Every finding on record at Cove of Cascadia, The

Based on record review and staff interview, it was determined the facility failed to follow physician orders of delivering specific medications when residents do not have BM within 72 hours for 4 of 12 residents (#17, #20, #24, and #30) whose records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include: Resident #17 was admitted to the facility initially on 6/22/22 with readmission on [DATE] with multiple diagnoses including post-surgical left above knee amputation and obesity. Resident #17's physician orders for bowel care management were documented as: - Bisacodyl Tablet Delayed Release, Give 10 mg by mouth every 24 hours as needed for constipation on Bowel Day 3. If no result within 24 hours follow bowel day 4. Start date 5/1/24 - Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally as needed for Bowel Care Give day 4 (when) no bm. If no results in 24 hours, see Fleets Enema order. -Start Date 5/31/24 - Fleet Enema Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 unit rectally as needed for Bowel care give day 5 (when) no bm. Complete bowel assessment and notify MD if no results. -Start Date 5/31/24 - Polyethylene Glycol 3350, Give 17 gram by mouth as needed for Bowel Care Mix with 4-6 oz. of juice or water. -Start Date 9/27/23 Resident #17 had a documented bowel movement on 10/29/25 at 4:35 PM and not again until 11/3/25 at 5:39 AM, over 114 hours with no documented bowel movement. No documentation of Resident #17 receiving the physician ordered medications for constipation management during 10/29/25 to 11/3/25. On 11/21/25 at 8:25 AM, the CNO stated the nurse had not documented any bowel medication interventions for Resident #17 and should have. 2. Resident #20 was admitted to the facility initially on 11/15/18 with readmission on [DATE] with multiple diagnoses including dementia and anxiety. Resident #20's physician orders for bowel care management were documented as: - Bisacodyl Tablet Delayed Release, Give 10 mg by mouth every 24 hours as needed for constipation on Bowel Day 3. If no result within 24 hours follow bowel day 4. Start date 5/31/24 - Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally as needed for Bowel Care Give day 4 (when) no bm. Notify provider when resident on Bowel ay 4. -Start Date 1/6/21 - Fleet Oil Enema (Mineral Oil) Insert 1 dose rectally every 24 hours as needed for constipation on Bowel Day 5. -Start Date 1/6/21 Resident #20 had a documented bowel movement on 11/7/25 at 3:23 PM and not again until 11/12/25 at 1:34 AM, over 106 hours with no documented bowel movement. No documentation of Resident #20 receiving the physician ordered medications for constipation management during 11/7/25 to 11/12/25. On 11/21/25 at 8:25 AM, the CNO stated the nurse had not documented any bowel medication interventions for Resident #20 and should have. 3. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and chronic kidney disease. Resident #24's physician order related to bowel care issues were documented as: - Bisacodyl Tablet Delayed Release, Give 10 mg by mouth every 24 hours as needed for constipation on Bowel Day 3. If no result within 24 hours follow bowel day 4. Start date 5/1/24 - Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally as needed for Bowel Care, Give day 4 (when) no BM. If no results in 24 hours, see Fleets Enema order. -Start Date 5/31/24 - Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 unit rectally as needed for Bowel Care, Give day 5 (when) no BM. Complete bowel assessment and notify MD if no results. -Start Date 5/31/24 - Polyethylene Glycol 3350, Give 17 gram by mouth as needed for Bowel Care, Mix with 4-6 oz. of juice or water. -Start Date 9/27/23 Resident #24 had a documented bowel movement on 11/6/25 and not again until 11/11/25 at 17:57, over 108 hours with no documented bowel movement. None of Resident #24's physician ordered medication for constipation were given from 11/6/25 until 11/11/25. On 11/11/25 at 4:56 AM, Resident #24's medical record had documented Dulcolax was given. On 11/20/25 at 9:20 AM, the CNO stated the nurse assigned to that building had not documented any bowel medication interventions for Resident #24 from 11/6/25 until 11/11/25 and should have. 4. Resident #30 was admitted to the facility initially on 10/16/25 with readmission on [DATE] with multiple diagnoses including transient cerebral ischemic attack (a brief stroke-like event) and anxiety. Resident #30's physician orders for bowel care management were documented as: - Bisacodyl Tablet Delayed Release, Give 10 mg by mouth every 24 hours as needed for constipation on Bowel Day 3. If no result within 24 hours follow bowel day 4. Start date 11/6/25 - Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 unit rectally every 24 hours as needed for constipation on Bowel Day 4 -Start Date 11/6/25 - Fleet Enema Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for constipation on Bowel Day 5. Notify MD, note bowel evaluation. -Start Date 11/6/25 Resident #30 had a documented bowel movement on 11/14/25 at 3:38 PM and not again until 11/19/25 at 5:19 AM, over 110 hours with no documented bowel movement. No documentation of Resident #30 receiving the physician ordered medications for constipation management during 11/14/25 to 11/19/25. On 11/21/25 at 8:25 AM, the CNO stated the nurse had not documented any bowel medication interventions for Resident #30 and should have.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 11/19/25 at 2:45 PM, the surveyor noted the posted daily licensed and CNA staffing list had the scheduled hours listed at 72 hours for days and 48 hours for nights but not the actual hours worked for RN, LPN, and CNA as required. Additionally, the daily staffing sheet for 2/12/25 had not been completed with any staffing information.On 11/19/25 at 3:30 PM, the CEO stated the posted daily staffing list should have had scheduled and actual hours worked for each of the nursing categories and had not.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.The facility Food Safety and Storage policy dated 11/28/17, documented under Labeling and Rotation:- Opened or repackaged food must be labeled with contents and use-by-date.- Food removed from original packaging must be labeled with its common name (unless clearly identifiable) and use-by or expiration date. On 11/18/25 at 9:20 AM, the following was observed in the [NAME] kitchen dry food storage area and again with the Culinary Manager present at 1:30 PM:- Unopened Home Brand Syrup with best used date of 10/28/25. - Opened Marshmallow syrup with no opened date.- Opened Peach syrup with no opened date and best used date of 3/20/25.- Opened [NAME] Bag was not properly sealed and was spilling out rice.On 11/18/25 at 9:25 AM, the following was observed in the [NAME] kitchen prep area and again with the Culinary Manager present at 1:32 PM:- Squeeze bottle and small plastic tub were not labeled with contents, or use-by-dates. The contents were later identified by the cook as melted butter.On 11/18/25 at 9:27 AM, the following was observed in the [NAME] kitchen area:- Observed cook #1 with gloved hands, cutting up bell peppers. She then slipped on oven mitts over her gloved hands to remove some items from the oven. [NAME] #1 removed the oven mitts to continue cutting the bell peppers with the same gloves with no hand washing or change of gloves. On 11/18/25 at 9:30 AM, the following was observed in the [NAME] reach-in freezer and refrigerator area and again with the Culinary Manager present at 1:35 PM:- Opened bag of broccoli that had not been labeled with opened date.- Half cut onion and half cut head of lettuce both wrapped in saran wrap plastic, with no opened dated.- Observed dirt and food particles on top of the refrigerator that had large cooking pots stored upside down on top of refrigerator.On 11/18/25 at 10:00 AM, the following was observed in the [NAME] kitchen dry food storage area and again with the Culinary Manager present at 1:40 PM:- Krusteaz buttermilk pancake mix with open date of 6/25 but no use by date on it. On 11/18/25 at 10:05 AM, the following was observed in the [NAME] reach-in freezer and refrigerator area and again with the Culinary Manager present at 1:42 PM:Reach in Refrigerator:- Open container of cranberry juice without opened date labeled. On 11/18/25 at 4:30 PM, the Culinary Manager stated those food items without opened dates or use by dates should have been discarded and were not.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 11/18/25 at 11:20 AM, during the [NAME] Unit medication cart audit, observed the narcotic accountability sheets, dated 11/1/25 to 11/18/25, with 1 licensed nurse signature not documented. On 11/18/25 at 11:22 AM, LPN #1 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 11/20/25 at 4:40 PM, during the [NAME] Unit medication cart audit, observed the narcotic accountability sheets, dated 11/1/25 to 11/20/25, with 1 licensed nurse signature not documented. On 11/20/25 at 4:41 PM, RN #2 stated I should have signed the narcotic accountability sheet this morning when I accepted the medication cart but did not. On 11/21/25 at 8:05 AM, the CNO stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observations, State Operations Manual Appendix PP, and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and biologicals were labeled when opened. This was true for the [NAME] Unit and the [NAME] Unit. This failure created the potential for residents to receive expired medications with decreased efficacy, use of expired biologicals, and the potential for theft and/or diversion. Findings include:The State Operations Manual, Appendix PP, updated 8/8/24, Schedule II-V medications must be maintained in separately locked, permanently affixed compartments. 1. On 11/19/25 at 8:52 AM, observed the following in the [NAME] and [NAME] medication storage cabinets: - one bottle of Mucus Relief 400 mg with an expiration date of 6/11/25- one bottle of Mucus Relief 400 mg with a date of 6/24 marked on the bottle. LPN #1 unable to state if the marking was month and year or month and day.- one bottle of Sunmark B6 vitamins 100 mg with an expiration date of 7/2025- two bottles of Aspirin 325 mg with an expiration date of 10/2025- one opened bottle of Melatonin 50 mg with no open date - one opened bottle of Folic Acid 400 mcg with no open date- one Albuterol inhaler with an expiration date printed on the inhaler of 3/21/25 On 11/19/25 at 4:07 PM, the Clinical Resource Nurse stated the expired medications should have been removed from the storage cabinets and had not been. 2.The following was observed for biologicals.On 11/18/25 at 11:20 AM, one set (2 bottles) of glucose test solutions with an expiration date printed on one bottle of 10/10/25 and one bottle of 10/12/25. On 11/18/25 at 11:25 AM, observed bottle of glucose test strips with expiration date printed on bottle of 11/5/25.On 11/20/25 at 4:15 PM, the Clinical Resource Nurse stated the glucose test solution and strips were expired and should have been removed from the cart and had not been.3. The following was observed during the medication cart audits. On 11/19/25 at 11:05 AM, the [NAME] Unit medication cart was audited with LPN #2 present. Observed on the bottom of the 3rd drawer 1 small yellow tablet, 1 green tablet, 1 oval shaped white tablet, and 1 small light red tablet. On 11/19/25 at 11:13 AM, LPN #2 stated the pills should not have been loose in the medication cart. On 11/19/25 at 11:20 AM, the [NAME] Unit medication cart was audited with LPN #1 present. Observed on the bottom of the 3rd drawer 3 oval white pills and 1 small oval pink pill. Surveyor observed one of the medication cart organizer trays with a dark orange colored dried sediment on the inside edges of the tray. On 11/19/25 at 11:42 AM, LPN #1 stated the pills should not have been loose in the medication cart and should have been destroyed. On 11/21/25 at 8:20 AM, the CNO stated the medication carts should be clean and the nurses should have destroyed the loose pills. 4. The following was observed for controlled medications. On 11/19/25 at 11:50 AM, observed in the [NAME] Unit medication refrigerator, lorazepam (Schedule IV controlled medication) stored in a removable green plastic box on the medication refrigerator shelf. On 11/19/25 at 12:10 PM, observed in the [NAME] Unit medication refrigerator, lorazepam (Schedule IV controlled medication) stored in a removable gray plastic bath basin on the medication refrigerator shelf. On 11/21/25 at 8:14 AM, the Clinical Resource Nurse stated the controlled medication for the [NAME] Unit and [NAME] Unit should have been in an affixed box in the medication refrigerators and were not.

Based on observation, record review and interview, the facility failed to ensure residents were free of medication preparation and administration errors for 1 of 1 resident (Resident #9) observed for medication preparation and administration of insulin. This failed practice placed the resident at risk for not receiving their prescribed medication dosage and other adverse outcomes. Findings include: Resident #9 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses which include diabetes and heart failure. Resident #9's physician orders documented Novolog OG Injection Solution inject 15 IU subcutaneously three times a day related to Type 2 Diabetes Mellitus and Novolog Injection Solution as per sliding scale: blood sugar 70-149 = 0 units, 150-199 = 1 unit, 200-249 = 2 units. On 11/20/25 at 11:30 AM, observed RN #2 remove Novolog insulin pen from the medication cart and dial the insulin pen to 15 Units as ordered plus 2 units for the sliding scale for a total of 17 units (Resident #9's blood glucose was 233). RN #2 did not prime the insulin pen with 2 Units before dialing the ordered dose. On 11/20/25 at 11:35 AM, RN #2 administered the Novolog insulin to Resident #9. On 11/20/25 at 11:45 AM, RN #2 stated he did not prime the insulin pen and was unaware of the need to prior to administering insulin. On 11/21/25 at 8:10 AM, the CNO stated insulin pens should be primed with 2 units prior to administering the ordered insulin dosage.

