) was affected by the pain when they moved him, he cried out in pain every time he was moved and didn't want to be moved from his bed. P. On 11/05/19 at 5:55 pm during an interview with RN #2, she stated that she recalls that there was some kind of incident in (MONTH) but is unsure exactly when. Q. On 11/06/19 at 3:39 pm during an interview RN #1 stated (Name of R #40) did complain about pain to his left leg and about pain during transfers according to the CNAs (Certified Nurse Aides). It was frustrating from not knowing if the pain he was having was from his chronic pain or something new. R. On 11/06/19 at 4:45 pm during an interview, PHYS #1 stated, I saw (name of R #40) on the 14th of July. I ordered an x-ray and when we got the results of the x-ray he was sent to a hospital. This was not reported to me because the staff wasn't sure he had hurt himself. When I examined him on the 14th he was in so much pain he would not let me touch him so I ordered an x-ray.

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to manage pain for 1 (#18) of 1 (#18) resident's observed with pain during a treatment. The failures were evidenced by: 1. During treatment of [REDACTED].#18 was observed to have high levels of pain during a wound treatment and stated the pain level was a 10 on a scale of 1 to 10. Resident #18 did not receive pain medication prior to getting wound treatments every other day. 2. The facility failed to assess Resident #18's pain before and during wound treatments and implement a pain management plan. This was likely to cause the resident to continue to have unmanaged pain. The findings are: A. On 04/20/12 at 10:25 am, observation of pressure ulcer dressing change by Registered Nurse (RN) #1 revealed Resident #18 had a Stage IV pressure ulcer to the buttock area. RN #1 removed packing from the pressure ulcer, cleansed the wound, put packing into the wound and covered it with a dressing. During the dressing change, Resident #18 complained of pain. Resident #18 was observed wincing and grimacing during the treatment and stated that it hurt. The resident was asked by the surveyor on a scale of 1-10, with 10 being the worst pain imaginable, what the pain level was. Resident #18 quickly stated, "A ten" and stated, "When the nurses do the treatment it's a ten and the pain lasts for some time." The resident was asked when she last had a pain pill. RN #1 stated, "Can I answer that? At 2:00 am, [MEDICATION NAME] and received [MEDICATION NAME] 7.5 milligrams (mg) at 8 am." The resident asked for a pain pill after the treatment change. During the interview, the resident stated that she got her shower around 10:00 am on Mondays, Wednesdays, and Fridays and after her shower she would get her wound treatment. She would ask for her pain medication after the treatment, and would then be able to get up in her wheelchair for lunch. Resident #18 stated that she did have pain medication to get up because the pressure ulcer hurt. B. Record review of Resident #18's record revealed the following: 1. The 08/12/11 Care Plan revealed, "Problem: (Name of Resident #18) has a decubitus ulcer 4 cm X 3 cm X 5 cm to her right ischium... Approaches: prevent or treat pain during dressing changes and debridement prior to wound care, Problem: risk for self isolation, decreased intake/appetite, skin breakdown and self injury due to chronic pain to right buttock and hip wounds complicated by [MEDICAL CONDITION]. Approaches: evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge." 2. History and Physical dated 10/28/11 revealed [DIAGNOSES REDACTED]. 3. The Physician orders, dated 11/29/11, revealed, "Cleanse buttocks/wound with normal saline, blot with 4 X 4 gauze apply 1 cc (cubic centimeter) apg/[MEDICATION NAME] (Autologous growth factors) blue foam, tape to secure, cover with dressing every other day and prn for soiling, loosening, or bleeding." 4. The Physician orders, dated 01/13/12, revealed to increase the [MEDICATION NAME] 10-500 milligrams (mg) pain medication to every 4 hours prn pain from every 6 hours prn. 5. The Minimum Data Set Assessment, dated 02/08/12, revealed, "Stage IV pressure ulcer." 6. A Pain document titled "Pain Management- pain observation for cognitively aware" dated 02/25/12 at 1:22 am revealed, "Manner of expressing pain" "anxiety agitation/restlessness" and "sleep disturbance" was checked. Question: "Frequency- How much of the time have you experienced pain or hurting over the last 5 days?" "Frequently" was checked. Question: "Over the past 5 days, has pain made it hard for you to sleep at night?" " Yes" was checked. Question: "Over the past 5 days, have you limited your day to day activities because of pain?" "Yes" was checked. Pain intensity- Question: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." "09" was entered. "Continue current Plan of Care" was checked. 7. Review of Resident #18's 03/15/12 Wound Care Center current pressure ulcer measurements revealed, "2.5 cm (cubic centimeters) X 3.0 cm X 2.0 cm presize, 2.75 cm X 3.25 cm X 2.1 cm, tunneling 5 cm. Procedure debridement subcutaneous tissue." 8. Physician orders [REDACTED]." 9. The 14 day Treatment Administration History dated 04/01/12 to 04/25/12 revealed treatments were given 04/01/12, 04/03/12, 04/05/12, 04/07/12, 04/09/12, 04/11/12, 04/13/12, 04/15/12, 04/17/12, 04/19/12. Treatment was changed to daily on 04/19/12. 10. the April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the PRN (as needed) Administration 14 day history, dated April 1-25, 2012, revealed that Resident #18 received [MEDICATION NAME] the following times: Monday 04/02/12 11:31 am, reason pain legs/wound. Tuesday 04/03/12 11:31 am. Wednesday 04/04/12 at 11:43 pm, pain pain legs/wound. Thursday 04/05/12 11:33 am. Friday 04/06/12 11:32 am, pain legs/wound. Saturday 04/07/12 11:21 am. Sunday 04/08/12 11:21 am. Monday 04/09/12 11:13 am, pain legs/wound. Tuesday 04/10/12 11:53 am. Wednesday 04/11/12 at 11:29 am, pain wound. Thursday 04/12/12 12:44 pm. Friday 04/13/12 at 11:49 am, pain wound. Saturday 04/14/12 11:33 am. Sunday 04/15/12 11:05 am. Monday 04/16/12 11:43 am, pain wound. Tuesday 04/17/12 at 1146 am, pain wound. Wednesday 04/18/12 at 11:39 am, wound pain. Thursday 04/19/12 11:43 am. Friday 04/20/12 at 11:33 am, coccyx, leg. 11. Resident Progress notes dated 12/21/11-04/19/12 revealed no entries related to discussion with Resident #18 concerning pain management. There was no documentation of discussion for Resident #18 to receive [MEDICATION NAME] prior to pressure ulcer treatments to lessen the pain during the treatment. C. On 04/20/12 at 2:50 pm, the Director of Nursing (DON) was interviewed about the pain with the dressing change for Resident #18. The DON was asked if Resident #18 was assessed for receiving pain medication prior to the treatment on the pressure ulcer. The DON stated that when she (the DON) was oriented to the facility, she was told that the resident wanted the pain medication before she got up for lunch. The DON stated that the resident was able to make her needs known and would ask for pain medication when she wanted it. D. On 04/20/12 at 3:05 pm, Resident #18 was interviewed. Resident #18 was asked if anyone had ever discussed taking the [MEDICATION NAME] pain medication prior to getting the wound treatment. Resident #18 stated, "No. No one ever talked to me or suggested that. That might be a good idea." Resident #18 stated that she was concerned because the treatment was going to be changed to daily. E. On 04/24/12 at 1:15 pm, Resident #18 was observed sitting in the doorway of her room after lunch waiting to be put to bed. She stated that her pressure ulcer pain was bad and hurting all the way down her leg. She requested a pain pill. She stated that she had one ([MEDICATION NAME]) that morning at 9:00 am before the dressing change. She stated that she told the nurse that the surveyor said it might help to have one prior to the dressing change. F. On 04/24/12 at 1:17 pm, RN #2 was asked about Resident #18's pain with the pressure ulcer treatments. RN #2 stated that the resident had always asked for the pain medication after the treatment and would complain of pain during measurement days during the dressing change, but not every day. RN #2 was asked if she had ever discussed with the resident to get the pain medication prior to the treatment. RN #2 stated, "No." RN #2 added that the resident asked for the pain medication after the treatment. G. Record review of the facility's Pressure Ulcer Clinical Protocol dated April 2007 revealed, "The physician will help identify medical interventions related to wound management for example ... managing pain related to the wound or to wound treatment, etc." H. Review of the facility's Pain Clinical Protocol dated April 2009 revealed, "Staff will assess pain using a consistent approach .. Cause Identification:...The staff will observe the resident for evidence of pain; for example grimacing while being repositioned or having a wound dressing changed... 4. The nursing staff will identify any situation or interventions where an increase in the resident's pain may be anticipated; for example, wound care ... Treatment/Management With input from the resident and or advocate, the physician and staff will establish goals of pain treatment... Monitoring 1. The staff will reassess the individuals pain and related consequences at regular intervals at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain... Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions that exacerbate pain, consequences or complications of pain, and effectiveness of current interventions for pain...The staff will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions accordingly. ..." I. On 04/25/12 at 11:50 am, the DON was interviewed. The DON was asked if Resident #18's pain should be managed prior to treatment being done on the pressure ulcer. The DON stated that the resident was alert and made her needs known and that she could ask for the pain medication when she wanted it. The DON was asked if it was a caregiver's responsibility to educate the residents on pain management. The DON stated that the resident, like us, could pick up a phone and make a phone call and request what she wanted. The DON was asked about the care plan for pain dated 08/12/11. The DON was asked, "What have you done to change the pain with treatments?" The DON stated, "We have not put in the care plan to give her medication prior to treatments." The DON was asked if there was any discussion with the resident about pain management. The DON looked in the computer and stated, "I don't see anything in the computer for documentation of discussion with her of getting pain medication prior to dressing changes." J. On 04/25/12 at 4:00 pm, during an interview, Resident #18 stated that she thought her pressure ulcer was going to heal now, that it was much better now that she was getting her pain medication prior to the dressing change. Resident #18 stated, "It doesn't hurt as much when they remove the packing." K. On 04/26/12 at 2:40 pm, RN #2 was interviewed. RN #2 was asked about Resident #18's pain medications. RN #2 stated that the resident took [MEDICATION NAME] for arthritis and took [MEDICATION NAME] as needed (prn) when the resident had pain. RN #2 stated that the [MEDICATION NAME] was increased to every 4 hours from every 6 hours prn when the resident started having debridements of the pressure ulcer.

