Every finding on record at Creekside Transitional Care and Rehabilitation

Based on observation, interview, policy review, and U.S. Food and Drug Administration 2022 Food Code, the kitchen staff failed to appropriately store and label foods and properly wear beard and mustache nets when preparing or serving food. This deficient practice had the potential to affect all 131 residents who received meals prepared in the facility's kitchen. Findings include:The facility's Dietary Services Meals and Food policy dated 6/2017, documented food purchased, stored, and served in this facility is labeled and dated according to all applicable food service regulations.The FDA Food Code Section 3-501.17 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.On 8/31/26 at 10:40 AM, observed the following during the initial kitchen tour:- several open bread loaf bags that were not labeled with an open date.- an open garlic salt container with a use by date of 8/18/26.On 8/31/26 at 10:47 AM, the Dietary Manager stated the opened food products should have been labeled with an open date and disposed of when the use by date is reached.The facility's Dietary Sanitary Standards - Dietary Personnel dated 5/2025, documented hair restraints (hairnet, hat, and/or beard restraint) must be worn at all times while in the kitchen or other food preparation areas.The FDA Food Code Section 2-402.11 Effectiveness, documented, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens.On 9/1/26 at 11:56 AM, observed cook #1 and cook #2 serving food onto plates, both have beards and mustaches and the mustaches were not covered with the beard net.The Dietary Manager stated the cooks should be wearing the hair and beard nets correctly and were not.

Based on review of staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a nurse aide successfully complete a State approved training and competency evaluation program within 4 months of being hired. This was true for 2 of 3 nurse aides (NA #1 and #2) whose personnel file was reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility. Findings include:Nurse Aide #1 started employment with the facility on 4/30/26.On 9/2/26, Nurse Aide #1's personnel file documented she had registered for a CNA State approved training on 8/28/26 but had not completed the CNA State approved training and competency evaluation program within 4 months of being hired. Nurse Aide #2 started employment with the facility on 3/18/26.On 9/2/26, Nurse Aide #2's personnel file documented she had not registered or completed a CNA State approved training and competency evaluation program within 4 months of being hired. On 9/3/26 at 1:08 PM, the DON stated Nurse Aide #1 and Nurse Aide #2 had not completed a CNA training program within the 4 months of hire and should have.

Based on observation and staff interviews, it was determined the facility failed to ensure residents were provided with a safe and clean, homelike environment that did not pose any safety or infection risks. This was true for 1 of 3 shower rooms (300 Hall shower room) observed. This deficient practice created the potential for diminished quality of life and psychosocial distress for the 34 residents that use the 300 Hall shower room where a portion of the floor tile was missing. Findings include:On 8/31/26 at 11:06 AM, observed the 300 Hall shower room to have a 1/8-to-1/4-inch drop in the tile floor that was replaced with a clear coat causing a potential trip/fall or tip of shower chair hazard.On 8/31/26 at 2:35 PM, the DON stated the missing tile had been replaced with a clear coat filler because the tile kept lifting up after repair.On 8/31/26 at 5:25 PM, the Executive Director stated the 300 Hall shower room tile had a clear coat repair on it. The surveyor with the Administrator present observed the repair and noted there is still a drop between the shower threshold and the floor. The Executive Director demonstrated with the shower chair that the lip caused by the lack of linoleum does stop the shower chair wheels, not allowing them to roll into the shower which caused a potential fall hazard.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 2 of 27 residents (Resident #58 and #103) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include:Resident #58 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis (arthritis marked by progressive deterioration of cartilage in synovial joints and vertebrae), chronic respiratory failure, and diabetes. On 8/31/26 at 11:27 AM, observed Resident #58 sitting on a Hoyer lift sling in his recliner which was placed on the right side of his bed in the middle of the room and his call light was lying on his bed and not within his independent reach. On 8/31/26 at 11:29 AM, Resident #58 stated he is unable to self-ambulate and could not reach the call light if he needed it. Resident #103 was admitted to the facility on [DATE], with multiple diagnoses including adult failure to thrive, muscle weakness, and diabetes. On 8/31/26 at 12:46 PM, observed Resident #103 sitting in his wheelchair in the middle of his room watching television and his call light was lying on his bed and not within his independent reach. On 8/31/26 at 12:47 PM, Resident #103 stated he could not reach his call light if he needed it. On 8/31/26 at 1:07 PM, review of Resident #103's Care Plan documented at risk for falls r/t h/o falls, DM 2, diabetic neuropathy.Interventions - Be sure the call light is within reach and encourage to use it to call for assistance as needed - Date initiated 8/10/26. On 9/1/26 at 1:31 PM, the DON stated the facility does not have a call light policy. On 9/1/26 at 1:33 PM, the DON stated resident call light should be within resident's reach and had not been.

Based on interview and record review, it was determined the facility failed to provide notice to 1 of 1 resident ( Resident #70) reviewed for room change notification. This deficient practice had the potential to cause psychosocial harm for residents and their family members who were not notified in advance of a resident's room change. Findings include: Resident #70 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including Alzheimer's Disease, Dementia and Palliative Care (care focused on relieving symptoms and stress of the illness).On 9/1/26 at 9:05 AM, Resident #70's daughter stated she went to the facility to visit Resident #70 on or around 8/11/26 and found her mother's name had been removed from room [ROOM NUMBER]B where she had been residing. Daughter states she questioned staff regarding the whereabouts of her mother and was told they had moved her to room [ROOM NUMBER]A. Resident #70's daughter states she was not informed in advance of the room change and was very upset when she went to visit and found she had been moved from her room.Resident #70's most recent Quarterly MDS dated [DATE], documented her BIMS score was 3 (severe cognitive loss). On 9/2/26 at 1:25 PM, the DON stated that Resident #70's daughter should have been notified in advance of the room change and would look for the room change notification form. No further documentation of notification was received.

Based on observation, the facility Water Management Program binder, CDC's water management guidelines, interview, and record review, the facility failed to ensure its water management program included an assessment of the facility's cooling tower and one of two decorative water features to identify where Legionella and other opportunistic waterborne pathogens could grow and spread and failed to establish measures to prevent the growth of opportunistic waterborne pathogens and how those measures would be monitored. This deficient practice had the potential to expose residents to opportunistic waterborne pathogens, including Legionella, from a water-containing system that was not identified, assessed, or addressed in the facility's water management program. CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings A Practical Guide to Implementing Industry Standards, dated 9/30/25, at https://www.cdc.gov/control-legionella/media/pdfs/toolkit.pdf, documented that water management programs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens. Hospitals and long-term care facilities are among the settings where the entire building needs a water management program. CDC's Steps to Develop a Water Management Program documented that an effective Legionella water management program includes describing the building water systems; identifying areas where Legionella could grow and spread; determining where to apply and how to monitor control measures; establishing interventions when control limits are not met; ensuring the program operates as designed and is effective; and documenting and communicating program activities. On 8/31/26 at 10:45 AM, observed a decorative water feature (aquarium) located in the hallway outside of the facility salon with cascading water and a bubbler partially exposed. On 9/2/26 at 3:30 PM, an interview with the Maintenance Director (MD) revealed the absence of 1 of 2 decorative water features from the Water Management Program. MD stated he was not aware that aquariums needed to be included in the Water Management Program. The MD stated the decorative water feature was not included in the facility's Water Management Program because they hire an outside business that services the cleaning and testing of the decorative water features. The MD stated he had not assessed the decorative water features for Legionella risk and had no established Legionella control measures for them. On 9/2/26 at 4:10 PM, during record review the Mapped Risk Assessment, Control Measure, and Water Flow Diagrams had not documented the water cooling tower. The facility's testing logs and water treatment program performed by the ASCO Engineered systems had documented a water cooling tower. On 9/3/26 at 10:20 AM, an interview with the Maintenance Assistant confirmed that there is a cooling tower. When asked if the same cooling tower that is being tested should be on the Risk Assessment Diagram, he stated he believed so. Review of the facility's Water Management Program revealed the program identified ice machines, water filters, showerheads, less frequently used areas, hot water storage tanks, and eyewash stations. The program did not identify or include the cooling tower or decorative water feature in the description/assessment of the facility's water systems. The program did not contain an assessment of the decorative water feature for locations or conditions where Legionella or other opportunistic waterborne pathogens could grow and spread, control measures to prevent such growth, or monitoring of control measures.On 9/3/26 at 12:18 PM, the Executive Director stated he was not aware that the cooling tower was not included in the risk assessment of the Water Management Program. The Executive Director also stated he was not aware that the 2 decorative water features had not been assessed and were not included in the Water Management Program.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 3 of 27 Residents (#7, #65, and #156) whose care plans was reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include:The facility's Comprehensive Person-Centered Care Planning policy dated 4/2025, documented the facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan. Resident #65 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (progressive brain disorder that affects movement and nervous system functions) and Diabetes. On 9/2/26 at 10:05 PM, NA #1 was observed performing peri-care for Resident #65. NA #1 was observed to remove two soiled briefs, provide peri-care and apply two clean briefs. On 9/2/26 at 10:10 PM, Resident #65 stated she requests to wear two briefs as she wets a lot. On 9/3/26 at 9:15 AM, Resident #65's care plan was reviewed and had not documented her preference for the use of two briefs. On 9/3/26 at 9:30 AM, the DON stated the intervention for the use of two briefs was not documented on Resident #65's care plan and it should have been. Resident #156 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including kidney disease, heart failure, and diabetes. On 9/1/26 at 10:05 AM, review of Resident 156's care plan had not documented the left side bed rail that had been placed on his bed to assist in his mobility independence while in bed. On 9/3/26 at 11:17 AM, the DON stated Resident #156's care plan should have been revised to include documentation of the bed rail use and had not. Resident #7 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including diabetes and major depressive disorder. On 8/31/26 at 4:59 PM, Resident #7's care plan documented his code status as DNR (do not resuscitate) while the medical record face-sheet and POST documented full code. On 9/2/26 at 3:10 PM, the DON stated Resident #7's care plan should have been revised to match the medical record face-sheet and POST.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 10 residents (Resident #169) reviewed for baseline care plan. This failure created the potential for harm when the baseline care plan failed to provide directions for care. Findings include:The facility's Comprehensive Person-Centered Care Planning policy, revision date 4/25, documented - Procedure 1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.Resident #169 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including syncope and collapse (a sudden loss of consciousness, accompanied by an inability to maintain an upright posture), depression, and diabetes.On 9/2/26 at 8:32 AM, Resident #169's medical record documented in Assessments - Initial Care Plan-V2.0-V4 Admission/readmission the baseline 48-hour care plan was created on 9/1/26 and locked on 9/1/26.On 9/3/26 at 8:12 AM, the DON stated the baseline care plan is reviewed daily for 72 hours then locked but should have been completed and locked within 48 hours and had not been.

Based on record review and staff interview, it was determined the facility failed to follow physician's oxygen orders and bowel care order for delivering specific medications when residents do not have BM within 72 hours for 1 of 12 residents (Resident #82) whose records were reviewed for bowel and bladder care and 1 of 6 residents (Resident #29) observed for oxygen administration. This failed practice created the potential for residents to experience discomfort when oxygen or medications were not administered according to the physician's order. Findings include: Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a group of long-lasting lung conditions that block airflow and make it hard to breathe), Diabetes and Chronic Respiratory failure with hypoxia (a medical condition where the body tissues do not get enough oxygen to function normally). On 8/31/26 at 12:09 PM, Resident #29 was observed in her room sitting in her wheelchair. She was noted to be wearing her oxygen (nasal cannula). The oxygen concentrator was not turned on to deliver the oxygen to her as ordered by the physician. On 8/31/26 at 12:12 PM, observed the following oxygen order in the Resident #29's record: Oxygen at 4 Liters via NC (nasal cannula) continuously with use of ear mates at all times every shift related to chronic obstructive pulmonary disease with acute exacerbation. On 8/31/26 at 12:15 PM, LPN #5 stated Resident #29 should have had her oxygen concentrator turned on to 4L/min continuously as ordered by the physician and it had not been. Resident #82 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and diabetes. On 9/1/26 at 9:35 AM, Resident #82's medical record documented he had no BM from 8/15/26 to 8/19/26. Resident #82's physician order related to BM care are as follows: - Bisacodyl EC Oral Tablet Delayed Release 5 MG, (Bisacodyl) Give 2 tablet by mouth every 24 hours as needed for Bowel Care if no BM after 3 days Administer 2 tabs to equal 10mg. - Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Bowel Care if No Results from Bisacodyl Tablets. - Fleet Enema 1 Unit Insert 1 unit rectally every 24 hours as needed for Bowel Care if No Results from suppository. On 9/1/26 at 9:42 AM, Resident #82's MAR for 8/15/26 to 8/19/26 documented no nursing intervention related to lack of BM care. On 9/3/26 at 8:00 AM, the DON stated Resident #82 medical record and MAR had not documented any BM for 8/15/26 to 8/19/26 and no documented nursing intervention related to BM issues.

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure that prior to the placement of a bed rail, a resident assessment was completed that included alternatives to bed rail use were attempted and how the alternatives failed to meet the resident's assessed needs. This was true for 1 of 7 residents (Resident #156) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment and/or death. Findings include:Resident #156 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including kidney disease, heart failure, and diabetes.On 8/31/26 and 9/1/26, observed Resident #156 with left bed rail on his bed and the rail in the up position. On 9/1/26 at 10:05 AM, review of Resident #156's medical record did not have documentation of the resident assessment, evaluation of the alternatives attempted or documentation of the purpose of the intended use of the bed rail, or documented discussion of risks and benefits with a signed consent for use of bed rail.On 9/1/26 at 4:27 PM, the DON emailed the surveyor in response to the request for the facility's bed rail policy stating, the facility does not have a specific bed rail policy. Grab bars are implemented upon requests of patient/resident, recommendation from IDT or skilled therapies. Bed Rail Safety UDA and/or LN-Restraint/Enabling Device/Safety Device Evaluation is completed implementing grab bar. On 9/3/26 at 11:14 AM, the DON stated Skilled Therapy had recommended Resident #156 have a bed rail, but the Bed Rail Safety UDA or Restraint/Enabling Device/Safety Device Evaluation had not been completed and should have been prior to the placement of the left bed rail.

Based on observation, policy review, CDC guidelines, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 2 medication storage rooms inspected, and 4 of 6 medication carts audited for labeling and storage of medication. This failure created the potential for residents to receive expired medications with decreased efficacy and created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices, dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. The facility's Storing and Controlling Medication policy revision date March 2025, documented Medications that are discontinued, expired, contaminated, or deteriorated, and those that are in containers that are cracked, soiled, or without secure closures are immediately removed from the locked medication storage area and disposed of in accordance with the Facility policies and procedures. On 9/2/26 at 7:50 AM, a medication storage audit was done on the 400 – hall medication cart with LPN #2 present. The following issues were observed: Resident #52: Two bottles of Latanoprost ophthalmic medication were expired. Bottle one had an expiration date of 8/10/26. Bottle two had an expiration date of 8/28/26. Resident #100: One Symbicort inhaler was stored in the cart without an open date. A concurrent medical record review for Resident #100 revealed no active physician order for a Symbicort inhaler. Resident #104: One container of Albuterol Sulfate was expired, displaying an expiration date of 5/28/26. On 9/2/26 at 7:57 AM, LPN #2 stated she believed Resident #100's family had brought the Symbicort inhaler to the facility. She further acknowledged that the expired medications should have been reordered. At 8:03 AM, LPN #2 stated she was unsure who was assigned to check the medication carts for expiration dates. She noted she thought it was the responsibility of the night shift but stated all floor nurses should be verifying expiration dates. On 9/2/26 at 8:06 AM, a medication storage audit was conducted in the main medication storage room with LPN #1 present. One multi-dose vial of Tuberculin Purified Derivative (PPD) solution was observed stored in the medication refrigerator without open date written on the vial. On 9/2/26 at 8:09 AM, LPN #1 stated TB bottle should have had an open date on it per the pharmacist. On 9/2/26 at 11:42 AM, the DON stated the nurses should have checked the medications for expiration dates during the medication pass. On 9/1/26 at 9:18 PM, observed the 300 Hall medication cart unlocked and unattended by staff. On 9/1/26 at 9:23 PM, observed RN #1 exiting a resident's room, walk down the hall past several resident rooms and approach the unlocked medication cart. On 9/1/26 at 9:26 PM, RN #1 stated the medication cart should not have been left unlocked when leaving the cart unattended. On 9/3/26 at 8:01 AM, the DON stated the medication cart should not have been left unlocked when the nurse left the cart unattended.

Based on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include:U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 9/2/26 at 10:51 AM, observed with the Dietary Manager, a full 55 gallon trash can in the food prep area without the lid on, and not in continuous use. The Dietary Manager stated there should have been a lid on the garbage can when not in use.

Based on observation, and staff interview, it was determined the facility failed to ensure food was stored in a safe and sanitary manner. This deficient practice had the potential to affect the 129 residents who consumed food prepared by the facility. This placed residents at risk for adverse health outcomes, including food-borne illnesses. Findings include: On 6/9/25 at 8:41 AM, during a kitchen inspection, a sack of potatoes and sack of onions were observed on a wire rack. The potatoes were observed to be mushy with bulging sprouts. The onions were observed to be green, soft, and mushy. On 6/9/25 at 8:42 AM, the CDM stated the potatoes and onions were not fresh and should have been disposed of.

Based on observation, record review, and interviews, it was determined the facility failed to ensure resident's medications were administered according to professional standards of practice. This was true for 1 of 3 residents (Resident #184) whose insulin administrations were observed. This failed practice created the potential for Resident #184 to receive an incorrect dose of insulin and experienced hypoglycemia. Findings include: The Lantus Insulin Glargine website, accessed on 6/16/25, documented to always perform a safety test (prime) before each injection as follows: - Dial a test dose of two units. - Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. - Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. The Lantus website also documented when you inject the insulin to slowly count to ten before removing the needle to make sure the full insulin dose was administered. Resident #184 was admitted to the facility on [DATE], with multiple diagnoses including diabetes. A physician's order, dated 6/5/25, documented Resident #184 was to receive 10 units of Insulin Glargine 100 units/ml subcutaneously one time a day for diabetes. On 6/12/25 at 11:48 AM, LPN #1 took the Insulin Glargine from the medication cart and prepare the insulin pen as follows: LPN #1 removed the cap, sanitized the tip of the insulin pen, placed a new needle and dialed the pen to 10 units. LPN #1 was not observed to prime the insulin pen. LPN #1 then went to Resident #184's room, sanitized Resident #184's left upper arm, and administered the insulin. LPN #1 was not observed to hold the insulin pen for at least 10 seconds before withdrawing the needle from Resident #184's left upper arm. On 6/12/25 at 11:54 AM, when asked about the preparation of insulin pen injections, LPN #1 stated she did not prime the insulin pen prior to giving it to Resident #184. When asked about the insulin administration, LPN #1 stated it was only 10 units and it does not take long to administer 10 units. LPN #1 stated she held the needle to Resident #184's arm for about 3 seconds. On 6/12/25 at 2:45 PM, the ADON stated the facility followed the manufacturers direction for insulin administration. ADON stated after sanitizing the tip of the insulin pen and replacing the needle, she would prime the insulin pen and then dial the required amount of insulin as ordered by the physician. The ADON also stated she would inject the insulin and leave the needle for about ten seconds before withdrawing the needle.

Based on observation and staff interview it was determined the facility failed to ensure residents were provided with assistance to meet their needs. This was true for 1 of 24 residents (Resident #92) who were reviewed for activities of daily living. This failed practice created the potential for embarrassment and psychosocial harm when Resident #92's toenails were not maintained. Findings include: Resident #92 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness and unsteadiness on her feet. On 6/9/25 at 9:46 AM, Resident # 92 stated she had asked the nurses, doctors, and CNA's to cut her toe nails but no one had helped her. She also stated her toenails have not been trimmed since she was admitted to the facility. On 6/11/25 at 11:02 AM, both of Resident #92's great toenails were noted to be long and thick and yellow. On 6/11/25 at 11:53 AM, the SDC stated Resident #92's left, and right great toenails measured ¼ of an inch long. She also stated Resident #92's toenails were long and should have been trimmed.

2. Resident #104 was admitted to the facility on [DATE], with multiple diagnoses including Wernicke's encephalopathy (a neurological disorder caused by a thiamine vitamin deficiency) and cognitive communication deficit. Resident #104's medical record documented on 3/14/24, he was diagnosed with delusional disorder and alcohol-induced dementia. Resident #104's Annual MDS Assessment, dated 7/18/24, documented the following: -In Section A, under A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This question was answered no. -In Section I, under I5950, Resident #104 had an active diagnosis of a psychotic disorder other than schizophrenia. On 6/13/25 at 11:43 AM, the MDS Coordinator, stated Resident #104's Annual MDS Assessment was not accurate because his diagnoses had been updated but the PASRR Level I and Level II had not been updated when he received new mental health diagnoses. Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 2 of 2 residents (#53 and #104) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #53 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including post traumatic stress disorder (PTSD), major depressive disorder, and anxiety. Resident #53's Annual MDS Assessment, dated 3/13/25, documented under A1500 in Section A, no for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II observed in his electronic medical record, dated 6/21/19. On 6/13/25 at 11:38 AM, the MDS Coordinator stated Resident #53's MDS assessment was coded that the resident did not receive a PASRR Level II, and it should have been coded yes.

Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 15 residents (Resident #18) reviewed for bowel and bladder care. This failed practice created the potential for Resident #18 to experience discomfort when his medications were not administered according to the physician's order. Findings include: Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple sclerosis (a disease that affects the brain and spinal cord), malnutrition, and dementia. A physician's order, documented Resident #18 was to receive the following bowel medications as needed: -Miralax Powder, give 17 grams by mouth every 24 hours as needed for bowel care if no bowel movement for 3 days. -Dulcolax suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel care if no results from Miralax. -Fleets enema, insert one dose rectally every 24 hours as needed for bowel care if no results from Dulcolax. Resident #18's bowel movement records, dated 5/13/25 through 6/13/25, documented he did not have a bowel movement from: 6/1/25 through 6/5/25 (5 days). Resident #18's MAR, dated 6/1/25 through 6/4/25, did not include documentation he had received any of his bowel care medications as ordered for 4 days. On 6/13/25 at 11:04 AM, the ADON confirmed Resident #18 did not have a bowel movement from 6/1/25 through 6/5/25 and should have been given an as needed bowel medication on day 4 and he wasn't given one until day 5.

