Every finding on record at Discovery Rehabilitation and Living

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 12/1/25 at 9:45 AM, during a tour of the kitchen with the dietary supervisor the following were observed. - Dishwashing machine temperatures were not obtained and recorded before the morning breakfast dishes had been washed. On 12/1/25 at 9:47 AM, the dietary supervisor stated the dishwashing machine should have been temperature checked before the breakfast dishes had been washed but had not been. In the Dry food storage area -- an opened box of white rice with no opened date labeled. - an opened container of Hollandaise sauce mix with used by date of 11/11/25. In the Walk in Refrigerator -- 1-gallon opened milk container with no opened date label.- 2-gallon container with apple juice (according to the food manager) was not labeled with contents, prep date or used by date.- 1 zip lock bag of cheese not labeled with opened date or use by date. On 12/1/25 at 10:15 AM, the dietary supervisor stated the opened food items should have been correctly labeled and were not. On 12/2/25 at 1:55 PM, a lunch test tray was requested and delivered by dietary staff containing meat loaf, cubed carrots, mashed potatoes with gravy, and a glass of milk. The meat loaf was temperature checked at 88 degrees F and when cut open appeared raw with red meat exposed. The cup of milk temperature checked at 50 degrees F. On 12/2/25 at 2:30 PM, the dietary supervisor and registered dietitian stated the meat loaf had been temperature checked before being served but the portion on the test tray must have been missed. On 12/3/25 at 9:05 AM, during a follow-up visit to the kitchen observed with the dietary manager, three opened gallon milk containers with no opened date labels. On 12/3/25 at 9:08 AM, the dietary supervisor stated the milk should have been dated when opened and had not been. On 12/3/25 at 9:17 AM, observed the following opened and unlabeled food items in the resident refrigerator.- Plastic container with some type of homemade soup liquid in it, only labeled with the resident's name and room number, no dates labeled. - One opened bag containing a half sandwich not labeled with any dates. On 12/3/25 at 10:05 AM, the DON stated the food in the resident refrigerator should have been properly labeled and was not.

Based on record review, policy review, and 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 3 residents (Resident #36) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care. Findings include:The facility's Comprehensive Person-Centered Care Planning policy dated 4/2025, documented 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 #36 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cauda equina syndrome (an injury or herniated disk compresses nerve roots at the bottom of your spinal cord) and chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung).Resident #36's medical record documented her initial baseline care plan had been completed and signed by an RN on 11/24/25, four days after her admission to the facility. On 12/3/25 at 9:33 AM, the DON stated an RN had failed to locked Resident #36's initial baseline care plan in the medical record until 11/24/25, and it should have been locked on 11/22/25, but was not.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 4 residents (#5 and #15) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:a. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia.Resident #5 physician's order for oxygen documented START O2 AS NEEDED FOR EMERGENCY TO KEEP SAO2 >90% AT 2 L PER N/C AND NOTIFY MD **THIS IS A STANDARD ORDER ** NOTIFY MD UPON IMPLEMENTATION start date 7/2/25.On 12/2/25 at 11:35 AM, Resident #5's medical record documented SpO2 information gathered on the following dates. - On 9/18/25 SpO2 91% on O2 via nasal cannula.- On 10/3/25 SpO2 94% on O2 via nasal cannula.- On 10/16/25 SpO2 92% on O2 via nasal cannula. On 12/2/25 at 12:00 PM, Resident #5's medical record had no documentation in nursing progress notes regarding oxygen therapy had been started and no documentation the physician had been notified. b. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses including left femur fracture and orthopedic aftercare.Resident #15 physician's order for oxygen documented START O2 AS NEEDED FOR EMERGENCY TO KEEP SAO2 >90% AT 1-5 L PER N/C AND NOTIFY MD **THIS IS A STANDARD ORDER ** NOTIFY MD UPON IMPLEMENTATION.On 12/2/25 at 11:21 AM, Resident #15's medical record documented SpO2 information gathered on the following date. - On 11/22/25 SpO2 96% on oxygen via nasal cannula. On 12/2/25 at 12:05 PM, Resident #15's medical record had no documentation in nursing progress notes on 11/21/25 thru 11/23/25 regarding oxygen therapy had been started and no documentation the physician had been notified. On 12/3/25 at 10:30 AM, the DON stated the SpO2 documentation in Resident #5 and Resident #15's medical records were documentation errors and should not have been made.

Based on observation and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately and not expired, this was true for 1 of 1 for medication carts audited and 1 of 1 treatment carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication, created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff, and to receive expired medications with decreased efficacy. Findings include: The following was observed for medication storage: 1.On 12/1/25 at 2:05 PM, observed the medication cart unlocked without a nurse present. On 12/1/25 at 2:08 PM, the Regional Resource Nurse stated the medication cart should not have been left unlocked and locked the drawer. 2. On 12/2/25 at 10:10 AM, the treatment cart was observed by the nurse's station, unlocked. No nurse was present. On 12/2/25 at 10:16 AM, RN #1 stated the treatment cart had medicated creams and wound dressings in it and the treatment cart should have been locked. 3. On 12/2/25 at 10:37 AM, observed in the medication refrigerator a plastic box with a lock on it. The DON stated the box had narcotics in it. The narcotic box was not permanently affixed to the refrigerator. On 12/2/25 at 10:40 AM, the DON stated she did not realize the narcotic box needed to be permanently affixed. 4. On 12/2/25 at 11:02 AM, observed in the medication cart, with LPN #1 present: -an open Saline Nasal spray bottle with an open date of 4/28/24. No manufacturer's expiration date noted. -on the bottom of the 3rd drawer of the medication cart observed one small white round pill and a small white oval pill. On 12/2/25 11:04 AM, LPN #1 confirmed the bottle of Saline Nasal spray did not have a manufacturer's expiration date on it and stated she thought it was only good for a month after opening it and it should not have been on the cart and the loose pills should have been destroyed. On 12/2/25 at 3:20 PM, the DON stated the nasal saline was only good for a month and should not have been on the medication cart. She also stated the medication cart is checked once a month for loose pills by the night nurse. The pills must have been dropped since the last time the medication cart was checked.

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 12/1/25 at 9:49 AM, observed with the dietary supervisor in the kitchen food prep area a trash can had a hole cut in the top so it could not be closed and was always open to the air.On 12/1/25 at 9:50 AM, the dietary supervisor stated he was not aware the trash can in the food prep area needed to have a closable lid.

Based on observation, document reviews, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens regulations 1910.1030, updated 10/19/21, states, Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure and Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.The follow was observed for infection control:On 12/2/25 at 8:04 AM, observed the medication cart by the nurse's station with a blue mug and an energy drink on top of the cart.On 12/2/25 at 8:06 AM, LPN #1 stated the personal drinks were hers and should not have been on top of the medication cart.