Based on record review and staff interview, it was determined the facility failed to provide adequate supervision and functioning devices to prevent elopement and fall. This was true for 1 of 6 residents (Resident #29) reviewed for accidents and elopement. This deficiency created the potential for physical harm (Resident #29 was harmed) if residents were not supervised or assistive devices not functioning when residents at risk for elopement left the facility. Findings include: Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the right hip and pubic bone, prostate and bone cancer, and dementia. A quarterly MDS assessment, dated 8/23/24, documented Resident #29 was severely cognitively impaired. Resident #29's care plan, initiated on 1/14/24, documented the resident was at risk for wandering and elopement. His care plan was updated on 4/21/24, 6/26/24, 7/8/24, and 9/19/24, directing staff to provide the following interventions: Distract Resident #29 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books; Provide structured activities; Place Wander Alert on Wheelchair; and Document number of aimless wandering episodes. A physician's order, dated 1/14/24 and 6/29/24, directed staff to place a Wander Alert on Resident #29's wheelchair. A consent was signed on 11/20/23, and 6/9/24. A nursing progress noted, dated 8/15/24, documented Resident #29 attempted to get out the front door and set off the wander alarm. He had been wandering for 22 days previously. An I&A report, dated 8/31/24, documented Resident #29 was found in the parking lot of the facility trying to get off the floor and into his wheelchair. Resident #29 was noted to have 0.5 cm by 2.8 cm laceration to his right temporal area, and abrasions to his right elbow and right pinky toe. The provider was notified and gave an order to send Resident #29 to the hospital. The I&A also documented the emergency exit alarm was turned off. An investigation report, dated 9/5/24, documented Resident #29 exited the facility using the emergency exit door with delayed egress. It appeared Resident #29 propelled his wheelchair on the sidewalk and two of his wheelchair wheels fell off the curb and potentially tripped his chair forward causing him to fall and hit head on the ground. The I&A documented Resident #29 was sent to the hospital. A hospital report, dated 8/31/24, documented Resident #29 had a right parietal scalp laceration roughly 3 cm long without contamination and no pulsatile bleeding. Resident #29 received laceration repair with four staples, to return in 5-7 days to have them removed. A nursing note, dated 9/10/24, documented Resident #29 had the staples removed. On 10/25/24 at 9:56 AM, the CEO and CNO, stated the Wander Alert is set for the front door as it doesn't lock during the day. A Wander Guard would have locked the front doors and an alarm at the front door would have alerted staff. However, the alarm guards are not set to the side doors. Resident #29 exited the side door and the fire alarm on that door did not sound. The CEO and CNO stated, they do not know why the side door alarm was not activated, but it is now checked twice per day to ensure the alarm is activated. The facility's investigation concluded Resident #29 the exterior [side] door alarms were not set. Resident #29 did have a wandering device placed on his wheelchair. Resident #29 propelled himself in his wheelchair outside the door and when his wheels fell off the curb, he lost his balance and fell out of his wheelchair. The facility took the following actions: - Monitoring the side door alarms at least twice per day per shift (up to four times per day). - Checking to ensure the Wander Guard is functional. These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of 9/5/24, and there were no further occurrences Resident #29 wandered out of the facility. At the time of this survey the facility was in substantial compliance and therefore does not require a plan of correction.

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. Additionally, the facility failed to ensure food was not exposed to cross-contamination while raw food was defrosting over cooked food. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA (Food Drug Administration) Food Code Section ,d+[DATE].11 Preventing Food and Ingredient Contamination/Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross-contamination by: .Separating raw food animal foods during storage, preparation, holding, and display from: (b) Cooked ready-to-eat food. The FDA Food Code Section ,d+[DATE].17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. FDA Food Code Section ,d+[DATE].14 (A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials. The facility's Food and Supply Storage policy, dated [DATE], documented all food, non-food items, and supplies used in food preparation shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as set forth in the FDA code, state regulations, and city/county health codes. - Guidelines for food storage: Section 9: In refrigerators, store cooked foods about fresh foods to prevent cross contamination. All raw meat, poultry, and fish should be stored on bottom shelves in coolers/refrigerators and in pas deep enough to contain any juice from products. - Labeling and rotating food supply: Section 1: For food products that are opened and completely used or prepared at the facility and stored, the product should be labeled as to its contents and use-by dates. The facility's Sanitizing Stationary Food Service Equipment and Food Contact Surfaces policy, dated [DATE], documented proper cleaning and sanitizing station food service equipment (e.g., mixers, slicers, and other equipment that cannot be readily immersed in water) and food contact surfaces minimizes the growth of microorganisms that may result in food contamination. The cleaning and sanitation tasks are established on a cleaning schedule; assigned by employee position by shift and frequency. The initial kitchen inspection was conducted on [DATE] at 3:15 PM. The following was observed: - In the [NAME] Kitchen Refrigerator raw chicken was defrosting above packaged ready-to-eat hardboiled eggs. - In both [NAME] and [NAME] kitchen refrigerators, there was a build-up of hanging dust particles on the ceiling fans. A follow-up kitchen inspection was conducted on [DATE] at 11:15 AM with the CDM. The following was observed: - In both [NAME] and [NAME] kitchen refrigerators, there was a build-up of hanging dust particles on the ceiling fans. - Lettuce, dated [DATE], was in the [NAME] refrigerator. - Expired spices were found in the cabinet with the following expiration/use-by dates: Thyme leaves, ([DATE]); Garlic powder ([DATE]); Thyme powder - no date; Lemon pepper ([DATE]); Celery seed ([DATE]); Tarragon ([DATE]); Dill weed ([DATE]); Ground white pepper ([DATE]); Whole celery seed ([DATE]); undated chili powder; chicken seasoning ([DATE]); Poppy seed ([DATE]); nutmeg ([DATE]); Johnny's season salt - no date. breadcrumbs - no date; cayenne pepper ([DATE]). Spices stored in cabinet with temperature recorded at 81 degrees F. A review of the kitchen cleaning schedule for September and [DATE] documented the main refrigerator and freezer were not cleaned on [DATE], [DATE], and [DATE]. On [DATE] at 3:45 PM, the CDM confirmed the spices in the cabinet should have been thrown away by the expiration or use-by date. She also stated morning and afternoon cooks will clean the refrigerators at the end of each shift. The CDM was not sure why there was a build-up of dust on the ventilation cooling fans.

Based on observation, record review, policy review, review of the State Survey Long-Term Care Reporting Portal and interviews, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 1 of 2 residents (Resident #8) reviewed for abuse and neglect. Resident #8 experienced physical and verbal abuse from another resident. This failure placed all residents at risk of ongoing abuse, potential physical and psychosocial harm. Findings include: The facility's Abuse policy, revised 8/1/23, documented the facility respects residents' rights to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy identified residents who are at most risk of neglect and abuse have dementia, or who have psychosocial, interactive, and/or behavioral dysfunction such as verbally aggressive behaviors and/or physically aggressive behavior. Additionally, residents are identified at risk for abusing other residents through family interviews, chart review, behavior monitoring, and mood and behavior triggers. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia, diabetes, chronic obstructive pulmonary disease, and brain injury. A quarterly MDS assessment, dated 9/23/24, documented Resident #8 was cognitively intact. Resident #26 was admitted to the facility on [DATE] with multiple diagnoses including brain hemorrhage, and dementia. A quarterly MDS, dated [DATE], documented Resident #26 was severely cognitively impaired. Resident #8 and Resident #26 share a Suite which includes rooms adjacent to each other sharing a common bathroom and entry way, but each have private room space. A review of I&A reports investigated by the facility, and reported on time to the State LTC portal documented Resident #8 experienced physical and verbal abuse from Resident #26 as follows: Incident 1: On 5/23/24, Resident #26 was yelling at Resident #8. Resident #26 hit Resident #8 four times with a cup. A nursing progress note, dated 5/23/24, documented Resident #8 left her cup by a common area sink. When Resident #8 returned, her cup was missing and she asked if Resident #26 took it, to which Resident #26 responded, no. Resident #8 saw her cup on Resident #26's bedside table and reclaimed the cup. The residents began yelling at each other and calling each other curse words. Resident #26 hit Resident #8 four times with a different cup. According to Resident #8's statement, dated 5/24/24, Resident #26 hit her four times on the head with a different cup. The investigative summary, dated 5/24/24, documented that Resident #8 stated Resident #26 hit her in the head with the cup and called her a bitch. Resident #8 put her hands up to protect herself from Resident #26 slapping her before staff intervened. Resident #8 was offered another room to prevent a recurrence, but declined stating she likes her room and view. Resident #8 also stated Resident #26 would not remember the incident. Staff did not see any physical altercation between the residents, and no injuries were documented. Incident 2: On 7/29/24, Resident #26 threw juice on Resident #8 as she was rolling away in her wheelchair. The investigative summary, dated 8/2/24, documented Resident #26 was waiting at the kitchen window asking for juice when Resident #8 came to the window to ask for coffee. Resident #8 received her coffee first as the juice was not available at the same time. Resident #26 was verbally aggressive with Resident #8, who rolled away in her wheelchair. Resident #26 then threw her juice on Resident #8's back. No physical or mental injuries were identified. Resident #8 has no recollection of the incident. The facility stated they would continue to monitor. It was unclear what the facility would continue to monitor. A nursing progress note, dated 7/29/24, documented Resident #8 understood Resident #26 has cognition deficits, and Resident #8 was not distraught or wanting to move rooms after the incident. Incident 3: On 9/4/24, Resident #8 was rolling away from a verbal fight with Resident #26 and bumped into Resident #26. Resident #26 then punched Resident #8 in the shoulder three times. Resident #8 and Resident #26 were passing each other in the hallway going opposite directions. Words were exchanged between the two residents, and a nurse overhead Resident #26 calling Resident #8 a Fat Cow. Resident #8 turned her wheelchair around, hitting Resident #26 who claimed her foot had been run over. Resident #26 then hit Resident #8 in the shoulder/arm area three times. Nursing checked Resident #8's arm and noted there was a red area where Resident #26 hit her. Both Resident #8 and Resident #26 were inspected for skin injuries and bruising, and none were noted on Resident #26's foot or Resident #8's arm. The investigative summary, dated 9/10/24, documented the medication for both Resident #8 and Resident #26 was adjusted, and the facility would monitor changes in behavior, anger, anxiety, and depression. It was also recommended on moving one of the resident's when a room becomes available. On 10/25/24 at 8:45 AM, the Administrator and DON stated there had been no further incidents regarding Resident #8 and Resident #26 after their medication was adjusted. No comment was made as to why the residents were still in rooms adjacent to each other or why Resident #26 was not moved to another building of the facility. The facility's investigation concluded Resident #8 and Resident #26 have had several interactions of resident-to-resident abuse. The facility took the following actions: - They offered a change in room location to Resident #8. - They modified the medication of both Resident #8 and Resident #26. - They monitor the behavior of both residents of increases in anger, anxiety, and depression. - Staff training regarding resident-to-resident abuse on 9/10/24. These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of 9/10/24, and there have been no further occurrences reported between Resident #8 and Resident #26, although they remain in adjacent rooms. At the time of this survey the facility was in substantial compliance and therefore does not require a plan of correction.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 2 of 12 residents (Resident #6 and Resident #32) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information on the care plan. Findings include: The facility's Care Plans policy, revised [DATE], documented a team of qualified persons monitors the resident's condition and effectiveness of the care plan interventions, revising the care plan quarterly, annually, with a significant change assessment or more frequently as needed with the input by the resident and/or the representative, to the extent possible. 1. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including personal history of traumatic brain injury and dysphagia (difficulty in swallowing). A care plan, revised [DATE], documented Resident #6 was a smoker and required supervision while smoking. Resident #6's care plan also documented he used cigarette extenders due to burning his fingers because he chose to smoke cigarettes down to the filter and refused to let staff put them out any sooner. On [DATE] at 9:12 AM, Resident #6 was observed in the smoking area with NA#1 standing next to him. Resident #6 was holding the cigarette with no extender. On [DATE] at 2:39 PM, the CNO stated Resident #1 no longer need the cigarette extender. The CNO stated the cigarette extender should have been taken out from his care plan and it was not. 50603 2. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder with psychotic symptoms, dementia with agitation, mental disorders, brain injury, and parkinsonism. A quarterly MDS assessment, dated [DATE], documented Resident #32 was severely cognitively impaired. A review of Resident #32's care plan, dated [DATE] and revised on [DATE], documented an Advance Directive was in place and a full code was requested. On [DATE] at 9:26 AM, a review of Resident #32's record documented the following: - A POST (Physician Orders for Scope of Treatment), dated [DATE], signed by Resident #32, documented his code status was Full Code. A physician's progress note, dated [DATE], documented the physician spoke to the guardian about Resident's #32's condition, and she stated she did not want CPR, as aggressive interventions would increase Resident #32's distress without prolonging life. - A POST, dated [DATE], signed by the physician, documented Resident #32's code status of DNR (Do Not Resuscitate). On [DATE] at 3:55 PM, the CNO verified the updated POST from [DATE] was not added to Resident #32's care plan. She confirmed the care plan should have been updated, as needed, to reflect the change from full code to DNR and it was not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure nutrition was administered as ordered by the physician for 1 of 2 residents (Resident #6) whose nutritional needs were reviewed. This deficient practice created the potential for harm when Resident #6 was not provided with physician ordered nutrition. Findings include: The International Dysphagia Diet Standardisation Initiative (IDDSI), documented the dental diet was previously known as Mechanical Diet. It was designed to provide a texture modification of the regular diet for patients without dysphagia who are in need of a texture modification. Meats are in ground form or small bit-size, moist, and mashable or flakable. All hard foods are omitted, or their form is altered. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including personal history of traumatic brain injury and dysphagia (difficulty in swallowing). A physician's order, directed staff to provide Resident #6 with dental/mechanical soft texture diet with thin consistency, extra sauce, and gravy on meals on scoop plate and built-up utensils for all meals. On 10/22/24 at 12:19 PM, Resident #6 was served ground chicken with mushrooms cut into slices, green beans, and pasta. Resident #6 started eating, when suddenly he started coughing. LPN #1 and AD quickly assisted Resident #6. LPN #1 was heard asking Resident #6 if he would like to be brought back to his room. Resident #6 responded yes, and LPN #1 and AD pushed his wheelchair back to his room. On 10/22/24 at 12:30 PM, the CDM stated Resident #6 was on mechanical soft diet. Resident #6's meal card did not indicate he was on mechanical soft diet. The CDM stated Resident #6's meal card should indicate what type of diet he was on, but it was not. The Surveyor then asked the CDM to bring Resident #6's meal to the Nurse's station. The ground chicken, green beans and pasta were easily mashed with a fork but not the mushrooms slices. When asked if the mushrooms were fresh mushroom or canned mushrooms. The CDM stated they were fresh mushrooms. The smallest mushroom slice noted was about 1 cm (centimeter) by 1 cm in size. The CDM stated the mushrooms were cut small but not small enough and should have been put into the food processor together with the chicken. On 10/22/24 at 1:20 PM, the [NAME] stated she knew Resident #6 was on mechanical diet. She stated she put the chicken and mushrooms into the food processor, and it was finished. The [NAME] stated she added some gravy to make it moist. The [NAME] stated when she ladled some gravy, she did not notice that some mushrooms came with it. On 10/22/24 at 4:17 PM, the CNO stated Resident #6 was on mechanical diet and should be indicated in his meal card. The CNO stated she did not know why Resident #6's diet information was not in his meal card. On 10/24/24 at 12:03 PM, the RD stated the mushroom should have been put in the food processor together with the chicken or been finely chopped.