3. Resident #183 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection, constipation and depression. On 6/10/25 at 9:34 AM, the computer screen on top of the 500 Hall medication cart was observed to be open with Resident #183's medical information visible. On 6/10/25 at 9:47 AM, LPN #3 stated she did not realize she left the computer open. LPN #3 stated she should have made sure to log off from the computer before leaving her medication cart. Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents' privacy was maintained, treatment information was protected, and residents received mail and packages unopened. This was true for 3 of 24 residents (#29, #35, and #183) reviewed for privacy and confidentiality. This deficient practice placed residents at risk of embarrassment, loss of control over their personal information, diminished quality of life, and psychosocial distress. Findings include: The facility's list of Resident Rights provided to each resident at admission, dated 10/4/16, documented residents residing in the facility had the right to personal privacy and confidentiality of their personal and medical records and included the right to promptly receive unopened mail and packages. On 6/11/25 at 2:00 PM, during the Resident Council meeting with surveyors, 2 of the 9 residents in attendance stated they had received mail and packages that had already been opened. 1. Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stroke, diabetes, and major depressive disorder. Resident #29's Annual MDS Assessment, dated 10/13/24, documented she was cognitively intact. On 6/11/25 at 2:00 PM, Resident #29 stated her packages arrived opened all the time. She stated the packages were gifts from family and addressed to her directly. Resident #29 added her packages did not include anything illegal, like drugs, and she did not understand why the facility felt they needed to open them before delivering it to her. On 6/11/25 at 4:30 PM, the Administrator stated there was no reason he could think of that residents' packages would be opened prior to delivering them. 2. Resident #35 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including, chronic obstructive pulmonary disease (COPD), heart failure, and anxiety. Resident #35's Annual MDS Assessment, dated 11/5/24, documented she was cognitively intact. On 6/11/25 at 2:25 PM, Resident #35 stated her mail arrived opened on one occasion. She added, she knew she had the right to receive her mail unopened and complained to staff. Resident #35 stated, when her mail is delivered, staff hand it to her and say with exaggeration here's your mail- unopened. Resident #35 stated this made her feel sad because the staff were retaliating against her when she exercised her rights. On 6/11/25 at 3:30 PM, the Activities Director stated she received the resident mail to deliver from the receptionist/accounts payable staff person, and at times some items had been opened. She further stated she never opened resident mail or packages herself. On 6/11/25 at 4:00 PM, the receptionist/accounts payable staff stated she got the mail and sorted it into 3 piles. 1. Resident mail 2. Billing 3. Receivables The receptionist/accounts payable staff stated the billing department and business office opened any mail that had to do with the residents insurance. She added, if she thought the mail might contain a new insurance card by feeling the envelope, she would open the envelope, make a copy of the insurance card for the billing department before giving the mail to the Activities Director. On 6/11/25 at 4:30 PM, the Administrator stated mail comes into the facility and gets sorted the following way: -Resident mail goes to resident -Payor source and social security documents goes to the business office -Office mail goes to each department -Insurance documents go to the business office The Administrator stated the staff would open mail based on a judgement call depending on where the return address stated and how the envelope felt when sorting the mail.

Based on observation, record review, and resident and staff interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 2 of 2 residents (#37 and #82) whose shared room was observed for a homelike environment. This deficient practice created the potential for diminished quality of life and psychosocial distress for Resident #82 when his roommate, Resident #37's, living space was not kept clean. Findings include: 1. Resident #37 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including left and right below the knee amputations, diabetes, anxiety, and muscle weakness. Resident #37's Quarterly MDS assessment, dated 4/9/25, documented he was severely cognitively impaired. Resident #37's care plan, initiated on 9/9/19, and revised on 12/24/24, indicated resident had potential for mood problems [related to] agitation with the intervention to document episodes of behavior including refusal of cares, aggression, urinating on floor. Resident #37's Behavior Monitoring Log, dated 5/12/25-6/12/25, documented he refused care 8 times during the last 30 days. 2. Resident #82 was admitted to the facility on [DATE], with multiple diagnoses including spinal cord compression, major depressive disorder, and diabetes. Resident #82's Quarterly MDS assessment, dated 5/15/25, documented he was cognitively intact. Resident #82's care plan initiated on 5/15/25, documented potential for self-care deficit related to poor awareness due to major depressive disorder with the intervention to document episodes of behavior including irritability. Resident #82's Behavior Monitoring Log, dated 5/12/25-6/12/25, documented he refused care 1 time during the last 30 days. A strong foul urine odor was observed in the hallway outside Resident #37 and Resident #82's room on the following instances: -6/9/25 at 10:00 AM -6/10/25 at 8:00 AM -6/11/25 at 8:00 AM, 10:00 AM, 1:50 PM, and 5:00 PM -6/12/25 at 10:00 AM -6/13/25 at 12:45 PM On 6/9/25 at 1:45 PM, observed Resident #37's urinal was half full and uncapped, and his bedside commode was open with urine in it and splattered across the seat. The room smelled like stale urine. When asked about the odor in the room, Resident #37 stated he did not smell anything. On 6/12/25 at 10:05 AM, Resident # 82 stated he didn't like strong odor in the room, and added there's nothing I can do about it On 6/12/25 at 10:15 AM, the ADON stated Resident #37 had behaviors that keep staff from emptying the bedside commode and urinal. She added, staff would rush to clean his living space when he would leave his room. The ADON stated Resident #82 also had a history of refusing care, such as showering and changing his linens, which added to the foul odor of the living space and moving Resident #82 to another room had not been offered. The ADON was asked if she could describe the odor in the hallway coming from Resident #37 and Resident #82's room, she stated Oh yeah, it smells funky. When asked to describe the term funky, she stated just funky.

Based on record review and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was accurately completed when new mental health diagnoses were identified for 1 of 2 residents (Resident #104), whose records were reviewed for PASRR screenings. This failure created the potential for harm if the resident required, but did not receive, specialized services for mental health while residing in the facility. Findings include: Appendix PP of the State Operations Manual, revised 8/8/24, documented any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Resident #104 was admitted to the facility on [DATE], with multiple diagnoses including Wernicke's encephalopathy (a neurological disorder caused by a thiamine vitamin deficiency) and cognitive communication deficit. Resident #104's medical record documented on 3/14/24, he received 2 new mental health diagnoses, delusional disorder and alcohol-induced dementia. On 6/12/25 at 5:05 PM, the ADON stated Resident #104 should have had a new PASRR Level I conducted when he was diagnosed with delusional disorder and alcohol-induced dementia on 3/14/24.

Based on reviews of incident reports, medical records, hospital records, and staff interviews, it was determined the facility failed to ensure residents' safety during mechanical lift transfers. This was true for two of two residents (#1 and #2) reviewed for accidents. This failure harmed Resident #1 when she sustained a facial contusion and fractures to her lumbar vertebrae and left leg. Findings include: 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia (paralysis that affect only one side of the body) and hemiparesis (one-sided weakness or inability to move) following a stroke. Resident #1's quarterly MDS, dated [DATE], documented she was severely cognitively impaired. A care plan intervention, initiated 1/24/25, stated Resident #1 was dependent for transfers, and instructed staff to transfer Resident #1 using a mechanical lift with two staff members assisting and providing all the effort. An incident report, dated 3/9/25, documented Resident #1 fell on [DATE] during a mechanical lift transfer. The report documented CNA #1 and CNA #2 were using a mechanical lift to transfer Resident #1 from her bed to a chair when she slid out of the sling. Resident #1's left side landed on the floor and her head hit the bed frame. She was assessed by a nurse and transferred to the hospital where it was determined she had a nosebleed, contusion of her nose, and suffered hip and spinal fractures. Surgery was performed to repair Resident #1's hip. The mechanical lift competencies for CNA #1 and CNA #2 were reviewed and found to be current and complete before the incident. The facility's investigation concluded there was no deficiency found as a cause of the incident, and the following measures were implemented: - Competency training for CNAs related to safe mechanical transfers to be completed by 3/25/25. - Safety inspection of all mechanical lifts. Completed on 3/19/25 with no issues found. - Visual inspection of all mechanical lift slings. Completed 3/19/25 with no issues found. - The sling inventory was upgraded to include full-body-style slings on 3/17/25. - All resident care plans were updated to include specific sling size requirements, as needed. The facility's competencies were reviewed on 3/24/25. Two CNAs had not yet completed the new training which was to be completed on 3/25/25. On 3/24/25 at 1:47 PM, the [NAME] was interviewed. When asked what caused Resident #1 to fall, she stated that, after the incident, the CNAs reenacted the transfer for the nurse and the nurse reported they did everything correctly; the lift and sling were found to be in working order; and the fall was just an accident. 2. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's, muscle weakness, and contracture of both knees. Resident #2's quarterly MDS, dated [DATE], documented she was severely cognitively impaired A care plan intervention, initiated 6/7/24, stated Resident #2 was to be transferred with the use of a mechanical lift with two staff assisting. A fall report, dated 3/16/25, documented Resident #2 fell during a mechanical lift transfer from a chair to her bed. CNA #3 and CNA #4 were assisting with her transfer. The report stated Resident #2 slid feet first from the sling, landing on her bottom, on the floor. A nurse assessed Resident #2, and no injuries were found. The facility's investigation documented no causative factors for the incident. A progress note, dated 3/24/25, documented Resident #2's care plan was updated to instruct staff to use a green sling (full-body sling) for her transfers. The mechanical lift competencies for CNA #3 and CNA #4 were reviewed and found to be current and complete before the incident. On 3/24/25, beginning at 1:47 PM, the DON stated there were no issues found with staff competencies or equipment failure related to Resident #2's fall.

Based on observation, interview, review of policies, and record review the facility failed to implement and maintain an effective infection control program to contain and prevent facility transmission of COVID-19 in accordance with Centers for Disease Prevention and Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines and requirements. The facility failed to ensure infection control standards related to resident and staff hand hygiene and use of personal protective equipment were implemented and maintained for randomly observed residents on the 100, 200, and 300 halls. The facility failed to ensure dental staff while providing services in the facility and family members during a [MEDICATION NAME] visit used appropriate PPE and practiced social distancing. The facility failed to ensure staff donned, doffed, and used PPE (personal protective equipment) in accordance with accepted standards of practice to prevent contamination of PPE intended for reuse when caring for R1 who had COVID-19. The facility failed to ensure staff used all recommended PPE in accordance with CDC guidelines for new and readmitted residents to prevent facility-transmission of COVID-19. The facility failed to implement appropriate transmission-based precautions during the 14-day period following admission for R10 and R 16. On 8/12/20 the facility was made aware 5 of 25 residents on the 100 hall (R1, R4, R5, R6, and R10) tested positive for COVID-19. Although the facility moved the five residents to the COVID unit; the facility failed to identify the 20 remaining 100 hall residents and 100 hall assigned or float staff as persons under investigation for COVID-19. The facility failed to implement use of full PPE for care of all residents on the 100 hall, failed to implement immediate separation of the 100 hall from the rest of the building and failed to ensure dedicated staff to contain COVID-19 to the affected unit (100 hall) and prevent spread to other areas of the facility. Two days later 10 additional COVID positive residents were identified on the 100 hall. The facility failed to implement a system to ensure accurate and timely identification of residents and staff exposed to COVID-19, with unknown COVID status, and with positive COVID-19 status. Accurate and timely information is necessary to ensure implementation of transmission-based pre-cautions, isolation of staff and residents, cohorting of residents, and assignment of staff. The facility failure to maintain infection control measures to prevent facility-transmission of COVID-19 placed staff and 96 residents on the non-COVID units in immediate jeopardy and at risk for serious illness and death related to COVID-19. Immediate action was required to prevent further spread of COVID-19 to other areas of the facility. The facility administrator was informed of the determination of immediate jeopardy verbally on 8/12/20 at 2:00 PM, verbally on 8/13/20 at 4:00 PM, and in writing by email on 8/13/20. Findings include: The facility administrator and the facility Infection Control Officer (IP, infection preventionist) were interviewed on 8/12/20 at 9:30 AM. The administrator reported a resident census of 106. IP said the facility had a dedicated COVID unit (700 hall). The COVID unit was self-sustaining with a separate entrance and exit, dedicated staff who worked only on the COVID unit and did their own housekeeping with meals delivered to the unit in disposable plates and utensils. IP reported the current census on the COVID unit was 10 and the facility staffed for 10 but could staff for a surge on the COVID unit. IP said the staff on the COVID unit used full PPE including washable gowns. The administrator reported the facility had adequate PPE and expected a delivery of N95 masks that day. IP said the 500 hall was designated for new admissions and readmissions for 14-day observation/quarantine before moving to other units in the facility. IP described the 400 hall as the step-down unit for residents under investigation for COVID and for residents who come out of the COVID unit to allow for an additional two weeks observation. IP said one resident, (R1) was in isolation at the end of the 400 hall because he was symptomatic and waiting for COVID test results. IP said the facility was open to visitors for a short time and had a fair amount of visitors but was again closed to visitors due to some positive COVID tests. IP said all residents were tested on admission and placed on isolation for 14 days. The facility conducted universal testing (testing all including those with no signs or symptoms of COVID) for staff and residents. IP said in July 2020; five staff tested positive for COVID-19 and were from different units. Documentation of facility surveillance and tracking of persons under investigation for COVID-19 such as persons with symptoms, known exposure, and new admissions, was requested. IP provided a spreadsheet that showed universal COVID testing of residents on 6/26/20 with no positive results and testing on 7/23/20 with COVID positive results identified for two residents on the 400 hall. When asked for all information regarding infection surveillance, IP provided a spreadsheet titled Admit Cohort Tracking Log. The log had seven columns: resident name, admit to, admitted , 1st test, results, 2nd test, results, and OFF ISO. The log included 28 resident names admitted to rooms on the 500 and 700 halls. The log covered dates from 5/11/20 through 6/30/20. IP said he was behind in updating the infection surveillance logs. IP provided a third spreadsheet titled, COVID Unit. The log had seven columns; name, positive test date, moved to unit, symptoms onset, symptoms, clear date, and discharged to. Fourteen resident names were entered. The log indicated R11 with a positive test date of 7/31/20 admitted to the unit on 8/5/20 with symptom onset 8/11/20 of shortness of breath and [MEDICAL CONDITION] symptoms. The clear date column indicated; continue to monitor if improved reeval (reevaluate) on 8/21/20. In an interview on 8/13/20 at 10:20 AM, IP said the facility moved the COVID unit from the 400 hall to the 700 hall around July 22, 2020 so the dates on the log may be skewed. When asked about the log entry for R11 with positive test on 7/31/20 and not moved to COVID unit until 8/5/20, IP said it probably took that long to get the test results back. When asked if R11 was in isolation while waiting test results, IP replied Probably so but IP said he did not include residents under investigation or waiting for test results and did not include staff in his surveillance data. IP said he recently passed his RN boards and although he completed the CDC course for infection control he was new to his role as infection control officer (infection preventionist) and did not yet have a coordinated and comprehensive system set up to document tracking and trending for surveillance during infection outbreaks such as COVID-19. IP said the facility based policies and procedures on CDC guidelines and he was not aware of tools available through CDC to assist LTC facilities to detect, characterize, and investigate outbreaks of respiratory illness such as COVID-19. A separate universal testing spreadsheet showed staff testing 6/26/20 identified two licensed nurses and one central supply staff who tested positive. Staff testing between 7/8/20 and 7/27/20 indicated two licensed nurses, two nursing assistants, and one physical therapist tested positive for COVID-19. The staff test spreadsheet did not indicate where the staff worked in the building, did not indicate if known exposure or presence or absence of COVID-19 symptoms, and did not indicate interventions or disposition. IP said the COVID positive staff worked on all units including the 100 hall. When asked to describe the measures taken to prevent facility spread of COVID-19 after positive staff were identified in July 2020, IP said, There was nothing to be done because we already required universal masking and face shields for all staff. IP stated the facility was trying to conserve PPE (personal protective equipment) and required gowns be worn with only the highest risk residents. IP said he only required isolation gowns be used with transmission-based isolation precautions for COVID positive residents, roommates of COVID positive residents, those exposed to COVID, or those residents on the same HVAC (heating ventilation and cooling) system as COVID positive residents. IP explained that the HVAC system was segmented with one system covering about three resident rooms. IP said he determined who required transmission-based precautions based on the HVAC system. IP said the facility did not implement a PPE reuse strategy for gowns due to an increased risk for error with re-use. IP said the facility did not require staff wear gowns for transmission-based precautions for residents on the 500 hall for 14 day observation following admission or readmission. IP said the decision regarding not using gowns was based on crisis capacity for PPE and CDC's ever changing guidance. However, during the initial interview, the administrator reported the facility had an adequate PPE supply. IP did not provide evidence the facility was at crisis capacity for PPE. IP provided an undated, 3-page facility document titled Creekside Testing Plan Section 5. New Admit Testing and screening read in part; *All new admits will be tested three times prior to removal of isolation/quarantine. Testing will be completed with 3 spaced out intermittent testing prior to removal of isolation protocol. Ongoing review of burn rate of PPE completed to determine PPE utilization and level of isolation precautions. *All new admits are placed on modified isolation precautions (standard plus droplet utilizing (gloves, face shield, or goggles) until 3 negative tests are returned. *After completion of 14 days of isolation with no s/sx (signs or symptoms) of COVID-19, resident is discontinued from droplet isolation. The facility policy titled; Infection Control and Prevention Policy; Emerging Infectious Disease (EID): Coronavirus 2019 (COVID-19), revised 6/12/20 identified four steps to take to minimize the spread 1. Isolate 2. Minimize contacts with all residents 3. Increase transmission-based precautions 4. Increase monitoring of residents and staff. On page 7 of 13, the policy read in part: Increase transmission-based precautions: As of June 11th, 2020 the facility PPE process is universal masking for all health care workers in the building. Residents are to be placed on droplet+ standard reaction (face shield, universal mask and gloves) until they have 2 negative COVID-19 nasal swabs. These tests are to be performed on day one and day four of admission. They are then moved to standard precautions and a third nasal swab will be performed on/around the 12th day of their stay. Test may vary depending on available supplies and resident wishes. The facility policy and practice was not consistent with CDC guidelines which required full PPE to include facemask, eye shield or goggles, gown, and gloves when caring for residents during the 14-days following admission. Medical record review revealed R16 admitted to the facility (500 hall) on 7/14/20. A swab was obtained for COVID testing on 7/15/20. MDS note dated 7/19/20 at 11:20 noted post admission on 7/18/20 R16 was found to be COVID positive and placed on strict isolation precautions. The note read in part; on 7/19/20 she had and elevation of temperature of 99.9. She has [MEDICAL CONDITION] (breathing machine for sleep apnea) at bedtime. Prior to going into isolation she was seen by PT (physical therapy) who worked with her on bed mobility, exercises, and transfers. She was seen by OT on 7/15/20 for functional ADL (activities of daily living) requiring moderate to maximum assist. The MAR indicated [REDACTED]. R16 received respiratory treatments, physical, occupational therapy, and nursing care for six days following admission without appropriate transmission-based precautions. A progress note written by the Director of Nursing Services on 7/18/20 indicated R16 was moved to the 400 COVID hall COVID unit due to the positive result of her COVID test that was performed on the 13th and facility was called with the positive results last night. A telehealth note written by the nurse practitioner on 7/21/20 indicated R16 tested positive for COVID-19 on 7/17/20. The COVID Unit surveillance log indicated R16 tested positive for COVID on 7/17/20, moved to the COVID unit on 7/17/20 and discharged to the hospital on [DATE]. Review of the medical record review revealed R10 admitted to the facility on [DATE] from a separate assisted living facility located on campus. R10 admitted directly to the 100 hall room [ROOM NUMBER]A. R10 was not placed on transmission-based precautions or isolation at the time of admission. Six days after admission, a nasal swab was collected on 7/23/20 for COVID testing. A progress note dated 8/12/20 noted R10 was New COVID positive, asymptomatic (no symptoms). Isolation, droplet precautions were ordered 8/13/20 at 6:00 PM. In an interview on 8/13/20 at 2:00 PM the DNS confirmed R10 was admitted directly to the 100 hall and was not placed on 14-day new admission observation or droplet precautions until R10 tested positive. The DNS said she did not consider R10 to be a new admission because she came from the Assisted Living Facility on campus. In a telephone interview the corporate clinical nurse (CNN) stated she was not aware IP changed the facility policy to not require gowns for droplet precautions. CCN concurred the changed facility policy was not consistent with CDC guidelines which required gowns. 400 Hall observations: PPE and transmission-based precautions On 8/12/20 at 12:10 PM resident room [ROOM NUMBER] had a caddy hanging on the door that held one yellow gown, a box of gloves, and a container of disinfectant wipes. No signage was present to indicate to staff if R1 required precautions (aka; isolation) or what specific PPE was required to enter the room to care for R1. LN1 and NAC1 wore face masks and face shields. LN1 and NAC1 stepped inside room [ROOM NUMBER] and donned gowns that hung in the room and gloves then entered the room. A few minutes later, LN1 stood just inside the doorway and removed the gloves and then the gown. LN1 touched the front of the gown with both bare hands to feel for the waist tie. LN1 untied the gown and then pulled on the front of the gown pull it off her torso, then pulled the sleeves off by holding the cuffs. LN1 hung the gown on a hook on the wall. The gown hung with the outside of the gown facing outward and the gown touched another gown that hung nearby. The hooks and gown were not labeled. LN1 used ABHR (alcohol based hand rub) immediately after exiting the room. A few minutes later, NAC1 stood near the doorway and removed gloves and then gown. NAC touched the outside front of the gown with bare hands then contaminated the gown as she held the inside of the gown and hung the gown on top of a gown already hanging on a hook (stacked two gowns on one hook). In an interview upon exiting the room, LN1 said the gowns were to be reused due to conservation mode. LN1 said each staff had their own gown for the room. When mentioned the gowns were not labeled, LN1 said No, you just remember which is yours. When asked if they were hung correctly to prevent contamination when reused, LN1 replied probably not, you should be able to put your arms right into the sleeves without touching the outside. On 8/12/20 at 12:25 PM IP was informed of the observation of gowns doffed improperly and stored improperly for reuse. IP said LN1 informed him about her response to questions about use of gowns for room [ROOM NUMBER]. IP said LN1 gave the surveyor inaccurate information. IP said the disposable gowns were not intended for reuse. The disposable gowns were one-time use to be discarded after use. IP said all staff were educated regarding use of disposable gowns. IP said LN1 was a unit manager and should know the expectations. IP was asked about R1's medical condition and any required transmission-based precautions. IP said R1 was moved from the 100 hall to the 400 hall on 8/11/20. IP said R1 had a negative COVID test but had persisting gastrointestinal symptoms so the facility was re-testing him. IP said he moved R1 to the 400 hall until the test results come in. IP said the facility followed CDC guidelines so R1 was on droplet plus precautions. Regarding no signage to indicate the type of precautions and the required PPE to enter room [ROOM NUMBER]; IP said, ideally the room should have signage, IP added But the iso (referring to isolation) caddy was a visual clue that iso was needed. During an interview on 8/12/20 at 12:30 PM the DNS agreed there should be signage on room [ROOM NUMBER] regarding transmission-based precautions. DNS added But staff use the door-hung supply caddy or the small cart next to the room as a visual clue. The DNS acknowledged there were different types of transmission-based precautions (aka, isolation) and the staff could not discern the required type of isolation or the specific required PPE from the caddy or cart. Observation on 8/12/20 at 12:35 PM revealed isolation caddies hung on two empty room doors on the 400 hall. Additionally a cart placed between resident rooms [ROOM NUMBERS] was not labeled to indicate which room if any required isolation precautions. IP placed signage on room [ROOM NUMBER] door indicating droplet plus contact precautions required and, dispose of gowns after use. The signage read: Droplet and Contact Precautions. Bed ___. Families and visitors STOP. Please report to staff before entering. Clean hands before entering and when leaving room. Graphic images of ABHR (alcohol based hand rub) and handwashing with text; clean hands with A. hand foam/gel or B. soap and water. Staff: KEEP SIGN POSTED UNTIL ROOM CLEANED. HOUSEKEEPER will remove sign after Discharge cleaning. POINT of CARE Risk Assessment. Gown and Gloves. Procedure mask with eye protection-when within 2 metres of patient. Keep 2 metres between patients. The sign indicated it was produced by PICnet, (provincial network of British Columbia), a program of the Provincial Health Services Authority. When asked why the facility did not use resources and signage available through CDC, in a written response, IP wrote that he felt the PICnet signs better encompassed our infection control protocols IP's response indicated the PICnet signage matched the CDC recommended guidelines. IP wrote: My rationale was that it is more complete and easy to edit in the case of adding a N95 (for example) to the precautions as recommendations have changed over the course of the COVID-19 season. IP further wrote; Droplet plus contact precautions signs are used for the COVID unit (because it includes the N-95 mask) while Contact-Plus is used upon admit residents, and the point of care assessment can be over ruled due to the fact that surgical mask or higher and face shield is required center wide. The PICnet Contact Plus Precautions sign directed; Contact Plus Precautions-Used for [MEDICAL CONDITION] Infection (CDI) Only. [MEDICAL CONDITION] is a bacterium that causes severe diarrhea. Contact Plus sign showed a picture of a person wearing gown and gloves but no facemask or eye shield. And directed Staff: Required gown and gloves. The sign read; Point-of-Care-Assessment. When there is a risk of splash or spray, wear face and eye protection. The facility policy titled Infection Control and Prevention Policy- Emerging Infectious Disease (EID): Coronavirus Disease 2019, revised 6/12/20 read in part; Procedure: 1. Minimize Chance for Exposures interventions included *Identify, stock, and staff separate designated areas of the building to room:-diagnosed COVID-19 positive resident(s) or suspected (symptomatic residents -Suspected COVID-19 positive resident (post exposure) pending test results and -New admissions to the building for 14 days (observation) may include [MEDICAL TREATMENT] residents (potential community exposure). *Ensure rapid safe triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection. 2. Adhere to Standard and Transmission-Based Precautions. Read in part; Attention should be paid to training and proper donning (putting on), doffing (taking off), and disposal of any PPE. Personal Protective Equipment; HCP (health Care professional) must receive training on and demonstrate an understanding of: when to use PPE, what PPE is necessary, how to properly don, use, and doff PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, and the limitations of PPE. The facility policy and procedure regarding transmission-based precautions, the PICnet signage, and directions for precautions were not consistent with the CDC guidelines which required an N95 mask, eye protection, gown, and gloves for care of residents suspected to have COVID-19, known COVID positive, and during the 14 day observation period following admission or readmission. From CDC website at www.cdc.gov. Preparing for COVID-19 in Nursing Homes Updated June 25, 2020 Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated. Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g. outside of resident's room, wing, or facility-wide). Review of Centers for Disease Control and Prevention (CDC) cases and deaths by county, https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/county-map.html showed Ada County, where the facility is located, had 2,104 cases per 100,000 which indicated high community COVID-19 activity. [MEDICATION NAME] visit Review of R5's medical record revealed a medical provider note dated 7/28/20 noted R5 has been isolating in her room currently with her spouse (R6) as he has been having a fever and is 'not feeling well'. Review of R6's medical record revealed a physician order [REDACTED]. The order did not specify what type of precautions and did not specify the reason for precautions. No directions were specified for the order and the order was not entered onto the medication or treatment record. The record did not reflect whether the precautions were implemented on 7/18/20 and the daily charting did not document isolation precautions. Progress notes written 7/27/20 noted R6 had elevated temperature at 101.1 and abnormal lung sounds. A progress note dated 7/30/20 noted R6 continued on antibiotics for pneumonia and was on gown isolation. Observation conducted on 8/12/20 from 1:18 PM to 1:25 PM revealed no signage to indicate precautions for R5 and R6's room [ROOM NUMBER]. NAC2 said room [ROOM NUMBER] was not on isolation. NAC2 was asked to identify persons in room [ROOM NUMBER]. NAC2 identified a family member, a hospice nurse and social service staff. NAC2 said it was a [MEDICATION NAME] visit for hospice. The family member at R5's bedside did not wear a facemask. The hospice nurse wore a facemask and eye protection but no gloves and no gown and leaned on the overbed table. Several staff came and went from the room at various times wearing face mask and eye shield but no gown or gloves. Hospice nurse, family, and facility staff engaged in comforting behaviors such as rubbing R6's back and patting shoulders, no hand hygiene was performed following such comfort measures. Social distancing was not maintained. Four hours later, positive COVID test results were reported for R5 and R6 at 5:40 PM on 8/12/20 and both were transferred to the COVID unit. Potentially contaminated intravenous fluid available for use On 8/12/20 at 11:45 AM a bag of 0.9% NACL (Normal saline) hung on a pole in the 400 corridor outside room [ROOM NUMBER]. The bag was spiked (bag punctured to attach tubing). The IV solution label had no date to show when it was opened (spiked) and no resident name or room number. LN1 exited room [ROOM NUMBER] and was asked about the IV solution. LN1 said she did not know anything about it, no resident on the hall needed IV fluids. On 8/12/20 at 11:47 AM, when shown the IV solution hanging on the pole, IP confirmed no current resident required IV fluid and said he would investigate. IP returned at 12:30 PM and reported he thought staff got the IV fluid ready to give to R2, but R2 went out to the hospital so they probably did not have time to start the IV. IP said R2 went to the hospital around the 4th or 5th. IP said the IV solution should have been labeled with the date and time it was spiked and the resident's name. IP said the IV solution was not safe, because it could be contaminated with bacteria. IP said IV fluid should be used within 24 hours after it is opened or spiked, but added he doubted anyone would use it. IP discarded the IV solution. Outside Professional Provider On 8/12/20 at 12:06 PM observed personnel P1 in room [ROOM NUMBER] as she washed her hands. P1 wore a face mask, face shield, and a gown. When asked about PPE requirements in the facility, P1 responded that she did not know because she was not facility staff. P1 explained she came into the facility with the dentist to provide dental exam and dental treatment to residents, and added, We wear this gown when we are working on residents. IP was called to the 400 hall. When IP was asked if the dentist and his staff were screened and instructed in the use of PPE, facility restrictions/process regarding movement of residents in the facility, where treatment would be provided, and which residents would be treated; IP said he did not know the dentist was in the building, IP said only essential services were to be allowed in the building and he should have been consulted before the dentist came into the facility. IP concurred dental treatment would be considered aerosol generating procedure (AGP) with increased risk for transmission of COVID-19. When asked the facility expectation for dental examination and treatment in the facility, IP said the dental staff would need full PPE including N95 facemask, face shield, gowns, and gloves due to the increased risk with AGP. IP said he obtained more information and reported the dentist came to the facility because two residents had pain. IP said both residents had negative COVID tests. IP said the dentist brought his own reusable washable gown which the dentist reported he wore. IP said he placed disposable gowns in room [ROOM NUMBER] and instructed the dentist and his staff to use disposable gowns, one gown per resident. IP said the dentist stated last Thursday (6 days prior) he was in a skilled nursing facility that had COVID-19. When asked about screening of the dentist for facility entry; IP said the screening should have identified that the dentist was in a COVID positive building 6 days earlier and either he (IP) or the DNS should have been informed to review the screening information and to provide direction regarding allowing access to the residents. IP reported social services set up the dental visit and the DNS was also unaware the dentist was in the building. Resident hand hygiene Observed distribution of lunch trays on 8/12/20 from 12:46 PM to 12:58 PM on the 300 hall. Transportation staff TS1 and maintenance staff MS1 assisted. TS1 delivered a meal tray to room [ROOM NUMBER] and set up the tray on the overbed table. TS1 did not perform hand hygiene when exiting the room. TS1 got a tray from the tray cart which he delivered to room [ROOM NUMBER] with no hand hygiene when entering or exiting the room. Observed trays delivered by various staff to rooms, 306, 308, 311, 313, and others with no pre-meal hand hygiene provided or offered to the residents. Similarly on the 100 hall NAC2 delivered and set up trays in rooms 106, 108, 114, and others without providing or offering the residents pre-meal hand hygiene. Observation of the evening meal on 8/12/20 from 5:00 PM to 5:25 PM revealed NAC4 delivered trays on the 200 hall to residents in rooms 205, 201, 203, 209, and 212. Residents were not provided or offered hand hygiene prior to the meal. The meal included sloppy joes, French fries, and vegetables. Residents ate the sloppy joes and French fries with their fingers. Evening meal observations conducted on the 300 hall revealed similar findings of no hand hygiene offered or provided by NAC3, unit manager, or Staff 1 to residents in rooms 308, 311, 312, and 313. CMS State Operations Manual: If residents need assistance with hand hygiene; staff should assist with washing hands after toileting, before meals, and use of ABHR or soap and water at other times when indicated. Observations 8/13/20 On 8/13/20 at 8:40 AM R3 stood at the door in room [ROOM NUMBER] and requested assistance. Social service staff SS sat in an office nearby and was informed of the request. SS did not perform hand hygiene before she donned a facemask and face shield that sat on her desk. SS went to room [ROOM NUMBER] and donned gloves and then a gown and entered the room. SS said last night R3 moved to 408 from another unit. SS said R3 did not test positive for COVID-19 but she was exposed so she had to move to a new room. Signage on the door indicated droplet plus contact precautions. IP confirmed R3 was a relative and had close personal contact with two residents who tested positive for COVID-19. R1 was no longer in room [ROOM NUMBER]. Review of the census log for 8/13/20 revealed the facility made eight room changes overnight; R1 moved from 412B to the COVID unit, R4, R5, R6, and R10 moved from the 100 hall to the COVID unit and R7, R8, and R9 moved out of the COVID unit to the 400 hall. The census log did not reflect R3's move from 110A to 408. Observation of the 100 hall at 10:00 AM revealed five resident rooms (109, 110, 112, 113, and 114) had signage indicating droplet precautions required. No rooms on the 100 hall required droplet precautions on 8/12/20. NAC5 said she was not told of concerns at 6:00 AM report, but then at 9:00 AM she noticed the isolation signs were up. NAC5 said she thought one resident was positive. NAC5 said she was informed it was precautionary, a roommate came back so be aware of that, watch for symptoms, wash hands, gown up and put on gloves and face shields and have resident wear a mask. In an interview on 8/13/20 at 10:30 AM IP said two employees who worked on the 100 hall tested COVID-19 positive around July 27, 2020 so the facility conducted COVID testing of all residents on the 100 hall. IP said the facility received a call last evening at 5:40 PM with the first results confirming COVID positive test results for 5 of 25 residents on the 100 hall (R1, R4, R5, R6, and R10). Test results for 20 residents were still pending. When asked to describe the measures the facility implemented to contain the outbreak on the 100 hall, IP said R1 was moved to the 400 hall on 8/11/20 because he spiked a temperature. IP said he was going under the assumption that R1 was negative when he moved him, but he (R1) turned up positive. IP said R10 was moved to the 400 hall on 8/12/20 because she was exposed through close contact (regular visits) with two positive residents. When asked why residents in only five 100 hall rooms were identified for droplet precautions and shouldn't all residents on the 100 hall be isolated. IP said he based his de (TRUNCATED)