Based on observation, staff interview, and policy review, 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 31 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food Storage Policy documented: - All food must be labeled and dated immediately after opening or being prepared. All dates must be in a visible location and easily readable. - All foods will be labeled with the name of the product and the use-by date. The day of opening or production counts as the first day. The FDA Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, states refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 F or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The initial kitchen inspection was conducted on 9/9/24 at 9:45 AM, with the DM present. The following was observed: 1. In the walk-in refrigerator - Large stainless-steel bowl of salad was uncovered and not dated. - Sliced cheese wrapped in saran wrap with no use by date. - 8 individual containers of sour cream which was uncovered and not dated. On 9/9/24 at 9:50 AM, the DM stated the salad and the individual containers of sour cream should have been covered and had a use by date on them. She stated the cheese should have had a use by date on it. 2. In the dry storage closet - Open cocoa package with no use by date. - Open vanilla pudding package with no use by date. - Multiple open gelatin packages with no use by date. On 9/9/24 at 10:00 AM, the DM stated there should be use by dates written on the opened packages. On 9/9/24 at 12:51 PM, during the lunch meal in the main dining room, observed an open gallon of milk that was not dated. On 9/9/24 at 1:00 PM, the DM stated they have not put an open and use by date on the milk because the facility goes through almost a gallon a day. On 9/11/24 at 7:40 AM, during a follow-up inspection of the walk-in refrigerator, with the DM present, the following was observed: - an box of brussel sprouts with a best by date of 7/23/24. - an opened container of sour cream with a use by date of 8/23/24. On 9/11/24 at 7:50 AM, the DM stated the food should have been properly rotated following the first in first out method.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 1 of 1 shower/tub room observed. This deficient practice created the potential for harm if: a) the holes in the floors caused a resident to fall and b) cross-contamination from spread of microorganisms. Findings include: The facility's Environmental Safety policy, revised August 2024, documented the facility would provide a safe environment, free from physical hazards to protect the health and safety of residents, personnel, and the public. The following were observed for safety concerns: On 9/10/24 at 1:40 PM, the shower/tub room, across from the nurses' station, was observed with: - 3 different areas of missing tiles, varying in different sizes, to the left of the entrance into the shower room. - a 17 X 15 area with missing floor tiles, in the shower area, to the right of the drain. - a 7 X 5 area with missing floor tiles, in the shower area, to the left of the drain. On 9/10/24 at 1:40 PM, the Maintenance Supervisor stated the floor in the shower room was a fall hazard and the facility had been working on getting the tiles in the shower room fixed. On 9/10/24 at 1:47 PM, the Administrator stated the shower room did need to be repaired and they are working on getting the remodeling approved.

Based in policy review, observation, and staff interview, it was determined the facility failed to ensure respiratory equipment was changed and stored as indicated. This was true for 1 of 2 residents (Resident #2) observed for respiratory equipment. This created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and kidney disease. A quarterly MDS assessment, dated 8/30/24, documented Resident #2 received oxygen therapy. A physician's order dated 12/18/23, documented Resident #2 was to receive Ipratropium - Albuterol 0.5mg-2.5 (a liquid medication used to help control the symptoms of lung diseases), give 3mg/3ml via nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) every 6 hours as needed for shortness of breath or wheezing. A physician's order dated 1/16/24, documented Resident #2's oxygen tubing, nasal canula, or mask was to be changed every Sunday. A physician order dated 6/10/24, documented Resident #2 was to receive oxygen at 2 liters a minute via nasal cannula. On 9/9/24 at 10:16 AM, Resident #2's oxygen tubing was observed with paper tape dated 8/14/24, and her nebulizer tubing was not dated. Resident #2's nebulizer tubing and mouthpiece were observed lying on her nightstand, not properly stored. On 9/11/24 at 10:21 AM, the DON stated the resident's nebulizer should have been cleaned after use, dried, and stored in their personal belonging bag. The oxygen tubing and nebulizer tubing should be changed every week and dated. The date should be written on the tubing but sometimes it gets rubbed off.

Based on observation, policy review, and resident and staff interview, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This directly impacted 7 residents (#2, #3, #5, #8, #14, #16, and #28) who were interviewed about food services, and had the potential to affect all 31 residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code states hot food will be maintained at 135 degrees F or above and cold food will be maintained at 41 degrees F or below. On 9/9/24 at 12:53 PM, the lunch meal service observation was conducted with the following observations: - The menu documented the main entree was honey mustard pork chops, scalloped potatoes, mixed vegetable blend, peach crunch, and milk. - Some residents were observed to have small, cubed potatoes which appeared dry. - There were no garnishes or condiments served with the meal. On 9/9/24 at 1:39 PM, the Dietary Aide (DA) approached the Dietary Manager (DM) in the main dining room, with the surveyor present, and stated there were complaints the pork chops were dry. The DM stated, That is the problem with pork chops, they are terrible. On 9/11/24 at 7:40 AM, observed the following during breakfast meal preparation: - Seasonal fruit was canned diced pears served at 71 degrees F and should have been chilled to 41 degrees F or below. - Yogurt served at 44 degrees F and should have been 41 degrees F or below. On 9/11/24 at 10:30 AM, during the Resident Council meeting, 4 of 7 residents stated the food served was cold and tasteless. On 9/11/24 at 12:26 PM, the RD stated the temperature of the canned pears and the yogurt should have been served at 41 degrees or below. The temperature of the yogurt at 44 degrees F was too high. On 9/11/24 at 1:30 PM, the last tray from the meal cart delivered to the small dining room, was tested for serving temperature, taste, and presentation with the following observations: - Mashed potatoes were served at 125 degrees F and should have been 135 degrees F, and tasted bland. - Monte [NAME] vegetables were served at 108 degrees F and should have been 135 degrees F, and tasted bland. - Chocolate peanut butter parfait was served at 48 degrees F and should have been 41 degrees F or below. - Milk was served at 46 degrees F and should have been 41 degrees F or below. 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and kidney disease. On 9/9/24 at 4:10 PM, Resident #2's representative stated the food did not taste good and had no nutritional value. 2. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stroke, anemia, and diabetes. On 9/10/24 at 10:38 AM, Resident #3 stated the food does not taste good and she does not like it. 3. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including herpes zoster (a viral infection that causes a painful rash) and COPD (a lung disease that causes breathing problems and restricted airflow). On 9/9/24 at 1:43 PM, Resident #5 stated the food did not taste good. 4. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage (a condition that occurs when blood leaks into the space between the brain and the arachnoids membrane), dysphagia (difficulty swallowing), right shoulder joint fracture, and diabetes. On 9/9/24 at 10:33 AM, Resident #8 stated the food is often late, cold, and not tasty. She stated she had told staff about the issues with the food, but nothing ever changes. 5. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including anemia, heart failure, and dementia. On 9/9/24 at 11:04 AM, Resident #14 stated the food is cold. 6. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, peripheral vascular disease, and renal failure. On 9/9/24 at 12:35 PM, Resident #16 stated the food is terrible and tastes bad. 7. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, renal insufficiency, and malnutrition. On 9/9/24 at 11:21 AM, Resident #28 stated the food is not so good. It is cold, no taste, and not prepared that great. On 9/11/24 at 2:00 PM, the Administrator stated the facility had been working on food quality and thought there had been improvements. She was not aware the residents had complaints about the food. On 9/11/24 at 3:27 PM, the DM stated they use garnish and gravies to make the food palatable and attractive. She stated she was not aware the residents had complaints about the food. 49552 51121