Based on observation, record review, resident and staff interviews, it was determined the facility failed to ensure residents were provided with appropriate devices to support their body positioning while sitting in their wheelchair. This was true for 1 of 1 resident (Resident #11) reviewed for positioning. Resident #11 was at risk of neck and back discomfort when his head and neck were not supported while he was sitting in his wheelchair. Findings include: Resident #11 was admitted to the facility on [DATE] and readmitted 11//18/20, with multiple diagnoses including schizoaffective disorder, anemia, and benign prostatic hyperplasia (enlargement of the prostate gland). Resident #11 was observed as follows: - On 10/21/24 at 5:10 PM and on 10/22/24 at 12:21 PM, he was in the dining room sitting at the table together with three other male residents. His head was observed to be tilted to his right side while he was eating. There was a neck cushion behind his neck. - On 10/23/24 at 10:33 AM, he was sitting in the [NAME] common area together with other residents listening to the Activity Director (AD) as she reads the Chronicle. Resident #11's head was observed to be tilted to his right side with a neck cushion behind his neck. - On 10/23/24 at 11:37 AM, he was observed listening to the surveyor during the Resident Council meeting. His head was tilted to his right side with a neck cushion behind his neck. - On 10/24/24 at 10:00 AM, Surveyor entered Resident #11's room. He was sitting in his wheelchair and looked up at the Surveyor without moving his head. When asked how he was doing, Resident #11 stated he was fine. When asked how his neck was, Resident #11 without moving his head pointed to his neck and stated bad. - On 10/24/24 at 10:04 AM, the AD together with the Surveyor, entered Resident #11's room. The AD asked Resident #11 how his neck was, Resident #11 brought both hands to his neck and stated rotten. with his face grimacing. - On 10/24/24 at 10:07 AM, during the group exercise, Resident #11 was seated together with the other residents. The AD who also was the RNA Coordinator instructed the resident to turn their head to their right, left, up and down. Six residents participated in the neck exercises. Resident #11 was not observed to participate in the neck exercises. All throughout these observations, Resident #11 was not observed to bring his neck to neutral anatomical position. Resident #11 was not observed to have a device to support his head to prevent him from tilting his head to right side. On 10/23/24 at 4:23 PM, the Acting Director of Rehabilitation (DOR) stated he did not believe Resident #11 had a neck contractures. He stated Resident #11 was provided with a u-shaped pillow for his neck, but he refused to use it. When asked the last time he assessed Resident #11's head for positioning, the Acting DOR stated he will check Resident #11's record and come back to the Surveyor. On 10/23/24 at 1:57 PM, during a follow-up interview. The Acting DOR stated all residents in the facility are being assessed quarterly and as needed. The Acting DOR provided documentation Resident #11 was seen for PT (Physical Therapy) from 6/13/24 to 8/23/24. When asked if Resident #11's neck positioning was addressed, the Acting DOR stated he did not assess Resident #11's neck positioning since he was told Resident #11 was doing good with his neck exercises and he refused to use his neck pillow. When asked what other devices was recommended or tried to keep Resident #11's head in the neutral position. The Acting DOR stated no other devices were tried for Resident #11 to keep his head in the neutral position, The WebMD website, accessed on 10/30/24, documented abnormal head posture occurs when your head is at an angle with the body. The head moves away or tilts from its straight position. Abnormal head positions include: chin up, chin down, head tilting to the right or left and combinations of these abnormal head positions. The WebMD website also stated Abnormal head posture can lead to permanently tight neck muscles. It can cause long term neck pain or headache.

Based on staff interview and record review, the facility failed to ensure the facility's arbitration agreement (a document that designates a third party to resolve a dispute between others), presented to residents to sign, included the selection of a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) was convenient to both parties and a choice of arbitration services (where the parties can choose an arbiter to use). This was true for 3 of 4 residents (#14, #15, and #183) whose records were reviewed for arbitration agreements. This had the potential to affect all residents in the facility who signed an arbitration agreement. Findings include: The facility's Voluntary Agreement for Arbitration, effective 10/21/22 was signed by the following residents or their representative: - Resident #14 and the facility representative on 2/15/23 - Resident #15's representative and the facility representative on 2/15/23 - Resident #183 and the facility representative, signature undated, but noted on the front page of the agreement the resident was admitted on [DATE]. On 6/29/23 at 3:18 PM, The facility's Voluntary Agreement for Arbitration, effective 10/21/22, was reviewed with the Assistant Administrator. The Agreement included the following language, An arbitration hearing arising under this Arbitration Agreement shall be held in the county where the Facility is located before a board of three arbitrators [from a specific Arbitration Association] . The Assistant Administrator agreed an arbitration hearing should accommodate a place to honor preferences of the resident or their representative. She agreed the current agreement did not give the resident a choice of location. When asked about giving the resident or their representative a choice of arbitrators, she agreed they should be given a choice, other than the association identified in the agreement, if they preferred an arbitrator from a different organization.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices for food storage. These failed practices placed the 31 residents who consumed food prepared by the facility at risk for adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food and Supply Storage policy, dated 11/28/17, states food products that are opened and not completely used or prepared at the facility and stored, the product should be labeled with contents and use-by dates. This policy was not followed. On 6/26/23 at 11:00 AM, during a brief tour of both kitchens with the Dietary Manager, the following was observed in the refrigerators, freezers, and pantry: Items out of date: - Frozen Tortillas dated 2/26/22 ([NAME] main freezer) - Sweet and Sour Sauce Use by date 5/5 ([NAME] pantry) - Cottage Cheese dated 5/10/23 ([NAME] main refrigerator) - Grape Juice dated 6/2/23 ([NAME] main refrigerator) - Ten cartons of individual chocolate milk dated 12/13/22 ([NAME] main refrigerator and freezer) Items not dated, not labeled, or both: - Leftover chicken Cordon Bleu ([NAME] main freezer) - Chicken breasts ([NAME] main freezer) - Opened hamburger patties ([NAME] main freezer) - Opened frozen waffles ([NAME] main freezer) - Bag of frozen precut chicken ([NAME] main freezer) - Several packages of bread and waffles in the freezer ([NAME] second freezer) - Container of chicken broccoli soup in the freezer ([NAME] second freezer) On 6/26/23 at 11:00 AM, during the kitchen tour, the Dietary Manager stated out of date items should be discarded. She stated the frozen items were not labeled and dated. The Dietary Manager stated items were not always labeled.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents received respiratory care for a resident receiving oxygen by nasal cannula. This was true for 1 of 4 residents (Resident #10) reviewed for respiratory care. This deficient practice had the potential for harm if the residents experienced discomfort from non-humidified oxygen. Findings include: Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low oxygen levels in body tissues) and atrial fibrillation (an irregular and often fast heart rate). A quarterly MDS assessment, dated 3/29/23, documented Resident #10 received oxygen. Resident #10's June 2023 MAR, directed staff to change her oxygen tubing/nebulizer tubing, humidification bottle, and clean filter every week. On 6/26/23 at 2:33 PM, 6/27/23 at 9:02 AM and 9:52 AM, and 6/28/23 at 8:46 AM, Resident #10 was observed in her room receiving oxygen via nasal cannula at 5 liters. The humidifier (container of water attached to the oxygen concentrator) was empty and was dated 6/17. On 6/28/23 at 8:46 AM, CNA #1 was asked to check Resident #10's humidifier. CNA #1 stated it was empty and dated 6/17. CNA #1 stated the humidifier should be changed every Monday and as needed.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 28 medications (7.14%) which affected 1 of 10 residents (Resident #29) whose medication administration was observed. This failed practice placed residents at risk of not receiving the prescribed dosage of their medication. Findings include: The facility's Eye Drop Administration policy, released 2/28/18, stated a sufficient contact time of approximately 3-5 minutes should be taken before applying additional medication to the eye. This policy was not followed. Resident #29 was admitted on [DATE], and readmitted on [DATE], with multiple diagnoses including glaucoma (a disease that damages the optic nerve resulting in loss of eyesight), kidney failure, and hypertension. On 6/28/23, at 4:49 PM, LPN #1 administered a medicated eye drop to Resident #29, giving 1 drop in each eye. LPN #1 waited approximately 15 seconds and administered a different medicated eye drop to Resident #29, giving 1 drop in each eye. On 6/29/23, at 4:35 PM, LPN #1 stated when giving more than one medicated eye drop she should wait 3-5 minutes between medications. LPN #1 stated she did not wait long enough between the eye drops.