Based on record review and staff interview, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers. This was true for 1 of 3 residents (#13) reviewed for pressure ulcers. Resident #13 was harmed when he developed 2 pressure ulcers on his buttocks. Findings include: Resident #13 was readmitted [DATE]. He had been discharged on [DATE] to the hospital with [DIAGNOSES REDACTED]. He had additional [DIAGNOSES REDACTED]. Resident #13's 6/8/18 Skin Check assessment documented he did not have skin impairments. An initial nursing assessment completed on 6/8/18 at 4:14 PM documented Resident #13's skin was constantly moist, of normal color, and warm to the touch with a skin impairment present. The assessment did not include the size, location, or description of the skin impairment. A 6/8/18 Physician order [REDACTED]. * Evaluate wound area daily report to MD (medical doctor) as indicated. * (Name of wound care agency) may eval(uate) and treat the wound. The Order Summary Report did not include the location of the wound. Resident #13's Progress Note of 6/10/18 at 3:02 PM, documented his skin was intact except for a DTI on his left foot. The facility had a contract with an outside agency to provide wound assessments. A wound assessment completed by the contract agency's staff on 6/13/18 documented the left dorsal foot wound. Resident #13's MDS assessment, dated 6/15/18, documented he had two unstageable deep tissue injuries (DTI). Resident #13's 6/15/18 Skin Check assessment documented he had new skin injury wounds. The new wounds were: * dark red/purple scratch/blood blister to right buttock, .3 cm (centimeters) x 0.7 cm (and the depth was) UTD (unable to determined) * Red blanchable area bilateral inner buttocks 5 cm x 6.5 cm x 0 cm. A Progress Note, dated 6/15/18 at 5:00 PM included documentation of a change in condition of Skin wound or ulcer 06/15/2018 in the afternoon. A Progress Note, dated 6/16/18 at 6:00 PM, documented Resident #13's right buttock area had areas of skin peeling with a pink, moist underlying wound base. The note stated there were no signs of infection or drainage. The note also documented the moisture associated skin damage to Resident #13's bilateral inner buttocks was less red. A Progress Note, dated 6/22/18 at 4:55 PM documented the blanchable area to Resident #13's right buttock was healed. A document titled RMS Event Summary Report, dated 6/27/18 at 12:00 PM, stated Resident #13 had new in-house acquired pressure ulcers, other DTI. The report documented that during wound rounds Resident #13 was found with two DTI's, one on his left proximal buttock and one on his left distal buttock. The report stated weekly skin checks were documented and the last skin check was completed on 6/22/18. Two Skin Integrity Reports were provided by the facility. The reports documented Resident #13 had two DTIs, one on the distal left buttock and one on the proximal left buttock. The Skin Integrity Reports documented the wounds were first identified on 6/27/18. The Skin Integrity Reports documented assessments of the left distal buttock wound on 6/27/18, 7/4/18, 7/11/18, and 7/18/18. The Skin Integrity Reports documented assessments of the left proximal buttock wound on 6/27/18, 7/6/18, 7/11/18, and 7/18/18. The assessments were not completed daily as ordered by the physician on 6/8/18. The documentation on 6/27/18, for the distal left buttock, was: appearance: 90% intact/deep purple, 10% granulation; 2 cm length; 1.5. cm width; 0 cm depth; no drainage; healthy wound edges; healthy surrounding tissues; and no odor. The documentation on 6/27/18, for the proximal left buttock wound was: appearance: 90% intact/deep purple 10% granulation; 5 cm length; 2 cm width; 0 cm depth; no drainage; healthy wound edges; healthy surrounding tissues; and no odor. The distal left buttock wound was resolved by 7/18/18, and did not open into a sore. The wound on Resident #13's proximal left buttock, on 7/11/18, was described as: appearance 90% intact/deep purple and 10% granulation; 0.4 cm length; 0.5 cm width; and 0.1 cm depth; no drainage; healthy surrounding tissue; healthy wound edges; and no odor. The 7/18/18 documentation was: appearance 100% scab; 0.4 cm length; 0.5 cm width; UTD depth; no drainage; healthy surrounding tissue; healthy wound edges; and no odor. Resident #13 was transferred to the hospital 7/23/18 and did not return to the facility prior to the survey team's exit on 7/26/18. Resident #13's current care plan included multiple instructions and interventions related to wounds, including the following: * Single turn sheet for repositioning starting 3/18/16 * Air mattress starting 4/27/16 * Highback tilt in space wheelchair for positioning initiated 11/17/17 * Evaluate wound daily, added 6/17/18 * Weekly skin assessments, added 6/17/18 * Assist and encourage turning and repositioning frequently, added on 6/28/18 * Weekly wound assessments to include measurement and description of the wound, added 6/28/18 * Wound (location not specified) to be evaluated daily, initiated 2/17/18 * Bi-weekly skin checks by a licensed nurse, starting 7/12/18 * Pressure reduction wheelchair cushion * New wheelchair cushion ordered 7/19/18 Resident #13's care plan included conflicting information, stating his skin and wound(s) were to be assessed/evaluated daily, bi-weekly, and weekly. The Corporate Quality Service Nurse was interviewed on 7/25/18 at 12:30 PM about the DTIs. The wound sheets were provided and she stated Resident #13 had multiple co-morbidities.