Based on observation, record review, and interview, the facility failed to identify and accurately assess wounds that were pressure ulcers for 3 (#58, 1, 23) of 4 (#18, 58, 1, 23) residents reviewed for pressure ulcers. This was evidenced by: 1. Resident #1 had treatments to the gluteal (between leg and buttock) fold which were discontinued on 01/23/12, new treatment started to an open area on the left lower buttock on 02/26/12, and the resident developed 2 wounds on 04/17/12. The facility did not identify these areas as pressure ulcers. Resident #1 was also identified as having Stage I pressure ulcers during the survey that the facility failed to recognize. 2. Resident #58 had "open areas" to the buttocks on 01/08/12, 03/02/12, 04/07/12, and 04/17/12. Observation revealed that Resident #58 had two Stage II pressure ulcers, which were not identified by the facility as pressure ulcers. 3. Resident #23 developed a stage II pressure ulcer on 04/08/12. Staff did not identify this as a pressure ulcer. This likely caused actual harm with re-occurrences of Stage II pressure ulcers for Residents. The findings are: Resident #58 A. On 04/17/12 at 9:14 am, the Director of Nurses (DON) was asked if Resident #58 had a pressure ulcer. The DON stated that the resident did not have a pressure ulcer. The DON stated that there were only 2 pressure ulcers in the facility. B. Review of Resident #58's record revealed the following: 1. Review of physician orders [REDACTED].#58's buttocks on 01/08/12, 03/02/12, 04/07/12, and 04/17/12. 2. Record review of Braden Scale for Pressure ulcer risk dated 01/03/12 revealed a score of 10 (8 or more represented high risk.) 3. Care Plan dated 08/26/11 revealed, "at risk for development of pressure ulcer." 4. A 01/09/12 Physician Notification Form order revealed, "protect from pressure, needs padded wheelchair, change position Q (every) 2 hours. Monitor daily." 5. A physician progress notes [REDACTED]. ...Continue decub treatment." 6. Resident Progress Notes (Nurses Notes) dated 02/24/12 at 2:40 am revealed, "...Residents bottom noted to have excoriated (skin worn off) areas on both buttocks, 0.5 cm (centimeter) open area to coccyx area and a red mark 0.5 cm wide and approximately 10 centimeters long from labia to buttock areas." 7. On 04/17/12, a 03/02/12 Weekly Skin Check (WSC) documented by Registered Nurse (RN) #1 revealed, "pressure ulcer" was checked; "Location: one area in the coccyx 0.4 X 0.6 cm and another open area to the side of the coccyx 0.4 x 0.5 to coccyx." "Slough -yellow or white tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder that surrounding skin" was checked. The "Slough" indicated an unstagable pressure ulcer. 8. On 04/19/12, the same document 03/02/12 at 2:07 pm, was altered and revealed that "Laceration" was checked, other open area redness and irritated open area in the coccyx 0.4 x 0.6 and another open area to the side of coccyx 0.4 X 0.5. Initiate plan of care was checked." Pressure ulcer and slough had been removed. 9. The WSC dated 3/31/12 at 5:56 am revealed, "Other redness, irritation...location coccyx, measurement 3 cm X 2 cm..." Pressure ulcer was not checked. 10. The WSC dated 04/07/12 at 8:21 am revealed, "other open area... location coccyx... Measurement 1 cm X .3 cm X 0 cm. Describe - open area." Pressure ulcer was not checked. 11. Resident's Progress note dated 04/07/12 at 1:06 am revealed, "Skin check done open area to coccyx .3 X 1 cm cleaned and dressed..." 12. Resident's 04/07/12 at 11:52 pm Progress Note revealed, "Assessment of open area to coccyx area measures 1 cm X 0.5 cm today cleaned apply protective dressing." 13. A Physician order [REDACTED]." 14. Progress Note dated 04/17/12 at 11:45 pm revealed, "On rounds one cm linear skin crack found on coccyx of resident and 0.5 cm linear (straight line)open area found on right buttocks.... No redness around open area. Some redness on coccyx noted." 15. The WSC dated 04/17/12 at 6:40 pm, revealed, "location coccyx, other open area, pink in color, open "slit" 1 cm x 0 cm x 0 cm." Pressure ulcer was not checked. C. On 04/19/12 at 10:25 am, RN #3 was interviewed and asked the condition of Resident #58's current wound. RN #3 stated that it was a pink open area. RN #3 was asked if it was a pressure ulcer. RN #3 stated, "I think it is because she (Resident #58) doesn't like to lay down, sits in her recliner or wheelchair (W/C) and won't lay down." D. On 04/19/12 at 3:30 pm, observation was made of Resident #58's wound care. Observation revealed two Stage II pressure ulcers, one to the coccyx area, pressure ulcer #1, and pressure ulcer #2 to the buttock area below pressure ulcer #1 next to the coccyx. The pressure ulcers areas were superficial, open, linear in shape, with a pink wound bed. E. On 04/19/12 at 5:00 pm, the DON was asked about Resident #58's pressure ulcer. The DON stated that nurses' education on wounds is different. The DON would not agree that the open area was a pressure ulcer. The DON did state that the resident would not go to bed and sits in the W/C or the recliner. The DON was asked about the altered medical record, the 03/02/12 WSC. The DON stated that she had RN #1 change the medical record last night (4/18/12) because the nurse was not experienced in wounds. F. On 04/19/12 at 5:12 pm, the DON was asked for a list of all wounds in the facility. The DON was asked for documentation from the computer for Resident #58's pressure ulcers or wounds. The DON printed a current list of wounds and next to Resident #58's name, the DON hand wrote "open area." The DON identified on the form 2 residents, Resident #18 and Resident #30, as having pressure ulcers. She did not identify Resident #58 as having pressure ulcers. Resident #1 G. On 04/19/12 at 5:12 pm, the DON was asked about the wounds in the facility. She printed a current list of wounds and next to Resident #1's name, the DON hand wrote "abrasion left gluteal fold." H. On 04/20/12 at 10:55 am, observation of Resident #1 was conducted by Surveyor RN #1. Resident #1 was transferred from the W/C to the bed and placed on the left side. Observation of the Right trochanter (hip) revealed a large approximately 1 ? inch circular, red non-blanchable (does not turn white when pressure applied which indicates beginning tissue damage) area (Stage 1 Pressure ulcer). There were also 2 red, non-blanchable areas approximately 1 ? to 2 inches in diameter on the ischial tuberosity (buttock) area (Stage 1). The dressing on the left gluteal fold was removed to reveal a purple area with a small dark beefy red open Stage II pressure ulcer approximately 0.5 cm in diameter. Observation of the W/C cushion revealed an old cushion that consisted of flattened foam, a thin gel pad in the middle, and a plastic covering. During the pressure ulcer treatment observation on 04/20/12 at 11:10 am, RN #1 was interviewed. When asked to describe the area, RN #1 stated, "It is red but not an open area. I have seen it when it was open, and it is closed now." Surveyor RN #2 was asked to verify the condition of the pressure ulcer. Verification by observation revealed the Stage II pressure ulcer was small, superficial, not closed, dark beefy red. The open area was approximately 0.5 cm in diameter. I. Record review of Resident #1's record revealed the following: 1. At Risk for Pressure Ulcer Care Plan, dated 11/11/11, revealed an addition, "01/23/12 D/C TX (discontinue treatment) to gluteal fold buttock, area healed." 2. Review of Skin Risk Assessment with Braden Scale dated 02/06/12 and 02/17/12 revealed, "Score 12. Level 10-12 HIGH RISK." 3. Review of WSC dated 03/26/12 at 1:25 pm revealed, "Other-Red area, Lt (left) gluteal (buttock) fold..." 4. The WSC dated 04/11/12 revealed, "Abrasion to left gluteal fold and buttock, 1 cm X .5 cm open area. Continue current plan of care." Pressure ulcer was not checked. 