Based on policy review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure resident care was provided in accordance with professional standards of nursing practice. This was true for 3 of 6 residents (Resident #2, #17, and #21) reviewed for quality of care. Specifically: - Resident #2's facial skin condition was not assessed. - Resident #17 and Resident #21's physicians were not notified of their high or low blood sugar levels as ordered. These failures created the potential for harm if care was delayed due to lack of assessment or physician notification. Findings include: 1. The facility's Diabetes Mellitus, Guidelines for Management policy, released 10/31/17, directed staff to notify the physician of a resident's blood glucose levels below or above the established ranges and implement any new orders as applicable. This policy was not followed. a. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus and dementia. Resident #21's physician order included the following: - Check blood glucose (BG) and follow directives. If blood glucose was less than 70 initiate hypoglycemic (low blood glucosoe) protocol and notify the physician as indicated. If BG was greater than 400 notify the physician and follow directives every shift, ordered 4/26/23. - Humalog KwikPen (quick-acting insulin) Injector 100 units/ml, inject 5 units subcutaneously (fatty tissue under skin) with meals, ordered 5/16/23. - Humalog KwikPen Injector 100 units/ml, inject as per sliding scale with meals as follows if BG was: 150 - 200 give 2 units 201 - 250 give 4 units 251 - 300 give 6 units 301 - 350 give 8 units 351 - 400 give 10 units If higher than 400 call the physician. - Lantus (long-acting insulin) SoloStar Pen Injector 100 units/ml, inject 35 units at bedtime, ordered 6/7/23. Resident #21's May and June 2023 MAR, documented his BG result was greater than 400 on the following dates: - 5/5/23 = 471 at 5:00 PM - 6/22/23 = 454 at 7:00 PM There was no documentation in Resident #21's records the physician was notified of his blood glucose when it was greater than 400. On 6/28/23 at 10:58 AM, the CNO reviewed Resident #21's record and stated she did not see the physician was notified of Resident #21's BG level when it was greater than 400 on the above dates. The CNO stated the physician should have been notified of the Resident #21's BG level if it was greater than 400. 48400 b. Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnosis including diabetes. Resident #17's MAR for May and June 2023 included the following order: - If Resident #17's BG was greater than 300 notify the physician and follow directives every shift, Resident #17's MAR for May and June 2023 documented his BG was greater than 300 as follows: - 5/3/23 = 315 at 11:30 AM - 5/6/23 = 307 at 4:30 PM - 5/10/23 = 309 at 9:30 PM - 5/11/23 = 314 at 9:30 PM - 6/1/23 = 301 at 4:30 PM - 6/6/23 = 308 at 9:30 PM - 6/10/23 = 310 at 4:30 PM - 6/11/23 = 313 at 9:30 PM - 6/13/23 = 321 at 9:30 PM - 6/15/23 = 352 at 4:30 PM - 6/16/23 = 351 at 4:30 PM - 6/17/23 = 304 at 9:30 PM - 6/18/23 = 304 at 4:30 PM - 6/22/23 = 309 at 4:30 PM - 6/26/23 = 333 at 11:30 AM - 6/26/23 = 301 at 4:30 PM - 6/27/23 =389 at 11:30 AM - 6/27/23 = 391 at 4:30 PM - 6/28/23 = 343 at 11:30 AM There was no documentation in Resident #17's record the physician was notified as directed in his MAR for BGs greater than 300. On 6/29/23 at 4:46 PM, the CNO stated there were no physician notifications for Resident #17 when his blood sugar levels were over 300. 48401 2. The facility's Prevention and Treatment of Pressure Ulcers and Other Skin Alterations policy, revised 7/13/18, stated the facility had a system in place to promote skin integrity, prevent skin alterations, and prevent further development of additional skin alterations. Residents received weekly skin checks, to validate there were no unidentified skin concerns, and staff were to document the description of skin alterations. The policy further stated treatment of new non-pressure related wounds were initiated and the wounds were observed for signs and symptoms of infection. This policy was not followed. Resident #2 was admitted on [DATE], with multiple diagnoses including schizophrenia (a chronic mental disorder that affects the way a person thinks, acts, expresses emotion, perceives reality, and relates to others), depression, and chronic pain. Resident #2's care plan revised 6/7/23, stated Resident #2 picked at her face at times, and staff were directed to observe her skin during ADL care, notify the licensed nurse of skin integrity impairments, monitor/document location, size, and treatment of skin injury, report abnormalities, failure to heal, and signs and/or symptoms of infection to the physician. On 6/26/23 at 3:34 PM, Resident #2 was observed with multiple circular wounds on her face, varying in size from approximately pin size to the size of a pencil eraser. The lesions were located on the right lower quadrant of her face, her chin, and the bridge of her nose. The areas were crusted and inflamed with reddened edges. Resident #2 stated the lesions appeared after she washed her face on 6/23/23, the areas became itchy, and she scratched at them until they opened. Resident #2 stated no one from the facility assessed the marks on her face or offered medical treatment. A Weekly Skin Alteration Report, dated 6/27/23. did not include documentation of the lesions on Resident #2's face. During an interview on 6/28/23 at 10:59 AM, Resident #2 stated the lesions were painful and itchy. She stated she requested antibiotic ointment from the nurse, but it was never administered. Resident #2 stated no one assessed the lesions. On 6/28/23 at 2:13 PM, the CNO stated she did not observe the lesions on Resident #2's face but confirmed she had a history of picking her face and the marks should be treated, monitored for signs of infection, and documented on her skin assessment. On 6/29/23 at 11:49 AM, the ACNO stated it is common for Resident #2 to pick her face. The ACNO stated the lesions on her face were not documented. She stated first aid was not offered and the facility was not monitoring the lesions for signs or symptoms of infection.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure a licensed nurse had competency for acting upon a significant change in condition of a resident who was unarousable resulting in emergent transfer to the hospital. This was true for 1 of 1 resident (Resident #8) who was observed experiencing a significant change in conditon. This deficient practice placed related to staff failing to recognize the resident's decline and need for emergent medical attention resulting in Resident #8's emergent transfer to the hospital. Findings include: The facility's Resident Change of Condition policy, dated 11/28/17, stated upon recognition of a potentially life-threatening condition or significant change in status, the nurse should communicate with other health care providers to meet the needs of the resident. The facility was to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status and obtain a full set of vital signs. This policy was not followed. Resident #8 was admitted on [DATE], with multiple diagnoses including dementia, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), depression, anxiety, psychosis (a condition of the mind that results in difficulties determining what is real and what is not real), and chronic pain. Resident #8's care plan documented to notify the nurse of any changes in drowsiness or lack of energy. Resident #8's care plan directed staff to monitor side effects of antipsychotic medications including sedation and drowsiness and to notify the physician. Resident #8's care plan also directed staff to monitor and document for side effects of pain medications and to report signficant changes in usual routine, sleep patterns, and decrease in functional abilities. Resident #8's June 2023 MAR included the following medications: - Seroquel (antipsychotic) 100 mg orallty two times a day for depression with severe psychotic symptoms and to monitor for side effects including sedation, drowsiness, and dry mouth. - Baclofen (muscle relaxant that can cause drwsiness) 20 mg orally three times a day for pain. - Oxycodone (opiod medication used to treat moderate to severe pain) 5 mg, one tablet orally three times a day related to chronic pain. - Fentanyl Transdermal Patch (opiod medication used to treat moderate to severe pain administered as a patch and absorbed through the skin) 75 mcg/hour; apply 1 patch transdermally every 72 hours for pain. The Drugs.com website, accessed 7/12/23, documented the following side effects for the above medications: - Seroquel: Common side efffects include somnolence (dowsiness) and sedation. - Baclofen: Common side effects include drowsiness and asthenia (abnormal physical weakness or lack of energy). - Oxycodone: Common side effects include sedation/somnolence. - Fentanyl Transdermal Patch: Common side effects include unusual tiredness or weakness. A progress note signed by LPN #1, dated 6/28/23 at 11:16 AM, documented Resident #8 was very sleepy/sedated and could not be woken up to drink his supplement. There was no documentation in Resident #8's record the physician was notified he was sleepy/sedated and could not be awakened, as directed in his care plan. On 6/28/23, at 5:15 PM, LPN #1 was observed during medication pass. LPN #1 was unable to rouse Resident #8 to take his medication. Resident #8 was lying in his bed, the skin on his face was drawn and pale, his eyes were closed and were sunken with dark circles, his mouth was hanging open and sticky mucus membranes were observed in his mouth. LPN #1 attempted to wake Resident #8 for approximately 10 minutes by gently shaking him and calling his name, applying Biofreeze (menthol pain relieving gel) and rubbing his neck and shoulders, and removing his hand splints and stimulating his hands and arms. Resident #8 did not respond to verbal stimulus, he would respond to physical stimulus by fluttering his eyelids, but not fully opening his eyes or vocalizing. During the same observation, LPN #1 stated Resident #8 was this way all day, he had not eaten, and struggled to wake enough to take his medications in the morning. She stated it was uncommon for him to be so sedated and he was usually easy to rouse when napping. LPN #1 stated she checked his vital signs that morning and they were within normal range. LPN #1 stated she would come back and see if Resident #8 woke up enough to take his medication at a later time. She stated she would check Resident #8's vital signs again after she finished passing medications for another resident. LPN #1 continued with medication pass. She did not notify Resident #8's physician he was unarousable. On 6/28/23 at 5:25 PM, 10 minutes later, LPN #1 stated for a second time she was going to check Resident #8's vital signs after she finished giving medications to another resident. On 6/28/23 at 5:48 PM, the survey team lead notified the CNO of the survey team's concern that Resident #8 may need immediate medical attention due to his prolonged unresponsiveness. At 5:54 PM, the ACEO was looking for the CNO and went to join her on the unit to check on Resident #8. A progress note signed by LPN #1, dated 6/28/23 at 5:53 PM, documented Resident #8 was sedated the entire shift, did not eat during the day, and his heart rate was 50 beats per minute. The Mayo Clinic website, accessed 7/12/23, documented a normal resting heart rate for adults ranges from 60 to 100 beats per minute. There was no documentation in Resident #8's record the physician was notified he was sedated the entire shift. On 6/28/23 at 6:25 PM, the ACEO stated Resident #8 was sent to the Emergency Department for further evaluation. She stated the CNO administered Narcan (a fast-acting emergency medication given when an opiate overdose is suspected) with no response from Resident #8. A progress note signed by the CNO, dated 6/28/23 at 6:26 PM, documented she was given a verbal order from the physician to give Resident #8 Narcan. The CNO administered 0.4 mg Narcan IM (intramuscular injection) as ordered by the physician for Resident #8 being difficult to arouse, very sleepy, and low [food and water] intake. The physician was called again five minutes after the Narcan was administered and there was no visible change in Resident #8's status. The CNO documented the physician directed staff to remove Resident #8's Fentanyl patch (a synthetic opiate medication patch used for severe pain) and call Emergency Medical Services to have Resident #8 transported to the Emergency Department for further assessment. A progress note signed by LPN #1, dated 6/28/23 at 6:49 PM, documented Resident #8 was mostly non-responsive today, more than his usual self. The note documented the CNAs reported very little food or liquid intake and Resident #8 was very difficult to rouse. The note further documented he took his morning medications, but not his evening medications. The note documented Resident #8 was transferred to the emergency room for further evaluation. There was no documentation in Resident #8's record the physician was notified he was mostly non-responsive during the day or that he was very difficult to rouse during the day shift prior to the progress note dated 6/28/23 at 6:26 PM.