Based on record review, staff interview, and review of the facility's investigations and policies, it was determined the facility failed to ensure residents were provided with the level of supervision necessary for safety and staff were competent to perform life-saving interventions for residents who experienced choking episodes. This was true for 1 or 4 sampled residents (Resident #1). The failure to provide lifesaving interventions contributed to, or resulted in, the death of Resident #1, and placed all residents who consumed food orally, in Immediate Jeopardy of brain, tissue, and/or organ damage, and coma, due to severe hypoxia, or death due to asphyxiation. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's Nutrition Care Plan, revised [DATE], documented interventions including: * Provide Resident #1's diet as ordered by the physician, revised [DATE]. * Honor Resident #1's food preferences within his meal plan, revised [DATE]. * Staff to encourage Resident #1 to chew and swallow each bite, revised [DATE]. Resident #1's (MONTH) (YEAR) physicians' orders documented: * Resident #1 was to receive a regular/liberalized diet, initiated on [DATE]. * Resident #1 had a DNR order, initiated on [DATE]. * Speech Therapy was to evaluate and treat Resident #1 for increased swallowing difficulties, ordered on [DATE]. On [DATE], the facility submitted a self-reported Summary of Investigation to the State Agency (SA) which documented Resident #1 choked during the evening meal on [DATE], and died of asphyxia. The investigation did not include a review of staff's compliance with facility policies and procedures or if staff's actions in response to the choking were consistent with current standards of practice. The SA contacted the facility on [DATE] and requested further information. On [DATE] the facility provided the following additional information to the SA: * An undated Investigation Report - The Report documented that on [DATE] at 5:20 pm, CNA #6 provided a dinner tray to Resident #1 which contained chicken, potatoes, squash, and a biscuit, and offered to cut up the chicken. * An undated Incident Report Witness Statement from CNA #7 - CNA #7 documented Resident #1 received his dinner meal at approximately 5:15 pm. CNA #7 stated she heard someone coughing and turned and saw Resident #1 touching his throat and struggling to breathe. CNA #7 went to Resident #1's side and tapped him on the back to make sure he was sitting in an upright position. CNA #7 encouraged Resident #1 to cough and noticed Resident #1's face had turned red from trying to cough and expel the food. CNA #7 asked CNA #6 for assistance in locating a nurse. CNA #6 stated the RN had stepped out of the dining room. CNA #7 asked CNA #6 to take Resident #1 from the dining room to find an RN. * An undated Incident Report Witness Statement from CNA #6 - The statement documented CNA #6 rushed Resident #1 to LPN #2 who was in the hall. LPN #2 instructed CNA #6 to take Resident #1 to his room and LPN #2 would be there quickly with a suction machine. The statement documented LPN #2 tried using the suction machine and when it was not successful the nursing staff started the Heimlich maneuver. In addition, the statement documented the two CNAs stood Resident #1 up while LPN #2 performed the Heimlich maneuver. The statement documented Resident #1 had to be lowered to the floor and abdominal thrusts were attempted. * An undated Incident Report Witness Statement from CNA #8 - The statement documented CNA #8 went to assist CNA #6 when she heard her calling for help in the hallway. The statement documented Resident #1 was red in color and was coughing hard and CNA #8 encouraged Resident #1 to continue coughing. CNA #8 continued to wheel Resident #1 down to towards the nurses' station where LPN #2 was located. CNA #8 documented Resident #1's face turned a dusky/gray color. LPN #2 instructed CNA #8 to take Resident #1 to his room while he grabbed the suction machine. While LPN #2 suctioned Resident #1's mouth, he was able to dislodge small pieces of chicken. CNA #8 documented Resident #1 was stood up and the Heimlich maneuver was performed. She described Resident #1 as taking raspy breaths. Staff sat Resident #1 in his wheelchair and the nursing staff attempted to suction him again. The nurses stood him up again and tried the Heimlich maneuver. CNA #8 documented Resident #1 was losing his color after another unsuccessful attempt with the Heimlich maneuver. After the failed attempt they laid him on the floor and initiated abdominal thrusts. She documented Resident #1 passed away. * An undated Incident Report Witness Statement from LPN #2 - The report documented that on [DATE] at 5:25 pm, LPN #2 stated he was heading to the dining room, when CNA #6 met him in the hall and told him Resident #1 was choking. LPN #2 instructed one of the CNAs to get the RN, and directed the other to take Resident #1 to his room. LPN #2 stated he got a suction machine and tried to suction and clear Resident #1's airway. After a bit, RN #2 entered the room and the nurses started to perform the Heimlich maneuver. LPN #2 was able to get some food particles out, however Resident #1 remained cyanotic and did not respond to verbal stimuli. The statement documented LPN #2 continued to perform the Heimlich maneuver and RN #2 called Resident #1's physician. The physician instructed the staff to call 911. RN #2 took over performing the Heimlich maneuver while LPN #2 left the room and called 911. When LPN #2 returned to the room, Resident #1 was on the floor and non-responsive. The paramedics declared Resident #1 dead when they arrived. * Summary of an interview facility staff completed with LPN #2 - The summary documented LPN #2 as stating Resident #1's room was approximately 125 feet from the dining room and when he went to grab the suction machine he was .only away (from Resident #1) maybe two minutes while I got the equipment. * Copy of RN #2's [DATE] Nurses' Note as an Incident Report Witness Statement from RN #2 - Resident #1's Nurses' Note, dated [DATE], documented RN #2 was notified at 5:30 pm, that Resident #1 was possibly choking on food. Another LN had taken Resident #1 to his room and begun an assessment. The note documented Resident #1's face was dusky and he presented with taking gasping respirations with mucus heard in (his) airway. In addition, it documented Resident #1 did not respond to verbal stimuli. The note documented the Heimlich maneuver was performed by LPN #2 and several small food particles were expelled. RN #2 took over the thrusts and more food particles were expelled. Resident #1's facial color was turning pink and Resident #1 clamped his mouth shut when the nurses attempted to suction him again. Nursing staff stood Resident #1 up again and provided him additional abdominal thrusts. The note documented at 5:43 pm, Resident #1's physician was called and gave orders for the RN to call 911. The note documented Resident #1 coughed, lost consciousness, and was dusky. He was placed on the floor and abdominal thrusts were performed. In addition, the note documented, at 5:50 pm, Resident #1 had no heartbeat or respirations and when the emergency medical crew arrived, Resident #1 was declared dead. * An undated Summary of Investigation: Accidental Death Report - The report documented an initial coroner's report determined the cause of death for Resident #1 was mechanical asphyxia (airway obstruction or choking on a foreign object) from a food bolus in the trachea. An on-site visit was made to the facility on [DATE]. Resident #1's Nurses' Note, dated [DATE], documented he had increased coughing after taking his bedtime medications and an order for [REDACTED]. Resident #1's (MONTH) (YEAR) physicians' orders included an order, dated [DATE], for ST to evaluate and treat him. On [DATE] at 2:00 pm, the Therapy Director stated Resident #1 was served by a different SLP in the past. She said Resident #1 was discharged from services on [DATE], with SLP recommendations for a regular textured food diet and for staff to refer him to speech therapy if his swallowing function declined. She stated she received an email, on [DATE], from RN #3 requesting speech therapy to evaluate and treat Resident #1 for increased coughing after taking medications. The Therapy Director stated her staff was waiting for a physician order [REDACTED]. On [DATE], the physician ordered ST to evaluate Resident #1's swallowing difficulties and initiate treatment. An evaluation was not initiated prior to his death on [DATE]. During an interview on [DATE] at 11:45 am, LPN #2 stated he was assigned to start his shift in the dining room at 5:15 pm; however he was assisting another resident with his/her needs and was walking to the dining room at 5:20 pm. As he was walking to the dining room CNA #6 was pushing Resident #1 down the hall in his wheelchair towards him. LPN #2 stated Resident #1 was cyanotic and could not speak. However, Resident #1 could look at him and did respond to verbal commands to cough. LPN #2 stated he encouraged Resident #1 to cough, only Resident #1 was unable to cough with much force. LPN #2 stated when Resident #1 could not cough or clear his airway he instructed a CNA to take him to his room and another CNA to find the RN. LPN #2 stated he ran to get a suction machine from an O2 storage closet because it was close to his approximate location. He stated the crash cart was down in the dining room and the O2 storage closet was closer. LPN #2 met CNA #6 and Resident #1 in his room where he initiated suctioning of the food. LPN #2 stated the suction was able to get some small food particles out and LPN #2 instructed Resident #2 to try and cough between suctioning. LPN #2 stated RN #2 entered Resident #1's room, and when Resident #1 was unable to cough at all the nurses started to perform the Heimlich maneuver. CNA #6 and #8 picked Resident #1 up into a standing position and LPN #2 performed ,[DATE] thrusts. He stated some food particles did come out. RN #2 was standing in front of Resident #1 and assessing him. LPN #2 stated RN #2 said Resident #1's airway was not clear and she would do thrusts. RN #2 performed 6 thrusts on Resident #1. LPN #2 stated he attempted to suction Resident #1 again and he clamped his mouth shut. LPN #2 stated he asked RN #2 to call Resident #1's physician while he took over the abdominal thrusts. LPN #2 stated he performed ,[DATE] thrusts with more pressure and Resident #1 was able to expel more food particles. LPN #2 stated at the 10th thrust Resident #1's physician told RN #2 to call 911. LPN #2 stated RN #2 took over performing thrusts and instructed him to go call 911. He stated he left the room and made the phone call to 911. In addition, LPN #2 stated he initially chose to use the suction machine on Resident #1 because he had a history of [REDACTED].#1 would get upset; swat at their hands; and tell staff to not hit him because it hurt. LPN #2 stated he chose the suction because it was less invasive. On [DATE] at 3:30 pm, CNA #6 stated she was called to assist another CNA in the dining room with a resident that appeared to be choking. CNA #6 stated Resident #1 was coughing when she approached him at approximately 5:25 pm (on [DATE]). CNA #6 stated Resident #6 did not say anything, when asked if he was choking Resident #1 nodded his head. CNA #6 assisted with transporting Resident #1 from the dining room. She stated he continued coughing until they reached the nursing station. She stated he made eye contact but did not follow simple directions. CNA #6 stated when they reached Resident #1's room he was blue. The website mayoclinic.org states, the universal sign for choking is hands clutched to the throat. If the person does not give the signal, to look for these indications: * Inability to talk * Difficulty breathing or noisy breathing * Inability to cough forcefully * Skin, lips and nails turning blue or dusky * Loss of consciousness The facility's [DATE] policy, Obstructed Airway Intervention, instructed staff that if a resident was choking and could not speak, cough, or breathe, emergency medical services (EMS) was to be activated and subdiaphragmatic thrusts began (Heimlich maneuver). The undated Investigation Report received in the SA on [DATE], included an approximate time line of events. Key points included: * 5:25 pm - A CNA noticed Resident #1 coughing, stating with difficulty, I can't breathe. One CNA instructed another CNA to take Resident #1 from the dining room and find an LN. * 5:26 pm - The CNA took Resident to LPN #2 who was in the hall walking toward the dining room. LPN #2 assessed Resident #1 and described his skin as dusky in color. LPN #2 directed the CNA to pushed Resident #1 to his room while he got a suction machine. * 5:28 pm - Resident #1 was in his room, appeared gurgley, and gasping for breath. * 5:29 pm - Resident #1 appeared dusky, non-verbal, and his eyes were open and pupils dilated. Resident #1's mouth was checked and no food observed. An unsuccessful suction attempt was completed with a small amount of food expelled. * 5:30 pm - Resident #1's skin was dusky and he appeared to be gasping for air. The Heimlich maneuver was attempted and some food was dislodged. Resident #1's skin appeared pinker. Suction was again attempted, however, Resident #1 clenched his teeth shut and suctioning could not be performed. * 5:43 pm - The Heimlich maneuver was attempted again without success. Resident #1's physician was called and the physician directed staff to call 911. * 5:44 pm - 911 was called. * 5:45 pm - Resident #1 was coughing and lost consciousness. Abdominal thrusts were continued without response. * 5:50 pm - Resident #1 was without a pulse and respirations. * 5:50 pm - Paramedics arrived (within 6 minutes of 911 call) and did not attempt further interventions. The first lifesaving intervention (suctioning) was initiated 4 minutes after Resident #1 began choking and stated he could not breathe. There was no further documentation of words spoken by Resident #1. The Heimlich maneuver was first attempted 5 minutes after the incident began. 911 was called 19 minutes after Resident #1 began choking and paramedics arrived 6 minutes later. The website BrainInjuryFoundation.org, states that without oxygen reaching the brain, irreversible brain damage starts to occur within 5 minutes. The facility failed to initiate appropriate, timely lifesaving measures necessary to sustain Resident #1's life. 2. Professional standards of practice review and policy review included: a. The American Red Cross: Basic Life support for Healthcare Providers Handbook (YEAR), documented the practice to follow for individuals who are choking is: * Ask the individual if s/he is choking and would the individual like assistance. * Notify the individual that you are trained to assist him/her. * If the individual cannot breathe or has a weak or ineffective cough, initiation of the Heimlich maneuver is required. * Emergency response (EMS) should be called if the individual was identified as requiring the Heimlich maneuver. * Deliver abdominal thrusts until the object is forced out; the person can cough, speak or breathe; or the patient becomes unconscious. * If an individual has lost consciousness, immediately initiate CPR, starting with chest compressions. In addition, the handbook documented a blind finger sweep (when an object is not observed in the mouth) was not to be performed and to continue CPR. The handbook documented further to never try more than 2 ventilations during one cycle of CPR, even if the chest doesn't rise. b. The facility's Obstructed Airway Interventions Policy and Procedure, revised [DATE], documented if a resident was choking EMS was to be activated, and if the resident was conscious, the Heimlich maneuver initiated. If the resident became unconscious staff was to open the resident's mouth and look for the object. If they saw the object they were instructed to remove it with their finger. If objects were not visualized, staff was to open the resident's airway by tilting the head and attempting two rescue breaths. If the chest did not clearly rise, staff was instructed to re-tilt the head and perform another rescue breath. If the chest continued to not rise, staff was instructed to begin CPR. Facility staff failed to promptly initiate the Heimlich maneuver while Resident #1 was conscious, as instructed in the facility's policy. Additionally, the facility's Policy and Procedure for Obstructed Airway Interventions was inconsistent with the standards of practice described in the American Red Cross: Basic Life support for Healthcare Providers Handbook (YEAR). The facility's policy did not instruct staff to immediately initiate CPR if the choking resident became unconscious. c. The facility's Cardiac and/or Respiratory Arrest Policy and Procedure, revised [DATE], documented if a resident had a DNR order, CPR and ALS would not be initiated. However, under certain emergency circumstances, a resident who had a DNR order would be provided lifesaving treatment; for example if they were choking, staff would initiate obstructed airway interventions. On [DATE] at 2:50 pm, the DNS stated that the nursing staff watched videos for training on CPR and choking. He stated there was information in a book on the crash cart regarding how to manage choking. The DNS stated that in the case of Resident #1, the staff did not use the crash cart and probably did not look at the book. The DNS stated rescue breathing was not initiated by the staff, and they did not check the heart rate. The DNS stated the reason the rescue breaths and heart rates were not check was because Resident #1 was alert, his eyes were open, and he was coughing. They did not check for pulse. The DNS stated the RN checked Resident #1's airway but Resident #1 went quickly from staff completing abdominal thrusts to loss of consciousness. The DNS was asked if the staff recognized the signs of an occluded airway vs a restricted airway. The DNS stated Resident #1 was coughing and talking. He stated his staff would not initiate the Heimlich maneuver due to trauma, which may cause the foreign object to become lodged. The DNS stated Resident #1's cough was hard and forceful, and then became weak. The DNS was unable to speculate why the resident's cough weakened. He stated the initiation of the Heimlich, when someone was choking, was when there was no airway; no talking; and no coughing. On [DATE] at 3:00 pm, the Administrator and DNS stated the facility's corporate office required CNAs to be CPR certified. The DNS stated he initiated an After-Action Assessment review, spoke with staff regarding the event. The DNS stated each licensed nurse should be familiar with how to respond in accordance with the facility's policy and procedure and CNAs need to be able to recognize and identify episode of choking. CNAs were considered to be first responders. The DNS stated CNAs Scope of Practice does not include assessment. The American Red Cross: Basic Life Support for Healthcare Providers Handbook, (YEAR), documented a definition for Scope of Practice as being: The range of duties and skills you acquire in training that authorizes you to perform by your certification to practice. 3. Interviews with staff on how they would respond to residents who were choking: * On [DATE] at 7:30 am, CNA #1 was in the dining room preparing to serve residents breakfast. She stated several residents had difficulty with swallowing and, They sit in the back. More will be coming that (area) will be full. She stated she received her CPR certification a year and a half ago and commented, I have been trained. She stated that if she encountered a resident choking she would take care of them the best she could. She said she would have someone run for help and check to see if the resident was breathing. She said nurse should come soon and by then she would put the resident on the floor and help the resident clear the food from the his/her airway. She further stated, I might have to do the Heimlich, it is so hard, I have not had to do it. Both CNAs and nurses are usually always close. Have the resident take a drink if they are talking to me to try to clear it. Asked if she had read the facility's Policy and Procedure for obstructed airway, CNA #1 stated, I imagine so, I am not positive. I know they are always having us read. * On [DATE] at 7:48 am, LPN #2 stated he would recognize a choking victim when they used the universal sign of choking, of placing hands to the throat; were unable to talk; had changes to their skin color; and had a panicked look on their faces. He stated he would initiate the Heimlich maneuver if he came across someone choking. LPN #2 stated his most recent CPR training had been before he started working at the facility and he had been there for 11 months. He stated the facility had provided an in-service on managing choking incidences earlier that week. * On [DATE] at 7:50 am, Unit Manager LPN #1 was assigned to the medication cart which was positioned just outside the dining room. She stated she was still in orientation and was currently reviewing the Policy and Procedures in the training. She stated she received her CPR certification in (MONTH) (YEAR). She stated that if she encountered a resident choking, she would assess them and encourage them to cough for about a minute. LPN #1 further stated, I would provide privacy; probably take them to their room. Unit Manager LPN #1 stated if a resident was unconscious she would start the Heimlich and if not breathing she would begin compressions and suction if indicated to dislodge the piece of food. * On [DATE] at 7:50 am, CNA #10 stated she would recognize choking if the resident started to cough. She stated if the resident was obviously not breathing, she would probably do the Heimlich. She would have to decide whether to do it in the dining room or not, depending on how the resident looked due to the potential for it being traumatic for other residents to see. CNA #10, employed in her position for the last ,[DATE] months, stated the decision would be made based on color. If the resident was blue she would initiate the Heimlich maneuver in the dining room; if not blue, take them out to do it. CNA #10 said she was trained on the Heimlich maneuver ,[DATE] months ago as part of CPR training. She stated she had no training on the Heimlich/choking response since that time. * On [DATE] at 8:00 am, CNA #9 stated she would recognize that a resident was choking by their facial expression and coughing. CNA #9 stated she would encourage the resident to cough and send another CNA to get a nurse. If the resident was not breathing, she would lift the resident's arms over his/her head. If the resident was still not breathing, she would do CPR but would first check the facial expression to see if the resident's color was purple or blue. When asked if she had been trained in the Heimlich maneuver, CNA #9 asked What is the Heimlich maneuver? I don't know this, should I have been to a class? * On [DATE] at 8:12 am, Activities Assistant #1 stated she would recognize a choking victim if they were not coughing and turning gray. She stated she would tell a RN or CNA and let them handle the situation if she came upon someone choking; she would not intervene. * On [DATE] at 8:15 am, CNA #2 stated there were usually 3 CNAs present in the dining room for breakfast, 4 for lunch, and 3 for dinner. She stated there was usually a nurse there. CNA #2 stated she received CPR certification ,[DATE]. She stated if she encountered a resident choking, she would either encourage them to cough or start the Heimlich, mostly keep encouraging them to cough it up. She stated she would not pat them on the back. She stated she would start CPR (chest compressions and breathing). CNA #2 had been employed in her position for a year. She stated she had not seen mock codes for choking used for training. * On [DATE] at 8:22 am, the Activities Director stated she would recognize a choking victim if they were coughing. She stated she would put the person's hands up above the head if they were coughing and get an RN or CNA to assist. When asked if there was any immediate action she would take, she stated she would start by checking if an object was in the mouth and remove the object if seen. If she could not see the object she would initiate CPR. The Activities Director stated she had CPR training in the past. * On [DATE] at 8:31 am, CNA #4 stated she would recognize a choking victim when the resident used the universal sign of choking, of placing hands to the throat; were unable to talk; and turned red. She stated she would ask the resident if s/he was ok, and pat the resident on the back. If the resident did not respond she would get an RN. CNA #4 stated she had CPR training recently and the facility had done an in-service earlier that week as a refresher. In addition, she stated someone had choked last week and had passed away. * On [DATE] at 8:40 am, CNA #3 stated assignments for the dining room were communicated on Hall assignments. She stated they rotate but are very clear. CNA #3 has been in her position for approximately 2 and ½ years with her current CPR certification valid until sometime in (YEAR). She stated she has not participated in mock codes as continued training during her employment. CNA #3 stated that if she encountered a resident choking, she would assess them, encourage them to breathe and cough. If the airway was blocked, I would call for help and start the Heimlich maneuver. I would visually check the airway before performing the Heimlich, finger sweep if they could not open their mouth on their own. I would begin the process of CPR on the ground, chest compressions and rescue breathing. CNA #3 stated she would do this where the resident was because it was an emergency. CNA #3 stated she had read the policy and procedure on obstructed airway but could not remember the date. * On [DATE] at 8:42 am, CNA #5 stated she would recognize a choking victim if they were coughing and turned blue. She stated she would ask the resident if s/he were ok, have them try to cough harder, and see if the person could talk. If the resident did not respond she would get an RN. CNA #5 stated she would initiate the Heimlich maneuver when they stopped coughing. CNA #5 stated she had CPR training recently and the facility had done an in-service earlier that week, which she was unable to attend. She did not know when the next in-service was scheduled. In addition, she stated someone had choked last week and they had passed away. * On [DATE] at 8:50 am, LPN #3 stated she would recognize a choking victim when the person used the universal sign of choking, of placing hands to the throat and were unable to speak. She stated she would initiate the Heimlich maneuver in the dining room, to try and clear the airway as fast as possible, if she came across someone choking. In addition, she stated she would perform finger sweeps to try and get the food out. She stated she was current on her CPR and the facility had done an in-service earlier that week because there was a resident who had died a couple weeks ago from choking. 4. Interview with the DNS: On [DATE] at 2:50 pm, the DNS stated staff interviews were completed following the event. He stated LPN #2 was a newer nurse, scared and not confident. RN #2 tried the Heimlich maneuver and noticed some small pieces of food. Resident #1's color turned from gray to pink. Resident #1 was gurgly with a little bit of airway. The DNS stated Resident #1 never put his hands to his throat during the incident. The DNS said RN #2 called the physician first rather than EMS as Resident #1 was alert, e.g., his eyes were open. The DNS stated LPN #2 completed another abdominal thrust, and wrenched quite hard. The DNS stated RN #2 then directed 911 be called as Resident #1's condition was deteriorating. Resident #1 then coughed hard and passed out. The DNS said Resident #1 was lowered to the floor with RN #2 performing abdominal thrusts until she became winded. At that time, CNA #6 assumed the task. The DNS said by that time Resident #1 had passed and CPR was not initiated. The DNS stated the staff removed Resident #1 from the dining room for his dignity. 5. Emergency preparedness information included: On [DATE] at 1:45 pm, Unit Manager RN #1 was asked for the location of the Crash Carts used during emergencies. RN #1 walked to the dining room where the crash cart was positioned against the outside wall. RN #1 stated she had worked for the facility for 3 years and the crash cart had been in that spot for as long as I have worked here. The crash cart was observed to have a suction machine set up with tubing attached to a suction catheter. An oxygen tank was on the side of the cart. The drawers were labeled to identify the equipment in each drawer which included an ambu-bag, mouth barrier, gloves, and other misc. items. On [DATE] at 1:45 pm, RN #1 stated the unit managers help out in the dining room when needed. RN #1 said medication nurses were assigned to the dining room during meals. RN #1 stated the facility did stage mock codes, and the last one was within the last 6 months. As noted in example 1 above, during the choking episode Resident #1 was removed from the dining room, which included a suction machine and crash cart, and taken to his room. The Heimlich maneuver was not initiated and rescue efforts were further delayed as staff retrieved a suction machine from another location in the facility. 6. Training after the [DATE] incident included: An In-Service Sign - In Sheet, dated [DATE], documented titles of Choking and how to respond, Supervision in the dining room, and Heimlich maneuver as documented topics of staff training. Eleven signatures were on the sign-in sheet dated [DATE]. Upon review of the In-Service Sign-In Sheet and the Staff Assignment Sheets, all staff members who worked since [DATE] were not educated on the above topics. On [DATE] at 2:50 pm, the DNS was asked why the staff education started 10 days after the event. The DNS stated Because you (SA) called, I had to re-look. The facility did not ensure its policies and procedures were followed when Resident #1 experienced a choking episode. The Heimlich maneuver was not initiated timely, EMS was not notified promptly, CPR was not initiated, interventions attempted were not consistent with current standards of practice, and a policy and procedure was not current with standards of practice. Removal of Immediate Jeopardy: Facility Administration was informed of the Immediate Jeopardy and the need to develop and implement an acceptable plan to remove the Immediacy at 5:25 pm on [DATE]. On [DATE] at 3:20 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * Prior to the their next scheduled shift, each nursing staff would be re-educated by a CPR Certified Instructor on Obstructed Airway Intervention Procedures and staff competency demonstrated through return demonstration. * The facility's daily staff assignment sheets were updated to ensure adequate CNA and licensed nursing personnel were supervising the dining room during meal times. * Licensed nurses were educated that they could not leave the dining room while residents were eating until relieved by another licensed nurse. In addition, the education was provided by the Executive Director. * Any nursing staff who was not present for the education and training would not work until they had completed the training. * The facility provided re-education to the nursing staff on rounding during meal (TRUNCATED)

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure: a) Residents received catheter care necessary to prevent harm. This was true for 1 of 8 residents (#9) reviewed who had indwelling catheter. This resulted in harm to Resident #9, when a catheter strap was not used and she experienced ongoing pain due to the catheter tubing pulling at the insertion site; b) failed to follow physician orders. This was true for 1 of 17 sampled residents and had the potential to cause more than minimal harm when compression socks to treat [MEDICAL CONDITION] were not applied; c) failed to ensure medications were available. This was true for 1 of 25 residents (#25) sampled for medication availability and had the potential to cause more than minimal harm if a resident experienced increased pain and migraine headaches due to a lack of prescribed medications. Findings include: 1. Resident #9's Physician order [REDACTED]. On 4/25/2016 at 10:27 am, Resident #9 was observed in her room seated in the wheelchair to the right side of her bed. She said she was sitting on her catheter tubing and was experiencing pain in her lower abdomen area. Resident #9 had a continuous indwelling urine catheter with a urine collection bag hanging on the right side of her wheelchair. The surveyor asked Resident #9 to press the call light for staff assistance. Resident #9 was unable to reach the call light where it was tied to the bed rail. Resident #9 appeared to be in pain. On 4/26/16 at 9:20 am, Resident #9's incontinence care was observed. CNA #9 and CNA #10 transferred her from the wheelchair to the bed with a mechanical Hoyer lift. A thumbnail size blood clot and whitish sediments were noted inside of Resident #9's indwelling urine catheter tubing. The urine collection bag attached to the end of tubing was one third full. Resident #9 was tearful and repeatedly said it hurts down there while pointing to the lower abdominal area and the indwelling urine catheter insertion site. CNA #10 stated the catheter was leaking when she saw Resident #9's wet underwear during the care. Resident #9 continuously complained of pain at her catheter insertion site during the transfer from her wheelchair to the bed and during the incontinent care. Whenever the catheter was moved and touched, she said, Ouch . During the observation, there was not a leg strap to anchor the catheter to Resident #9's upper thigh to prevent tension or irritation caused by the catheter and the weight of the urine collection bag. CNA #10 said Resident #9 had been frequently complaining of pain at her catheter insertion site and lower abdominal area. CNA #9 and CNA #10 finished Resident #9's incontinence care and left room at 9:35 am. Resident #9 said she was still having pain down there where the catheter stuff is while pointing at her lower abdominal area and the catheter insertion site. She further stated her pain was a little better since the catheter was not moving around anymore. On 4/27/16 at 10:35 am and 10:50 am, LN #8 said nursing and CNA staff should have followed the care plan to make sure Resident #9's leg strap was secured to her leg and the leg strap was used to prevent the catheter from being pulled out which could cause pain. Resident #9 was harmed when she experienced ongoing pain when staff failed to follow her physician's orders [REDACTED]. 2. Resident #8 was admitted to the facility with multiple diagnoses, including hypertension and coronary [MEDICAL CONDITION]. Resident #8's 10/6/15 Physician order [REDACTED]. It further stated the TED hose were to be removed at bed time. Resident #8's 4/4/16 quarterly MDS assessment documented she was cognitively intact and required extensive staff assistance with dressing. Resident #8's care plan dated, 12/17/15, documented, TED hose on in the morning and off at bed time . Resident #8 did not have TED hose on her legs when observed on 4/25/16, 4/26/16, and 4/27/16, at 8:30 am, 10:30 am, and 3:45 pm, each day. On 4/27/16 at 8:00 am, Resident #8 said staff sometimes forgot to place the TED hose on her legs. Resident #8 said staff did not place the TED hose on her legs on 4/25/16, 4/26/16, and 4/27/16. On 4/27/16 at 3:50 pm, UM #12 said Resident #8 did not have TED hose on her legs per the physician order. 3. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #25's physician's orders [REDACTED]. A Progress Note, dated 11/5/15 at 11:17 am, stated, Awoke with migraine this am. The DON documented, Meds for his headache unavailable in pyxis, attempted to get from Omniview, also not available there. Med with [MEDICATION NAME] for headache with little help. Given an [MEDICATION NAME] that his wife brought from home. Later I found the [MEDICATION NAME] in the cart in side drawer .good response to [MEDICATION NAME], able to participate with therapy thereafter. During an interview on 4/28/16 at 1:42 pm, the DON stated the medication may have been misplaced. The DON stated the nurse should have called the physician or pharmacy if the medication was not located, and should have documented the contact in the nursing note. The DON confirmed that, even though present, the drug would be unavailable if the nurse was unable to locate it.