Based on observation, policy review, and staff interview, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when, 1. staff did not clean resident's equipment properly, 2. perform hand hygiene, 3. change gloves when going from dirty to clean areas, and 4. hairnet and glove use in the kitchen. Findings include: The facility's Infectoin Prevention and Control Program policy, revision date December 2023, documented the facility will provide areas, equipment and supplies to implement its infection control program with the goal of effective cleaning and disinfecting equipment as needed, to include bathing areas, between each resident use. The facility's Glucometer, Cleaning and Decontamination policy, revised August 2020, documented the glucometer is to be placed on a barrier after use, then disinfected. The glucometer is disinfected after each use using a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim. The facility's Hand Hygiene policy, undated, documented the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations: - Before and after direct contact with residents - Before handling clean or soiled dressings, gauze pads, ect. - Before moving from a contaminated body site to a clean body site during resident care - After handling used dressings, contaminated equipment, ect. - After removing gloves - Before and after eating or handling food - Before and after assisting a resident with meals 1. The following resident equipment was observed: a. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and heart disease. On 9/9/24 at 12:52 AM, LPN #1 used the glucometer (a device used to measure the amount of glucose in your blood) to check Resident #12's blood sugar. LPN #1 brought the glucometer to the medication cart and was observed wiping the glucometer off with a Sani-Hands instant hand sanitizing wipe (disinfecting wipes for hands) and then placed the glucometer on a tissue on top of the medication cart. LPN #1 did not use the proper disinfecting wipe to clean the glucometer. On 9/10/24 at 3:28 PM, the administrator stated the glucometer should have been cleaned with the EBP Sani-Wipes (disinfecting wipes). She also stated the Sani-wipes for hands were only to be used to clean hands. The glucometer should have been cleaned with the purple top wipes (Sani-Wipes). b. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including Parkinsonism (umbrella term that refers to brain conditions that cause slowed movements, rigidity or stiffness and tremors), dislocation of left hip prosthesis, emphysema, and dementia. On 9/09/24 at 1:12 PM, observed DON moving Hoyer lift out of Resident #11's room. When the DON was asked if the Hoyer lift had been cleaned, the DON stated yes, she had just used the last of the purple top wipes in the room. When asked to see the empty container, the DON stated it could not be found so the CNA must have forgotten to clean the Hoyer lift. 2. The following was observed for hand hygiene: a. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and kidney disease. b. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Myocardial Infarction, Atherosclerotic heart disease (a chronic disease that causes plaque to build up in the arteries, narrowing and stiffening them), and Autoimmune Lymphoproliferative Syndrome (characterized by the production of an abnormally large number of lymphocytes). c. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including heart disease and diabetes. d. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including Diverticulosis of large intestine (a clinical condition in which multiple sac-like protrusions develop along the gastrointestinal tract), muscle weakness, and difficulty walking. e. Resident #20 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and hypertension. On 9/9/24 at 12:48 PM, observed CNA #1 and CNA #3 had not offered residents hand hygiene prior to serving lunch meal trays in Resident #7 and Resident #18's rooms. On 9/9/24 at 12:52 PM, CNA #1 delivered Resident #2's meal to her in her room. CNA #1 did not offer hand hygiene to Resident #2. On 9/9/24 at 12:55 PM, CNA #1 stated she does wash the resident's hands, but she must have forgot Resident #2's hands. On 9/9/24 at 12:58 PM, CNA #3 was observed passing meal trays to residents eating in their room. She did not offer to wash the resident's hands before setting up their meals. On 9/9/24 at 1:00 PM, CNA #3 stated she had not offered to wash the resident's hands and she should have. She also stated, she should be asking the residents if they want their hands washed. 3. The following was observed for proper glove changes: Resident #20 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and hypertension. Resident #20 physician's order, dated 9/5/24, directed staff to flush the wound on her left lower leg, place a telfa (non-adherent dressing) on the wound and wrap with Kling (rolled gauze) for protection. Change dressing daily and as needed. On 9/11/24 at 11:47 AM LPN #1 was observed providing wound care to Resident #20. LPN #1 placed the wound care supplies on a barrier on Resident 20's bed. LPN #1 washed her hands using soap and water prior to donning gown and gloves. LPN #1 then removed the soiled dressing. LPN #1 removed the soiled gloves and performed hand hygiene using hand gel and donned a new pair of gloves. LPN #1 cleaned Resident #20's wound with normal saline and gauze. She then placed a telfa dressing on the wound and wrapped Resident #20's left lower leg with Kling. LPN #1 did not perform hand hygiene or donn new gloves after cleaning the wound and before applying a new dressing. On 9/11/24 at 11:57 AM, LPN #1 stated she removed her gloves and cleaned her hands when she first started wound care, between old and new dressing change, and after wound care. She also stated after she cleaned the wound she should have put on new gloves before applying a new dressing. 4. The following was observed for proper hairnet and glove use in the kitchen: On 9/9/24 at 9:45 AM, during the initial kitchen tour, [NAME] #1 was observed not wearing a hairnet while in the kitchen, preparing resident meals. On 9/9/24 at 1:15 PM, observed [NAME] #1 leaving the kitchen to deliver a hall tray with gloves on and without a hairnet. On 9/9/24 at 1:18 PM, observed [NAME] #1 returning to the kitchen. He had not applied a hairnet, washed his hands, or donned new gloves before prepping resident food. On 9/11/24 at 7:20 AM, with the DM present, observed [NAME] #1 in the kitchen preparing and serving resident breakfast meals without a hairnet on. On 9/11/24 at 7:30 AM, the DM stated everyone who comes in the kitchen should be wearing a hairnet and should be changing gloves in between tasks. 49552 51121

Based on policy and record review, and staff interview it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital for 1 of 1 resident (Resident #20) reviewed for transfers/discharge. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include: The facility's Transfer or Discharge policy, revised 2020, documented for an emergency transfer/discharge, staff were to complete transfer/discharge documentation and attach copies of: - Face sheet - Advance Directive - Current physician's orders, H&P, copies of pertinent labs/x-rays - Patient representative information, including contact information Staff were to document the entire process in the Nursing Notes. Resident #20 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and hypertension. A nurse's note dated 2/16/24 at 1:33 AM, documented Resident #20 was transported to the ER. On 9/11/24 at 1:34 PM, the DON stated, the resident's face sheet, POST, H&P, are to be sent with the resident when they are transferred to the hospital. She also stated what was sent to the hospital with the resident should have been documented in the progress note. Resident #20's record did not include documentation that pertinent medical information was provided to the receiving hospital.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 1 resident (Resident #20) reviewed for transfer/discharge. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's Bed Hold policy, revision date December 2023, documented the facility will inform the resident or resident's representative in writing of the right to exercise the Bed Hold provision of 7 days upon admission and provide a second notice before transfer to a hospital. In the event of an emergency transfer, the second notice will be provided within 24 hours. A copy of this notification shall become part of the resident's health record at the time of transfer. Resident #20 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD (a lung disease that causes breathing problems and restricted airflow) and hypertension. A nurse's note dated 2/16/24 at 1:33 AM, documented Resident #20 was transported to the ER. On 9/11/24 at 11:31 AM, a review of Resident #20's medical record did not have documentation that a Bed Hold had been provided to her or her representative. On 9/11/24 at 1:32 PM, the DON stated there was no Bed Hold in Resident #20's medical record.