Based on review of the Resident Council meeting minutes, policy review, and staff interview, it was determined the facility failed to ensure Resident Council concerns were addressed. These negative practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility. Findings include: The facility's Resident Council policy, revised 5/24/19, directed the facility to interview the resident group to obtain information to help the facility make improvements and enhance the quality of care and life for the residents. The policy also stated the Chief Executive Officer or designee would address the residents' recommendations and/or concerns and communicate back to the council and/or Council President. Resident Council minutes from September 2020 through January 2021 documented residents' concerns. Examples include: a. Resident Council minutes, dated 11/23/20, documented call lights on the isolation unit were not being answered, CNAs were asked to deliver medications, night shift staff were not helpful, housekeepers were not respectful, and staff continued to slam doors. b. Resident Council minutes, dated 12/21/20, documented living environment was good but tired of being in my room. c. Resident Council minutes, dated 1/20/21, documented some of the night staff were nasty. There was no further documentation what was meant by this statement. The facility did not document what actions the facility took to resolve these concerns. On 2/9/21 at 1:11 PM, the Resident Service Director said due to social distancing the Resident Council meeting was completed through survey. The Resident Service Director said residents who wanted to participate in the survey were asked questions regarding their concerns and suggestions. The Resident Service Director said residents' concerns were submitted to the supervisors who were responsible for the area related to the residents' concerns to address them. The Resident Service Director also stated the facility tried to resolve the concerns within five days and the concerns and actions taken were then presented to the Resident Council the following month. The Resident Service Director said she was unable to locate documentation the issues raised by the Resident Council on 11/23/20, 12/21/20, and 1/20/21 were addressed and resolved. The facility did not address residents' concerns.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure transmission-based precautions followed facility policy and nationally recognized guidance and hand hygiene was performed as directed and required. This failure directly impacted 8 of 18 residents (#1, #2, #3, #4, #5, #9, #11, and #12) who were negative for COVID-19 and who were observed. These failures had the potential to impact all residents, staff, and visitors entering the facility by placing them at risk of infection due to cross contamination of infectious agents, including COVID-19. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. Findings include: 1. The facility's Screening and Management of Coronavirus COVID-19 policy, revised 9/10/20, included the following: *Staff were directed to place a sign for Enhanced Droplet Precautions outside the resident's room for new admissions and re-admissions whose COVID-19 status was unknown and for residents who were positive for COVID-19 and still required transmission-based precautions. The Enhanced Droplet Precautions directed staff to put on an N95 mask, eye protection, a gown, and gloves. The policy stated for residents who tested negative or were recovered from COVID-19, Enhanced Droplet Precautions was not required. This policy was not followed. On 2/8/21, the Administrator said the facility census was 18 and the facility did not have residents who were COVID-19 positive. The Administrator said they transferred COVID-19 positive residents to another facility. The Administrator also said the facility was not admitting new residents since they had an outbreak of COVID-19 in 12/2020. On 2/8/21 at 11:58 AM, Resident #10's room had a PPE cart outside her room and there was no signage outside Resident #10's room regarding when and what PPE to wear. CNA #5 was wearing an N95 mask and a face shield when she put on a gown and gloves and then entered Resident #10's room. When CNA #5 exited Resident #10's room, she said she was told to put on a gown and gloves before entering Resident #10's room. On 2/8/21 between 12:00 PM and 12:30 PM, during the initial tour of the facility, Residents #2, #3, #5, #7, #8, #12, #13, #14, #15, and #16's rooms had Enhanced Droplet Precautions signs outside their doors directing staff to put on a gown, an N95 mask, eye protection, and gloves before entering their rooms. PPE carts were also observed outside their rooms. On 2/8/21 between 2:57 PM and 3:13 PM, the Enhanced Droplet Precautions sign was no longer posted outside Resident #8's door. Resident #1's room had an Enhanced Droplet Precautions sign outside his door and a PPE cart was also observed outside his room, which were not there earlier in the day. On 2/8/21 at 3:15 PM, CNA #3 had an N95 mask and a face shield on and put on a gown and gloves outside of Resident #2's room. When asked why Resident #2 had an Enhanced Droplet Precautions sign at his door, CNA #3 said she would find out the answer and would let the surveyor know when she found out. On 2/8/21 at 4:17 PM, the ICN said the facility had residents who were negative for COVID-19 and residents who had recovered from COVID-19. The ICN said Residents #1, #2, #3, #4, #5, #9, and #12 tested negative for COVID-19. The ICN said the facility had a COVID-19 outbreak on 12/17/20, so they put Enhanced Droplet Precautions signs outside the residents' doors who were COVID-19 negative. The ICN said the facility's staff were required to wear an N95 mask and face shield during their shift so they only needed to put on a gown and gloves upon entering those residents' rooms with an Enhanced Droplet Precautions sign. The ICN said the residents who had recovered from COVID-19 were within 90 days of having the infection and they were not likely to get re-infected with COVID-19 within this 90-day period so they did not require the enhanced precautions. The ICN said they wanted to keep the residents who were negative for COVID-19 safe from infection with it, that was why the Enhanced Droplet Precautions signs were placed outside their doors. When asked what guidance, from a nationally recognized organization, the facility based the practice of using Enhanced Droplet Precautions for the residents who were negative for COVID-19, the ICN said she could not remember what organization she got the information from. On 2/9/21 between 9:00 AM and 9:15 AM, Residents #9 and #11's rooms were observed with Enhanced Droplet Precautions signs outside their doors directing staff to put on a gown, an N95 mask, eye protection, and gloves before entering their rooms. A PPE cart was also observed outside their rooms. Residents #9 and #11's rooms did not have these signs posted outside their rooms on 2/8/21. On 2/9/21 at 10:02 AM, the ICN said she had added or removed a total of 6 signs from the time the surveyors entered the facility on 2/8/21 to now. The ICN stated she was, tying up loose ends that the signage for 6 of the resident rooms were incorrect. The ICN said she had removed the Enhanced Droplet Precautions signs from the doors of Residents #7, #8, #13 and #16 and placed Enhanced Droplet Precautions signs on Residents #1 and #12's doors. The ICN stated the Enhanced Droplet Precautions signs were placed outside the doors of residents who tested negative for COVID-19 to give them extra protection. The facility's policy for transmission-based precautions was not followed. 2. The facility's Hand Hygiene policy, revised 9/10/20, directed staff to assist residents to wash their hands prior to eating or entering the dining room. The policy also directed staff to perform hand hygiene before entering a resident's room. This policy was not followed. a. On 2/8/21 from 12:30 PM to 12:40 PM, lunch trays were delivered to the residents in the Galena building. During the delivery of the lunch trays the following was observed: - On 2/8/21 at 12:30 PM, CNA #3 entered Residents #1's room without performing hand hygiene and delivered Resident #1's meal and placed it on his overbed table. CNA #3 did not offer or assist Resident #1 with hand hygiene before his lunch. - At 12:31 PM, CNA #1 delivered Resident #5's food tray and placed it on her overbed table and left the room. CNA #1 did not offer hand hygiene to Resident #5 before her meal. On 2/8/21 at 3:11 PM, CNA #1 said she did not offer hand hygiene to Resident #5 before eating her meal. - At 12:35 PM, CNA #3 entered Residents #4's room without performing hand hygiene and delivered Resident #4's meal and placed it on his overbed table. CNA #3 did not offer or assist Resident #4 with hand hygiene before his lunch. On 2/8/21 at 1:15 PM, CNA #3 said she did not perform hand hygiene when she entered Residents #4's room and did not offer hand hygiene to Resident #4 before their meal. - At 12:35 PM, CNA #2 delivered Resident #2's meal and placed it on his overbed table in front of his wheelchair. CNA #2 did not offer or assist Resident #2 with hand hygiene before his lunch. On 2/8/21 at 12:54 PM, CNA #2 said she forgot to offer hand hygiene to Resident #2 before his meal. - At 12:40 PM, CNA #1 delivered Resident #8's meal and placed in on her overbed table. CNA #1 then sat down next to Resident #8 and assisted her with eating. CNA #1 did not offer hand hygiene to Resident #8 before assisting her with her meal. On 2/8/21 at 3:10 PM, CNA #1 stated she forgot to offer hand hygiene to Resident #8 before lunch. - At 12:41 PM, LPN #1 entered Residents #11''s room and delivered Resident #11's meal and placed it on her overbed table. LPN #1 did not offer or assist Resident #11 with hand hygiene before her lunch. On 2/8/21 at 3:16 PM, LPN #1 said she did not offer hand hygiene to Resident #11 before her meal. b. On 2/9/21 at 9:08 AM, CNA #2 entered Resident #6's room to deliver reading material. CNA #2 did not perform hand hygiene prior to entering Resident #6's room. On 2/9/21 at 9:13 AM, CNA #2 entered Resident #12's room to deliver reading material. CNA #2 did not perform hand hygiene prior to entering Resident #12's room. On 2/9/21 at 9:15 AM, CNA #2 said she did not perform hand hygiene prior to entering Residents #6 and #12's room. She stated, I was only dropping off (reading material). On 2/8/21 at 2:50 PM, the ICN said the expectation was for all staff to perform hand hygiene when entering a residents room even when there was no direct resident contact. c. A sign posted at the entrance of the Galena building stated: STOP .please use hand sanitizer before entering premises . This instruction was not followed. - On 2/8/21 Central Supply Staff #1 entered the Galena building without performing hand hygiene at 12:20 PM, 12:45 PM, 12:58 PM, 3:02 PM and 3:10 PM. On 2/9/21 at 12:53 PM, Central Supply Staff #1 was asked if hand hygiene was required before entering the Galena building. Central Supply Staff #1 said To be honest, I don't know. - On 2/8/21 at 3:20 PM, LPN #1 entered the Galena building without performing hand hygiene. On 2/8/21 at 3:21, LPN #1 said she did not perform hand hygiene when she entered the Galena building and stated, I already used it at the other building. Hand hygiene was not offered to residents prior to meals and was not performed by staff according to facility policy and signage.