5. The WSC dated 04/17/12 at 10:36 am revealed, "Other abrasion left gluteal fold, 1.5 cm X .2 cm X 2 wounds. Continue current plan of care." Pressure ulcer was not checked. J. On 04/24/12 at 2:00 pm, Resident #1 was observed up in the W/C playing bingo and at 3:05 pm in exercise class. Resident #1 was not repositioned. Exercise was over at 3:45 pm. Resident #1 was still in the W/C and had not been repositioned. At 4:45 pm, Resident #1 was still in the W/C at the nurses desk, ready for supper, and not repositioned. K. On 04/25/12 at 9:50 am, Resident #1 was in bed turned to the right side. The Stage I pressure ulcer remained to left buttocks with a reddened nonblanchable large area. The Stage II pressure ulcer was approximately .5 X .5 cm superficial open area located in the middle of the Stage I pressure ulcer. L. On 04/25/12 at 9:50 am, RN #2 was interviewed about Resident #1's pressure ulcers. RN #2 stated that the resident had been laying down approximately 45 minutes. RN #2 agreed that the reddened area was nonblanchable and was a Stage I pressure ulcer. When asked about the stage 2 pressure ulcer, RN #2 stated that when the open ulcer on the buttocks first appeared, it was more linear in shape, superficial, and larger. RN #2 stated that she did not think it was a pressure ulcer because it was superficial and the shape was not like a round ulcer. RN #2 stated, "I thought it looked like a shear." Resident #23 M. On 04/19/12 at 5:12 pm, the DON was asked for a list of pressure ulcers and wounds in the facility. The DON printed a current list of wounds and next to Resident #23's name, the DON hand wrote "abrasion". N. On 04/20/12 at 10:40 am, observation of Resident #23 revealed she had been up in the wheelchair since 8:00 am, with no pressure relieving device in the wheelchair. Resident #23 was placed in bed for observation of a wound on the coccyx. RN #1 removed the dressing to reveal a shallow, Stage II pressure ulcer, approximately 0.3 cm (centimeter) in diameter. The area was bright beefy red with no skin covering it. The area around the opening was pink and there was no drainage noted. RN #1 was interviewed. When asked to describe the wound, RN #1 stated, "It was an abrasion, but now it is healed. It is not an open area." O. Review of Resident #23's record revealed the following: 1. Quarterly Observation Report, Braden Scale for Prediction of Pressure Sore Risk, dated 04/08/12 at 6:00 pm, revealed, "Description open area to coccyx 1.5 X 0.4, ... resident chair fast, very limited mobility, very poor nutrition, Braden Scale of 13 - 13-14 Moderate Risk..." 2. Review of a Physician notification dated 04/08/12 revealed, "Open area to coccyx 1.5 X 0.4 noticed. Cleansed with NS (Normal Saline), applied solosite and covered with foam." 3. WSC dated 04/17/12 at 3:33 pm revealed, "Other abrasion, coccyx, .75 cm X .2 cm. Area is healing. Superficial..." Pressure ulcer was not checked. 4. Care Plan dated 12/22/11 revealed, "Risk for developing pressure ulcers and impaired skin integrity..." a. Review of a hand written notation on the Care plan revealed, "4/8/12 - cleanse open area to coccyx with NS. Apply solosite and cover with foam twice daily until healed." b. An additional notation dated 04/10/12 revealed, "Monitor wound to coccyx daily and protect from pressure." There were no additional revisions. P. On 04/25/12 from 10:47 am to 11:30 am, the DON was asked about the Stage 1 pressure ulcer for Resident #1 discovered Friday 04/20/12, and the stage II pressure ulcers for Resident's 58, 23, and 1. The DON was asked about the nurses staging pressure ulcers. The DON stated that the nurses did not stage the pressure ulcers, that the nurses are leery of staging. The DON was interviewed about Resident #23's pressure ulcer. The DON stated that the resident had nutrition issues. The DON stated that dietary changes, ensure was added 04/05/12, and [MEDICATION NAME] added for appetite. The DON was asked if poor nutrition put Resident #23 more at risk for pressure ulcers. The DON stated, "Yeah."

Based on observation, record review, and interview, the facility had systemic failures in pressure ulcer care to prevent multiple stage 2 pressure ulcers for 3 (#23, 58, 1) of 4 (#18, 58, 1, 23) residents reviewed for pressure ulcers. These systemic failures in pressure ulcer management were evidenced by: 1. The facility failed to identify Stage I and Stage II pressure ulcers. 2. The facility failed to implement pressure reduction interventions. 3. The facility failed to reposition residents every 2 hours. 4. The facility failed to implement new interventions to prevent re-occurrences of pressure ulcers. These failures likely caused re-occurrences of stage II pressure ulcers for Residents. The findings are: Resident #58 A. On 04/17/12 at 9:14 am, the Director of Nurses (DON) was asked if Resident #58 had a pressure ulcer. The DON stated that the resident did not have a pressure ulcer. The DON stated that there were only 2 pressure ulcers in the facility. B. On 04/17/12 record review of a 03/02/12 Weekly Skin Assessment- Clinical Documentation-Skin Integrity Conditions (WSC), documented by Registered Nurse (RN) #1 revealed, "pressure ulcer" was checked; "Location: one area in the coccyx 0.4 X 0.6 cm (centimeters) and another open area to the side of the coccyx 0.4 x 0.5 to coccyx." "Slough -yellow or white tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder that surrounding skin" was checked. The "Slough" indicated an unstagable pressure ulcer. C. Record review on 04/19/12 of Resident #58's 03/02/12 WSC in the computer revealed that the document was altered and pressure ulcer was not checked. The slough check had been removed, and "other open area redness and irritated, laceration" was checked. D. On 04/19/12 at 10:25 am, RN #3 was interviewed and asked the condition of Resident #58's wound. RN #3 stated that it was a pink open area. RN #3 was asked if it was a pressure ulcer. RN #3 stated, "I think it is because she (Resident #58) doesn't like to lay down, sits in her recliner or wheelchair (W/C) and won't lay down." E. On 04/19/12 at 10:15 am, during observation, Resident #58 was sitting in her W/C. A pommel cushion, not a pressure relieving device, was in the W/C. The resident was put in her recliner. There was no pressure relieving device in the recliner. Certified Nursing Assistant (CNA) #1 was asked if the resident would get off of her buttocks. CNA #1 stated that Resident #58 does not like to lay down and sits in her recliner or W/C. CNA #1 stated that if they put Resident #58 in bed, she will yell to get up within 5 minutes. F. On 04/19/12 at 10:50 am, Resident #58 was transferred to the toilet then put in the W/C. The dressing to the coccyx area was observed coming loose and not intact at the bottom edge. G. On 04/19/12 at 2:10 pm, RN #3 was asked if there was a pressure reducing pad in the recliner and stated, "No." RN #3 was asked if there should be one. RN #3 stated that she would ask the DON. RN #3 stated that the resident sleeps in the recliner and they move her from the W/C to the recliner. H. On 04/19/12 at 2:15 pm until 3:21 pm, during observation, Resident #58 was in a W/C with the pommel cushion, not a presssure relieving device. I. On 04/19/12 at 3:30 pm, observation was made of Resident #58's wound care. Observation revealed two Stage II pressure ulcers, one to the coccyx area, pressure ulcer #1, and pressure ulcer #2 to the buttock area below pressure ulcer #1 next to the coccyx. The pressure ulcers areas were superficial, open, linear (straight line) in shape, with a pink wound bed. J. On 4/19/12 at 3:40 pm, the DON was interviewed and asked if a pressure reducing device should be put in Resident #58's W/C and recliner, since she would not go to bed. The DON stated that the resident had a gel cushion in her W/C. The DON was told that the resident had a pummel cushion, not a pressure reducing device to W/C and no pressure reducing device to the recliner. The DON stated that the aides were supposed to put the cushion in the recliner when they transferred her to the recliner. K. On 04/19/12 at 4:00 pm, the pommel cushion had been removed from the W/C and a pressure ulcer reduction wedge cushion had been put in the W/C. L. On 04/19/12 at 4:45 pm, RN #1 was interviewed about the altered 03/02/12 WSC document. RN #1 was asked what RN #1's initial observation was on 03/02/12. RN #1 was asked if the initial observation on 03/02/12 was a pressure ulcer. RN #1 stated, "Yes." RN #1 was asked if it had slough in the wound. RN #1 stated that she saw a small white and yellow area in the wound. RN #1 was asked if the medical record had been altered. RN #1 stated, "Yes." RN #1 stated that she initially had checked "Pressure ulcer" and "Slough", and that it was linear shaped. M. On 04/19/12 at 5:00 pm, the DON was asked about Resident #58's pressure ulcer. The DON stated that nurses' education on wounds is different. The DON would not agree that the open area was a pressure ulcer. The DON did state that the resident would not go to bed and sits in the W/C or the recliner. The DON stated that they had to use the pommel cushion to keep her from falling and prior to that she (Resident #58) had a gel cushion. The DON was asked if the care plan was revised for the Pressure ulcer or followed if there was not a cushion in the W/C or recliner. The DON stated that she would not agree to anything and stated, " I won't answer yes or no." The DON was asked about the altered medical record, the 03/02/12 WSC. The DON stated that she had RN #1 change the medical record last night (04/18/12) because the nurse was not experienced in wounds. N. On 04/19/12 at 5:12 pm, the DON was asked for a list of all wounds in the facility. The DON was asked for documentation from the computer for Resident #58's pressure ulcers or wounds. The DON printed a current list of wounds and next to Resident #58's name, the DON hand wrote "open area." The DON identified on the form 2 residents, Resident #18 and Resident #30, as having pressure ulcers. She did not identify Resident #58 as having pressure ulcers. O. Review of Resident #58's record revealed the following: 1. Physician orders [REDACTED].#58's buttocks on 01/08/12, 03/02/12, 04/07/12, and 04/17/12. 2. Record review of Resident #58's Braden Scale for Pressure ulcer risk dated 01/03/12 revealed a score of 10 (8 or more represented high risk.) 3. Care Plan dated 08/26/11 "at risk for development of pressure ulcer" revealed, " 01/08/12 Cleanse abrasion to left buttock, with N/S (Normal Saline) apply [MEDICATION NAME] and foam Q (every) day and prn (as needed) until healed. A note to discontinue the treatment (TX) was made on 01/27/12. 4. A 01/09/12 Physician Notification Form order revealed, "protect from pressure, needs padded wheelchair, change position Q 2 hours. Monitor daily." 5. A physician progress notes [REDACTED]. ...Continue decub treatment." 6. Resident Progress Notes (Nurses Notes) dated 02/24/12 at 2:40 am revealed, "...Residents bottom noted to have excoriated areas on both buttocks, 0.5 cm open area to coccyx area and a red mark 0.5 cm wide and approximately 10 centimeters long from labia to buttock areas." 7. The 03/02/12 Physician Notification Form revealed, "to inform you that upon skin check noticed 2 open areas to coccyx 0.4 X 0.6, and 0.9 X 0.5 to coccyx and above the coccyx respectfully. ...Physician response 03/02/12 was "turn every 2 hours and wound care daily." 8. A 03/02/12 WSC documented by RN #1 revealed, "pressure ulcer" was checked; "Location: one area in the coccyx 0.4 X 0.6 cm and another open area to the side of the coccyx 0.4 x 0.5 to coccyx." "Slough -yellow or white tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder that surrounding skin" was checked. The "Slough" indicated an unstagable pressure ulcer. The same document 03/02/12 at 2:07 pm, (after edits were made) revealed that "Laceration" was checked, other open area redness and irritated open area in the coccyx 0.4 x 0.6 and another open area to the side of coccyx 0.4 X 0.5. Initiate plan of care was checked." Pressure ulcer and slough had been removed. 9. The At risk for Pressure ulcer Care Plan had an addition dated 03/02/12 to "Cleanse open areas to coccyx with NS, apply solosite and cover with foam until healed." There were no other revisions. 10. The WSC dated 03/16/12 at 11:36 pm, revealed, "Laceration to the coccyx... Wound is closing... Surrounding tissue [DIAGNOSES REDACTED] (redness)." "Continue current plan of care was checked." 11. Treatment Sheet dated 03/02/12 -03/31/12 revealed that on 03/23/12 the TX to the coccyx was discontinued. 12. The WSC dated 03/31/12 at 5:56 am revealed, "Other redness, irritation...location coccyx, measurement 3 cm X 2 cm..." "Continue current plan of care" was checked. 13. The WSC dated 04/07/12 at 8:21 am revealed, "other open area... location coccyx... Measurement 1 cm X .3 cm X 0 cm. Describe - open area." "Initiate plan of care" was checked. 14. Resident's Progress note dated 04/07/12 at 1:06 am revealed, "Skin check done open area to coccyx .3 X 1 cm cleaned and dressed..." 15. Resident's 04/07/12 at 11:52 pm Progress Note revealed, "Assessment of open area to coccyx area measures 1 cm X 0.5 cm today cleaned apply protective dressing." 16. The 04/07/12 Physician order [REDACTED]. DC (discontinue) corona TX continue to change position Q 2 hours." 17. The Care plan last updated 04/11/12 had no new interventions, other than wound treatments, to reduce the reoccurring Stage II pressure ulcers. 18. A 04/14/12 Physician order [REDACTED]." 19. Progress Note dated 04/17/12 at 11:45 pm revealed, "On rounds one cm linear skin crack found on coccyx of resident and 0.5 cm linear open area found on right buttocks. Solosite wound gel applied and area covered with nonstick [MEDICATION NAME] and foam for protection. [MEDICATION NAME] applied to hold dressing in place. No redness around open area. Some redness on coccyx noted." 20. The WSC dated 04/17/12 at 6:40 pm, revealed, "location coccyx, other open area, pink in color, open "slit" 1 cm x 0 cm x 0 cm." "Initiate plan of care" was checked. 21. The Physician order [REDACTED]. .." 22. The Care Plan had a notation dated 04/17/12, "Open area to coccyx 1 cm linear crack on coccyx apply solosite wound gel cover with nonstick foam change qd (every day)." There were no revisions to interventions to reduce pressure ulcers. 23. The only revision in the plan of care for pressure ulcers was the physician order [REDACTED]." There was no revision to include applying a pressure redistribution surface to the recliner. P. On 04/24/12 from 2:00 pm to 3:15 pm, Resident #58 was observed in the W/C. At 3:25 pm, Resident #58 was taken to the bathroom. There was no dressing on the coccyx pressure ulcer. CNA #2 was asked if the dressing had come off in the adult incontinent pad. When checked, there was no dressing in the incontinent pad. RN #1 verified that the resident did not have a dressing to the pressure ulcer. Q. On 04/24/12 at 3:35 pm, CNA #2 was interviewed. When asked about Resident #58 sitting in the W/C and recliner, CNA #2 stated, "She won't go to bed until after her family visits in the pm, usually they stay until 10:00 pm." R. On 04/24/12 at 3:40 pm, during observation, Resident #58 was transferred to a recliner beside the nurses' desk. No pressure relieving device was put in the recliner. At 4:40 pm, CNA #3 got Resident #58 out of the recliner. RN #1 was asked if there was a pressure relieving device in the recliner, and RN #1 stated, "No." S. On 04/25/12 at 10:47 am, an interview was conducted with the DON. The DON was asked about Resident #58's pressure ulcers. The DON was asked if there had been revisions to the care plan after the reoccurring pressure ulcers. The DON stated after reviewing the care plan that the staff were to continue to change the resident's position Q 2 hours. The DON stated that the staff do change the residents position from the W/C to the toilet and to the recliner. The DON stated that they had changed the wedge cushion to the pommel cushion after a fall. The DON was asked about the observation of the dressing not being on the wound on 04/24/12. The DON stated that the CNAs should have told the nurse when the dressing came off so that the nurse could change the dressing. The DON stated, " I think now we are just going to have to lay her down." Resident #1 T. On 04/19/12 at 5:12 pm, the DON was asked about the wounds in the facility. She printed a current list of wounds and next to Resident #1's name, the DON hand wrote "abrasion left gluteal fold." U. On 04/20/12 at 10:55 am, observation of Resident #1 was conducted by Surveyor RN #1. Resident #1 was transferred from the W/C to the bed and placed on the left side. Observation of the Right trochanter (hip) revealed a large approximately 1 ? inch