Based on observation, record review, and staff interview, the facility failed to follow physician's orders for 1 of 4 residents (Resident #8) for Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (SP) to evaluate and treat as needed. This failure created the potential for harm, adverse outcomes, and reduced opportunity for independence when residents did not receive ordered specialized therapy treatment. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage (a condition that occurs when blood leaks into the space between the brain and the arachnoid membrane), dysphagia (difficulty swallowing), right shoulder joint fracture, and diabetes. On 9/11/24, observed in Resident #8's medical record, physician's orders, dated 7/23/24, for OT, PT, and SP to evaluate and treat as indicated . Resident #8's care plan documented interventions for Occupational, Physical, and Speech-Language Therapy evaluation and treatment per physician orders. No documentation was observed in Resident #8's medical record that OT or SP had been notified to evaluate or treat. On 9/12/24 at 8:47 AM, the DON stated, the referrals should have been made to Therapy and documented but had not been made.

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 2 of 13 residents (Resident #5 and #8) whose care plans were 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 Care Plan policy, dated [DATE], documented care plans will be reviewed quarterly, annually, and with change of status to ensure that they are current for the resident's care. 1. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including herpes zoster (a viral infection that causes a painful rash) and COPD (a lung disease that causes breathing problems and restricted airflow). A quarterly MDS, dated [DATE], documented Resident #5 had an application of a non-surgical wound. Resident #5's care plan, dated [DATE], directed staff to use contact transmission-based precautions and follow posted transmission-based signs. Care plan also documented Resident #5's left hand lesions was to be covered at all times until resolved. On [DATE] at 9:13 AM, Resident #5 was observed without a wound dressing to her left hand. On [DATE] at 3:07 PM, the IP stated Resident #5's open wound to the left hand had resolved. The orders to treat the wound and the order for isolation were discontinued. She also stated Resident #5's care plan should have been updated to reflect that her herpes wound was resolved and she no longer needed to be on isolation. 2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage (a condition that occurs when blood leaks into the space between the brain and the arachnoid membrane), dysphagia (difficulty swallowing), right shoulder joint fracture, and diabetes. On [DATE], observed page 3 of Resident #8's care plan which documented, she desired to have cardiopulmonary resuscitation (CPR) and call 911, while on page 6 it documented she desired to be a DNR (Do not resuscitate). On [DATE] at 8:37 AM, the DON stated they had been updating resident care plans and both CPR and DNR should not have been in Resident #8's care plan. 51121

Based on observation, interview, and record review, the facility failed to obtain physician's orders for 1. diabetic toenail and fingernail checks and 2. follow care plan for wound care for 1 of 4 residents (Resident #8). This deficient practice created the potential for harm or adverse outcomes related to diabetic skin and nail infection, skin breakdown, and development of pressure ulcers. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage (a condition that occurs when blood leaks into the space between the brain and the arachnoid membrane), dysphagia (difficulty swallowing), right shoulder joint fracture, and diabetes. 1. On 9/9/24 at 10:34 AM, observed Resident #8's legs and feet to be red, slightly swollen, and unkept long toenails. On 9/11/24, a physician's order dated 5/31/24, for a Podiatrist to evaluate and treat as indicated. No documentation in Resident #8's record that a referral was made. On 9/11/24, Resident #8's care plan had no interventions in place for diabetic nail care. On 9/12/24 at 8:30 AM, the DON stated they no longer had a Podiatrist that would serve the rural facility and the nursing staff should have care planned resident diabetic nail care. 2. On 9/11/24 at 8:30 AM, review of Resident #8's TAR did not document wound care on 9/6/24 on the following areas: - to right upper inner arm - to right elbow, which is schedule for every three days - each shift to check skin under the clamshell brace on right arm - for left lower extremity, not completed on mid-day shift On 9/12/24 at 8:33 AM, the DON stated sometimes nurses have missed wound care. If the day shift had not completed wound care, the next shift should have completed and documented wound care.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and had not expired. This was true for 1 of 1 medication carts inspected. This failure created the potential for residents to receive medication used for another resident, presenting a risk for cross-contamination or to receive expired medications, with decreased efficacy. Findings include: The facility's Storing and Controlling Medications policy, revision date July 2018, documented: - the pharmacy provider dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. - 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 policy and procedures. The facility's Disposal of Wasted or Expired Medications policy, revision date, August 2020, documented: - Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law, and applicable environmental regulations. - Once an order to discontinue a medication is received, the facility staff should remove this medication from the resident's medication supply. - Facility should place all discontinued or outdated medication in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. - Facility should dispose of discontinued medications, outdated medications, or medications left in the facility after a resident has been discharged in a timely fashion or no more than 90 days of the date the medication was discontinued by Physician/Prescriber, or sooner per applicable law. On 9/10/24 at 9:56 AM, the medication cart was inspected with LPN #1 present. The following were observed: - An Atrovent inhaler, 17mg/ACT, was laying in the top drawer of the medication cart without a label. - 22 normal saline vials with expiration date of April 2024. - 1 levothyroxine tablet loose in the top drawer. - 1 unidentified half of a white tablet loose in the top drawer. On 9/10/24 at 10:36 AM, LPN #1 stated she was not sure if the Atrovent inhaler should have been in the original package. She also stated the expired normal saline should not have been in the medication cart and there should not be any loose pills in the medication cart.

Based on observation and interviews, it was determined the facility failed to ensure all call light strings in resident restrooms were proper length and easily accessible to residents. This issue was observed for 1 of 12 residents (Resident #8) call lights. This failure had the potential for harm if residents were not able to summon staff for assistance. Findings include: The facility's Environmental Safety policy, revision date August 2024, documented the facility will provide a resident call system to allow residents to call for staff assistance. These are provided at each resident's bed and toilet/bathing areas. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage (a condition that occurs when blood leaks into the space between the brain and the arachnoid membrane), dysphagia (difficulty swallowing), right shoulder joint fracture, and diabetes. On 9/9/24 at 10:56 AM, Resident #8 stated when she fell in the bathroom, she was not able to reach the call light in the bathroom because it was wrapped around the grab bar. On 9/9/24 at 11:00 AM, observed the call light string in the bathroom, wrapped around the grab bar thereby shortening the call light string length so it was not accessible from the ground. On 9/12/24 at 8:51 AM, the DON stated the facility conducts rounds throughout the building, to ensure call lights are accessible to residents in rooms and bathrooms. This should have been corrected in Resident #8's room.

Based on observation and interview, the facility failed to provide accessible closet doors handles in all resident rooms to meet their physical needs. This was true for 1 of 12 residents (Resident #8) whose closet door handles were 58 inches high, and not accessible from a wheelchair. This deficient practice had the potential to cause harm and distress for residents wanting to remain independent. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage (a condition that occurs when blood leaks into the space between the brain and the arachnoid membrane), dysphagia (difficulty swallowing), right shoulder joint fracture, and diabetes. On 9/9/24 at 10:41 AM, observed Resident #8 attempting to open the closet door in her room by pushing her finger between the two doors and trying to pry the door open. Resident #8 was unable to reach the closet door handles. On 9/12/24 at 2:10 PM, the DON stated that height of the closet door handles related to a resident confined to a wheelchair is an issue and should have been corrected.