Based on observation, record review, and staff interview, it was determined the facility failed to follow physician orders [REDACTED]. This was true for 3 of 6 sampled residents (#s 2, 3, and 4), and resulted in harm to: *Resident #2, whose scrotum and penis were injured; *Resident #4, who required hosptialization for septic shock; and *Resident #3, who required hospitalization for weeping wounds and [MEDICAL CONDITION]. Findings included: 1. Resident #2 was admitted to the facility from an acute care hospital on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's admission MDS assessment, dated [DATE], coded: *Extensive assist of 2 for bed mobility, transfers, dressing, personal hygiene, and bathing; *Indwelling foley catheter present, incontinent of bowel, dependent on 2 persons for toileting; *Two Stage III pressure ulcers present, with treatments and medications ordered; *Had received injectable medications and anticoagulants each of the previous 7 days; and *Receiced IV medications while a resident. a. Scrotum and Penis Injuries. Resident #2's [DATE] Recapitulation orders, care plan, and TAR documented the resident had an indwelling catheter, that was to receive "catheter care" each shift, beginning the date of admission. However, the resident's [DATE] TAR documented this care was not completed on night shift on [DATE], [DATE], or [DATE]. Resident #2's MAR for [DATE] documented the "catheter securement device" that was ordered be changed weekly and as needed, beginning [DATE], documented the device was changed on [DATE], but at no other time for the remainder of the month. A [DATE] Change of Condition Documentation in Resident #2's Nurse's Progress Notes (PNs) documented, "Was alerted by staff on end of shift res(ident) was noted to have a scab on his penis last Thursday ([DATE]) but forgot to tell anyone. On inspection res was found to have an irregular skin tear on his scrotum 4 X 2 cm (centimeters) approx(imately) 0.5 (cm) in depth, bleeding...Attempted to steri-strip would not hold. Abrasion to (left) shaft of penis, measures 1.2 X 0.2 cm...sent to ER (emergency room ) for wound care to scrotum...returned from ER (at 3:30 AM). No sutures..." On [DATE] at 10:45 PM, a facility Risk Management System (I/A) documented the resident had a "self-inflicted injury" of a skin tear and an abrasion. The form documented an LPN noted an abrasion to the resident's penis four days prior, which had not been reported, as well as the "torn" area to his scrotum, noted in the above entry on [DATE]. The "root cause conclusion" was documented as, "The skin tear was not witnessed, but seems likely it was caused by extra tubing from the foley catheter catching the skin of the scrotum and tearing the skin. Catheter to be securely attached to leg with no extra tubing..." Missing from the I/A report was any investigation regarding the allegation the abrasion to the resident's penis had been noted four days prior, how the injuries were determined to be self-inflicted, and how the conclusion of the catheter causing the areas had been determined. Please see F 225 regarding the missing elements of the facility's investigation. On [DATE], a facility Skin Integrity Report for Resident #2 documented a wound to the resident's scrotum which was incontinence related. This wound was tracked weekly until the time of the resident's discharge, and was documented to decrease in size each week. On [DATE], a physician's orders [REDACTED]. An additional order documented the facility was to monitor the abrasion to the resident's penis and skin tear to his scrotum on day shift and evening shift daily. This was not documented as completed on the evening of [DATE]. On [DATE], the physician ordered the facility's wound nurse to assess and treat the wound to the resident's scrotum. On [DATE], a physician's orders [REDACTED]. The order now directed the nurse to cleanse the wound with wound cleanser, apply triple antibiotic ointment, and cover with [MEDICATION NAME]. This dressing change was not documented as completed on night shift for [DATE], [DATE], [DATE], [DATE]-[DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. The dressing change was not documented as completed on day shift for [DATE], [DATE], or [DATE]. Although the resident discharged from the facility on [DATE], several treatments, including the dressing change to the resident's scrotum, catheter care, and flushing the resident's PICC line, were all documented as completed on the night shift [DATE], more than 24 hours after the resident discharged from the facility. On [DATE] at 2:30 PM, the RNC and RVP were asked about the missing documentation on the resident's TARs. After reviewing the documentation, the RNC stated, "There's nothing I can say. It's not there." On [DATE] at 8:15 AM, the DNS and Wound Nurse (WN) stated the WN was asked to assess the area after the resident was found with a skin tear. Regarding the area on the resident's scrotum, the WN stated she felt the joint between the catheter tubing and drain bag tubing had become lodged under the resident's scrotum, and when it was removed the skin in that area was torn. The WN stated the tear was not "that bad," but because of the delicacy and moisture in the area, the nurse was unable to approximate the wound so the resident was sent to the ER. Although the nurse originally thought the resident might receive stitches, the resident returned to the facility with only a dressing in place. Regarding the area to the resident's penis, the DNS stated she had not been aware until the previous day ([DATE]) that there had been a statement indicating the area may have been present but untreated for [REDACTED]." The DNS could not explain why treatments had been documented as completed more than 24 hours after the resident discharged . On [DATE] at 4:30 PM, the Administrator, DNS, RNC, and RVP were informed of the concerns. The facility offered no further information. b. Other Orders Not Followed. Resident # 2's MAR for [DATE] documented the following medications were not administered as ordered by the physician: *Mupiroxin topical ointment, ordered to the nostrils [MEDICAL CONDITION], afternoon dose on [DATE]. *[MEDICATION NAME] Sodium IV ordered daily for [MEDICAL CONDITION], [DATE] or [DATE]. *House dietary supplement, ordered twice daily at 3:00 PM and 8:00 PM beginning [DATE]. 3:00 PM dose [DATE] or [DATE]. 8:00 PM dose [DATE], [DATE], [DATE], or [DATE]. Resident #2's TAR for [DATE] documented the following treatments not administered as ordered: *Monitor abrasion to the bottom of the right foot, night shift for [DATE]. *PICC line flushed night shift [DATE]. *PICC site observed before and after IV medications administered on the day shift for [DATE], or the night shift on [DATE] or [DATE]. *Catheter site dressing changed weekly, the date of admission on [DATE], through [DATE]. *Abrasion to knee and blister to top of right foot not monitored on the night shift of [DATE]. *[MEDICATION NAME] lotion the morning of [DATE]. *Output from the foley catheter documented twice daily day shift [DATE] - [DATE], [DATE], [DATE], [DATE], or [DATE]. Night shift on [DATE], [DATE] - [DATE], [DATE], or [DATE]. *Daily shin check from the waist down [DATE]. Resident #2's TAR for [DATE] failed to document the following treatments as administered: *[MEDICATION NAME] lotion, [DATE], [DATE], [DATE]. *Foley output day shift of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Night shift on [DATE], [DATE], [DATE], [DATE] - [DATE], or [DATE] - [DATE]. *House supplement at 8:00 PM on [DATE] - [DATE], [DATE] or [DATE]. *PICC line flush on the day shift [DATE] - [DATE], [DATE], or [DATE] - [DATE]. Night shift [DATE] - [DATE], [DATE], [DATE], [DATE], or [DATE]. *Observation of the PICC site before and after the administration of IV medications for day shift [DATE] and [DATE]. Night shift [DATE], [DATE] - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. *Oxygen administration for day shift [DATE] - [DATE], or [DATE]. Night shift [DATE] - [DATE], [DATE], [DATE] or [DATE]. According to the Idaho Administrative Code for Skilled Nursing Facilities (IDAPA), medications and treatments must be documented in the resident's medical record by the person administering them at the time they are given, in order to be considered as given or completed. On [DATE] at 8:15 AM, the DNS was asked about the missing documentation for the above medications and treatments. The DNS stated she was confident all medications and treatments had been administered as ordered, but had simply not been documented. The DNS stated, "We are planning to look at documentation as part of our Quality Improvement plan." On [DATE] at 4:30 PM, the Administrator, DNS, RNC, and RVP were informed of the findings. The facility offered no further information. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including aftercare healing traumatic [MEDICAL CONDITION], End Stage [MEDICAL CONDITIONS], and diarrhea, and joint pain in the shoulder region, pelvic region, and thigh. On [DATE], the resident was transferred from the [MEDICAL TREATMENT] Center to a local hospital where she was admitted with septic shock secondary to [MEDICAL CONDITIONS], and persistent diarrhea. * The resident's Admission MDS, dated [DATE], coded the following: - Extensive assistance of two people for bed mobility, transfers, and toileting. * The resident's Hydration care plan dated [DATE], Bowel Elimination/Diarrhea care plan dated [DATE], and [MEDICAL TREATMENT] care plan dated [DATE] documented the following interventions: - Limit fluids to 1500 ml/day. Dietary to provide 1080 mls. Nursing to provide approximately 420 ml. Nursing to monitor and document all fluids consumed from all sources. - Encourage fluids. - Observe resident for signs of dehydration (tenting skin, dry mouth etc.) - Evaluate for medications that cause diarrhea. - Weekly weights x 4 weeks - started [DATE]. - Daily weights started on [DATE] (Daily weights were d/c'd on [DATE].) - Notify MD of weight gain of 3 or more pounds since last weight. The resident's Weights and Vitals Summary documented the following three weights: - [DATE] at 2:34 PM, 129.6. - [DATE] at 2:06 PM, 124.6. - [DATE] at 2:34 PM, 121.8. The resident's discharge weight from the hospital on [DATE] was 116.6 pounds. The first weight taken by the facility for Resident #4 was on [DATE] and the resident weighed 129.6 pounds. There was no documentation in the resident's record to indicate the physician had been notified of the resident's weight gain of more than three pounds. Addtionally, there were no daily weights documented for 6 days, from [DATE] to [DATE]. The resident's labs, Facility Faxes (FF), Interdisciplinary Progress Notes (IPN), Nutrition Note (NN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (SP), Physician Notes (PN), ADL Record, [MEDICAL TREATMENT] Notes (DN), Hospital History and Physical (HH&P), Hospital discharge summary (HDS), [MEDICAL TREATMENT] Communication Record (DCR), [MEDICAL TREATMENT] Patients Notes (DPN), and emergency room Report (ER) were reviewed and documented the following: The resident's Interagency/Interfacility physician's orders [REDACTED]. - Low Potassium diet. - Less than 1.5 Liters of fluid every day. - [MEDICATION NAME] XL 25 mg by mouth once daily. Do not take if systolic blood pressure is less than 110 (mm Hg). Do not take on [MEDICAL TREATMENT] days. The resident's All Active facility Orders for [DATE] and the MAR indicated [REDACTED] - [MEDICATION NAME] ER 12.5 mg tablet by mouth on Tuesday, Thursday, Saturday, and Sunday. Do not give if systolic blood pressure is less than 100, Heart Rate (HR) less than 55. Do not give on [MEDICAL TREATMENT] days. Note: The All Active Orders for [DATE] signed by the resident's physician did not include low potassium diet or the fluid restriction of less than 1.5 Liters of fluid every day. In addition, The Interagency/Interfacility physician's orders [REDACTED]. Additionally, the MAR indicated [REDACTED]. - HDS dated [DATE] documented, "She (Resident #4) has chronic diarrhea that was [DIAGNOSES REDACTED]icile negative, so we continued her [MEDICATION NAME] that she takes outpatient." - FF dated [DATE] at 2:45 PM documented, "New Admit, Noted to have loose, mucousy (sic) stool with foul odor. Collected sample would you like to send for C&S?" - IPN dated [DATE] at 3:00 PM documented, stool sample sent to the lab with orders to culture stool, O&P, and [DIAGNOSES REDACTED]. will follow-up with results. - IPN dated [DATE] at 5:00 PM documented, resident noted to have blood in toilet x 2 this day. MD notified possible hemorrhoids resident with multiple episodes of loose stool/diarrhea. Pending [DIAGNOSES REDACTED]. test. - IPN dated [DATE] at 7:30 PM documented, Patient continues with loose stools. Stool sample sent via taxi this AM. Hemorrhoids present with mild frank blood in AM. Note: The IPN note dated [DATE] documented the stool sample was sent to the lab on [DATE], however the IPN note dated [DATE] documented the stool sample was sent on [DATE] via taxi. The Communication record dated [DATE] sent with the resident to [MEDICAL TREATMENT] documented the stool sample was sent to the lab on [DATE]. It could not be determined why the stool sample that was ordered on [DATE] was not collected and sent until [DATE]. The RNC was asked about the discrepancy of the dates and she stated the sample was collected and sent via taxi on [DATE]. -Lab results dated [DATE] documented, stool negative for [MEDICAL CONDITION] and toxin and no OVA or Parasites seen. Stool culture pending. - PO dated [DATE] documented, "Obtain appt. (appointment with) Pt's GI MD ASAP r/t (related to) GI bleed." - Lab results dated [DATE] documented, "Stool culture positive with many Staphylococcus Aureus present." - IPN dated [DATE] documented, bloody stools noted per rectum. appt. scheduled with GI physician. Note: The resident's medical record did not include the GI Physician's report for Resident #4. On [DATE] at 10:00 AM the DNS and RNC were asked to provide a copy of the GI report. The RNC at 3:00 PM said the report was not in the resident's chart and she could not obtain a copy from the physician's office because there was no documentation an appointment had ever been scheduled. The DNS stated she didn't know whether the resident had been seen by a [MEDICATION NAME] during her stay at the facility. The DNS and RNC could not explain why the appointment was not scheduled. - The facility portion of the DCR dated [DATE] documented, "... continues to have bleeding with bowel movements," however the facility failed to document the resident had been diagnosed with [REDACTED]. Note: The DCR ([MEDICAL TREATMENT] Communication Record) is completed by the facility and was to be sent with the resident to every [MEDICAL TREATMENT] appointment. The [MEDICAL TREATMENT] Center completed the bottom portion of the form and sent it back to the facility with the resident. The facility and [MEDICAL TREATMENT] Center were responsible for documenting the resident's general condition, special instructions, change in condition and/or other pertinent information on this form. - The DCR dated [DATE] from the facility to the dialyis center did not communicate the resident had been diagnosed with [REDACTED].#4) has fever with chills post treatment, temperature 99.1 F, and incontinent of stool (diarrhea-foul smelling). HD notified and orders given for Blood Cultures x 2 and Tylenol. Orders faxed to facility and report given to (Nurse)." - IPN dated [DATE] at 6:00 PM documented, "[MEDICAL TREATMENT] requesting blood cultures x 2 and for resident to be assessed by medical doctor. Nurse Practitioner in facility and resident placed on alert charting." - MAR indicated [REDACTED]. - MAR indicated [REDACTED]. She missed her second dose at 4:00 PM, and received what was documented as a "third" dose at 12:00 AM. The MAR indicated [REDACTED]. There was nothing documented in the resident's record that the physician was notified of the missed doses. - IPN dated [DATE] at 3:00 PM documented, "Resident currently going out of facility for single lumen PICC placement for IV antibiotic." Note: The results of the Staphylococcus Aureus with the sensitivities for antibiotic treatment were received by the facility on [DATE]; however the antibiotic was not started until [DATE] at 8:00 AM, two days after the infection was detected. There was nothing documented in the resident's record to indicate why there was a delay in treatment. - MAR indicated [REDACTED]. Note: It is unclear why the facility was drawing blood cultures on a resident who had already been diagnosed with [REDACTED]. The DNS was asked why the [MEDICAL TREATMENT] Center was not notified reletated to the Staphylococcyus Aureus in the resident's stool. The DNS stated, "I don't know." The DNS and RNC were asked if it is standard practice to draw blood cultures after an antibiotic is started. The RNC stated blood cultures are typically drawn before antibiotic treatement is started, unless the physician specifies otherwise. - DPN dated [DATE] at 3:52 PM documented, "The (residen't interested party) stated (Resident #4) went to the hospital yesterday to have a PICC line placed due to need for abx (antibiotic)... Patient's BP down into the 70's on the way to the hospital so (the) EMT stopped and gave (the) Patient fluids. (Resident #4) is now 4 kg (8.8 pounds) over her EDW today. Trying for 3.0 kg (6.6 pounds). Call to care center about the abx patient is on. Left a message, no return call." Note: There was nothing documented in the resident's record that the facility had followed up with the resident's interested party to ensure her questions about the antibiotics had been answered. Furthermore, the [MEDICAL TREATMENT] Center documented it had attempted to contact the facility with questions about the resident's antibiotic and left a message, but the facility had not returned the [MEDICAL TREATMENT] Center's call. - PN dated [DATE] documented, "The patient was admitted to the facility on [DATE] but I have not been able to evaluate her secondary to her typically being at [MEDICAL TREATMENT] during my visit day. The patient's (interested party) also informs me today that the patient was very hypotensive yesterday. She informs me that (Resident #4's) blood pressure had gone down to ,[DATE] the ambulance contacted the emergency department and they informed the crew to bring the patient in if they felt it was needed. Apparently the patient's blood pressure stabilized after a fluid bolus yesterday. Currently, (Resident #4) appears to be very anxious and nervous and is very uncertain on her answers it appears. The patient's (interested party) states that this is not a very common thing for (this resident) and states that she has had episodes like this in the past where she has had a urinary tract infection. Uncertain as to what is going on with this patient at this time but we will obtain a urinalysis with CNS (sic) if indicated." The UA was ordered that day at 7:00 PM. Note: There was nothing documented in the resident's medical record on [DATE] or [DATE] that the resident had a hypotensive crisis while en-route to the hospital for PICC line placement and that the ambulance crew had to contact the emergency room to obtain orders for a fluid bolus. Furthermore, there was nothing documented in the resident's medical record that the facility had informed the resident's physician or the [MEDICAL TREATMENT] Center related to the above incident on the day it occurred. The HD and the NP documented they were notified by the resident's interested party on [DATE], one day after the crisis occurred. - DPN dated [DATE] from 5:01- 5:09 PM documented, "Pt arrived to treatment 5.7 kg (12.5 pounds) over EDW. Pt tolerated a 1.5 L (3.3 pounds) fluid removal over a 3.00 hr (hour) treatment. Pt left 4.5 kg (9.9 pounds) over EDW. The RD at the [MEDICAL TREATMENT] Center reviewed the nutrition report with patient's interested party and RD at the Extended Care Facility. [MEDICATION NAME] continues to trend down. Patient to increase intake of protein as reviewed with (interested party) and RD at ECF. Patient was on liberalized renal diet. RD to change to regular NAS diet. Pt to receive Health Shakes 4 ounces (120 mls) twice a day." Note: There were no daily/24 hr fluid intake totals in the resident's record to ensure the resident did not exceed the daily 1500 ml fluid restriction. - FF dated [DATE] written by the RD to the physician documented, "Please change diet to NAS d/t decreased potassium per [MEDICAL TREATMENT] and start health shakes BID for increased protein intake. Nursing to document percent of intake." The order was not consistent with the [MEDICAL TREATMENT] RD's order of, "Health Shakes 4 ounces twice a day." - MAR indicated [REDACTED]. Additionally, the order was written for the percentage of intake instead of the amount in ml's which was necessary to ensure resident did not receive more than 1500 ml's of fluid a day. - FF dated [DATE] written by the RD to the physician documented, "May we d/c 1500 ml fluid restriction? (Resident) now receiving supplements which adds to fluid intake." The physician responded, "OK." - Weight Report from [MEDICAL TREATMENT] documented the following: * [DATE] pre-[MEDICAL TREATMENT] weight = 59.2 kg and post [MEDICAL TREATMENT] weight = 58 kg, 4.5 kg over DW. * [DATE] pre-[MEDICAL TREATMENT] weight = 59.6 kg and post [MEDICAL TREATMENT] weight = 57.9 kg, 4.4 kg over DW. * [DATE] pre-[MEDICAL TREATMENT] weight = 57.8 kg and post [MEDICAL TREATMENT] weight = 56.3 kg, 2.8 kg over DW. - Lab results dated [DATE] and [DATE] related to the two blood cultures documented, "No growth 5 days." However, there was nothing documented in the resident's record related to the results of the blood cultures or that the HD or primary care physician had been notified. - DPN dated [DATE] documented, "Pt in a lot of pain today. Brought over by non-emergent transport at 12:00(PM) on a gurney. She was sent back to care center due to we did not have a chair or anywhere to put her for one hour to wait. Came back at scheduled time of 1:15 (PM). Did not tolerate fluid goal well today. Lots of pain, generalized, but mostly in neck. She was taken of (sic) 16 minutes early at her request due to pain. Care center ... reports that patient was given a pain pill before she left for treatment. Patient is very anxious and is clearly in a lot of pain." Note: There was nothing documented in the resident's record based on the above note that the primary care physician was notified related to the resident having increased pain or being transferred to [MEDICAL TREATMENT] on a gurney. -IPN dated [DATE] documented: * 12:00 PM, Pt with complaints of loose stool. * 5:00 PM, [MEDICAL CONDITION]. stool sample and UA sent to lab. Note: The UA collected on [DATE] was ordered to be collected on [DATE] by the facility NP related to the resident experiencing increased confusion. It could not be determined why the UA was not collected until eleven days after it was ordered. Additionally, it could not be determined why a stool sample was sent to the lab to check for [DIAGNOSES REDACTED]. The resident completed the antibiotic treatment of [REDACTED]. The resident missed 4 doses of the antibiotic prescribed for the stool infection. - IPN dated [DATE] at 8:00 PM, "Called into patient's room. Patient's guest stated, 'Pt wasn't feeling well.' Pt was asked what was wrong, she stated, 'she was just sleepy she thinks.' Patient's pulse was 71, temperature was 99.8 F, and her oxygen saturation was 92% on room air." There was no blood pressure documented. "The patient's (interested party) asked if we could give her (resident) something for the fever and I explained there was Tylenol in the pain medication she got at 1930 (7:30 PM) so the temp. would be monitored. The (interested party) had concerns about the resident's 'confusion.' I told her that she had just had pain medication and that it could be from the meds. (Interested party) stated, 'She (resident) has been taking this medication for years and has never had this confusion/sleepiness from them.'" There was no documentation in the IPN that the nurse had done a complete assessment on the resident or notified the physician. Note: The resident received 61 doses of narcotic pain medication from [DATE] to [DATE] without showing signs of sedation per the resident's MAR. Starting on [DATE] the facility started documenting the resident was showing signs of sedation. There was no documentation in the resident's medical record that the physician had been notified of the resident's change in condition. - IPN dated [DATE] at 10:40 PM, "(Interested party) called concerned about why we were testing the pt's stool. She would like the NP to call her tomorrow while he is here after seeing (the resident)." Note: The resident's medical record did not include the NP's dictated note from [DATE] or documentation as to whether the resident was seen by the NP on [DATE]. Additionally, there was no documentation that the NP contacted the interested party to discuss concerns. When asked on [DATE] to provide a copy of the Physician's note for [DATE], the RCN stated there was no note. - Lab results dated [DATE], at 11:51 PM, reported positive for [MEDICAL CONDITION], as well as positive for the presence of blood, protein, and yeast in the resident's urine. Hand written, but not initialed or dated, on the bottom of the lab result was, "Obtain C&S." - DPN dated [DATE] documented: * "Pt dropped off in lobby by transportation from (facility) at approximately 12:45 PM and brought back to treatment floor around 1:20 PM. * Pt oriented to self only, answers with yes/no and follows simple commands. * Unable to verbalize where pain is located, states, 'everywhere.' * Weakness notedly more-so on right side of body. * Patient's blood pressure ,[DATE] pre-[MEDICAL TREATMENT] weight = 53.5 kg, the resident's post [MEDICAL TREATMENT] weight = 53.6 kg after the resident received a fluid bolus for low blood pressure." Note: The resident's record did not document the resident's primary physician had been notified about the significant change in the resident's condition as identified by the [MEDICAL TREATMENT] center. - NN dated [DATE] at 12:00 PM, "Res(idents) family at bedside, it was requested for res to have some 'pain pills' per (family) present. This nurse approached charge med(ication) nurse regarding request it was stated res received APAP as ordered (with) (family) present. Charge nurse and this nurse approached res and family, re-educated/informed of already medicated. Res had (no) s/sx of pain when asked where her pain was res stating, 'I don't know.' Res noted to have increased sedation, diff(iculty) keeping eyes open during assessment." Note: The resident's pain MAR indicated [REDACTED]. The resident received no narcotic or non-narcotic pain medications from [DATE] at 7:00 PM until [DATE] at 6:00 AM. - Lab results dated [DATE] at 6:21 AM, final report, documented, greater than 100,000 [MEDICAL CONDITION][MEDICATION NAME] (bacteria) present in the resident's urine. - DPN dated [DATE] documented, "Treatment initiated, pt placed on 15 min B/P checks. O2 (oxygen) placed for [MEDICAL CONDITION]. Pt reclined at 1433 (2:43 PM) for comfort. At approximately 1500 (3:00 PM) pt appeared to be less oriented. ([MEDICAL TREATMENT] staff) was unable to get pt to respond to her name. This LN was notified. Pt unresponsive to verbal stimuli, but grimaces with sternal rub. Orders received to transport pt to ER for decreased LOC." - IPN dated [DATE] documented: * 12:30 PM, "At approximately 12:30 PM this nurse received a call from a physician at a medical network. This nurse explained MD/Pt interactions per facility protocol. It was addressed that pt was often absent from center (at [MEDICAL TREATMENT]) at times when NP rounds, but NP/MD were still following pt and were involved (with) all cares as well as kept up to date on pt status." * 4:00 PM, "I explained to (interested party) I spoke (with) NP and asked him to call her. I also called the (Physician's) office and left a message for him to call her in case the NP did not. (Interested Party) stated neither (the Physician or the NP) had called her... Sent an e-mail to (Physician) at that time, today NP informed me he was planning to call (interested party)." The (interested party) had requested a call from the NP on [DATE] and on [DATE] the NP had still not contacted the resident's (interested party). - ER report dated [DATE] at 5:26 PM documented, "I spoke with the [MEDICAL TREATMENT] nurses who confirmed that she (the resident) has been slightly below her ideal dry weight on her last two visits and her blood pressures have been trending down from the 150's to the low 100s over the last several weeks. Her (interested party) also confirmed that her blood pressures have been very difficult to control and that her normal routine is to hold off on blood pressure medicines on the days that she dialyzes. We made several attempts to contact the nursing facility where she is staying, but no one would answer the phone. I do not have any further information available at this time." The resident was admitted to the ICU at a local hospital on [DATE] and expired on [DATE] with multiple diagnoses, including septic shock secondary to [MEDICAL CONDITION] with refractory [MEDICAL CONDITION] requiring multiple vasopressors, [MEDICAL CONDITION], and pleural effusions. On [DATE] at 10:00 AM the DNS was asked why the NP had not been notified about the resident's rapid and significant decline, why the NP had not seen the resident until 10 days after admission (the facility identified the NP rounded on residents at the facility three times a week), and why the facility had not communicated with the [MEDICAL TREATMENT] Doctor about the resident's stool infection.The DNS answered, "I don't know." Additionally, the DNS was asked why the facility's RD did not follow the Hemodialyis Doctor's order for health shakes and why the resident's daily fluid intake was not documented. The DNS stated, "I don't know." The DNS was asked why was there a delay in treatment for [REDACTED]. The DNS stated, "I don't know." The DNS was asked why the resident's order for the [MEDICATION NAME] was not clarified and why the resident's blood pressure and pulse were not taken prior to administration. The DNS stated, "I don't know." The RNC stated she and the DNS would review the resident's record for answers to the above questions/concerns. On [DATE] at 1:20 PM, the RNC stated she was not able to provide the documentation to answer the above questions. 3. Resident #3 was admitted to the facili