circular, red non-blanchable (does not turn white when pressure applied which indicates beginning tissue damage and Stage 1 Pressure ulcer) area. There were also 2 red, non-blanchable areas approximately 1 ? to 2 inches in diameter on the ischial tuberosity (buttock) area (Stage 1). The dressing on the left gluteal fold was removed to reveal a purple area with a small dark beefy red open Stage II pressure ulcer approximately 0.5 cm in diameter. Observation of the W/C cushion revealed an old cushion that consisted of flattened foam, a thin gel pad in the middle, and a plastic covering. V. On 04/20/12 at 11:10 am, during the pressure ulcer treatment observation, RN #1 was interviewed. When asked to describe the area, RN #1 stated, "It is red, but not an open area. I have seen it when it was open, and it is closed now." Surveyor RN #2 was asked to verify the condition of the pressure ulcer. Verification by observation revealed the Stage II pressure ulcer was small, superficial, not closed, dark beefy red. The open area was approximately 0.5 cm in diameter. W. On 04/20/12 at 11:15 am, CNA #4 was interviewed. When asked if Resident #1 had been up in the W/C all morning, CNA #4 stated, "She gets up before breakfast and goes to activities until lunch. When she gets changed, she can stay in bed if she wants to, but now she likes to stay up in the afternoons." CNA #4 was asked when the resident got up for breakfast and stated, "Around 6:00 am." CNA #4 was asked if the resident had been up in the W/C since 6:00 am. CNA #4 stated that the resident had not gone to bed that morning. X. Record review of Resident #1's record revealed the following: 1. At Risk for Pressure Ulcer Care Plan, dated 11/11/11, revealed an addition, "01/23/12 D/C TX (discontinue treatment) to gluteal fold buttock, area healed." 2. Skin Risk Assessment with Braden Scale dated 02/06/12 and 02/17/12 revealed, "Score 12. Level 10-12 HIGH RISK." "Continue current plan of care" was checked. 3. The WSC dated 02/26/12 at 5:19 pm revealed, "Pressure ulcer, open area 0.4 X 0.2 to lower buttock. Plan of care updated see below. Nursing order cleanse open area to left lower buttock with NS apply solosite, and nursing cover with foam until healed." 4. Review of a Physician order [REDACTED]." 5. Resident Progress Notes dated 02/26/12 at 5:19 pm revealed, "..cleanse open area to left lower buttock, apply solosite, and cover with foam until healed." 6. Review of the 11/11/11 care plan revealed the treatment as per the physician orders [REDACTED]. 7. The WSC dated 03/26/12 at 1:25 pm revealed, "Other-Red area, Lt (left) gluteal fold, Area dark pink at times Peri area red at this time." 8. The WSC dated 04/11/12 revealed, "Abrasion to left gluteal fold and buttock, 1 cm X .5 cm open area. Continue current plan of care." 9. The WSC dated 04/17/12 at 10:36 am revealed, "Other abrasion left gluteal fold, 1.5 cm X .2 cm X 2 wounds. Continue current plan of care." Y. On 04/24/12 at 2:00 pm, Resident #1 was observed up in the W/C playing bingo and at 3:05 pm in exercise class. Resident #1 was not repositioned. Exercise was over at 3:45 pm. Resident #1 was still in the W/C and had not been repositioned. At 4:45 pm, Resident #1 was still in the W/C at the nurses desk, ready for supper, and not repositioned. Z. On 04/25/12 at 9:50 am, Resident #1 was in bed turned to the right side. The Stage I pressure ulcer remained to left buttocks with a non-blanchable reddened large area. The Stage II pressure ulcer was approximately .5 X .5 cm superficial open area located in the middle of the Stage I pressure ulcer. AA. On 04/25/12 at 9:50 am, RN #2 was interviewed about Resident #1's pressure ulcers. RN #2 stated that the resident had been laying down approximately 45 minutes. RN #2 agreed that the reddened area was non-blanchable and was a Stage I pressure ulcer. When asked about the stage 2 pressure ulcer, RN #2 stated that when the open ulcer on the buttocks first appeared, it was more linear in shape, superficial, and larger. RN #2 stated that she did not think it was a pressure ulcer because if was superficial and the shape was not like an round ulcer. RN #2 stated, "I thought it looked like a shear." BB. On 04/25/12 at 10:47 am, the DON was interviewed about Resident #1's pressure ulcers and revisions to the plan of care. The DON was told the observations of Resident #1 being left up in the W/C and the Stage 1 pressure ulcers. The DON was asked if the care plan for repositioning every 2 hours was being followed. The DON stated that the CNAs started laying her down in the afternoon after the 2/26 ulcer. The DON reviewed the care plan and stated for the 3/26 pressure ulcer, they did not change anything. The DON was asked if there were any revisions in the care plan on 04/11/12. The DON also agreed that staff were not following the care plan for repositioning, not revising the care plan after pressure ulcers reoccurred, and did not chart the Stage 1 pressure ulcer discovered 04/20/12. The DON was asked about the nurses staging pressure ulcers. The DON stated that the nurses did not stage the pressure ulcers, that the nurses are leery of staging. Resident #23 CC. On 04/19/12 at 5:12 pm, the DON was asked for a list of pressure ulcers and wounds in the facility. The DON printed a current list of wounds and next to Resident #23's name, the DON hand wrote "abrasion". DD. On 04/20/12 at 10:40 am, observation of Resident #23 revealed she had been up in the wheelchair since 8:00 am, with no pressure relieving device in the wheelchair. Resident #23 was placed in bed for observation of a wound on the coccyx. RN #1 removed the dressing to reveal a shallow, Stage II, pressure ulcer approximately 0.3 cm (centimeter) in diameter. The area was bright beefy red with no skin covering it. The area around the opening was pink and there was no drainage noted. RN #1 was interviewed. When asked to describe the wound, RN #1 stated, "It was an abrasion, but now it is healed. It is not an open area." EE. Record review of Resident #23's record revealed the following: 1. Quarterly Observation Report, Braden Scale for Prediction of Pressure Sore Risk, dated 04/08/12 at 6:00 pm, revealed, "Description open area to coccyx 1.5 X 0.4, ... resident chair fast, very limited mobility, very poor nutrition, Braden Scale of 13 - 13-14 Moderate Risk..." 2. Review of a Physician notification dated 04/08/12 revealed, "Open area to coccyx 1.5 X 0.4 noticed. Cleansed with NS, applied solosite and covered with foam." 3. A treatment order received 04/09/12 revealed, "Monitor daily and protect from pressure, change positions Q 2 hours, have me check it Thursday." There was no physician progress notes [REDACTED]. 4. The WSC dated 04/17/12 at 3:33 pm revealed, "Other abrasion, coccyx, .75 cm X .2 cm. Area is healing. Superficial....Continue current plan of care." 5. Care Plan dated 12/22/11 revealed, "Risk for developing pressure ulcers and impaired skin integrity due to incontinence of bladder, wears pull on briefs, and has impaired bed mobility, complicated by dementia with behaviors." Interventions included, "Remind (Name of Resident) to Turn and reposition herself frequently throughout the day. Assist as necessary." a. Review of a hand written notation on the Care plan revealed, "4/8/12 - cleanse open area to coccyx with NS. Apply solosite and cover with foam twice daily until healed." b. A notation dated 04/10/12 revealed, "Monitor wound to coccyx daily and protect from pressure." There was no additional revisions. There was no intervention to put a cushion in the W/C, or to reposition Q 2 hours. FF. On 04/25/12 at 11:16 am, the DON was interviewed about Resident #23's pressure ulcer. The DON stated that the resident had nutrition issues. The DON was asked if the Care Plan included a pressure relieving device for the chair. The DON stated, "No." The DON was asked what intervention changes had been done since 04/08/12 in the care plan. The DON stated, "I don't know any changes we have made except the treatment." The DON stated that dietary changes, ensure was added 04/05/12, and [MEDICATION NAME] added for appetite. The DON was asked if poor nutrition put Resident #23 more at risk for pressure ulcers. The DON stated, "Yeah."