Based on observation, record review, Incident & Accident reports, and staff interview, it was determined the facility failed to ensure a seatbelt and wheelchair anchor straps were properly secured for a resident during transport in the facility's van. The facility also failed to ensure adequate interventions and care plan updates were in place to prevent falls and injuries. This was true for 2 of 7 residents (#2 and #10) reviewed for falls. Resident #10 was harmed when he sustained multiple injuries including a scalp laceration, traumatic subarachnoid hemorrhage, and a C2 (second cervical vertebra) fracture related to a fall during transport in the facility's van. Resident #2, who was admitted with a history of falls, experienced minor injuries related to multiple falls without new interventions and care plan updates. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses, including traumatic brain injury and aphasia. A quarterly MDS (Minimum Data Set) assessment, dated 5/23/17, documented Resident #10 was totally dependent on staff for ADLs (Activities of Daily Living) assistance and severely cognitively impaired. A Fall Care plan, dated 5/7/17, documented Resident #10 was totally dependent on staff for all cares and the resident's wheelchair brakes were to be locked to prevent falls and provide safety. A Fall Scene Investigation Report, dated 7/18/17 at 5:00 pm, documented the following: * Resident #10 was returning from an appointment in the facility's van. During a turn, Resident #10 fell out of the wheelchair, hitting his head on the van's floor, and sustained a laceration to his head. * Van Driver #1's witness statement documented she was returning Resident #10 from a doctor's appointment in the facility's van when she turned the vehicle and Resident #10 fell out of his wheelchair. She pulled over, called 911, and applied an adult incontinence brief to a laceration on the resident's head, which was bleeding from a laceration when Resident #10's head struck the van floor. Paramedics arrived about five minutes after receiving the 911 call. The statement did not document any information regarding seatbelts. * Root Cause of This Fall: Assistive/protective device, Medical status/Physical condition/Diagnoses, and Inadequate transport driver training. Resident unable to maintain position in w/c (wheelchair) - was not restrained in chair. Chair was improperly secured in transport van. * Resident taken to ER (emergency room ) for evaluation, van drivers to be inserviced on securing w/c in van and securing residents in w/c during transport, and new safety belts have been ordered for vans. * Conclusion: (Resident #10) was injured when he fell from w/c during transport as w/c was improperly secured in w/c van. An ER final report, dated 7/18/17, documented Resident #10 sustained a scalp laceration requiring sutures and staples, an acute traumatic subarachnoid hemorrhage, and an unstable fracture of the second cervical vertebra (C2). On 7/19/17, the Administrator and the Assistant Administrator conducted an interview with Van Driver #1 about the 7/18/17 incident. Van Driver #1, when asked by the Administrator to demonstrate how she secured the wheelchair and resident before transporting him in the van, demonstrated locking the wheelchair brakes,and anchoring the wheelchair to the van's floor metal brackets by attaching the anchor straps to both rear and both front wheel spokes. She then demonstrated the wheelchair was at a 35-degree angle when Resident #10 fell out and struck his head on the van floor. After Van Driver #1 demonstrated how she secured Resident #10 in the van, the Administrator noted the slack and incorrect placement of the wheelchair anchor straps. On 7/25/17 at 12:00 pm, the Administrator said immediately after the 7/18/17 incident the van was not used until all drivers passed a competency test. The van involved in the incident was not used until new seatbelts were delivered and installed. The Administrator said Van Driver #1 locked Resident #10's brakes, used the anchor straps to secure the wheelchair, but did not tighten the anchor straps and did not apply a seatbelt, which led to Resident #10's wheelchair tipping over and spilling the resident onto the rubber floor. There was not a seatbelt in the van to secure Resident #10. Resident #10 was harmed when he sustained multiple injuries including a scalp laceration, traumatic subarachnoid hemorrhage, and a C2 fracture during transport in the facility's van. The facility failed to ensure the van was equipped with seatbelts and transport staff knew to apply the seatbelt and how to properly secure the wheelchair anchor straps to prevent the wheelchair from tipping. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, history of falls, and Parkinson's Disease. The annual MDS assessment, dated 5/19/17, documented Resident #2 was moderately cognitively impaired, experienced more than two falls with minor injury, and required extensive assistance of 1 staff with transfers. A Falls Care Plan, dated 10/3/16, documented Resident #2 had a history of [REDACTED]. Interventions included: * 10/17/16 - Therapy to review ambulation/gait pattern. *10/17/16 - (Resident #2) chooses not to use a w/c at this time as he chooses to direct his own care including his right to maintain his independence with transfers and ambulation. POA (Power of Attorney) and resident are aware of risk of injury with self ambulation/transfers and they choose to maintain Resident #2's quality of life with independence. * 2/16/17 - (Resident #2) continues to choose not to use assistive devices at times. Does not use call light appropriately. * 2/16/17 - Increased supervision with neuro's (neurological assessments). A Fall Scene Investigation Report, dated 1/19/17 at 3:00 pm, documented the following: * Resident #2 fell backwards while playing catch during a therapy session, hit a chair with his left inner arm, and sat on the floor. * The root cause of the fall was determined to be footwear. He had his slip on slippers on, which tend to not be supportive. * Initial interventions to prevent future falls included tennis shoes rather than slippers. * Conclusion: Resident needs encouraged (sic) to wear tennis shoes rather than slippers when out of room. Staff will assist. A Fall Scene Investigation Report, dated 2/16/17 at 3:10 pm, documented the following: * Root cause of Fall: Medical status/Physical condition/Diagnoses. * The area to describe initial interventions to prevent future falls was left blank. * Conclusion: Longstanding history of balance issues. Has had med(ication) review, therapy-which he refuses to participate in, neurologist review and nephrologist to review. Increased supervision with neuro's implemented. A Fall Scene Investigation Report, dated 5/18/17 at 12:00 pm, documented the following: * Resident #2 experienced a fall that was witnessed by staff who were not able to prevent the fall and an alarm sounded. * The root cause of the fall was determined to be amount of assistance, medical status, physical condition, diagnoses, and mood or mental status. Resident has [DIAGNOSES REDACTED]. * Initial interventions to prevent future falls included directions to staff to keep the resident within view as much as possible. * The report's conclusion documented staff were to continue with the care plan as written. On 7/27/17 at 6:40 pm, the DNS said the care plan should have been updated. A Fall Scene Investigation Report, dated 5/30/17 at 8:20 pm, documented the following: * Resident #2 was in his room, self-transferred to use the bathroom, alarm did not sound, and was found kneeling by the bedroom sink. * Root cause of Fall: Alarm-not on, Medical status/Physical condition/Diagnoses. * Why did the incident happen: Staff failed. * Conclusion: Staff did not check pressure alarm in chair - when resident got up, alarm did not sound - Resident very unsteady on his feet and impulsive. A Fall Scene Investigation Report, dated 6/2/17 at 5:35 pm, documented the following: * Resident #2 stood up from a w/c at a dining room table. The w/c, which was not locked, rolled back as he turned around, and the resident fell to his knees. * The root cause of the fall was documented as assistive/protective device, medical status, physical condition, diagnoses, and mood or mental status. Impulsive ambulation by resident with insufficient stabilization. * Initial interventions to prevent future falls included locking the resident's w/c brakes when the resident is stationary to prevent w/c from moving when resident spontaneously stands. Increase supervision. On 7/24/17 at 4:45 pm, Resident #2 was observed in w/c at a dining room table reading a book. Alarms were attached to his shirt and automatic locking brakes were observed on the w/c. On 7/25/17 at 9:30 am, Resident #2 was in a recliner in his room reading a book with alarms attached to his shirt. On 7/25/17 at 11:30 am, CNA #3 was observed assisting Resident #2 from a recliner to the bathroom to his w/c. CNA #3 attached the alarm to the resident's shirt. On 7/25/17 at 5:10 pm, Resident #2 was observed eating dinner when his alarm sounded without his moving. CNA #3 said the alarm was very sensitive. On 7/26/17 at 9:00 am, Resident #2 was observed sitting in a w/c at a dining room table reading a book. On 7/26/17 at 10:30 am, Resident #2 was observed sitting in a w/c at a dining room table reading a book. On 7/26/17 at 11:50 am, CNA #3 asked Resident #2 if he needed to use the bathroom prior to lunch and he said, Yes. CNA #3 then assisted Resident #2 to the bathroom. The facility's fall policy and procedure, dated 7/14/16, documented staff were to determine the root cause of incidents to determine appropriate interventions to prevent repeated falls. On 7/27/17 at 6:20 pm, the DNS said Resident #2 had not fallen since the automatic locking brakes were applied to his w/c following the 6/2/17 incident. The DNS was unable to find documentation in the care plan for the auto-lock brakes or other interventions related to the incidents of 1/19/17, 5/18/17, 5/30/17, and 6/2/17.

Based on observation, staff interview, record reviews, and policy review, it was determined the facility failed to: Ensure a resident (# 8) with a catheter received services to protect against catheter-related complications; and Ensure that residents (# 13, 14, & 16) who were incontinent of urine, received care and services to improve their level of continence. This was true for 4 of 9 (#s 8, 13, 14 , & 16) sampled residents. Resident #8 was harmed when alterations in treatment caused the resident to become septic and require admission to the hospital. Findings include: 1. Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The 10/4/14 admission MDS documented the resident: - Had short and long term memory impairment. - Required assistance with ADLs. - Had a foley catheter. - Received an antibiotic 7 days a week. The 9/21/14 care plan documented "Infection: admitted with urinary tract infection evidenced by lab report indicating organism. Risk for infection related to catheter, overall condition." The care plan also documented, undated, "He handles catheter, pulls." The interventions included: "* Interventions as prescribed including medication, lab work." "* Monitor for the need and effectiveness of medication." "* Assess effectiveness of interventions and adjust plan as indicated." "* Resident is prescribed Keflex." The Care Plan also documented: "Potential for injury related to presence of indwelling catheter." Interventions included:"* Change collection foley catheter bag and tubing q 14 days." "* Change foley catheter q 4 weeks (ensure that catheter is secure at all times.)" "* [MEDICATION NAME] is prescribed." "* Resident is prescribed Keflex" "* Resident is to drink full glass - 8 oz- of water q 2 hours during normal waking hours." "* Secure catheter to thigh to prevent pulling on tubing. Keep collection bag below bladder level." "* Use urine collection leg bag only when resident is sitting, standing, or walking." "* Provide assistance to resident during transfers and ambulation." "* Monitor and record intake/output. Report any negative fluid balance trends to the physician." "* Monitor VS every shift. Report any temperature elevations to physician." "* Observe and document urine appearance at least daily. Report any abnormalities to physician." "* Change catheter per facility protocol or physician order." The care plan failed to address catheter care, including when and how it was to be completed. Care instructions from a 10/7/14 appointment with a urologist documented, "Please have the foley catheter changed on 10/17/14 with a 16 french foley catheter. Change every 4 weeks based on this schedule with the next foley change. Ensure the catheter is secured at all times, not pulling on the tubing. I have sent an Rx {prescription} for Keflex 250 mg nightly for uti {urinary tract infection} [MEDICATION NAME]. I discussed timed drinking. He should drink a full glass - 8 oz- of water every 2 hours during normal waking hours to help flush the urine." The physician sent catheter care instructions, but these were not added to the care plan. The resident was seen on 12/19/14 by an ENT {Ear, Nose, and Throat} physician for the resident's [MEDICAL CONDITION]. A physician's orders [REDACTED]. On 1/6/15 at 1:00 pm, the resident had another appointment with the urologist, who ordered continuing the Keflex antibiotic. Although the resident was not taking the Keflex, this was not communicated to the urologist, and it was still listed on the "Current Medications" section of the physicians progress note. Additionally, the urologist also ordered "Apply thin ribbon/tiny amount of vaseline or [MEDICATION NAME] ointment around tip of catheter each day to keep catheter lubricated." This information was not care planned, nor was it added to the resident's MAR/Treatment sheet. On 1/13/15, the resident was admitted to the hospital with [REDACTED].{the resident} reportedly had a fever last night...When they tried to assess him this morning, he was unresponsive except to a deep sternal rub... Patient was unresponsive in the emergency room department and found to be [MEDICATION NAME] Patient has a long standing history of severe urinary obstruction due to [MEDICAL CONDITION] has had an indwelling Foley catheter for quire sometime. He was actually just seen by Dr.{name}, the urologist, who noted in November {2014} he had a urine culture that was growing Proteus species and he is known to have some bladder stones and so she recommended consideration for a [MEDICATION NAME] antibiotic q.h.s. {at bedtime}, but this was apparently not communicated to the Bell Mountain staff and has not been receiving this..." The resident was transferred back to the facility on [DATE]. The Discharge Summary documented, "He does have Proteus Mirabilis in his urine. He does have evidence of urinary stones, which may contribute to his ongoing recurrent infections." The "Blaine Manor Use and Care of Indwelling Catheters" policy and procedure, dated April 2001 and Revised June 2009, failed to provide a process for changing a catheter, maintaining a catheter, providing catheter care, and using a leg bag. The resident was observed each day of the survey with a catheter. The catheter was covered with clothing and the resident was not observed pulling on the catheter. The staff ambulated the resident twice a day and connected the catheter to a leg bag. The resident was observed going to bed after breakfast and lunch and sleeping until the next meal time. There were no observations of staff offering fluids, although this was documented as being done. The ADON was interviewed on 2/12/15 at 10:30 am about bowel and bladder issues. She did not have any information as to why he became [MEDICATION NAME]. No further information was provided. The resident was harmed when the facility failed to: - ensure the [MEDICATION NAME] antibiotic was continually administered. - catheter care was completed based on approved procedures. - changing from the catheter bag to the leg bag was completed based on set procedures. - provide 8 ounces of water every two hours. The resident slept most of the mornings and afternoons. The Administrator, DON and Consultant were informed on 2/11/15 at 5:00 pm. No further information was provided by the facility. 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 10/8/14, documented the resident: - Was cognitively intact with a BIMS of 15. - Required extensive assistance with ADLs. - Was occasionally incontinent of Bowel and Bladder. Review of the care plan it was revealed there was no toileting plan developed for the resident. Review of the medical record there was no assessment completed for the resident's incontinence. The MDS/ADON was interviewed on 2/12/15 at 10:30 am. She indicated there was nothing completed on the residentrelated to assessing her incontinence and times when she was voiding. The Administrator, DON and Consultant were 2/12/15 at 1:30 pm and no further information was provided. 3. Resident #13 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 8/20/14 annual MDS assessment documented the resident was frequently incontinent of bladder and did not have a toileting plan. The resident's 11/18/14 quarterly MDS assessment documented the resident was always incontinent of bladder and did not have a toileting plan. The resident's Urinary incontinence care plan, reviewed on 10/15/14, documented as an intervention, "Toilet (Resident #13) before and after each meal and PRN..." A bladder assessment was not found in the medical record. On 2/12/15 at 10:30 AM, the MDS Coordinator was asked about the bladder assessment and she said she would look for it. On 2/12/15 at 12:25 PM, the MDS Coordinator informed the surveyor she could not find a bladder assessment in the resident's record. She also said she could not find any documentation the facility had tried a toileting plan for the resident. 4. Resident #14 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 1/20/15 quarterly MDS assessment, documented the resident was occasionally incontinent of bladder and did not have a toileting plan. The resident's Urinary Incontinence care plan, dated 7/18/14, documented a problem of, "Frequent episodes of urinary incontinence..." and an intervention of, "Encourage resident to call for assistance with toileting." A bladder assessment was not found in the resident's medical record. On 2/12/15 at 12:20 PM, the MDS Coordinator informed the surveyor she could not find a bladder assessment in the resident's record. She also said she could not find any documentation the facility had tried a toileting plan for the resident. On 2/12/15 at 2:15 PM, the Administrator, DON, and Regional Operations Director were informed of the issues. No further information was provided by the facility.