Based on observation, policy review, and staff interview the facility failed to ensure staff provided meal service according to the facility's posted meal time schedule. This failure resulted in residents in the dining rooms having to wait 30 minutes to an hour before being served, which placed residents at risk for decreased quality of life and potential nutritional issues. Findings include: The facility's Meal times and Frequency policy, dated 2019, documented the facility provided at least three meals a day at regular times. Meals were served in a timely manner to maintain food quality. The facility's Timely Meal Service, dated 2019, documented food was delivered promptly to assure safe, palatable, and high-quality food. These policies were not followed. A meal schedule that was posted throughout facility, which could be seen from the dining rooms included the following: Breakfast: Hall cart 7:30 AM Small dining room [ROOM NUMBER]:45 AM Assisted dining 8:00 AM Main dining 8:15 AM Lunch: Hall cart 12:30 PM Small dining room [ROOM NUMBER]:45 PM Assisted dining 1:00 PM Main dining 1:15 PM Supper: Hall cart 5:30 PM Small dining room [ROOM NUMBER]:45 PM Assisted dining 6:00 PM Main dining 6:15 PM On 8/21/23 at 2:01 PM, the first lunch tray was delivered to Assisted dining room, 1 hour later than the posted time. On 8/22/23 at 1:38 PM, first lunch tray delivered to Assisted dining room, 38 minutes later than the posted time. The last tray was delivered at 1:50 PM, 50 minutes later than the posted time. On 8/23/23 at 11:04 AM during a resident council meeting, 8 of 8 residents stated it was common to wait long periods of times for meals. On 8/22/23 at 12:05 PM, the Dietary Manager stated she had put into place several new plans to improve the timeliness of food delivery. She stated there were usually only two people working in the kitchen and it was not enough to get all the preparations and meals ready timely. She stated she was aware meals were late. On 8/23/23 at 8:20 AM, the Dietary Manager stated she was aware of complaints about meals being late. She stated the facility has had an increase in residents. On 8/23/23 at 1:53 PM, the AIT stated the facility followed the posted scheduled times for the meals. He said meals that are more than 15 minutes were considered late and that was communicated to the staff.