Based on observation, record review, and interview, the facility failed to follow the plan of care to manage pain for 1 (#18) of 1 (#18) resident's observed with pain during a pressure ulcer treatment. The failure was evidenced by: 1. During treatment of [REDACTED].#18 was observed to have high levels of pain and stated the level was a 10. Resident #18 did not receive pain medication prior to getting a wound treatment every other day from records reviewed for April 2012. The resident had pain levels of 9 and 10 on a scale of 1 to 10, with 10 being the worst. 2. The resident's plan of care was to prevent or treat pain during dressing changes and debridement prior to wound care. These failures caused the resident to continue to have unmanaged pain. The findings are: A. Review of Resident #18's record revealed the following: 1. The 08/12/11 Care Plan revealed, "Problem: (Name of Resident #18) has a decubitus ulcer 4 cm (centimeters) X 3 cm X 5 cm to her right ischium... Approaches: prevent or treat pain during dressing changes and debridement prior to wound care, Problem: risk for self isolation, decreased intake/appetite, skin breakdown and self injury due to chronic pain to right buttock and hip wounds complicated by [MEDICAL CONDITION]. Approaches: evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge." 2. The April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the PRN (as needed) Administration 14 day history, dated April 1-25, 2012, revealed that Resident #18 received [MEDICATION NAME] the following times: Monday 04/02/12 11:31 am, reason pain legs/wound. Tuesday 04/03/12 11:31 am. Wednesday 04/04/12 at 11:43 pm, pain pain legs/wound. Thursday 04/05/12 11:33 am. Friday 04/06/12 11:32 am, pain legs/wound. Saturday 04/07/12 11:21 am. Sunday 04/08/12 11:21 am. Monday 04/09/12 11:13 am, pain legs/wound. Tuesday 04/10/12 11:53 am. Wednesday 04/11/12 at 11:29 am, pain wound. Thursday 04/12/12 12:44 pm. Friday 04/13/12 at 11:49 am, pain wound. Saturday 04/14/12 11:33 am. Sunday 04/15/12 11:05 am. Monday 04/16/12 11:43 am, pain wound. Tuesday 04/17/12 at 1146 am, pain wound. Wednesday 04/18/12 at 11:39 am, wound pain. Thursday 04/19/12 11:43 am. Friday 04/20/12 at 11:33 am, coccyx, leg. 3. The Physician orders, dated 11/29/11, revealed, "Cleanse buttocks/wound with normal saline, blot with 4 X 4 gauze apply 1 cc (cubic centimeter) apg/[MEDICATION NAME] (Autologous growth factors) blue foam, tape to secure, cover with dressing every other day and prn (as needed) for soiling, loosening, or bleeding." 4. The Physician orders, dated 01/13/12, revealed to increase the [MEDICATION NAME] 10-500 milligrams (mg) pain medication to every 4 hours prn pain from every 6 hours prn. 5. Review of the 14 day Treatment Administration History dated 04/01/12 to 04/25/12 revealed treatments were given 04/01/12, 04/03/12, 04/05/12, 04/07/12, 04/09/12, 04/11/12, 04/13/12, 04/15/12, 04/17/12, 04/19/12. Treatment was changed to daily on 04/19/12. 6. Review of a Resident #18's Pain document titled "Pain Management- pain observation for cognitively aware" dated 02/25/12 at 1:22 am revealed, "Manner of expressing pain" "anxiety agitation/restlessness" and "sleep disturbance" was checked. Question: "Frequency- How much of the time have you experienced pain or hurting over the last 5 days?" "Frequently" was checked. Question: "Over the past 5 days, has pain made it hard for you to sleep at night?" " Yes" was checked. Question: "Over the past 5 days, have you limited your day to day activities because of pain?" "Yes" was checked. Pain intensity- Question: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." "09" was entered. "Continue current Plan of Care" was checked. 7. Progress notes dated 12/21/11-04/19/12 revealed no entries related to discussion with Resident #18 concerning pain management. There was no documentation of discussion for Resident #18 to manage pain during pressure ulcer treatment. B. On 04/20/12 at 10:25 am, observation of pressure ulcer dressing change by Registered Nurse (RN) #1 revealed Resident #18 had a Stage IV pressure ulcer to the buttock area. RN #1 removed packing from the pressure ulcer, cleansed the wound, put packing into the wound and covered it with a dressing. During the dressing change, Resident #18 complained of pain. Resident #18 was observed wincing and grimacing during the treatment and stated that it hurt. The resident was asked by the surveyor on a scale of 1-10, with 10 being the worst pain imaginable, what the pain level was. Resident #18 quickly stated, "A ten" and stated, "When the nurses do the treatment, it's a ten and the pain lasts for some time." The resident was asked when she last had a pain pill. RN #1 stated, "Can I answer that? At 2:00 am, [MEDICATION NAME] and received [MEDICATION NAME] 7.5 milligrams (mg) at 8 am." The resident asked for a pain pill after the treatment change. During the interview, the resident stated that she got her shower around 10:00 am on Mondays, Wednesdays, and Fridays and after her shower she would get her wound treatment. She would ask for her pain medication after the treatment, and would then be able to get up in her wheelchair for lunch. Resident #18 stated that she did have pain medication to get up because the pressure ulcer hurt. C. On 04/20/12 at 2:50 pm, the Director of Nursing (DON) was interviewed about the pain with the dressing change for Resident #18. The DON was asked if Resident #18 was assessed for receiving pain medication prior to the treatment on the pressure ulcer. The DON stated that when she (the DON) was oriented to the facility, she was told that the resident wanted the pain medication before she got up for lunch. The DON stated that the resident was able to make her needs known and would ask for pain medication when she wanted it. D. On 04/20/12 at 3:05 pm, Resident #18 was interviewed. Resident #18 was asked if anyone had ever discussed taking the [MEDICATION NAME] pain medication prior to getting the wound treatment. Resident #18 stated, "No. No one ever talked to me or suggested that. That might be a good idea." Resident #18 stated that she was concerned because the treatment was going to be changed to daily. E. On 04/24/12 at 1:17 pm, RN #2 was asked about Resident #18's pain with the pressure ulcer treatments. RN #2 stated that the resident had always asked for the pain medication after the treatment and would complain of pain during measurement days during the dressing change, but not every day. RN #2 was asked if she had ever discussed with the resident to get the pain medication prior to the treatment. RN #2 stated, "No." RN #2 added that the resident asked for the pain medication after the treatment. F. On 04/25/12 at 11:50 am, the DON was interviewed. The DON was asked about the care plan for pain dated 08/12/11. The DON was asked, "What have you done to change the pain with treatments?" The DON stated, "We have not put in the care plan to give her medication prior to treatments." The DON was asked if there was any discussion with the resident about pain management. The DON looked in the computer and stated, "I don't see anything in the computer for documentation of discussion with her of getting pain medication prior to dressing changes." Based on observation, record review, and interview the facility failed to follow the Comprehensive Care Plan and Physician order [REDACTED].#18, 58, 1, 23) residents reviewed for pressure ulcers. These failures likely caused re-occurrences of stage II pressure ulcers for Residents #58. This could likely cause other residents to have multiple stage II pressure ulcers. The findings are: Resident #58 A. Review of Resident #58's record revealed the following: 1. The Care Plan dated 08/26/11 "at risk for development of pressure ulcer" revealed, " 01/08/12 Cleanse abrasion to left buttock, with N/S (Normal Saline) apply [MEDICATION NAME] and foam Q (every) day and prn (as needed) until healed. A note to discontinue the treatment (TX) was made on 01/27/12. Physician orders [REDACTED].#58's buttocks on 01/08/12, 3/2/12, 04/07/12, and 04/17/12. The Care Plan updated 01/09/12 revealed, "Protect from pressure - needs padded wheelchair. Change position every 2 hours, monitor daily." 2. A 01/09/12 Physician Notification Form order revealed, "protect from pressure, needs padded wheelchair, change position Q 2 hours. Monitor daily." 3. A physician progress notes [REDACTED]. ...Continue decub treatment." 4. Review of Resident #58's 02/24/12 at 2:40 am Resident Progress Notes (Nurses Notes) revealed, "...Residents bottom noted to have excoriated (top of skin rubbed off) areas on both buttocks, 0.5 cm open area to coccyx area and a red mark 0.5 cm wide and approximately 10 centimeters long from labia to buttock areas." 5. The 03/02/12 Physician Notification Form revealed, "to inform you that upon skin check noticed 2 open areas to coccyx 0.4 X 0.6, and 0.9 X 0.5 to coccyx and above the coccyx respectfully. ...Physician response 03/02/12 was "turn every 2 hours and wound care daily." 6. The At Risk for Pressure ulcer Care Plan had an addition dated 03/02/12 to "Cleanse open areas to coccyx with NS (Normal Saline), apply solosite and cover with foam until healed." 7. The WSC dated 03/16/12 at 11:36 pm, revealed, "Laceration to the coccyx... Wound is closing... Surrounding tissue [DIAGNOSES REDACTED] (redness)." "Continue current plan of care was checked." 8. Treatment Sheet dated 03/02/12 -03/31/12 revealed that on 03/23/12 the treatment (TX) to the coccyx was discontinued. 