Based on observation, record review, and staff interview it was determined the facility failed to prevent pressure sores, and document pressure sore treatment for 2 of 2 (#2 & #5) sampled residents. The deficient practice caused harm to Resident #5 when the resident developed a Stage III pressure sore to the left heel, and a Suspected Deep Tissue Injury (STDI) to the right buttocks, while in the facility. Resident #2 was harmed when the resident developed an STDI to his buttocks and treatments were not consistently documented for Stage III pressure sores to the resident's bilateral heels. Findings include: 1. Resident # 5 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The resident's Annual MDS, dated [DATE], and Quarterly MDS, dated [DATE], documented the resident had long and short term memory problems and a decline in bed mobility, dressing, eating, toilet use, and personal hygiene from extensive assistance to total dependence on staff for cares on 3/13/14. The quarterly MDS dated [DATE], documented the same levels of need as the 3/13/14 MDS, except bed mobility increased from a 1 person assist to 2 person assist. All three MDS's documented the resident was high risk for pressure sores and had no pressure sores. The resident's Braden scale, dated 4/17/14, placed the resident at severe risk for developing pressure sores. The next Braden Scale completed on 6/30/14, placed the resident at High risk. The resident's Care plan documented: *Interventions for potential for skin breakdown related to: immobility, incontinence, advanced age and general debility... revision on: 3/14/14, included air mattress, Broda chair, [MEDICATION NAME]: to buttocks and coccyx, encourage to lay down between meals, float heels in bed, Quarterly and (as needed) Braden assessments, skin assessments per facility protocol, turn and reposition frequently to relieve pressure (every) 2 hrs (hours), keep skin clean and dry, pressure reducing/relieving devices to bed and w/c (wheelchair), observe skin every shift for s/sx (sign and symptoms) of potential skin breakdown. Alert charge nurse if observed for notification of physician as needed for tx orders, and skin breakdown unavoidable d/t (due to)terminal dx of dementia & immobility. The resident's Nurse Interdisciplinary Progress Note (NIPN), Skin Integrity Report (SIR), physician progress notes [REDACTED]. -6/7/14, NIPN with similar documentation on 6/8, 6/9, 6/13 documented: -"...Resident's skin warm dry, and pink. Skin is very fragile on arms & legs." -6/16/14 SIR Left heel: *Primary Type of Wound: "Pressure." *Pressure Ulcer Stage: "III" *Appearance: (Granulation) 100% *Length: 0.5 cm (centimeter), Width: 0.5 cm, Depth: (less than) 1 mm (millimeter). *Care Plan Updated. -6/16/14 COCD: -"Res. was found to have a pressure sore to the left heel... Prevalon boots applied." NOTE: The Prevalon boots were applied to resident's feet after the development of a Stage III pressure sore to the left heel on 6/16/14. - 6/16/14, Initial CP: *Prevalon boots to bilateral feet at all times; weekly wound measurements documented on flow sheet to include intact, reddened, and/or opened areas of skin; daily monitoring for s/s of infection; report abnormalities to MD, treatment as ordered. -6/17/14 PPN: *Subjective: "(Resident's name) is seen again today for evaluation of a wound she has developed on the left posterior heel...." *Objective: "The patient is nonverbal, sitting up in a reclining wheelchair. she has a stage 2 ulcerated area on the posterior aspect of the left heel which, unfortunately, appears to be exactly at a site of pressure on the firm ridge of her wheelchair steps or foot rest. .." *Assessment and Plan: "Stage 2 pressure sore left posterior heel secondary to foot rest on wheelchair. The wound has been appropriately dressed, just with protection. Staff will address the presence of her foot rest and ensure that it is either removed or at least padded when she is in the supine position..." -6/19/14 NIPN: -"IDT (Interdisciplinary Team) f/u (follow up) for PU (pressure ulcer) (left) heel. Environment & equipment assessed, Res. on air mattress, turn schedule, float heels, padded broda chair & has foot cushion. When assessing chair if cushion on foot pedals fall down to(sic) much back of ankle area would rest on foot pedal where site of PU was found. Foot pedals were extended out further by maint(enance) to prevent this from occurring. Prevalons placed to BLE (bilateral lower extremities) (at) all times..." -6/19/14 CP updated: *...foot pedals were extended out further by maintenance. -6/23/14 SIR Left heel: *Primary Type of Wound: "Pressure." *Pressure Ulcer Stage: "III" *Appearance: (Necrotic) 100% *Length: 1.6 cm, Width: 1.8 cm, Depth: "UTD" (Unable to Determine). *Care plan not updated. NOTE: The Pressure sore to the resident's left heel had more than doubled in size in the week after it was discovered, and the "granulated" tissue was now necrotic. -6/25/14 NIPN: -"...Skin checks changed to 2x/wk." -The resident's June 2014 TAR, did not include the following documentation: *Pillow in between legs at all times to keep legs from crossing. Start Date 6/23/14. Four times on night shift. *Prevalon boots to bilateral feet at all times. Start date 6/16/14. Two times on night shift. -7/25/14 NIPN: -"Cares- Res (with) endstage dementia & has had slow, steady decline & is on pallative care. Res. (with) multiple co-morbities CKD, [MEDICAL CONDITIONS], periphral [MEDICAL CONDITION], immobility, poor circulation BLE (with) delayed cap(illary) refill & skin to BLE pale, cool, tight shiny (with) no hair growth... Further interventions implemented, prevalons BLE, & foot pedals extended. Res. potential to heal is poor & additional wounds are unavoidable d/t co morbities & disease process despite skin care & pressure relief interventions." -The residents July 2014 TAR, did not include the following documentation: *Skin at risk: Check 2x weekly. Start Date: 6/25/14. Three times on day shift. NOTE: The resident was "high" risk for skin breakdown, had developed a pressure sore on the left heel on 6/16/14, had 2 x a week skin assessments ordered and the assessments were not documented as completed. -8/6/14 SIR left heel: *Primary Type of Wound: "Pressure." *Pressure Ulcer Stage: "III" *Appearance: Granulation 100% *Length: 0.9 cm, Width: 1 cm, Depth: "0.1" cm. *Care plan not updated. -8/20/14 NIPN with similar notes documented on 8/1, and 8/6: -"Will cont(inue) (with) prevalon boots at all times, air mattress, and turning Q (every) 2 (hours) as res. allows." -8/23/14 SBARCF, signed by the physician 8/26/14: -Started on: 8/23/14 -Assessment: "Alert, has a blanchable, red peeling area on (right) buttocks r/t moisture exposure. Requesting [MEDICATION NAME] cream after each incontinent episode." -8/25/14 at 9:30 AM, NIPN: -"Moisture associated excoriation noted to (right) buttocks surrounding tissue is blanching. ...res. on air mattress. Turned Q 2 (hours) as res. allows. Calazeme cream applied..." -8/26/14 SBARCF, not signed by Physician: -Situation: "Worsening excoriation to (right) buttock." -Started on: 8/25/14 -Request: "Upon assessment of excoriation to (Right) buttock, skin noted to have a deep purple area surrounded by excoriated skin. (No) s/sx of pain, (no) s/sx of infection. See SIR for measurements MD in and notified of skin issues. N. O. (new order) received for cream and OT to eval(uate) and treat." NOTE: The physician was sent a SBARCF on 8/23/14 to notify him of the new skin condition, and request of new orders, which was not signed until 8/26/14. On 8/26/14 the MD was "in" and notified by staff a second time of the resident's skin condition, which had developed an area that was "deep purple." -8/26/14 at 11:45 AM, NIPN: -" N.O. (new order) received for nightly heel and coccyx checks, turn Q 1 (hour) as tolerated, and OT eval and treat for wc positioning and eval wc cushion..." NOTE: The new orders written on 8/26/14, which increased skin checks to include nightly heel and coccyx checks, and increase the resident's turn and reposition schedule to every 1 hour were written 3 days after the resident had a change in her skin condition, and a "deep purple" area had developed. 8/26/14 SIR Buttocks: *Primary Type of Wound: "Incontinence related." *Pressure Ulcer Stage: "-" *Appearance: [MEDICATION NAME] 100% *Length: 1.5 cm, Width: 1 cm, Depth: "<0.1" cm. *Care plan updated. The resident's TAR for August 2014 did not include the following documentation: *Check placement and function of air mattress: One time on day shift. *Prevalon boots: One time on day shift. *Skin checks 2x weekly: Two times on day shift. *Monitor excoriation to right buttocks every shift: One time on day shift. *Ensure resident is turned every 1 hour: One time on day shift and one time on night shift. NOTE: The resident not turned every 1 hour on day shift and night shift occurred on the same day. *Monitor SDTI (Suspected Deep Tissue Injury) to right buttock every shift: One time on day shift and one time on night shift. NOTE: This occurred on the same day. -9/3/14 SIR Buttocks: *Primary Type of Wound: "Incontinence related." *Pressure Ulcer Stage: "SDTI (Suspected Deep Tissue Injury)" *Appearance: [MEDICATION NAME] 100% *Length: 1.5 cm, Width: 1.5 cm, Depth: "<0.1" cm. *Care plan not updated. -9/3/14 SIR left heel: *Primary Type of Wound: "Pressure." *Pressure Ulcer Stage: "III" *Appearance: Granulation 100% *Length: "0.5" cm, Width: "0.9" cm, Depth: "0.1" cm. *Care plan not updated: -The resident's September 2014 TAR did not document the following 9/1- 9/3/14: *Foot cradle: Two times on night shift. *Excoriation to right buttocks: Two times on night shift. *Monitor SDTI to right buttocks: Two times on night shift. *Nightly heel and coccyx check: Two times on night shift. *Pillow in between legs: One time on night shift. *Prevalon boots in place: Two times on night shift. *Check placement and function of air mattress: Two times on night shift. *Resident turned Q hour: Two times on night shift. On 9/4/14 at 8:25 AM, the surveyor observed the resident sitting in the Broda chair by the nurses station. At 8:29 AM, the resident remained in the Broda and was taken to the dining room. At 9:00 AM, the resident was taken from the dining room to her room. The resident was set beside her bed in the Broda chair with the Television on. On 9/4/14 at 9:15 AM, CNA #3 and CNA # 4 assisted the resident to bed. The resident was positioned on her left side, prevalon boots were in place with the left leg/foot directly on the bed with a pillow on top of it and the right leg on top of the pillow. A foot cradle was in place at the foot of the bed. When asked when the resident got out of bed, CNA#3 stated, "She was one of our last ones up so probably close to 8:00 AM." CNA #3 identified herself as the resident's caregiver for the day. On 9/4/14 at 10:20 AM, the surveyor observed the resident in the same position as that described for 9:15 AM. On 9/4/14 at 10:40 AM, the surveyor observed CNA# 3 with CNA # 5 reposition the resident. The resident was incontinent of bowel and bladder. CNA # 3 provided pericare. The dressing to the right buttocks was loose and CNA # 3 pulled it up and tucked under the corners. The surveyor observed a dime size open area with red granulation tissue to the buttocks. CNA# 3 applied Calamazine cream with soiled gloves to the buttocks and the wound. The resident was positioned on the right side with a pillow between her legs. The surveyor asked CNA # 3 what skin prevention measures were provided for the resident and CNA # 3 stated, "She is last up and first down, and we turn her about every hour and a half." On 9/4/14 at 11:00 AM, the surveyor met with the DON and Corporate Consultant, and asked if repositioning the resident every hour and a half was too long, to which the DON gestured "Yes" with a nod of her head. The surveyor asked when the Broda chair was implemented, whether an assessment had been completed prior to the Stage III pressure sore that developed on the heel from the Broda chair, and to provide the skin care plan that was in place prior to the skin issues now present. The Corporate Consultant stated, "I know they had a lot in place, she has been here a while. I am looking for it now." On 9/4/14 at 11:45 AM, the Occupational Therapy (OT) Supervisor stated that typically her department would get a referral and do the assessment for a Broda chair. The OT Supervisor stated she did not know whether this procedure was followed for Resident #5. On 9/4/14 at 2:20 PM, CNA # 3 approached the surveyor and stated she had talked with the other CNAs on the floor and was told the resident was supposed to be turned every hour, and she should have turned her sooner. On 9/4/14 at 4:30 PM the Adminstrator, DON and Corporate Consultant were notified of the findings. Additional information provided did not resolve the concerns. On 9/8/14 the facility faxed 2 documents to the surveyor which documented: *5/22/13 Interdisciplinary Progress note: The Broda chair had been placed for positioning and comfort. An assessment of the chair at placement and when the resident had declined was not provided. *4/29/14 Podiatry Care Center Note: Assessment documented the resident had a [DIAGNOSES REDACTED]. The resident had a decline in ADL's with new [DIAGNOSES REDACTED]. placed her feet and heels at risk for breakdown. New interventions to protect the resident's feet and heels were not implemented until after the resident had developed the left heel pressure sore on 6/16/14. The additional information provided by the facility did not resolve the concerns. 2. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. Development of an SDTI: A 5/13/14 Braden Scale for Predicting Pressure Sore Risk (Braden) scored a 13, indicating the resident was at high risk of developing pressure ulcers. On 5/13/14, Resident #2's Discharge Instructions from the acute care hospital documented, "...Keep your leg elevated at the level of your heart while you are sitting" and contained a diagram for positioning of a person in a hospital-type bed, with the head and feet elevated and heels floated on pillows, with a dip in elevation at the person's mid-section. As diagramed, the person's feet were pictured as level with the person's heart, and the bulk of body weight on the person's buttock area. A 5/14/14 nurse's progress note (PN) for Resident #2 documented the resident was admitted with stage III pressure ulcers to both heels. The resident was documented to have no deep tissue injuries or other pressure ulcers. On 5/14/14, Resident #2's care plan documented pressure ulcer interventions of offloading boots, heels floated on pillows while in bed, an air bed, assistance with turning and repositioning every 2 hours, and observing skin each shift for skin breakdown. Although the resident was paraplegic and had already developed pressure ulcers on each heel, the care plan did not include special considerations to protect the resident's skin to his coccyx, either when in bed or in the wheelchair, and did not include repositioning more frequently than once every 2 hours or identify how he could be repositioned in the bed if the bed was positioned as identified in the 5/13/14 Discharge Instructions. The care plan did not specify whether the resident's wheelchair had any kind of a pressure relieving cushion. A 5/20/14 Braden scored deteriorated 11, indicating increased risk for pressure ulcer development since the time of admission, with a decline in the resident's mobility and an increase in the moisture on his skin noted. Resident #2's 5/20/14 admission MDS assessment coded: *Two stage III pressure ulcers were present on admission, with no other pressure ulcers present. No deep tissue injuries were coded. *BIMS of 11, indicating moderately impaired cognition; *Extensive assist of 2 for bed mobility, transfers, dressing, personal hygiene, and bathing; and *Did not ambulate and needed extensive assistance of 1 for wheelchair mobility. On 5/27/14, Resident #2's care plan documented a new focus area related to impaired memory, judgment, and decision making. One intervention documented, "Provide cueing & prompting to ensure resident makes attempts at own care before offering assistance." On 5/28/14, a progress note from the infectious disease clinic documented, "Elevate legs above heart (for four hours) mid day every day." On 6/10/14 at 6:30 PM, a Change of Condition Documentation form for Resident #2 documented, "Noted open area to lower back above sacrum. Area measures 3 cm X 1.5 cm X 0 cm. Wound covered with macerated tissue (with) 2 (small) areas open that reveal pink moist wound base. (No) drainage, (no) odor (no complaints of) pain. Suspect wound origin from perspiring when (up) in (wheelchair with) back against (wheelchair) padding..." On 6/11/14 at 5:00 PM, Resident #2's PNs documented, "(Patient) noted to have SDTI to coccyx (with) denuded skin...educated (patient) to turn and reposition (every 2 hours) while in bed and to offload (every hour) while in (wheelchair). Voiced understanding of education. Cont(inue with) current (plan of care)." NOTE: There is no evidence that the coccyx wound identified here is a different one than is described as a sacrum wound the previous day. On 6/11/14, Resident #2's care plan was updated to include encouraging the resident to change positions every hour while in his wheelchair as a result of the development of the SDTI. No other new positioning interventions were added to direct staff to assist the resident with repositioning in his wheelchair, to reposition the resident more frequently in his bed, or how to protect both his heels and his coccyx from further damage from skin breakdown. There was no documentation as to whether or not the facility had ensured the resident had a pressure relieving cushion in his wheelchair, even with the development of the SDTI. Resident #2's Skin Integrity Reports for his coccyx documented: *6/11/14 & 6/17/14, SDTI 2 cm long X 2 cm wide, unable to determine depth, intact and deep purple. *6/24/14, SDTI 2 cm X 2.5 cm (0.5 cm wider than the previous week), unable to determine depth, 100 percent [MEDICATION NAME] tissue. Please see example b. below regarding missed treatments for the SDTI to Resident #2's coccyx. The RAI manual for MDS version 3.0, section M Skin Conditions, documented, "...A pressure ulcer with intact skin that is a suspected deep tissue injury should....be coded as unstageable..." On 9/3/14 at 2:30 PM, the RNC stated it was her understanding the resident could move himself "pretty well," and it may have been possible for him to follow the command to reposition himself. The RNC was not sure how the facility was assuring the resident did not create additional shearing on his coccyx when repositioning himself, but would have facility staff research the matter. The RNC was unable to explain how direct care staff would know when, how, and how much to help the resident with repositioning, given the care plan put in place on 5/14/14 and the update on 5/27/14. On 9/4/14 at 8:15 AM, the DNS and WN stated the interventions in place prior to the development of the SDTI were an air mattress and positioning every 2 hours. They were unable to explain the care plan update from 5/27/14, in light of the resident's MDS assessment, although the WN stated, "He could do quite a bit for himself. I think cueing him was appropriate." The WN stated when she first assessed the area to the resident's coccyx on 6/11/14, she determined it was an SDTI with excoriation. The WN stated since the resident liked to spend a great deal of time in his wheelchair, and had doctor's appointments outside the facility where no one was available to help him reposition, she felt educating the resident on repositioning was appropriate. No explanation was offered as to why the staff would not have been directed to help the resident to reposition more frequently when he was in the facility, or why, if the resident needed help to reposition while out for a doctor's appointment, the facility did not ensure an appropriately trained person was sent with the resident to ensure his safety. The WN did not know why the facility had not identified the resident was at risk for skin breakdown on his coccyx, but thought an air mattress and repositioning every two hours would have been sufficient interventions even if that assessment had been made. Resident #2 was harmed when the facility failed to identify a resident at high risk for skin breakdown, who had already developed pressure ulcers, needed additional interventions to prevent development of further pressure ulcers. The facility did not implement care plans to provide relief to his coccyx while the resident was in his wheelchair, and to relieve added pressure to his coccyx caused by the positioning required to protect the wounds to his heels. Additionally, even though the facility had assessed the resident required extensive assistance of 2 for bed mobility and extensive assistance of 1 for wheelchair mobility, his care plan was updated to direct staff not to assist the resident unless he had first attempted to care for himself. These failures culminated in the resident developing an unstageable SDTI to his coccyx, which then grew in size prior to his discharge. On 9/4/14 at 4:30 PM, the Administrator, DNS, RVP, and RNC were informed of these findings. The facility offered no further information, b. Treatments not done: Resident #2's TAR for May 2014 documented the following treatments not administered: *Cleanse and treat the wound to the left heel, ordered twice daily. Day shift 5/18/14. Night shift 5/18/14 and 5/20/14. *Cleanse and treat wound to right heel, ordered twice daily. Day shift 5/17/14 and 5/18/14. Night shift 5/17/14, 5/18/14, and 5/20/14. *Monitor opened blister to top of right foot, ordered twice daily. Night shift 5/27/14. *Cleanse and treat opened blister to top of right foot, ordered daily, 5/28/14. *Offloading boots to both feet, to be checked twice daily. Night shift 5/13/14 and 5/22/14. Day shift 5/14/14. Resident #2's TAR for June 2014 documented the following treatments not administered: *Change dressing to heels daily. 6/6/14, 6/16/14, 6/24/14. and 6/26/14. *Float heels with pillows, to be checked twice daily. Day shift 6/16/14 and 6/26/14. Night shift 6/1/14, 6/7/14, 6/9/14, 6/19/14, 6/22/14, 6/23/14, 6/25/14, and 6/26/14. *Monitor opened blister to top of right foot, ordered twice daily. Day shift 6/14/14 and 6/25/14. Night shift 6/1/14, 6/7/14 - 6/9/14, 6/14/14, 6/17/14, 6/19/14, and 6/25/14. *Offloading boots to both heels, to be checked twice daily. Day shift 6/14/14, 6/16/14, and 6/23/14. Night shift 6/7/14 - 6/9/14, 6/14/14, 6/18/14, 6/19/14, and 6/26/14. *Apply skin prep to area surrounding SDTI, cover with foam daily. 6/13/14 - 6/17/14, and 6/26/14. *Monitor SDTI, ordered twice daily. Day shift 6/13/14, 6/16/14, 6/22/14, and 6/26/14. Night shift 6/12/14, 6/14/14, 6/18/14, 6/19/14, 6/22/14, 6/25/14, and 6/26/14. *Ensure resident is offloading every hour while in wheelchair, to be confirmed twice daily. Day shift 6/13/14, 6/16/14, and 6/26/14. Night shift 6/11/14, 6/12/14, 6/14/14, 6/22/14, 6/25/14, and 6/26/14. On 9/3/14 at 2:30 PM, the RNC stated, "There's nothing I can say. It's not there." On 9/4/14 at 4:30 PM, the Administrator, DNS, RVP, and RNC were informed of the surveyor's findings. The facility offered no further information.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents who entered the facility without pressure sores did not develop pressure sores. This was true of 2 of 11 (#'s 1 & 4) residents reviewed for pressure sores. Additionally the facility failed to implement weekly skin assessments for Resident #8. Resident #1 was harmed when she developed a Stage III pressure ulcer to the left heel in the facility. Resident #4 was harmed when he developed an unstageable pressure ulcer to his [MEDICATION NAME] spine. Findings included: The Federal Guidance under F 314 documented: -"Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough..." -"Stage III - Full thickness tissue loss...slough may be present but does not obscure the depth of tissue loss..." -"Stage IV - Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed..." 1. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent 8/20/13 Annual MDS documented in part: * BIMS Score 15, cognitively intact * continent of bowel and bladder * at risk for developing pressure ulcers * had 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar Resident #4's "All Active Orders for September 2013" documented in part: "Weekly skin check by licensed nurse." The order date and start date was 5/13/2013. "Wound to [MEDICATION NAME] back; cleanse wound with skintegrty (sp) wound cleanser and apply sure prep to periwound skin and adhesive contact area. Apply [MEDICATION NAME] hydrogen cover with bordered gauze - day shift every 3 days." The order date and start date was 8/10/2013. Resident #4's July 2013 Treatment Administration Record (TAR) documented in part: "Weekly skin check by licensed nurse; Y =skin intact, N = Skin not intact." July 6 and July 27 had a Y in the box, indicating the skin was intact; but no other boxes were marked. Note: The weekly skin check ordered by the physician were also to be performed on July 13th and 20th, but these boxes were not marked as either skin intact or skin not intact. Resident #4's August 2013 and September 2013 Treatment Administration Record (TAR) documented in part: *"Weekly skin check by licensed nurse; Y =skin intact, N = Skin not intact" August 2nd & 10th had a Y in the box as skin intact, and August 17, 24, 30, and September 7th had an N in the box, as the skin was not intact. *"Wound to [MEDICATION NAME] back; cleanse wound with skintegrty (sp) wound cleanser and apply sure prep to periwound skin and adhesive contact area. Apply [MEDICATION NAME] Hydrogel cover with bordered gauze Start Date: 8/10/13 Day shift Every 3 Days." This treatment was initialed as being performed on August 10, 12, 15, 16, 20, 25, and 28th. Note: There were 4 days between the August 16th and 20th treatment and 5 days between the August 20th and 25th treatment. The physicians order documented to perform the treatment every 3 days. Note: The Weekly skin check on August 10th above, indicated the skin was intact and is conflicting to the treatment start date of 8/10/13. Resident #4's "Skin Integrity Report" initiated on 8/10/13 documented an unstageable pressure wound. The body diagram indicated the pressure wound was located on Resident #4's [MEDICATION NAME] spine. The weekly data collection information documented in part: 8/10/13-unstageable, slough, .5 cm x .5 cm, no depth recorded, inflamed 8/20/13-unstageable, slough 100, 1.0 cm x 0.6 cm, depth 0.3 cm, inflamed 8/28/13-unstageable, slough 25-50 & granulation 50, 1.0 cm x 1.0 cm, no depth recorded, inflamed 9/1/13-unstageable, slough 25 & granulation 75, 1.0 cm x 0.6 cm, depth 0.2 cm, inflamed 9/8/13-stage II, [MEDICATION NAME] 100, 0.8 cm x 0.5 cm, depth 0.1 cm, inflamed NOTE: Even though the wound was documented to be unstageable, the presence of slough meets the definition of a Stage III or greater pressure ulcer. Resident #4's 8/5/13 Care Plan documented in part: Problem-Potential for skin breakdown related to immobility, lack of sensation Goal-Will have no skin breakdown daily Interventions-initiated on 8/18/12; elevate heels off of bed with pillow/other floatation devices, keep skin clean and dry, use positioning devices as ordered, pressure reducing/relieving devices as ordered, weekly skin assessment. Another problem that was added and written in ink on the care plan documented in part: Problem-"8/12/13-Skin impairment actual open area to back" Goal-"8/12/13-Open area will heal s (without) developing infection" Interventions-"8/12/13- Position resident for comfort using pillows D/T (due to) kyphosis, assist resident to reposition in wheelchair as needed, Tx (treatment) per MD order, OT (occupational therapy) for w/c (wheelchair) positioning, monitor area until healed" Resident #4's, 8/12/13 11:00 Interdisciplinary Progress Notes documented: *"Resident with a small open area to [MEDICATION NAME] spine, the base is obscured by yellow/white slough and the wound edges are defined." *"The resident has had a protective foam drsg (dressing) in place. Pillow to back of w/c (wheelchair) to pad and protect area. This resident has Kyphosis and chooses to sit up in wheelchair the majority of the day." *"Will refer to OT for W/C positioning that may be more effective than current measure of padding back (with) pillow. Resident #4's 8/20/13, "Wound Healing Hyperbaric Medicine Consult" documented: "[MEDICATION NAME] spine wound measures 1 x 0.6 x 0.3, 100 % slough in the wound bed" "Pressure Ulcer [MEDICATION NAME] Spine, unstageable." Resident #4 was observed to be up in his wheelchair through out the days during the time of the survey, and was never observed in his bed or a different chair. A thin cushion covered in a blue vinyl material was observed to be on the back of Resident #4's wheelchair. A white towel was placed over the back cushion. Note: Staff were never observed to have assisted Resident #4 with repositioning in his wheelchair. On 9/10/13 at 8:40 am, RN#3 was asked how Resident #4 received a pressure wound on his [MEDICATION NAME] spine. RN #3 said, "He likes to sit in his chair (wheelchair) all the time. We think he got it from that. We referred him to OT and he has a cushion in the back of his wheelchair now. " RN#3 stated the wound nurse came in on the weekends and looked at and measured the wounds in the facility, and also did treatments then. The treatments were also done through out the week by nursing staff. On 9/10/13 at 9:00 am, the surveyor asked the DON where she could find the wound nurse to discus Resident #4's wound and to observe wound care. The DON said the facility was in "transition" and the transition would begin tomorrow (on 9/11/13). The new wound nurse would be in that day. On 9/11/13 at 10:30 am, RN #8 was observed while providing wound care to Resident #4's [MEDICATION NAME] spine. The wound treatment was provided while Resident #4 was sitting up in his wheelchair. The resident asked RN #8 if his wound looked better, and RN #8 said she could not say because she had never seen Resident #4's wound before. RN #8 measured the wound to be 0.5 cm x 0.8 cm, with a depth of 0.1 cm. Note: 9/11/13 was RN #8's first day as the wound nurse. Resident #4 had Kyphosis and spent the majority of his time in his wheelchair. Resident #4 developed a pressure sore to his [MEDICATION NAME] spine. The facility failed to refer Resident #4 to the OT for his positioning needs before Resident #4 had developed an unstageable pressure sore on his [MEDICATION NAME] spine. Additionally, the facility failed to consistantly provide the physician's orders [REDACTED]. On 8/12/13 at 9:00 am, the DON and Regional Nurse Consultant were informed of the concern regarding Resident #4 developing an unstageable pressure sore after his admission into the facility. No documentation or information was provided which resolved the issue. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's most recent Quarterly MDS assessment dated [DATE] coded: *Severely impaired cognitive skills with disorganized thinking. *A Stage III Pressure Ulcer. *Extensive assistance of 2 persons for bed mobility, transfers, dressing, and toilet use. *Extensive assistance of 1 person for wheelchair mobility and hygiene. Resident #1's Norton Plus Pressure Ulcer Scale, dated 5/20/13, documented a score of 10, which indicated the resident was at high risk for pressure ulcers. Resident #1's initial Nursing assessment dated [DATE] did not document a pressure ulcer was present. A second Nursing assessment dated [DATE] indicated a Stage III Pressure Ulcer of the left heel. Resident #1's Skin Integrity Report (SIR) for the left heel PU (pressure ulcer), documented: *Initial date 5/18/13 - IHA (In House Acquired), Stage DTI (Deep Tissue Injury), no measurements noted. *5/20/13 - Stage DTI, length 3 cm (centimeters) x width 3 cm (centimeters). *5/21/13 - Stage DTI, length 3 cm x width 3.5 cm, healthy wound edges. *5/28/13 - Stage DTI, length 3.5 cm x width 5.2 cm, callused wound edges. *6/4/13 - Stage Un (unstageable), length 3 cm x width 3.2 cm, necrotic (eschar) 50% , [MEDICATION NAME] 50% , minimal bloody drainage, callused wound edges, pain present. *6/11/13 - Stage Un, length 4.5 cm x width 4.5 cm, necrotic 50%, [MEDICATION NAME] 50%, minimal serosanguinous (serum and blood) drainage, callused wound edges. *6/18/13 - Stage Un, length 2.5 cm x width 2.0 cm, necrotic 50%, [MEDICATION NAME] 50%, minimal serosanguinous drainage, healthy wound edges, pain present. *6/25/13 - Stage Un, length 2.5 cm x width 1.5 cm, necrotic 80%, slough 20%, minimal serosanguinous drainage, healthy wound edges pain present. *7/2/13 - Stage Un, length 2.3 cm x width 2.5 cm, necrotic 80%, granulation 20%, debrided, minimal serosanguinous drainage, callused wound edges, pain present. *7/9/13 - Stage Un, length 2.4 cm x width 1.4 cm, necrotic, granulation with no percentages noted, minimal serosanguinous drainage, callused wound edges. *7/16/13 - Stage - Un, length 2.5 cm x width 1.5 cm, slough 20%, granulation 80%, no drainage, macerated surrounding tissue healthy wound edges. *7/23/13 - Stage III, length 2.5 cm x width 1.5, slough 20%, granulation 80%, minimal serosanguinous drainage, healthy surrounding tissue, macerated surrounding edges. *7/30/13 - Stage III, length 1.7 cm x width 1 cm, granulation 100%, depth 0.2 cm, minimal serosanguinous drainage, healthy surrounding tissue, healthy wound edges. *8/6/13 - Stage III, length 2.2 cm x width 1 cm, slough 50%, granulation 50%, moderate serosanguinous drainage, surrounding tissue is macerated and circumferential, macerated wound edges. *8/13/13 - Stage III, length 1.90 cm x width 0.9 cm, granulation 50%, slough 50%, minimal serosanguinous drainage, healthy surrounding tissue, healthy wound edges. *8/20/13 - Stage III, length 1.5 cm x width 1.5 cm, granulation 100%, moderate serosanguinous drainage, surrounding tissue is macerated and inflamed, macerated wound edges. *8/30/12 - Stage III, length 1.5 cm x width 1.5 cm, [MEDICATION NAME] 100% moderate serosanguinous drainage, healthy surrounding tissue and wound edges. *9/6/13 - Stage III, length 1.5 cm x width 0.7 cm, [MEDICATION NAME] 100%, minimal serous drainage, healthy surrounding tissue and wound edges. An Office History and Physical for Resident #1 from a local wound clinic documented the following: 5/21/13 - Pressure Ulcer on left heel appears to be pressure related, measures 3 cm x 3.9 cm, 90% epithelium and 10% granulation tissue. Plan: Left heel wound will be dressed and offloaded with Prevalon boot. Office Progress Notes for Resident #1 from a local wound clinic document documented the following: 5/28/13 - Pressure Ulcer of left heel, "there do not appear to be Prevalon boots on her today," measures 3.5 x 5.2 with 100% callus and eschar. Debridement with no wound noted past the intradermal layers. "Total wound measures 0.2 x 1.3 that is mostly callus." Plan: "If Prevalon boots were not ordered, please order them today." Resident continues to need offloading. 6/4/13 - Pressure Ulcer of left heel, measures 3 cm x 3.2 cm, with 50% epithelium and 50% surface eschar. Added Santyl with daily dressing change with foam dressing. Plan: No documentation. 6/11/13 - Pressure ulcer of left heel, measures 4.5 cm x 4.5 cm, mostly eschar with some epithelium along edges. Plan: "I will speak with staff today regarding Prevalon boots. These are very important for healing and prevention." 6/18/13 - Pressure ulcer of left heel, measures 2.5 x 2 cm, mild periwound maceration, minimal discharge, wound bed has granulation tissue. Plan: Discontinue Santyl, continue with foam dressing, change daily, offload with Prevalon boots. 6/25/13 - Pressure ulcer of left heel unstageable, measures 2.5 x 1.5 cm, 80% eschar, 20% slough. Plan: Santyl daily, foam dressing, cover, change daily. Continue to offload with Prevalon boots. 7/2/13 - Pressure ulcer of left heel, unstageable, no measurement noted. Plan: Continue with Santyl to soften. "Continue to offload with Prevalon boots. I did not find her in her Prevalons boot today. I think offloading will be important." 7/16/13 - Resident developed a DTI that has progressed to a pressure ulcer of the heel, continues to be offloaded with Prevalon boots. Heel measures 2.5 x 1.5 cm, area is slightly macerated, bed is 20% slough, 80% granulation tissue after debridement. Plan: Continue to offload, continue with Santyl, encourage offloading, frequent turning, Prevalon boots. Note: Documentation after 7/16/13 from the wound clinic was not provided. The 5/21/13 "Plan" was to offload with Prevalon boots. On 6/5/13, Resident #1's physician assessment documented a Stage I pressure ulcer of the left heel. All Active Orders for August 2013 (physician recapitulation) documented an order for [REDACTED]. Note: The start date for the Prevalon boots was 2-1/2 weeks after the recommended date of 5/23/13 by the wound clinic. The TAR included Prevalon Boots while in bed, however, there was no documentation for the months of August and September. Additionally, there were orders for weekly skin checks by a licensed nurse and to float heels with pillows in bed with start dates of 5/9/13. The TAR for the month of August did not include documentation of a skin check for the week of 8/26/13. Resident #1's care plan for potential skin breakdown, initiated 5/9/13 and revised 5/21/13, documented in part: *Assist resident to turn and reposition every 2-3 hrs as resident allows *Elevate heels while in bed, initiated 5/21/13 *Observe skin every shift for s/sx (signs and symptoms) of potential skin breakdown (e.g. redness/discoloration or open areas) Note: The TAR for the month of September documented to cleanse left heel with wound cleanser, cover with foam and change daily, with a start date of 8/20/13. However, there is no documentation the treatment was completed on 9/2, 9/3, or 9/6 to 9/11/13. Resident #1 was observed on 9/9/13 at 3:18 PM and at 4:00 PM to be resting in bed with her eyes closed, her feet were not elevated or in the Prevalon Boots as ordered. There was a sign at the head of her bed which documented "Please put Prevelon Boots on while in bed." On 9/10/13 at 11:30, the surveyor requested to observe the treatment for [REDACTED]. The observation was scheduled for 9/11/13. The surveyor was unable to observe the treatment as the resident was sent to the hospital for evaluation and treatment due to a fall on 9/11/13. Resident #1 was harmed when a Stage III pressure ulcer was allowed to develop due to the facility's failure to ensure the resident's heels were elevated as ordered by the physician, to order the Prevalon Boots in a timely manner, to ensure the boots were used while in bed or at other times as documented by a local wound clinic. The facility also failed to obtain a physician order [REDACTED]. 3. Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #8's All Active Orders for September 2013 (Physician Recapitulation Orders) included an order for [REDACTED]. Resident #8's care plan for alteration in skin integrity dated 12/13/12, documented the resident was to have weekly skin assessment per protocol. Resident #8's Treatment Administration Record (TAR) for the month of August, 2013, had a schedule for weekly skin checks to be monitored on Tuesdays, however, there was no documentation for Tuesday, August 13, 2013, or Tuesday, August 20, 2013. On 9/12/13 at 9:40 AM, the surveyor showed LN #3 the TAR for the month of August 2013, for weekly skin checks. LN #3 stated, "Since it (TAR for the weekly skin checks) is blank, it wasn't done."