Based on observation, resident and staff interview, and record review it was determined the facility failed to recognize continued and worsening signs of depression; develop and implement resident-specific care plans to address signs and symptoms of depression; and ensure safety notifications were made to qualified professionals to rule out suicidal ideation, intent, or plan. The facility also failed to identify key psychosocial issues and identify support systems to help residents resolve them. This was true for 4 of 9 (#s 4, 5, 6, and 9) sampled residents. *Resident #5 sustained psychosocial harm when she experienced a pattern of feelings of being "better off dead," which continued to be present at the time of survey, without notification or assessment to a qualified professional and without development of a care plan to address these feelings; *Resident #9 was harmed when she expressed ongoing depression and began to verbalize feelings she would be "better off dead," which continued at the time of survey, without notification or safety assessment from a qualified professional; *Resident #4 had the potential for harm when the facility failed to identify concerns the resident was having with the health status changes which precipitated her skilled nursing placement, and the impact of those changes on her situation in the community; and *Resident #6 had the potential for harm when he expressed feelings of being "better off dead" without notification to a qualified professional to rule out suicidal ideation or intent. Findings included: Federal guidance in the State Operations Manual, Appendix P - Survey Protocol for Long Term Care Facilities Psychosocial Outcome Severity Guide documented, "Severity Level 3 Considerations: Actual Harm...Persistent depressed mood that may be manifested by verbal and nonverbal symptoms such as: Social withdrawal; irritability; anxiety, hopelessness; tearfulness; crying...Loss of interest or ability to experience or feel pleasure nearly every day for much of the day...Expressions of feelings of worthlessness or excessive guilt nearly every day...Recurrent thoughts of death (not just fear of dying) or statements without an intent to act (e.g., 'I wish I were dead')..." The facility provided a policy and procedure for "Suicide Precautions" however, the policy did not address a clear delineation of what should be done, when, and by whom suicidal ideation and intent should be managed. The policy only addressed what should happen if a resident expressed a suicide plan. The facility utilized a Social Services Designee for the provision of social services in the facility. The employee filling that role at the time the survey took place had completed some, but not all, of the state's required training program for a Social Services Designee (SSD). The facility did not document referrals to mental health or social services professionals for any of the identified residents. See interviews below. 1. Resident #5 was admitted to the facility in March of 2013 with a [DIAGNOSES REDACTED]. The resident was later diagnosed with [REDACTED]. Resident #5's 3/20/14 Annual MDS assessment coded the resident was cognitively intact. Her overall mood severity score was a 3 (minimal depression); however, she answered in the affirmative that she had had thoughts she would be better off dead or of hurting herself nearly half of the days in the previous two weeks. The affirmative response triggered a follow up Safety Notification question on the MDS of, "Was responsible staff or provider informed that there is a potential for resident self-harm?" This question was answered, "yes." It was not clear from the response which staff or provider should be, or was, notified of a safety concern with the resident. Resident #5's CAA Worksheets, dated 3/20/14, documented a "triggering condition" for the Mood State area due to the resident's response to the self-harm question on the MDS. The Resident input area of the CAA documented, "Res(ident) does verbalize frustrations as needed to staff...declines antidepressant." The CAA indicated a care plan would be developed, as "Res(ident) is very candid living with MS is not ideal and will verbalize frustrations as needed...does come out for meals...and chooses not to participate in activities in the facility." The CAA did not document an analysis of the resident's statement regarding the potential for sell-harm, nor whether any safety notification had been made. On 3/21/14, a Social Services Annual Evaluation for Resident #5 documented, "...alert and oriented. She is very self-conscience (sic) of her limitations and prefers to be alone...She spends most of her time in her room...does not like having a roommate and whenever she gets one she complains about small things...She eats adequately although she states she only does so because she knows she needs to not because she desires to do so..." Resident #5's care plan did not document a focus area specific to the resident's mood state, nor regarding any feelings she may have regarding harming herself. There was a focus area documented for, "Potential for a psychosocial well-being problem (related to) social isolation due to her issues with her MS," dated 3/26/14. The interventions included allowing the resident time to verbalize her feelings, the resident's preference to remain in her room, and to "increase communication" between the resident, staff, and the resident's family about the resident's living environment. It was not clear how this last intervention was to be implemented. There was no documentation on the resident's care plan regarding her potential for self-harm, or her wish to be dead. There was no guidance for the staff as to how to proceed in the event these indicators should occur. Review of Resident #5's interdisciplinary Progress Notes (PNs) between 3/10/14 and 3/31/14 revealed no social services entries. There was no documentation regarding the resident's mood state or "increased communication" in the nursing entries. On 4/8/14, a physician's progress note for Resident #5 documented, "Subjective...The patient has some anger regarding her [DIAGNOSES REDACTED]." There was no documentation under the Assessment or Plan as to how severe this depression was, or a plan to address the depression. On 6/11/14, a nursing PN documented, "Res(ident) saw (physician) today and was notified that she has [DIAGNOSES REDACTED], locally advanced...recommended that res(ident) see oncologist for (chemotherapy and radiation)..." On 6/16/14 at 5:24 PM, a Social Services PN documented, "... She has felt down, depressed, and hopeless nearly every day, stating all three. (Resident #5) said I know I would be better off dead and feels this way nearly everyday (sic). She said she would never harm herself..." The PN was signed by the facility's Activities Director, who also served as the Social Services Designee. There was no documentation as to whether the resident's new [DIAGNOSES REDACTED]. Resident # 5's quarterly MDS, dated [DATE], coded she was cognitively intact. Her overall mood score was a 6, indicating mild depression. This mood score represented an increase from the previous score. The resident reported feeling down, depressed, or hopeless daily; and that she had daily thoughts that she would be better off dead or hurting herself in some way. The Safety Notification question was answered in the affirmative, although there was no documentation this was carried out. No mood state care plan was initiated for the resident. On 6/18/14, a Social Services Quarterly Evaluation documented the resident preferred to be in her room and to watch TV, did not participate in groups, and felt she could not do things due to her MS diagnosis. There was no documentation which evaluated the resident's response to her new [DIAGNOSES REDACTED]. On 6/23/14, a nursing PN documented the resident had returned from seeing the gastroenterologist, with no new orders. On that same date, the resident's care plan was updated to include that the resident had a rectal mass, but had opted for no further treatment. There were no updates documented on the resident's psychosocial well-being care plan. On 8/12/14, a physician's progress note documented, "Patient has no new acute complaints or concerns. Staff has noted ongoing withdrawal from activities she was previously positive about and noted for. She really would like to be left to herself on these issues..." The assessment and plan was documented as, "...will continue to encourage to socialize and provide supportive care." The resident's 9/12/14 quarterly MDS assessment coded the resident was cognitively intact. Her overall mood severity score was a 9, indicating mild depression. However, the MDS coded the resident had felt decreased pleasure or interest in doing things more than half of the days in the past two weeks. The MDS also coded the resident felt down, depressed, or hopeless daily and had daily thoughts she would be better off dead or of harming herself. Additionally, the resident chose not to respond to the inquiry of whether she felt badly about herself or if she had let her family down, which she had previously answered in the negative. The MDS documented a Safety Notification had been made, but no documentation regarding this notification was present. No mood state or psychosocial well-being care plan updates were documented following the 9/12/14 MDS, despite an increase in the resident's total mood severity score. This was the second consecutive MDS which coded an increase in the resident's total mood severity score. On 9/12/14 at 5:07 PM, a Social Services PN documented, "...also feels she would be better off dead nearly every day but would not hurt herself." There was no documentation from either the nursing staff nor the resident's physician regarding the resident's mood state. A 9/18/14 Social Services Quarterly Assessment did not contain documentation regarding the resident's mood state. On 10/14/14, a physician's progress note documented, "No new concerns from this resident. No new nursing concerns." On 12/3/14 at 3:00 PM, during a resident interview, the resident stated, "I wish I was dead. And I mean that. This is no way to live. And I'm tired of hearing that I should be happy to be alive or grateful to be alive. That's baloney." The resident stated she had been encouraged to attend religious services at the facility, and "of desperation" she tried to attend but, "That's not for me. I've never been religious and I'm not going to start now." When asked if she had ever been offered counseling services, the resident stated, "I don't need therapy to make me want to be alive. I want therapy to help me cope." The resident did not verbalize an active suicide plan, but stated, "Maybe you could push me outside in the snow and leave me there." On 12/4/14 at 11:40 AM, when asked, the SSD, with the Administrator present, stated the DNS was notified of the resident responding in the affirmative to the question regarding being better off dead or thoughts of harming herself. The SSD did not know what the DNS did once given the information. When asked, the SSD said she did not think the resident would harm herself, stating, "she says she would be better off dead but would never hurt herself." When asked, the SSD stated she had not had training regarding assessing a resident for suicidal ideation, intent, or plan, beyond what she had received from the state health care association. The Administrator stated the SSD had completed the first portion of a state required 2-part course, but the second had not yet been offered since the SSD accepted her current position. When asked, the Administrator stated the facility's consultant licensed social worker had quit without notice several months prior, as had several subsequent social workers. The Administrator stated the facility recently entered into a new contract with another social worker, but that person had not been consulted on this resident. The Administrator stated the nearest formalized mental health services were provided in a city several hours' drive from the facility. The Administrator stated he would need to research to determine if the resident's physician had been informed of the results of the mood interviews. When asked, the Administrator and SSD both stated the staff would not respond to the resident by telling her she should be grateful or happy to be alive, in light of her circumstance. However, neither was able to state what interventions the staff should use to respond to the resident when her statements were made. On 12/4/14 at 1:15 PM, the DNS stated she recalled the SSD telling her about the resident's MDS results, but did not document that notification. The DNS stated, "I know she (the resident) wasn't suicidal." When asked how the resident's state of mind had been assessed, the DNS stated, "I point blank asked her." The DNS stated she did not have additional training, beyond being an RN, regarding mental health issues, including suicide. The DNS stated she did not feel the resident had been continually depressed throughout the entire time from the 3/30/14 MDS until the 9/12/14 MDS as, "The MDS is only a snapshot in time. It doesn't tell you how the person is really doing." However, the DNS was not able to explain what the facility had done to alleviate the resident's expressions of despair, the increase in the types and frequency of depressive responses on the MDSs, nor why the resident continued to express those feelings and frustration with the facility's interventions during the surveyor's interview with the resident. Resident #5 was harmed when she experienced feelings of distress and despair, to the point where she consistently felt she would be better off dead. During this time she also began to withdraw from pleasurable activities she previously enjoyed, all the while experiencing continued progression in her MS as well as receiving a new [DIAGNOSES REDACTED]. While the physician did document periodically on an awareness of the deterioration in the resident's mood state, there was no documented assessment of that deterioration or plan to address those feelings. Additionally, it was not clear the physician was made aware of the resident's mood state severity scores per her answers on her MDS, including her feelings of being better off dead or hurting herself in some way. On 12/4/14 at 6:45 PM, the Administrator, DNS, ADON, and SSD were informed of these findings. On 12/8/14, a fax was received by the Bureau of Facility Standards with additional information. However, this information did not resolve the concerns. 