9. The WSC dated 03/31/12 at 5:56 am revealed, "Other redness, irritation...location coccyx, measurement 3 cm X 2 cm..." "Continue current plan of care" was checked. 10. The WSC dated 04/07/12 at 8:21 am revealed, "other open area... location coccyx... Measurement 1 cm X .3 cm X 0 cm. Describe - open area." "Initiate plan of care" was checked. 11. The 04/07/12 Physician order [REDACTED]. DC (discontinue) corona TX continue to change position Q 2 hours." 12. The WSC dated 04/17/12 at 6:40 pm, revealed, "location coccyx, other open area, pink in color, open "slit" 1 cm x 0 cm x 0 cm." "Initiate plan of care" was checked. 13. The Care Plan had a notation dated 4/17/12, "Open area to coccyx 1 cm linear crack on coccyx apply ...change qd (every day)." 14. On 04/17/12 record review of Resident #58's 03/02/12 Weekly Skin Assessment- Clinical Documentation-Skin Integrity Conditions (WSC), documented by Registered Nurse (RN) #1 revealed, "pressure ulcer" was checked; "Location: one area in the coccyx 0.4 X 0.6 cm (centimeters) and another open area to the side of the coccyx 0.4 x 0.5 to coccyx." "Slough -yellow or white tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder that surrounding skin" was checked. The "Slough" indicated an unstagable pressure ulcer. On 04/19/12 the document was altered and pressure ulcer and slough were removed. B. On 04/19/12 at 10:25 am, RN #3 was interviewed and asked the condition of Resident #58's wound. RN #3 stated that it was a pink open area. RN #3 was asked if it was a pressure ulcer. RN #3 stated, "I think it is because she (Resident #58) doesn't like to lay down, sits in her recliner or wheelchair (W/C) and won't lay down." C. On 04/19/12 at 4:45 pm, RN #1 was asked what RN#1's initial observation was on 03/02/12 and if it was a pressure ulcer. RN #1 stated, "Yes." RN #1 was asked if it had slough in the wound. RN #1 stated that she saw a small white and yellow area in the wound. D. On 04/19/12 at 10:15 am, during observation, Resident #58 was sitting in her W/C. A pommel cushion, not a pressure relieving device, was in the W/C. The resident was put in her recliner. There was no pressure relieving device in the recliner. E. On 04/19/12 at 2:10 pm, RN #3 was asked if there was a pressure reducing pad in the recliner and stated, "No." RN #3 was asked if there should be one. RN #3 stated that she would ask the DON. RN #3 stated that the resident sleeps in the recliner, and they move her from the W/C to the recliner. F. On 04/19/12 at 2:15 pm, during observation, Resident #58 was in the activity room in the W/C with a pommel cushion. The resident remained in the W/C with the pommel cushion until 3:21 pm. G. On 04/19/12 at 3:30 pm, observation was made of Resident #58's wound care. Observation revealed two Stage II pressure ulcers, pressure ulcer #1 to the coccyx area and pressure ulcer #2 below #1 at the buttock area next to the coccyx. The pressure ulcers areas were superficial, open, linear in shape, with a pink wound bed. H. On 4/19/12 at 3:40 pm, the Director of Nurses (DON) was interviewed and asked if a pressure reducing device should be put in Resident #58's W/C and recliner, since she would not go to bed. The DON stated that the resident had a gel cushion in her W/C. The DON was told that the resident had a pummel cushion to W/C, not a pressure reducing device, and no cushion to the recliner. The DON stated that the aides were supposed to put the cushion in the recliner when they transferred her to the recliner. I. On 04/19/12 at 5:00 pm, the DON was asked about Resident #58's pressure ulcer. The DON stated that nurses' education on wounds is different. The DON would not agree that the open area was a pressure ulcer. The DON did state that the resident would not go to bed and sits in the W/C or the recliner. The DON was asked if the care plan was followed for the Pressure ulcer if there was not a pressure reducing cushion in the W/C or recliner. The DON stated that she would not agree to anything and stated, " I won't answer yes or no." J. On 04/24/12 at 3:35 pm, CNA #2 was interviewed. When asked about pressure relief and Resident #58 sitting in the W/C and recliner, CNA #2 stated, "She won't go to bed until after her family visits in the pm, usually they stay until 10:00 pm." K. On 04/25/12 at 10:47 am, an interview was conducted with the DON about Resident #58's reoccurring pressure ulcers and care plan. The DON stated after reviewing the care plan that the staff were to continue to change the resident's position Q 2 hours. The DON stated that they had changed the wedge cushion to the pommel cushion after a fall. The DON stated, " I think now we are just going to have to lay her down." Based on interview and record review, the facility failed to inform 1 (#37) of 3 (#37, 69, 29) residents' families interviewed of the dates of the care planning conference. This was a violation of the patients rights to be fully informed. This could likely cause the resident's need and preferences to not be addressed. The findings are: A. On 04/19/12 at 11:30 am, during a family interview, Family Member (FM) #2 of Resident #37 stated that the family had not been notified of the care plan meetings and they had complained to the nursing staff. FM #2 stated that there were some concerns that they wanted addressed. B. Review of Resident #37's record revealed the following: 1. The Care Plan Conference Summaries dated 11/02/11 and 02/01/12 did not have the Family Members' signatures as having attended. Care Plan Conference Summaries dated 05/04/11, 08/10/11 did have family participation. 2. A letter of invitation to the family for the care plan conference dated 08/10/11. There were no letters for 11/02/11 and 02/01/12. C. On 04/26/12 at 9:20 am, the Social Services Director (SSD) was interviewed. The SSD was asked if she knew the family had complained about not getting notification of the care conferences. The SSD stated, "No." The SSD was asked when the family was last notified of the care conference meeting. The SSD looked in the medical record. The SSD verified that the last notification letter was August 2011. The Director of Nurses came into the SSD's office. The DON was asked if she knew that the family had complained about not getting notifications of care plan meetings. The DON stated, "Yes, the (Name of son) had told me he was not getting notified. I asked him if he had any other concerns and he said no." The SSD was asked again if she knew that the son had complained. The SSD stated, "Yes." The SSD was asked if it was a patient's right to be a part of the care plan meeting. The SSD stated that the patients and families had a right to participate. Based on record review and interview, the facility failed to follow the care plan for hydration for 1 (#29) of 5 (#29, 37, 64, 69, 83) residents sampled for hydration. This failure could likely cause the resident to not be properly hydrated. The findings are: A. Record review of Resident #29's clinical record revealed a form titled, "Patient Transfer Form" dated 10/28/11 from local Hospital to the nursing facility on 10/28/11 with a section titled, "Diet, Drugs, and other Therapy at time of discharge to "Continue Pre-Admission meds (medications) and Physical Therapy; Diet: Regular (Do not limit salt intake) offer fluids every two hours." B. Record review of Care Area Assessment (CAA) dated 10/25/12 for Resident #29 revealed, "A careplan will be developed at this time to maintain his nutritional and electrolyte imbalances, prevent the resident from any dehydration, injuries, maintain his strength and ability to feed himself and help meet his daily needs." C. Record review of the Temporary Care Plan dated 10/28/11 for Resident #29 revealed, "Problem- Risk for dehydration due to daily use of diuretics (HCTZ) complicated by A Fib ([MEDICAL CONDITION] Fibrillation),[MEDICAL CONDITION](Hypertension) and [MEDICAL CONDITION] (Benign Prostatic Hypertension), Short Term Goal- (Name of Resident #29) will consume adequate fluids daily and remain free from s/sx (signs/symptoms) of dehydration over the next 90 days. Plan/Approach-Encourage increased fluids during and between meals, offer full glass of water with meds (medications), offer supplemental nutrition/hydration between meals and during activities, Provide fresh pitcher of water in room daily...." D. Record review of a form titled, "C.N.A. (Certified Nursing Assistant) Careplan review" dated 10/28/11, for Resident #29 revealed in the section titled, "Fluids" was a notation, "Offer fluids Q (every) 2 hours." E. Record review of the "Skilled Daily Nurses Note" dated 10/29/11 for Resident #29 revealed, "Family in to visit. (Name of Family Member #2) and raised voice to CNA (Certified Nurse Assistant) due to resident didn't have water pitcher in room, stating resident had not had water all day. Water pitcher with iced water given to resident and apologized to her..." F. On 04/19/12 at 2:40 pm, an interview was conducted with the Director of Nurses (DON) concerning hydration issues for Resident #29. When asked if there was a temporary care for hydration, the DON confirmed the care plan elements included providing fresh pitcher of water daily. The DON was interviewed concerning the complaint of no water in the room. When asked about the incident, the DON stated, "The CNA did not provide water for the resident and was counseled." When asked if not providing water for Resident #29 was not following the Care Plan, the DON stated, "Yes, It was."