Based on record review and staff interview, it was determined the facility failed to ensure that residents did not develop pressure ulcers while residing in the facility. This was true for 2 of 10 (#s 16 & 20) sampled residents. Resident #20 was harmed when a sore on the coccyx progressed to a Stage III pressure ulcer, and Resident #16 was harmed when a red area previously identified as a Stage I pressures ulcer deteriorated to a Stage II pressure ulcer. Findings include: 1. Resident #20 was admitted to the facility 12/5/10 with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: - had short and long term memory impairment. - had severely impaired decision making skills. - required extensive assistance with ADLs. - did not have a pressure sore. The resident's care plan, dated 11/13/14, documented: "Problem Onset 11/13/2014, Pressure ulcer to coccyx." Interventions included: "* Milkshake q {every} day. * Clean open area @ buttocks with [MEDICATION NAME], apply [MEDICATION NAME]/zinc to wound bed. Apply barrier/zinc cream to periwound area, BID or when soiled. * Head of the bed less then 30 degree, turn every 2 hrs, roho seat cushion, low air mattress, up for meals only. * Weigh resident weekly & record. * Bell Mountain wound and skin protocol. * Turn side to side Q {every}2 hours. * Air mattress overlay. * Up for meals only. * Wound clinic visits, per clinic recommendation. * Tylenol is prescribed. * Measure wound at least Q 7 days. Record HxWxL, appearance, amount and odor of any drainage. Record on Pressure Ulcer Log. Report any decline in wound status to physician. * Administer treatments as ordered by physician and document. * Administer pain medication at least 30" {minutes} prior to initiating treatment as indicated. * If no improvement in wound appearance by 10 days after treatment order changed, notify physician and request new treatment order. * Dietitian to evaluate and follow up at least weekly. * Provide diet high in protein, with and in between meal snacks. * Monitor labwork and report to physician and dietitian when available. * Record food intake % at each meal. Report any decline to physician and dietitian. * Offer food substitutes if resident refuses to eat. * Use pillows, air mattress, other supportive/protective devices to assist with positioning. * Avoid use of restrictive clothing. * Cleanse perineal area following each bowel movement. * Turn and position resident every 2 hours. Side to Side. Review of the resident's progress notes for several months prior to 11/12/14 revealed the resident was dependent on staff for all ADLs and was incontinent of bowel and bladder. The progress notes documented: - 11/12/14 WOUND/SKIN RECORD "Date:11/12; Site: A {right buttock/coccyx}; Stage: N/A; Size in CM (length x width): 3 cm x 3 cm; Depth (cm): SF {superficial}; Exudate: SS {serosanguinous} with crevice wound; Odor: none; Wound bed: red; Surrounding tissues: Flat uneven..." - 11/14/14 at 2:44 am Nurse Note {NN}, "Open area @ R buttocks, 3cm /3cm, 0 S/S of infection. RN to clean and apply Meplex..." - 11/16/14 3:43 pm NN "The dressing has come off with incontinence moisture. I have cleaned it with NS and applied ABX {antibiotic} ointment...He is last up and first down and resting 30 degree lateral side to side while in bed..." - 11/17/14 12:53 pm NN "Checked resident's bottom this morning. Area appear to be 1.5 cm x 1.5 cm wound. {Name}, DNS, assessed wound and said it appeared to be a moisture wound rather that a pressure wound. Wound is clean and barrier ointment was applied to area. Resident is currently on right side. He is turned every 2 hours and is last up, first down to prevent sore on the area..." - 11/18/14 9:52 am NN "...Buttock wound assessed. Noted an area approx 2cm x 2cm to gluteal cleft with a geographical appearance, superficial and an area within the wound which is approx 0.5 x 0.3 cm crevice wound. Area does not rest on a bony prominence and appears to be related to moisture. Resident is incontinent of Bowel and bladder despite regular toileting..." - 11/19/14 WOUND/SKIN RECORD "Date: 11/19; Site: A {right buttock/coccyx}; Stage: 2; Size in CM (length x width): 2.5 x 2; Depth (cm): 0.3; Exudate: Scant blood and slough; Odor: none; Wound Bed: red slough, Surrounding skin color: Purple/ Blanches; Surrounding Tissue/wound edges: Irregular" - 11/21/14 Wound Clinic Progress Note, "CHIEF COMPLAINT: The patient is seen for an ulceration on his coccyx... HISTORY OF PRESENT ILLNESS: ...The patient's history is given by the patient's wife which includes a 10 day history of developing an ulceration in the coccyx region...is incontinent of both bowel and bladder...he is on a standard mattress. Just recently has been turned every 2 hours, does not have a ROHO seat cushion but has a very thin cushion in his adjustable, non-motorized wheelchair...SKIN AND WOUND: Examination of the coccyx reveals an area of ulceration measuring 2.0 x 1.7 x 0.1 cm. There is no tunneling or undermining. The periwound tissue is [DIAGNOSES REDACTED]tous with indistinct wound margins and wound base 100% [MEDICATION NAME] and slough. The exudate was unable to to be determined due to being open to air. There was no odor...IMPRESSION: 1. Stage II pressure ulceration of the coccyx area...." - 11/24/14 10:53 am NN "...Late entry for 11-23-14. Resident positioned on his side this AM and was noted to have his head and left shoulder hanging over the side. Air mattress overlay requires very careful positioning of this resident who tends to grab nearby furniture and pull himself to the edge of the bed. It happened again later in the shift. The air mattress is slippery and side lying requires close moitoring. {sic}... His coccyx area has slough in the center of it and clean margins. Wound care done twice this shift. He continues as 'last up-first down.' ...With his grabbing behaviors, peri-care while lying in bed is more difficult than doing it while he is occupied with holding onto the EZ lift and standing but while standing he can make his buttocks very tight and careful cleaning is not easy." - 11/26/14 WOUND/SKIN RECORD "Date: 11/26; Site: A {right buttocks/coccyx}; Stage: 2; Size in CM: 2 x 2 ; Depth: 0.3; Exudate: none; Wound bed: Slough; Surrounding skin color: White; Surrounding tissue: Irregular, clean;" - 11/27/14 4:06 pm NN "....Resident is extremely difficult for staff to reposition, dress or transfer due to res stiffens and pushes against staff and grabs staff and his grasp is very strong. Requires at least two people for this....Incontinent of bowel and bladder..." - 11/30/14 2:31 pm NN "He continues as 'last up-first down for meals' some meals he has had while on bedrest. Airbed overlay continues and he has padded half bed rails for safety/grabbing behaviors (as in he grabs furniture and risks pulling himself out of bed) He usually has some stooling, ...open area which continues {sic} to have depth..." - 12/1/14 Wound Clinic Progress Note, "CHIEF COMPLAINT: Patient is seen today for a stage 2 pressure ulceration on the coccyx...SKIN AND WOUND: Examination of the coccyx reveals an area of ulceration measuring 3.6 x 2.0 x 1.0 cm. There is tunneling at 12 o'clock at 0.5cm and at 6 o'clock at 0.5 cm. There is no undermining. Periwound tissue is minimally [DIAGNOSES REDACTED]tous with defined wound margins. The wound base is 80% granulation and 20% [MEDICATION NAME] slough. There is a scant amount of serosanguineous exudate with no odor. periwound tissue is still blanchable, although it has a purple discoloration. There is necrotic tissue evident at the base of the wound. although I cannot visualize bone, I can probe to bone. There is no induration felt in the periwound area or fluctuance.... IMPRESSION: 1. Stage 4 pressure ulceration of the coccyx area... PLAN/DISCUSSION:...The wound has deteriorated from a Stage II pressure ulcer to a Stage IV pressure ulcer since his last visit with unknown cause...." - 12/3/14 WOUND/SKIN RECORD "Date: 12/3; Site:A {right buttocks/coccyx}; Stage: IV; Size in CM: 3.6 x 2; Depth: 1.0; Exudate: none; tunneling: none; Odor: none; Wound bed: Pink; Surrounding skin color: pink" The wound nurse was interviewed on 2/11/15 at 12:20 p.m. and stated the resident was a very tall person and the staff had a hard time cleaning him up after an incontinence episode. They started to use the stand assist lift to stand him to change his briefs. He would tighten his buttocks so that cleaning him was difficult. The "staff couldn't do a good job of cleaning him." As a result, "He had moisture issues and he ended up with a sore." She further indicated that she was working with staff on turning, positioning and body alignment, and stated the new DON wanted her to start using the Braden Scale for skin assessments. At the time of survey, the resident was no longer in the facility and observations of the pressure ulcer were not possible. The resident was harmed when: - he developed a Stage II pressure ulcer that deteriorated to a Stage IV pressure ulcer. - the facility did not give the resident an air mattress until after the area developed into a Stage II ulcer. - the facility was not aggressive in cleaning and keeping urine and stool off the residents skin. - The facility did not have a 4 inch ROHO for the resident's wheelchair. 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 10/8/14, documented the resident: - Was cognitively intact with a BIMS of 15. - Required extensive assistance with ADLs. - Was occasionally incontinent of bowel and bladder. - Had a pressure sore on the heel. The resident was admitted to the facility with a possible pressure sore to the right heel and red area to the coccyx. The area on the coccyx was documented as possibly a healed Stage II pressure sore the physician identified in the 9/4/14 operative report. The coccyx was monitored until it deteriorated again on 12/12/14. Summary of the care provided to the coccyx area follows. The resident's Care Plan,dated 10/1/14, documented: "Problem: Pressure ulcer to R Heel, present on admission, unstageable on admission/debrided. Redness to coccyx on admission." The resident's interventions for the coccyx included: "* Monitor redness to coccyx each shift until resolved." "* Administer treatments as ordered by physician and document." "* Record food intake % at each meal. Report any decline to physician and dietitian." "* Offer food substitutes if resident refuses to eat." "* Use pillows, air mattress, other supportive/protective devices to assist with positioning." "* Avoid restrictive clothing." "* Cleanse perineal area with soap and water following each bowel movement."' "* Turn and position resident every 1 - 2 hours as indicated by individual turning schedule posted in resident's room." "* Teach resident risk factors for development of pressure ulcers as appropriate." On 12/10/14 the intervention, "Gel Mattress to bed," was added to the Care Plan. The physician's admission orders [REDACTED] "Monitor redness to coccyx q shift until resolved." "Airbed overlay for skin protection." On 12/10/14 the air mattress overlay was discontinued and a "Gel Mattress" was ordered. On 12/12/14 the resident was complaining of a sore bottom and a 1 cm open area was found on the right buttock. The resident was seen the same day, 12/12/14, in the wound clinic, which documented, "Stage II ulcer coccyx." The wound clinic ordered, "Head of bed less than 30 degrees, turn every two hours, low air loss mattress, and up for meals only." The wound nurse was interviewed on 2/11/15 at 12:20 p.m. She indicated the resident would need to ask for staff to look in on her and that since she has been providing the wound care she has advocated for staff to go in and check and change the resident, especially on the night shift. The wound nurse also noted she had been training staff on positioning and body alignment. No further information was provided. Resident #16 was harmed when a reddened area identified on the operative report upon admission to the facility deteriorated to a Stage II pressure ulcer after approximately six weeks and the removal of an air mattress that had been placed to help protect the resident's skin. This area was resolved at the time of survey.