Based on a public complaint received by BFS on 11/26/12, record review and staff interview, it was determined the facility did not ensure the safety of 1 of 4 sampled residents (#4) reviewed for fractures and was harmed when staff transferred her without the use of a Hoyer lift (mechanical lift) during a transfer which required a Hoyer lift. The resident sustained [REDACTED]. Findings include: The complainant stated the resident was admitted to a local hospital on [DATE] from the facility due to a fall at the facility, where the resident sustained [REDACTED]. Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 11/9/12, documented the following: *Extensive assistance by one staff for bed mobility. *Total dependence by two staff for transfers. *Over the 7 day look back period the resident had not walked in her room or in the corridor. *The resident used the toilet with extensive assistance by one staff. *Severely cognitively impaired The PT department evaluated the resident on 7/5/10. Documentation included: "For upright positioning recommend Cardiac chair position of bed and mechanical lift if up to w/c (wheelchair) or shower chair. Pt. (patient) can't be left alone when upright. She is totally dependent with trunk control sitting at OB (edge of bed)." A facility "Nursing Assessment" for the resident was dated on 9/20/12. Under the "Functional Status/Musculo-Skeletal" category it documented, transfers were to be a 2 person assist with a mechanical device. The resident's Care Plan initiated on 10/21/10 under the focus of risk for falls identified the following interventions: *Provide level of assist with mobility ADLs. *Res. (Resident) was 2 staff member mechanical lift for transfers. The resident's CNA Care Card dated 8/29/12, documented the resident was a total dependence-Hoyer with a two plus person physical assist while transferring. A facility "Change of Condition Documentation" form dated 11/22/12 at 2:00 PM by RN #1 stated, "This nurse was alerted by the shower aide of a possible new skin condition. Upon assessment a large bruise to her left upper arm was noted. When asked if she was in pain, she replied 'no'...While moving her arm she stated, 'ow, that hurts.' The hematoma measured 7 cm (centimeters) x (by) 6.5 cm...Resident reassessed for pain every 30 minutes for two hours post initial assessment." A facility "Change of Condition Documentation" form dated 11/23/12 at 3:00 PM by LN #2 stated, "Resident LUE (left upper extremity) painful, swollen, blue in color, tight. X-ray done of left humerus. Fracture shown. Resident sent to (local hospital) ER for injury care." Documentation obtained from the hospital showed the resident was admitted to theER on [DATE] where X-rays were taken. The hospital Radiologist documented, "Radiographs demonstrate a proximal humerus fracture-oblique-extending from the fracture with high suspicion extending in the greater tuberosity and to the anatomic neck proximally. Fracture extends to the proximal diaphysis medially." A facility "Risk Management System" with a created date of 11/22/12 and a completed date of 12/5/12, documented, "Staff that was assigned to care for (Resident's name) 72 hours prior to the incident were interviewed. It was identified that the resident was transferred as a two person assist. Prior to incident resident was care planned to be a Hoyer transfer." A facility "Event Investigation Interview Record" included interviews with the staff involved in the resident's care at the time of the incident and included the following: *CNA #5 was interviewed by facility staff on 11/23/12 at 6:23 PM and the report documented, "(Resident) was transfered via two person into the shower chair." *CNA #3 was interviewed by facility staff on 11/23/12 at 6:20 PM and the report documented, "(CNA #3) and (CNA #4) transfered her (Resident #4) into the shower chair via 2 person." *CNA #4 was interviewed by facility staff on 11/26/12 at 7:00 AM and the report documented, "(CNA #3) and (CNA #4) 2 person transfered her from the bed to shower chair..." *CNA #6 was interviewed by facility staff on 11/23/12, the time was not recorded and the report documented, "(CNA #6) stated that she worked (with) (Resident) on Wednesday (11/21/12). (CNA #6) stated on Wednesday the bruising was not there. (CNA #6) stated she (the resident) is a Hoyer transfer although when she is showered she (CNA #6) knows that CNA's 2 person (transfer) her. (Resident) last showered yesterday (11/22/12)." *LN #2 was interviewed by facility staff on 11/23/12, the time was not recorded and the report documented, "...the aids {sic} notified her that her (Resident #4's) arm didn't look good today. ...Went to assess (Resident #4) wouldn't allow her to look at it but it felt swollen (&) hot. (LN #2) contacted the doctor & obtained an x-ray order due to concerns." The DON was interviewed on 12/5/12 at 4:10 PM regarding the incident and she stated the CNAs took it upon themselves to determine the resident did not need a mechanical lift at all times. The DON also stated, "The care plan was never consulted because she (Resident #4) was small enough to take care of with a two person assist." When asked what was the facility's final conclusion to the incident regarding the resident's fracture, the DON stated, "(The resident was) Improperly transferred with a two person assist and against the care plan." The facility failed to ensure to keep the resident safe during a transfer. The resident was harmed during an improper transfer by facility staff, which resulted in a fracture to the resident's left arm. The resident was sent to the hospital to receive further treatment for [REDACTED]. On 12/5/12 at 4:50 PM, the Administrator and DON were notified. No other information was provided.