Based on record review, observation, and interview, the facility failed to revise the care plan to prevent recurrences of stage 1 and stage 2 pressure ulcers for 1 (#1) of 4 (#1, 18, 58, 23) residents reviewed for pressure ulcers. Resident #1 had stage 2 pressure ulcers in January, February, and April 2012 and no revision to the plan of care except for wound treatments. The resident had a stage 1 pressure ulcer in March 2012. This could likely cause other residents to have multiple stage II pressure ulcers. The findings are: A. Review of Resident #1's record revealed the following: 1. Care plan, dated 11/11/11, revealed an addition, "01/23/12 D/C TX to gluteal fold buttock, area healed." 2. Review of Resident #1's Skin Risk Assessment with Braden Scale dated 02/06/12 and 02/17/12 revealed, "Score 12. Level 10-12 HIGH RISK." "Continue current plan of care" was checked. 3. Review of Resident #1's WSC dated 02/26/12 at 5:19 pm revealed, "Pressure ulcer, open area 0.4 X 0.2 to lower buttock. Plan of care updated see below. Nursing order cleanse open area to left lower buttock with NS apply solosite, and nursing cover with foam until healed." 4. Review of Resident #1's WSC dated 03/26/12 at 1:25 pm revealed, "Other - Red area, lt gluteal fold, area dark pink at times...(Stage I)" 5. The WSC dated 04/11/12 revealed, "Abrasion to left gluteal fold and buttock, 1 cm X .5 cm open area. Continue current plan of care." 6. The WSC dated 04/17/12 at 10:36 am revealed, "Other abrasion left gluteal fold, 1.5 cm X .2 cm X 2 wounds. Continue current plan of care." 7. Review of the 11/11/11 At Risk for Pressure ulcer care plan revealed the treatments as per the physician orders [REDACTED]. B. On 04/19/12 at 5:12 pm, the Director of Nurses (DON) was asked about the wounds in the facility. She printed a current list of wounds and next to Resident #1's name, the DON hand wrote "abrasion left gluteal fold." C. On 04/20/12 at 10:55 am, observation of Resident #1's wound care was conducted. Observation of the Right trochanter (hip) revealed a large approximately 1 ? inch circular, red non-blanchable area (does not turn white when pressure applied which indicates beginning tissue damage and Stage 1 Pressure ulcer). There were also 2 red, non-blanchable areas approximately 1 ? to 2 inches in diameter on the ischial tuberosity (buttock) area (Stage 1). The dressing on the left gluteal fold was removed to reveal a purple area with a small dark beefy red open Stage II pressure ulcer approximately 0.5 cm in diameter. Observation of the W/C cushion revealed an old cushion that consisted of flattened foam, a thin gel pad in the middle, and a plastic covering. D. On 04/25/12 at 9:50 am, Resident #1 was in bed turned to the right side. The Stage I pressure ulcer remained to left buttocks with a nonblanchable large area. A Stage II pressure ulcer was approximately .5 X .5 cm superficial open area located in the middle of the Stage I pressure ulcer. E. On 04/25/12 at 10:47 am, the DON was interviewed about Resident #1's pressure ulcers and revisions to the plan of care. The DON reviewed the care plan and stated they did not change anything. The DON stated that the resident would be referred to the new wound consultant. The DON agreed that the care plan were not revised after pressure ulcers reoccurred.

Based on record review and interview, the facility failed to implement the Resident's Care Plan for falls by not using a two-person transfer to help prevent falls for 1 of 6 sampled residents (#5). This failure to follow the care plan resulted in the resident having a fall with a fracture. This deficient practice had the to potential to affect the 13 other residents identified on the Roster/Sample Matrix provided by the facility on 01/03/11 who have had falls and/or fractures. The findings are: A. Record review of Resident #5's Care Plan dated 06/03/10 and revised 09/01/10 revealed, "Problems: Potential for falls related to history of falls at home, weakness, hx (history) [MEDICAL CONDITION] with right sided [MEDICAL CONDITION]. Goals: Resident will have no injury from falls over the next 90 days. Interventions: Transfers x 2 ( two-person) assist using gait belt. ...unable to ambulate as she did before d/t (due to) heaviness/weakness to (R) leg - dragging leg when walking." B. On 01/04/11 at 2:45 pm, Registered Nurse (RN) #1 was interviewed. When asked to describe what happened on 12/18/10 with Resident #5, she stated, "The CNA (Certified Nursing Assistant) came to get me and tell me she was in the bathroom with (Name of Resident #5) and when she was getting her from the toilet to the wheelchair, her legs got twisted as they often do. When I tried to turn her onto her back, she screamed with pain." When asked if Resident #5 needed assistance for transfers, RN #1 stated, "Yes, she needed a lot of help because of her bad leg and she would get one leg stuck behind the other one." When asked how many aides were supposed to transfer Resident #5, and was a gait belt used, RN #1 stated, "She was a two-person transfer and (Name of CNA #1) was the only one in with her. There was not a gait belt on her when I got in the bathroom." C. On 01/05/11 at 10:50 am, a phone interview was done with CNA #1. When asked to describe the fall incident with Resident #5 on 12/18/10, she stated, "Her bathroom call light was on and I went in to help her. When I was ready to get her up, she did not have a brief so I went into her room and got one for her. She stood up for me to pull up her brief and her pants. When I turned her to sit her in the wheelchair, her legs got twisted and I could feel her starting to go down. I was very careful to protect her head as she was falling toward the sink. I lowered her as slowly as I could. Her right knee was what hit the floor first. She was hurting and I went immediately to get the nurse. The nurse tried to move her and she cried with pain in her right knee. The nurse asked me to go get help. I had to go to the other unit to get another nurse to help us move her. I don't know if her leg was swollen. The 3 of us lifted her carefully into the wheelchair chair. She really was in a lot of pain in her right knee. The nurse called the doctor and the ambulance came. I have worked weekends here and know (Name of Resident #5) used to be very weak and needed 2 people to assist her. She has been in therapy and I noticed she had gotten much better. The weekend before this happened, I worked with her and did assist her several times by myself and there was not problem. I wish I could tell you how sorry I am that I did not do what I was supposed to. Believe me, I will follow the care plan from now on."