Based on observation, record review, and staff interview, it was determined the facility failed to provide adequate supervision and care planning needed to prevent resident falls and wandering. This was true for 4 of 8 residents reviewed (#s 1, 5, 7, & 9) for falls and wandering. * Resident #5 was harmed when she fell and fractured her pelvis and required hospitalization . The resident continued to fall after returning to the facility. * Resident #1 was put at risk for hypothermia and injury when she exited the facility and was later found lying face down in the snow. * Resident #7 was placed at risk for harm when she fell and injured her leg while attempting to move away from a resident who was wandering and disturbing residents in the facility. * Resident #8 had the potential to harm himself and put other resident at risk for psychosocial harm when he wandered into other residents' rooms and individual space. Findings include: 1. Resident #5 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a hospitalization for a fall which resulted in a fractured pelvis. The resident's initial [DIAGNOSES REDACTED]. Resident #5's 12/27/13 admission MDS assessment coded a BIMS of 9 indicating a moderately affected cognitive status; resistance to cares; extensive assistance of at least one person needed with bed mobility, transfers, dressing, and toilet hygiene; able to walk in room with the moderate assist of one person, walker or wheelchair for mobility; not able to steady self without human assistance when ambulating or transferring; and, almost constant severe pain. Physician's admission orders [REDACTED] * Hydrocodone-Acetaminophen 10-325 1 PO (by mouth) every 4 hours PRN; * May have ETOH (alcohol) with meals and PRN. This order was changed on 1/10/14 to read, "Offer resident ETOH-free wine. Resident may have two glasses. The Resident's Nursing Intervention/Initial Care Plan, dated 12/20/13, listed: Physical Function and Structural Problems: * "Encourage use of call light" * "Night light on (at night)" * "Keep path clear in room" * "Keep items within reach" * "Appropriate footwear" Nurses Notes (NN), dated 12/20/14 through 1/2/14, documented the resident used Norco 10-325 at least one time per day, frequently at bedtime and often drank one to two glasses of wine with the evening meal. Resident Incident and Accident Reports (I&As) and NNs, dated 1/1/14 through 2/2/14, documented the resident experienced 2 non-injury falls in 1/2014 and a fall with pelvic fractures and hospitalization on [DATE]. Falls on 1/1/14 * A 2:30 am NN, documented, "... (resident) was up independently as usual to the bathroom. She was standing at the sink washing her hands and apparently lost her balance and fell behind the bathroom door." The corresponding I&A, dated 1/1/14 documented the fall was not witnessed, the resident walked to the bathroom on her own, there was no apparent injury from the fall, and the resident was encouraged to use her call light when ambulating in the room. The I&A did not address when the resident was last assisted to toilet or visualized or why she did not use the call light and wait for assistance or how she fell . The Immediate Post-Incident Action Plan documented, "Increase frequency of status checks while resident is in her room." A 1/1/14 NN at 7:10 AM documented the resident "... got up to bathroom again unattended after it was requested that she call for standby assistance. Incontinent of large stool everywhere... Door left open for closer monitoring... " A 1/1/14 NN at 3:30 PM documented, "Bed alarm placed on bed for resident's protection... " Between 1/1/14 and 1/21/14 the following observations were documented in the resident's NNs: * 1/2/14, 3:43 am, "She does not use her call light to ask for assistance when she gets up and has been steady and unsteady on her feet... " * 1/3/14 at 3:57 am, "A regular night light is found to replace the regular overbed light... will continue to monitor as closely as possible since she is unsteady on her feet at times... " * 1/6/14 at 3:50 am, "(Alert and oriented x 3), confused (at) times about where some of her things are, able to make needs known. Resident with short term memory loss... " There was only one NN between 1/1/14 and 1/10/14 that documented staff increased monitoring to every hour. There was no documentation of hourly room checks between 1/1/14 and 1/22/14. Fall on 1/21/14 * 1/21/14 at 8:41 am, a NN documented, "Resident found on floor... stating she was going to the bathroom when she fell ... Resident was quite stubborn, not using call light and trying to refuse help getting up." The corresponding I&A, dated 1/22/14, documented, "Resident fell while trying to go to the bathroom alone, was barefoot, call light within reach and the facility provided, ... staff in-service training regarding proper foot wear while using walker and resident teaching regarding use of her call light." The Immediate Post-Incident Action documented, "Frequent reminder to use call light, and ask for assist prior to getting OOB (Out of Bed), and keep night light on at all times." The I&A did not document an analysis of why the resident continued to get out of bed without asking for assistance, analysis of voiding issues (i.e. urgency, leakage, stress incontinence), if interventions such as a voiding schedule would be helpful, if medications and/or wine intake may be involved, why the "increased monitoring" that was implemented on 1/1/14, was not working or if hourly monitoring was actually occurring. In addition, there was no analysis as to whether the resident's moderate cognitive impairment was interfering with her understanding and/or remembering staff instructions to use the call light before getting out of bed. Fall with fracture on 2/2/14 * NNs dated, 2/2/14 at 1:20 am, documented staff "... heard a crash and resident was yelling out. Resident was found on the floor in a puddle of urine, complained of pain, was sent to the emergency room where she was hospitalized with a fractured pelvis." The corresponding I&A, dated 2/2/14, documented, "The resident may need to have a mat alarm to alert staff (that) resident may need assistance... Resident's CP (care plan) will be updated when returns from hospital." NNs, Care Plans, & I&As did not document whether the mat alarm was placed after the resident returned to the facility. The 2/2/14 I&A documented, "The resident has demonstrated she knows how the call light (works). Resident has refused assistance to the bathroom in the past..." However, the I&A failed to provide an indepth analysis of why the resident was refusing assistance, to what degree her cognitive status limited her full understanding of using the call light to go to the bathroom, how her medications and continued wine intake could be affecting why she was falling and/or refusing to call for assistance. In addition, the I&A did not address if hourly checks were still being completed and if hourly checks were/were not effective. Resident #5 returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]." The resident was on bedrest when she returned from the hospital and had an indwelling catheter, which was discontinued prior to 2/14/14. No documentation was found that specified when the catheter was discontinued. Following her return from the hospital, the resident experienced 6 more documented falls between 2/14/14 and 6/9/14: One of these falls (2/14/14) occurred within 10 days of the resident's return to the facility. An I&A, dated 2/14/14, documented the resident was found on the floor next to bed. The tab alarm was not on the resident. The 2/14/14 I&A and associated care plan documented a sensor alarm was placed at the resident's bedside to alert staff when the resident placed her legs over the bed rails. The resident refused the alarm stating, "I do not need them and will not have them." No root cause analysis was documented on the event, nor was any new interventions implemented, other than the sensor alarm which the resident was refusing. Resident #5 experienced additional falls on 3/5/14, 4/17/14, 5/16/14, 5/19, and 6/9/14. No root cause analyses of the falls were found. Interventions included the following: 3/5/14 - Nurse completed a verbal Safety Contract with the resident, increased frequency of checks to every 15 minutes (no documentation of checks were provided). The I&A documented a bedside commode "which had been positioned next to the bed was immediately outside the bathroom door."; 4/17/14 - Motion sensor alarm, group in-service regarding alarms being turned on; 5/16/14 - Commode next to bed (Based on I&A this had already been in implemented. See documentation on 3/5/14 incident report.). The resident developed a large goose egg/bruising on her forehead, complained of increased pain in back; 5/19/14 - Implemented constant supervision of resident while up in wheelchair (Neither NNS or monitoring sheets documented this level of supervision); and, 6/9/14 - Airbed overlay removed due to being slippery. After each fall listed above, the facility stated one of the interventions would be to re-educate the resident regarding the use of the call light and, on 3/5/14, develop a safety contract with the resident. However, the resident's Quarterly MDS Assessment, dated 3/26/14, documented a BIMS of 2 (it was 8 when the resident was admitted ) indicating the resident had gone from a moderate cognitive deficit to a severe cognitive impairment, which affected her memory and ability to recall. On 11/13/14 at 11:25 AM, the DON and AIT were interviewed regarding Resident #5's falls, lack of documentation of root cause analyses of the falls, and documentation of decisions made regarding preventative interventions, based on the analysis of the cause of the falls, that were put into place to prevent further falls and injuries: * 1/1/14 fall- the DON stated the cause of the fall was that the resident lost her balance while washing her hands. There was no investigation into why she lost her balance or any other contributing factors. Although the resident was re-educated to use the call light when needing to get out of bed, the DON stated the resident continued to go to the bathroom unattended and a motion sensor bed alarm was put into place, and a night light was at the resident's bed. *1/21/14 fall - the DON said the resident was again reminded to use the call light and ask for assistance to get out of bed. Staff was instructed to frequently ask the resident if she needed to go to the bathroom, remind her to keep her call light within reach, and ensure she was wearing proper foot wear. The DON was not able to confirm that the root cause of the falls and contributing factors were formally discussed and documented. Because both the 1/5/14 fall and the 1/21/14 fall involved the resident going to the bathroom without assistance, the DON was asked if the facility had considered a toileting schedule based on her voiding assessment. The DON indicated this had not been discussed. When asked if her use of wine and Norco between dinner and bedtime had been evaluated in relationship to her falls, the DON indicated neither factor had been considered. The DON was asked to provide documentation (i.e. NNs or monitoring check sheets) of frequent monitoring and checks of the resident. However, none were provided for January 2014. On 11/14/14 at 2:00 pm, the DON and AIT were informed that the resident had experienced harm when she fell at the facility on 2/2/14 and fractured her pelvis, requiring hospitalization . The resident experienced two falls in the month previous to this. The facility failed to analyze the root cause of the falls and determine/put into place interventions based on the root cause of the falls. In addition, the interventions put into place, such as re-educating the resident, who was cognitively impaired, were not effective in preventing the resident from falling and injuring herself. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly MDS, dated 8/20/14, documented the resident had short and long term memory problems; had moderately impaired decision making skills; required extensive assistance of one staff for transfers, dressing, and personal hygiene; and impaired range of motion on one side. The resident's care plan for falls, dated 2/14/14, identified numerous interventions including: * Ensure the resident has and wears proper-fitting non-skid soled shoes for ambulation; * Assess resident's need for assistive/supportive device; * Instruct resident on appropriate use of assistive/supportive device, and * Maintain resident environment free of clutter and safety hazards. Based on review of an 11/1/14 I&A and Occurrence Report (OR) and an Investigative Report (IR) submitted to BFS on 11/7/14, the following occurred: The IR documented on 11/1/14 at about 7:30 PM, Resident #7 was taken to her room after dinner. The CNA left the room and closed the door. The IR further documented, the "door was closed to help prevent possible intrusion by a resident, (the other resident's name) during a particularly agitated state." The OR documented the other resident had already physically attacked a staff member. The DON had to provide 1:1 assistance to the other identified resident who was engaged in aggressive behavior. The I&A documented on 11/1/14 at 8:30 PM Resident #7, "was laying (sic) on the floor in front of her wheelchair with her left leg caught in an awkward position." The resident was transported to the hospital at 9:00 PM. The hospital emergency report documented the resident did not have a fracture; however, the resident did have a skin tear that was treated and returned to the facility. The resident returned to the facility at 11:00 PM with a dressing over the leg injury. The DON and AIT were interviewed on 11/14/14 at 11:45 AM. They stated the resident was not unattended for more then a couple minutes. However, all the documentation indicated the resident was unattended for up to one hour. The staff were busy with an aggressive resident, and the documentation was vague with what facility staff was doing from 7:30 PM to 8:30 PM, when the Resident #7, who was unattended and had her room door closed, was found on the floor in her room. 3. Resident #8 was admitted to the facility 9/21/14 with [DIAGNOSES REDACTED]. The Admission MDS, dated [DATE], documented the resident had short and long term memory problems; had severely impaired decision making skills; wandered daily; was at significant risk for getting to a potentially dangerous place; and, wandered significantly intruding on the privacy and activities of others. The 9/21/14 care plan included no plan for the resident's intrusive wandering. The facility's "CNA Guide" for the resident was reviewed. Under the heading of "Behavior/Mental", "Goes into other resident's rooms" was listed. Also "Wanders" and "Elopement Risk" were checked. No interventions were documents related to these behaviors. On 11/12/14 at 4:30 PM the resident was observed to wander into room 38. The resident who lived in that room was in her wheelchair with her back to the door. The resident walked to within 2 feet of the resident in room 38, stood for about 30 seconds and left the room. No staff were in the area. On 11/13/14 at 1:30 PM Resident #8 wandered into room 32. The resident in that room was eating her lunch when Resident #8 entered the room. A CNA entered and escorted the resident out of the room. The CNA asked Resident #8 what he wanted. He indicated he was looking for a bed. The CNA took him to his room so he could lie down. The DON and AIT were informed of the issue on 11/14/14 at 11:45 AM. The facility did not have a policy on dealing with the types of behavior that Resident #8 exhibited and there was no evidence of a supervision plan for Resident #8 who wandered intrusively throughout the facility. No further information was provided. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly MDS, dated [DATE], documented the resident had severely impaired cognition with a BIMS of 4; and, required extensive assistance of one to two staff for transfers, dressing, eating, personal hygiene and bathing. An I/A dated 1/26/14 at 6:30 PM documented the resident was found outside the facility's front door, at the end of the ramp, on her knees in the snow. The report documented the resident was observed at dinner at 6:00 PM. The resident left the dining room independently in her wheelchair. Around 6:30 PM, the RN heard someone yelling "help." The RN and a CNA went looking for who was yelling. They found the resident outside the facility kneeling in the snow after falling out of the wheelchair. The facility failed to supervise the resident who was able to exit the building and ultimately fall out of her wheelchair into the snow. The DON and AIT were informed 11/14/14 at 11:45 AM. No further information was provided.