Based on staff interview and record review, it was determined the facility failed to ensure that 2 of 20 (#s 8 & 19) sampled residents did not receive a pressure sore in the facility. - Resident #8 was harmed when she developed a deep tissue injury pressure sore of the coccyx. After it resolved, Resident #8 continued to have recurrent "shearing" to the area. The facility failed to develop and implement a comprehensive care plan to prevent the "shearing" from recurring and causing skin break down. The facility failed to investigate the cause of the "shearing" that caused the open areas. - Resident #19 had potential for harm when he developed a stage II pressure sore on his foot. Findings include: 1. Resident #8 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 4/11/12, documented the resident: * was severely cognitively impaired with BIMS =3 * required total to extensive assistance of one to two staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing * was always incontinent of bowel and bladder * was at risk for pressure sores * did not currently have a pressure sore * had pressure reducing device in chair and bed * was not on a turning and repositioning program. The resident's admission care plan, dated 3/11/11, for, "Potential for skin breakdown" documented interventions of: "* Notify MD as indicated/warranted with s/s (signs and symptoms) of skin breakdown. * Administer medication as ordered. * Check for incontinence and provide pericare as needed ac and pc meals (before and after meals).... * Document on Flow Sheet: if skin is intact.... * Follow center protocol/regime for treating breaks in skin integrity. * Labs and X rays as ordered. Notify physician of abnormal values. * Pressure reducing/relieving devices as ordered. * Treatment as ordered. * Weekly skin assessment per LN/RN per protocol." On 10/21/11 additional interventions were added: "* ROHO cushion to w/c at all times. * Air mattress to bed. * Prevalon Boots on at all times." On 10/24/11 a new problem was added to the resident's care plan. This was "SDTI" (Suspected deep tissue injury). The interventions were the same as the potential for skin breakdown except the following were added: "* Barrier cream to peri area as needed. * Cleanse perineal area well with each incontinence episode. * Keep skin clean and dry. * Turn and reposition with skin care (every) 2 (hours). * Use two person transfer and use turn sheet to avoid friction/shearing of resident skin. * Evaluate for pain.... * Monitor healing process and notify MD and responsible party.... * Weekly skin assessments and measure pressure ulcers. This care plan was resolved on 11/17/11. None of the interventions were transferred to the skin at risk care plan. On 2/28/12 the care plan had a problem added of "Alteration skin integrity coccyx: shearing." the goals were: "* coccyx site will decrease in size by target date 5/30/12" and "pt (patient) coccyx will remain (without) s/s infection...at coccyx." The interventions were: "* barrier cream bid and prn incontinence. * follow MD wound care orders. * air mattress. * ROHO cushion. * report c/o (complaints) discomfort to LN. * monitor for any new open areas, seek MD order." The "Interdisciplinary Progress Notes" (IDTPN) were reviewed. The resident received a pressure sore to the coccyx. On 6/7/12 at 11:45 a.m. the DON was interviewed and indicated that the facility was unable to locate the pressure sore documentation sheets for this pressure sore. The IDTPN documentation was: 10/21/11 at 5:00 p.m., "Res(ident) (with) 1.7 x 1.7 cm nonblanchable pressure (unopen) to coccyx.... Res(ident) to be laid down after each meal and turned side to side." 10/24/11 at 12:45 a.m., "Continuing to reposition resident frequently and apply mediseptic to coccyx with every incontinent episode." 10/25/11 at 3:35 p.m., "IDT review of cares....SDTI to coccyx. Will request increase protein...." 11/2/11 at 6:00 p.m., "Wound Note: Assess coccyx for SDTI, had been small 0.5 x 0.5 cm purple circle. Today (without) purple color, medpink and blanches. Using calozyme cream to cover area BID (twice day) and (as needed) (with) incontinence. Site (less than) 0.5 cm wide, 0 depth, 0 maceration or eschar." 11/7/11 at 6:20 p.m., "Resident coccyx area is closed (with) mild excoriation...." 11/10/11 at 2:25 p.m., "IDT review... area to coccyx healing well. Will cont (with) interventions in place." 11/16/11 at no time, "IDT Review in cares... Wound to coccyx resolved...." 11/17/11 at 1:30 p.m., "Resident coccyx is closed, no open sore. Still mild excoriation...." 11/29/11 at 10:00 p.m., "Resident continues to have excoriation to coccyx. Resident changed (and) repositioned (every) 2 (hours...." The notes continue to identify the resident had areas of "excoriation" and the facility was using barrier cream after incontinent episodes. There was an open area identified in February 2012 that documented: 2/25/12 at 5:00 p.m., "Resident found to have red open sore on coccyx during cares this shift. Barrier cream applied...." 2/27/12 at 3:00 p.m. "Area to coccyx red and nonblanchable. (No) open area noted. Barrier cream applied...." 2/28/12 at no time, "Area to coccyx assessed and noted to be an area caused by shearing. Area measured 2 cm long x 1 cm wide area superficial covered (with) peeling skin. Wound edges not well defined (with) small amount of serous drainage. Resident on an air mattress (with) Roho cushion. Resident has had decreased po (oral) intake (with) increased risk of unavoidable skin issues...." 3/6/12 at 7:00 p.m., "Wound skin note: Coccyx site improving, measures 2.0 cm x 0.8 cm x 0 depth. Pink, granular wound bed (without) slough, eschar or exudate. Pt (patient) (complains) discomfort with turning and palpation (gentle) to buttocks and coccyx. Staff relate pt is very sensitive to touch. Plan to request MD (discontinue) (prescribed) mediseptic, start zinc based barrier cream. Monitor for anticipated (decrease) size and resolution (less than) 6 weeks." 4/4/12 at 4:00 p.m., "Wound Note: Site on coccyx reduced in size and depth. Now 0.5 x 0.4 (cm) pink, new tissue (without) depth superficial. Barrier cream in use.... If (change) in resolved shearing, open site, exudate or slough, will need to refer to wound nurse." 4/23/12 at 7:55 p.m., " Res coccyx area has nickel sized open area (with) black color. Turned (every) 2 (hours) and applied barrier cream...." 4/24/12 at no time, "Area to coccyx assessed. Area intact tissue noted to be scar tissue due to history of pressure ulcers. Area nonblanchable. No concerns at this time..." The resident had an additional area of break down. The "Interdisciplinary Progress Notes' lacked documentation about the new sore but the "Non-pressure wound and skin condition documentation form" documented: 5/2/12, a shearing area of 1.5 cm length x 1.0 cm width x 0 cm depth, the wound bed had 100% granulation with no drainage. 5/7/12, a shearing area 1 cm length x 1 cm width x 0 cm depth, the wound bed had 100% granulation with no drainage. No date or time, "Resolved." The DON was interviewed on 6/6/12 at 11:45 a.m. and 6/7/12 at 11:45 a.m. The DON , who was also a skin nurse, stated that the resident's skin breakdown may be related to transfers with a hoyer lift She further stated that the barrier cream that the facility was using on the resident was hard to remove and that the shearing may have been caused by the "scrubbing" the CNAs did to remove it. The DON stated that in March the barrier cream was changed to a zinc type of cream which was easier to remove. When asked about how she determined that the sores were shearing and not pressure sores she stated it was based on the appearance of the wound. There was no investigation to show how the skin breakdown occurred or that the sores were shearing verse excoriation verses pressure related breakdown. The resident's current care plan did not address the resident's "fragile skin" or the chronic excoriation that was documented in the resident's records. The Administrator, DON and ADON provided additional information on 6/11/12 via fax. The facility provided a nutritional care plan that was in place during the time the resident had skin breakdown. In addition, the facility provided the "Nursing Assistant Care Card" for the resident. The care card did specify that the resident was to be turned and positioned every 2 hours. The care card also specified under "Skin Care" the resident was to have "Medseptic" applied, however which the physician ordered zinc in March 2012, which was easier to remove. The facility failed to: - develop a care plan for prevention of the skin excoriation/shearing and have the CNA sheets match the physician's orders [REDACTED]. - investigate the cause of two episodes of "shearing," - have appropriate "excoriation" preventive measures on the care plan: e.g. turning and positioning and increased frequency of incontinence care. 2. Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 5/18/12, documented the resident: - was cognitively intact with a BIMS of 15 - required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing - was frequently incontinent of bowel and bladder - had a pressure sore acquired on 4/11/12. The resident failed to have a care plan in place to prevent skin problems for occuring. when the resident obtained a pressure sore then a care plan was developed. The resident's care plan, dated 4/12/12, documented a problem of Alteration in skin integrity (related to): foot ulcer. The problem was resolved on 5/31/12. The interventions that the facility had in place were: " * Prevalon boots as ordered. * Barrier cream to gluteal cleft. * Assist with foot positioning to prevent heel to heel contact both up in chair and in bed. * Assist with offloading and turning in bed and chair as indicated. * Keep shoes off until wound resolved. * Airbed. * Report (complaints) of pain to LN. * Report new open area to LN. * Administer medication as ordered. * Weekly wound measurements. * Document on Flow Sheet .... * Follow center protocol/regime for treating breaks in skin integrity. * Labs and X rays as ordered. Notify physician of abnormal values. * Monitor daily for s/s (signs and symptoms) of infection .... * Monitor for s/s pain .... * Observe standard precautions. * Pressure reducing/relieving devices as ordered. * Provide education .... * Record percentage of meal consumed. * Refer to Dietician .... * Treatment as ordered. * Weekly skin assessment per protocol. " The "Interdisciplinary Progress Notes" documented the resident was first identified to have a blister on the bottom of the left foot. The documentation was: 4/11/12 at 7:30 p.m., "Res was found to have large de-roofed blister to L (left) inner heel, noted white moist surrounding skin, inner tissue red moist in color, (no) drainage noted ...." 4/12/12 at 11:00 a.m., "Blister to L heel measurements (Un-known word) blister 5 x 3.8 (cm) open area 2.4 [MEDICAL CONDITION] (cm) dark non-blanchable area 2 x 4 (cm). Area cleansed (with) NS (normal saline) ...." 4/13/12 at no time, "IDT review of unstagable to L foot. Res sits (with) feet crossed when in bed and w/c. (Treatment) for area in place, air mattress placed (and) prevalon boots on at all (sic) (no) shoes ...." 4/16/12 at no time, "Wound Note: Deroofed blister to Lt heel assessed (and) measured 4.5.cm length x 5 cm width. Wound bed moist with 25% slough on wound with 75% red granulating tissue. Small amount serous drainage. Periwound edges masserated.(sic) No odor, redness or s/sx of infection .... " 4/24/12 at no time, "Wound Note: Wound assessed to Lt inner heel measured 3 cm length x 4 cm width wound bed has 25% eschar to center of wound measuring 2 cm x 1 cm. Small amount of serous drainage. No odor or s/sx of infection. Peri wound edges attached ...." 5/8/12 at no time, "Wound to Lt heel assessed. Area measured 2 cm length x 2 cm width wound bed covered by 1 cm length x 1.5 cm width eschar. Small amount of serous drainage. Periwound edges attached (with) slight maseration. (sic) No odor or s/sx of infection noted. No s/sx of pain (with) treatment ...." 5/31/12 at no time, "Lt heel assessed. Skin intact, no drainage or s/sx of redness or infection ..." On 6/7/12 at 2:30 p.m. the DON was interviewed about the pressure sore on the resident's left heel. The resident's heel breakdown was a result of the resident sitting with his feet crossed and a blister formed. They treated it and it resolved. The "Pressure Ulcer Documentation Form" was provided. The facility initially staged the sore on 4/12/12 as "Unstagable" and it remained staged that way until 5/15/12 when it was staged as a stage II. The wound bed had eschar in the center from 4/24/12 until 5/8/12 which made staging difficult. The facility failed to identify the resident was at risk for skin breakdown on the heel and there was no care plan in place prior to the pressure sore appearing. The Administrator and DON were informed on 6/7/12 at 3:45 p.m. No further information was obtained.

Based on observation, record review and staff interview, it was determined the facility failed to implement a care-planned intervention for 1-1 supervision to Resident #20, who had multiple falls, with the last causing severe facial hematoma and increased pain. The result of the injury caused harm to the resident. This was true for 1 of 19 (20) sampled residents. Findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent admission MDS, dated [DATE], documented the resident: * had short and long term memory problems, * was severely cognitively impaired for decision making skills, * had no behaviors documented, * required extensive assistance of one to two staff for transfers, walking in the corridor, dressing, eating, personal hygiene, and bathing, * was always incontinent of bladder and bowel, * had a fall prior to admission and two falls with no injury after admission, and * received antipsychotic, antianxiety and antidepressant medications in the previous seven days. Resident #20's physician, on 4/19/11, documented in the "Nursing Home Visit, Admission history and physical examination [REDACTED] "...His main issues at this point in time seem to be related to some of his behaviors. He is not actively ambulatory but has had incidents in the past of falling from bed or from chair. Already since he has been here at (Facility name), he has been on the floor more than once....Today just prior to my arrival, apparently the patient was on the floor again and requires 4 people to help get him back up into the chair...." Resident #20 had 8 falls from 4/15/11 until 5/4/11. When the resident fell for the eighth time, he went face first out of the wheelchair. The fall caused a laceration, severe ecchymosis and hematoma to the face. The ecchymosis and hematoma was severe enough that the resident could not open his eyes. In addition, the resident's pain monitors for previous falls were documented as 0 (no pain) and the resident's pain monitor for 5/4/11, after the fall, documented a 3-4 (moderate pain). The resident's "Interdisciplinary Progress Notes" documented multiple incidents prior to the fall. These were: 4/15/11 - 5:05 p.m. "...admitted at 1445 (2:45 p.m.)....Mood was agitated and Restless...Resident sat up in bed unassisted and slipped to the floor. Alarms placed. Low bed and bedside mat placed...." 4/15/11 - 8:30 p.m. "Resident alarms sounded, found sitting on mat next to bed, when asked what occurred pt (patient) stated, 'just going to get a bite to eat.' ...resident was c/o (complaining) (R) (right)arm pain from previous fall before admit to our facility...." 4/16/11 - 6:25 p.m. "...multiple attempts to self transfer. Resident was by nurse most of shift. Low bed (with) alarms/mats on floor..." 4/17/11 - 2:45 p.m. "...multiple attempts to self transfer - 1 : 1 to re-orientate...stayed close to nurse during shift d/t (due to) safety risk...." 4/18/11 - 4:00 a.m. "...Res(ident) had a fall out of bed. Res was found after pressure alarm sounded. Tag alarm did not sound (because) Res had removed alarm from gown and tag remained in place. Res was found sitting on bottom on top of floor mat....Res is now in line-of-sight care for duration of shift...." 4/18/11 - 3:30 p.m. "...pleasant (with) staff until (after) lunch 1 : 1 d/t Res having multiple attempts to self transfer...will cont(inue) to keep close to nurse/nurse station for safety..." 4/18/11 - 4:45 p.m. "Res sustained fall from w/c. Res sitting in w/c in hallway - leaned forward grabbing at floor (and) fell out of w/c landing on (R) side. Alarm sounded. No injuries noted..." 4/20/11 - 11:30 p.m. "...Res still trying to climb out of bed..." 4/22/11 - 8:50 p.m. "...Multiple attempts to self transfer. Alarms in place functioning. Resident by staff (at) all times..." 4/23/11 - 12:45 a.m. "...Res had a fall in his room, and was found scooting across the floor. Res had slipped tag alarm off and Posey pressure alarm malfunctioned. Resident's skin is intact and has not complain of pain. Neuros started...Res kept within LOS (line of sight)" 4/24/11 - 5:50 p.m. "... he is becoming verbally aggressive (with) staff (and) making fists (with) his hands. Called spouse and hospice for a sitter....Currently having CNA push him up/down halls to calm down (with) fair results" 4/26/11 - 3:00 p.m. "...Res cont(inues) to make several attempts to self transfer...." 4/28/11 - 2:10 a.m. "...was up and down out of w/c several times attempting to self transfer. Staff alerted by and responded to alarms..." 4/29/11 - 4:30 a.m. "Res went to bed around 0100 (1:00 a.m.)....Res cont(inue) to try and Stand after Ativan. Had aide sit (with) Res for a couple hrs (hours) while he was in room. Awaiting him to settle down and be ready for bed. @ (at) 2230 (10:30 p.m.) Res was assisted back into his w/c d/t/trying to self transfer and brought out to the nurses station so people could keep a close eye on him...allowed to self propel down the halls until he was ready for bed...." 5/1/11 - 1:00 a.m. "Res had a fall at 2030 (8:30 p.m.) Res denies pain and has no s/s (sign or symptoms) of pain. Res has no new injuries r/t fall....Res slid out of w/c witnessed by CNA (name) and Resident's head did not contact the floor. W/c cushion was not secured and was most likely cause for fall...." 5/2/11 - 8:00 p.m. "At approx(imately) 1855 (6:55 p.m.) Res was lowered to Floor from w/c no injuries according to witness a nurse on another floor. Res was by MNS (Main Nurse Station) and appeared to be trying to reach for something on the floor by the time the nurse got to him he was to far forward and needed to be lowered to the floor...." 5/4/11 - 9:00 a.m. "Res sustained fall from w/c this am. Hit head on floor. Does appear to have hematoma to forehead sm(all) laceration to lip and below (R) eye measuring 1.5 cm (centimeters). Minimal bleeding from lacerations. Ice applied to hematoma. MD in facility and and assessed Res..." (Note: Actual time of the fall documented on the incident report was 7:30 a.m.) 5/5/11 - 9:00 p.m. "...Neuros (Neuro checks) wnl (within normal limits) for him - poor grasp of BUE (bilateral upper extremities) (R) eye swelled shut. He answers questions - appropriately, c/o neck, shoulder, facial, hand pain. Elevating BUE d/t pain/edema. PO PRN (oral as needed) pain meds (every) 4 (hours)...." The resident's care plan, initiated 4/18/11, documented a "focus" for a problem of, "Risk for falls related to: impaired balance, unstable health condition, unsteady gait." The "Goals" were: "* No significant injury related to a fall, * Anticipate fall with no injury." The "Interventions" were dated 4/18/11 except three which are noted with brackets. The interventions were: "* Assist resident getting in and out of bed with 1-2 person assistance using. (sic) * Assist resident with ambulation providing 1-2 person assistance. * Encourage resident to use handrails or assistive devices properly. * Resident to wear non slip footwear. * Remove all objects near bed to prevent injury if resident falls from bed. * Remind resident to use call light prior to ambulating or transfer. * When resident is in bed, place all necessary personal itmes (sic) within reach. * Reinforce need to call for assistance. * Place call light within easy reach of resident. * Evaluate effectiveness and monitor for side effects of psychotropic drugs. * Ensure environment is free of clutter. * Encourage resident to communicate needs/ask for assistance. * Hi/Low bed (Note: 4/15/11) * Room by nurses station. (Note: 4/15/11) * 1 : 1 Care (times) 24 (hours). * Med review. * Med review (Note: 5/4/11)" Resident #20 had a "Pain Evaluation" form completed after several of the falls. The pain evaluations for the falls that occurred on 4/15/11, 4/23/11 and 4/30/11 all documented 0, meaning no pain. The pain evaluation for the 4/18/11 fall documented a 1-2, for mild pain. The fall on 4/18/11, the resident fell hurting the right side of his back. The pain evaluation for the 5/4/11 fall documented a 3-4, for moderate pain. The pain was identified at two locations. One was the hematoma near the eye and the other was at the laceration on the chin. Resident #20 was observed on 5/9/11 at 11:45 a.m. in the assisted dining area with a staff member. The resident's face and eyes were ecchymotic and swollen. The resident was not able to open his eyes when asked due to the swelling that was still present from the fall that occurred on 5/4/11. The ADON was interviewed 5/12/11 at 1:20 p.m. and 3:15 p.m. the ADON indicated that she thought that there was increased supervision with the resident after the falls. The only documentation that the facility had for supervision was the nurses notes. The ADON said that staff were assigned supervision. Review of the staff assigned showed: * 4/30/11 - CNA assigned days and the Nursing supervisor on nights. (Note: facility staff worked 12 hour shifts, from 6 a.m. to 6:30 p.m. and 6 p.m. to 6:30 a.m.) * 5/1/11 - Nursing supervisor days and CNA evenings. * 5/2/11 - LPN assigned days, but did not start work until 8 a.m. The facility did not know who was assigned on evenings. (Note: Resident was lowered to floor to prevent fall at 6:50 p.m.) * 5/3/11 - Facility assignments were not available to review. * 5/4/11 - LPN was assigned but did not start work until 8:20 a.m. (Note: 50 minutes after the fall), RN supervisor was assigned on evenings. The ADON was asked for a policy describing increased vs levels of supervision of residents. The ADON did not have a policy that would define or describe levels of supervision of residents. The facility failed to ensure that Resident #20 did not receive an injury from falls. (received 1:1 supervision as care planned to prevent falls.) The resident gave the facility many warning falls prior to the fall that occurred on 5/4/11 that resulted in facial injury. The facility failed to: * Have a policy and procedure outlining different levels of supervision, * Failed to protect the resident by not having assigned staff with the resident, * Failed to update the resident's care plan to show increased supervision, and * Failed to analyse the falls and events occurring around them to develop a plan to decrease fall risks. The administrator and ADON were interviewed on 5/12/11 at 3:45 p.m. No further information was provided.