2. On 12/2/14 at 10:15 AM, during the resident group interview, Resident #9 requested a private interview with the surveyors to discuss some concerns. On 12/3/14 at 4:05 PM, the surveyor met with the resident. The resident asked for assistance to, "Get me out of here." Amongst the resident's concerns were, "My quality of life. There is nobody here I can go to and talk to. The girls are nice, but they can't give you the right advice." The resident, who had been lying across her bed, sat up at the edge of her bed, tightened her upper body, drew her elbows tightly against her rib cage, closed her eyes and grimaced, and stated forcefully, "I'm bored stiff!" (Please see F 248 for details). When asked, the resident stated she experienced anxiety. The resident stated, "It just feels so futile. Nothing gets done...I'm just angry." The resident requested assistance in looking into her concerns. The survey investigation revealed: Resident #9 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's care plan documented focus areas of, "Potential for mood problem (related to) anxiety (manifested by) negative comments about others," and, "...at risk for depression (manifested by) episodes tearfulness will verbalize that she is depressed," beginning 10/4/13. The focus areas were documented as revised on 10/16/14 and 11/14/14 respectively, although it was not clear from the documentation how the focus areas had been revised. Interventions included the administration of her anti-anxiety medication Buspar (initiated 10/4/13, revised 11/14/14), and allow time for the resident to verbalize her feelings (initiated 10/4/13, revised 6/21/14). There was also an intervention, initiated 10/4/13, which documented, "Encourage (Resident #9) to set realistic goals. Encourage participation from resident who depends on others to make decisions." Resident #9's Quarterly MDS, dated [DATE], documented the resident had moderately impaired cognition. Her overall mood severity score was 2, indicating minimal depression. The MDS coded the resident had experienced both little interest or pleasure in doing things; and feeling down, depressed, or hopeless several days out of the previous two weeks. The resident's care plan documented the resident was receiving 10 mg of Celexa per day at the time this MDS was completed. On 4/29/14, Resident #9's care plan documented her Celexa was discontinued due to a successful gradual dosage reduction attempt. Resident #9's Annual MDS, dated [DATE], documented she had moderately impaired cognition. Her overall mood severity score had increased to an 8, indicating mild depression. The MDS coded the resident had experienced little interest or pleasure in doing things and feeling down, depressed, or hopeless daily; and feeling tired or having little energy half or more of the days in the previous 2 weeks. These findings were also documented in a social services progress note from that date. Additionally, the progress note documented, "She stated, 'I just want to go home.'...(Resident #9) has been spending more time in her room and reading. She was in good spirits." It was unclear how the determination had been made the resident was in "good spirits" at the same time she reported multiple indicators of depression, and was noted to spend more time alone in her room. The CAAs for the 6/16/14 MDS triggered several care areas to be further evaluated for care plan development, including cognitive loss, communication, psychosocial well-being, mood state, and activities. The area of the CAA for resident or family input in each of these areas, was blank. Please see F 279 for details. There was no documentation the physician was consulted regarding the resident's statements in light of the discontinuation of her anti-depressant medication less than two months prior to this assessment. On 6/21/14, two of the existing interventions for Resident #9's mood state care plan were revised. It could not be determined what the interventions had been before the revisions. However, the updated interventions documented, "Allow (Resident #9) to answer and verbalize her feelings, perceptions, fears. (Resident #9) has episodes of forgetfulness, confusion, and may need repeated cues and time to verbalize issues," and, "Allow (Resident #9) to share feelings over lost riles ie (sic) life on assisted living and changes in functional mobility." On 8/12/14, a physician's progress note for Resident #9 documented, "Patient has done well with her depression..." On 8/28/14, Resident #9's care plan documented the resident was restarted on Celexa 10 mg daily, "after (Resident #9) complaints (sic) of being depressed for past couple months." The resident's physician's orders [REDACTED]. It could not be determined why or how the physician determined the resident was doing "well" with her depression on 8/12/14, then re-started her anti-depressant medication and added an anti-anxiety medication just 16 days later due to complaints of depression going back a "couple months." Resident #9's Quarterly MDS, dated [DATE], documented the resident had moderately impaired cognition. The resident's overall mood severity score had increased to an 11, indicating moderate depression. The MDS coded the resident had felt down, depressed, or hopeless daily; and had been tired with decreased energy, feeling badly about herself, and thoughts of being better off dead or of harming herself more than half the days in the past two weeks. The MDS coded a Safety Notification had been made due to the resident's affirmative response to the question for the potential of self-harm for the resident, however no documentation of such a notification was found. On 9/12/14 at 10:09 AM, a nursing progress note documented, "...Res(ident) receives Buspar 10 mg daily ([DIAGNOSES REDACTED].#9) also feels she would be better off dead 7-11 of the days over the previous two weeks, but would not hurt herself..." On 9/19/14 at 6:45 PM, a care conference progress note documented a meeting with the facility staff, the resident, and her family member. The note documented, "...Discussed restarting the Celexa (due to) the resident expressing that she 'felt depressed'..." The entry was made by the DNS. On 12/4/14 at 2:40 PM, the DNS initially stated the care conference was conducted by another nurse, so she could not speak to the content of the progress note. When asked why she would write a note for another nurse's work, the DNS stated, "Oh, well, I was present at the meeting." When asked about the answers coded on the resident's MDS in conjunction with the care conference, the DNS stated, "At the time of the care conference, she wasn't depressed, she said she was fine. Plus, per the behavior monitor, we know she wasn't depressed." The DNS could not explain why she had documented the resident expressed feelings of depression during the conference, if the resident had actually stated she was "fine." Additionally, the DNS's statements did not resolve the surveyor's concern regarding the MDS coding of increased depression, the resident's report of feelings of depression in a care conference 7 days later, and the resident's statements to the surveyor during the interview the previous day. Resident #9's Behavior Monthly Flow Sheet for September 2014, which documented target behaviors of anger, tearfulness, and degrading others; was blank. For October 2014, 5 episodes of anger were documented for evening shift for each 10/9/14, 10/10/14, and 10/13/14. On 10/14/14, the resident's care plan documented the resident's Celexa was decreased to 10 mg every other day. It could not be determined why the resident's Celexa was decreased in dosage when the resident had complained of increased depression within the past month, nor when target behaviors had been noted 3 times within the past week. The November 2014 Behavior Monthly Flow Sheet was blank. Resident #9 was harmed when she reported, and demonstrated, a continued deterioration in her mood state and quality of life, to the point where the resident felt she would be "better off dead" per her most recent MDS assessment. While the facility had documentation of these indicators, medically related social services were not provided to ensure the resident had the opportunity to achieve her highest practicable emotional and psychosocial well-being. On 12/4/14 at 6:45 PM, the Administrator, DNS and ADON were informed of these findings. On 12/8/14 the facility faxed additional information, which did not resolve the concerns. 3. Resident #4 was admitted to the facility on [DATE] following a left above the knee amputation, and readmitted in November following a right above the knee amputation. Resident #4's most recent quarterly MDS assessment, dated 10/1/14, coded she was cognitively intact; had little interest or pleasure in doing things several days out of the previous two weeks; felt down, depressed, or hopeless more than half the days; was tired with little energy several days; and had appetite changes several days. On 12/2/14 at 3:30 PM, during a resident interview, the resident became tearful. She stated she had come to the facility initially after she had her leg amputated, and was working hard with therapy towards a goal of returning home when the determination was made she had to have the second leg amputated. The resident stated while this was unfolding, her husband had cardiac issues which required him to be transported to a hospital several hours away for an extended period of time to become stabilized. The resident stated in addition to concern for her husband, she had concern for the couple's dog, which was "just like a child to us." The resident stated she arranged for the dog to be placed in a local kennel on a "temporary basis," but that was in July and the dog was still there. The resident stated, "Now I have to stay here, which is expensive, and my husband has had to move to assisted living, which is also expensive. I don't know how much longer we can afford to board the dog, and they called me last week to tell me the dog was depressed and not eating. I'm not ready to place him up for adoption, but I don't know if they will let my husband keep him in assisted living." The resident stated she was looking into Medicaid assistance, but "It's so complicated it's exhausting." The resident stated she hoped to get a specialized wheelchair which may give her enough independence either to return home or move to assisted living with her husband. However, the resident reported that she had to travel to a "specialist" in a community in a neighboring state several hours away to get authorization from her insurance company to cover the cost of the wheelchair. The journey would require travel over a "fairly treacherous" mountain pass. The resident stated, "I know my husband wants to drive me, but he just can't drive that pass safely. I'm trying to figure out another ride, but I haven't had any luck." When asked if the facility had someone who was working with her to resolve her multiple concerns, the resident stated, "The physical therapist is trying to help me get the wheelchair, but otherwise I didn't even know there was someone here who could help me figure it out." On 12/3/14 at 8:15 AM, the Administrator stated he helped the resident access an elder law attorney to assist her with the process of applying for Medicaid. The Administrator stated the facility was aware the resident needed to have an assessment for the specialized wheelchair, but had to be realistic about crossing the pass in the winter months. The Administrator stated, "We need to make sure it's safe." The Administrator was aware the resident's dog was in a kennel, but was unaware of the resident's level of attachment to the dog, or that the cost of keeping the dog in the kennel was wearing on the resident. The Administrator stated, "You know, it's a tough situation. Because of the condition of the home, we all knew her husband could not go back there. I helped get him into the assisted living. I really feel for them." The Administrator stated perhaps the SSD had done additional work to help the resident and her husband resolve the rest of their concerns. On 12/3/14 at 9:25 AM, when asked, the SSD stated, "I visit frequently with her (Resident #4) and assure her she will return to normal soon, listen to her feelings, and validate her feelings." When asked if the SSD felt assuring the resident she would return to "normal" was realistic in light of her recent double amputation, the SSD stated, "Well I was thinking more of activities like knitting." On 12/3/14 at 10:30 AM, the Administrator reported he had checked the weather report, and tentatively scheduled transportation for the resident to be assessed for her wheelchair the following week. On 12/4/14 at 6:45 PM, the Administrator, DNS, ADON, and SSD were informed of these findings. The facility offered no further information. 4. Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Section D of the MDS related to Mood was reviewed for 3/21/14, 5/9/14, 8/7/14, and 11/7/14. Each assessment documented the resident answered, "Yes" to having, "Thoughts that you would be better off dead, or of hurting yourself in some way." Additionally, the MDS documented, "Yes," the Responsible staff or provider (was) informed that there is potential for resident self harm. The current care plan indicated Resident #6 had depression manifested by tearfulness. Care plan interventions, dated 8/13/13, documented, "(Resident #6 needed assistance/encouragement/support to identify problems that could not be controlled and provide opportunities for resident's family to participate in care; 3/26/14, Zoloft 50 mg every other day; 10/26/14, observe for side effects of anti-depressant medication..." The Social Service Notes reviewed from 3/1/14 through 12/4/14 did not document follow-up had occurred with the responsible staff and/or provider when the resident had verbalized thoughts of being better off dead or of hurting himself in some way, during the above identified assessments. On 12/4/14 at 11:40 AM, when asked, the SSD and the Administrator stated the DNS would have been the responsible staff member notified of the resident's MDS results. On 12/4/14 at 1:15 PM, the DNS stated she had been informed of the resident's mood issues, and had assessed the resident was not at risk of hurting himself. The DNS stated she had no specialized mental health training beyond what she received as part of her RN education. The DNS could not identify a diagnostic tool which had been used to rule out suicidal ideation or intent for this resident. The DNS stated she did not document her interaction with the resident when determining he was not at risk of harming himself. On 12/4/14 at 6:45 PM the Administrator, DNS, ADON, and SSD were notified of these issues. On 12/8/14 the additional information was received via fax by the Bureau of Facility Standards, however, this information did not resolve the concerns.

Based on observation, record review, staff and resident interviews, it was determined the facility failed to ensure a resident admitted with pressure ulcers (PU) received services to promote healing and prevent new ulcers from developing. This was true for 1 of 2 (#3) residents sampled for high risk PUs. Resident #3 was harmed when she developed recurring Stage 2 PU on the right and left buttocks. Findings include: Resident #3 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's 7/29/13 most recent annual MDS coded: -makes self-understood and usually able to understand others. -cognition intact and mild depression -rejection of care "not exhibited" - extensive to total assist for most ADLs (eating was supervision only and walk in corridor was limited assist). -Upper and lower functional ROM limitations to both sides of the body -continent of bowel and occasional incontinence of bladder. -pain intensity was an 8 (0-10 pain scale) with scheduled and as needed pain medication. -at risk for developing pressure ulcers, unhealed PU Stage 1 or higher, and one Stage 2 PU, date of oldest Stage 2 PU 3/5/13. -One Unstageable PU and one Unstageable PU that was present upon admission/reentry - worsening in PU status since prior assessment, One Stage 2 -Section V triggered for pressure ulcers and indicated the area was care planned. Resident #3's 5/21/11 Care Plan contained numerous focus areas and interventions however the CP also documented "CANCELLED" for each focus, goal and intervention entry. NOTE: On 9/11/13 at 9:30 am, the MDS Coordinator stated, "The CP is the current CP and the computer printed canceled in order to do the care plan conversion." The MDS Coordinator confirmed the CP provided to the survey team was, "the most current care plan for Resident #3." The care plan focus was: A. Moderate Risk for further skin breakdown: H/O (history of) healed stage 2 bilateral buttocks. (2/2/12), "3/19/13 area to buttocks is healed." Interventions documented in care plan included, "L (left) buttocks appears to be worse A) will change dressing from foam cleanser, stoma adhesive, and saran wrap to cleanse with wound cleanser, apply [MEDICATION NAME] and change QOD (every other day) B) (Resident #3) rejects to lay down in bed and continues to sleep in recliner. C) Staff has educated Res (resident) regarding risk for not changing positioning and (Resident #3) continues to reject bed. D) (9/9/13) RSD(resident services director) spoke with (Resident #3) about need for repositioning off buttocks, again, and if res rejects to lie down in bed tonight, res recliner will be removed from room. Fax sent to MD regarding res current skin issues." "(Resident #3) states at times she does lay down in bed but needs assist to get up and out of bed." "Rejects to sleep in bed at night. Sleeps in recliner B) Nursing has educated (Resident #3) RE: (regarding) benefits of sleeping in bed, repositioning side to side while in bed." "ROHO cushion in wheelchair B)rejects gel cushion in regular chair in dining room." NOTE: There was no care plan for use of the Roho cushion or any form of pressure relief while the resident was in the recliner. Also documented in the care plan: B. "Alteration in comfort: DJD. Severe pain in shoulders, knees, hips ...." Interventions documented: - "Resident will sit in recliner stating it is hard to get in and out of bed. Resident complains cannot lay flat in bed and has to have head of bed elevated to tolerance. Resident prefers sitting/sleeping in recliner." Medical records documented: -03/15/13 bilateral buttocks healed. -06/25/13 bilateral buttocks are more discolored and fragile looking. -07/30/13 open areas to left buttock. -08/12/13 change treatment to foaming body cleanser, instead of wound cleanser. -08/19/13 left buttocks smaller. -09/03/13 left buttocks larger in size, change treatment to cleanse with wound cleanser, [MEDICATION NAME] and apply skin prep change QOD (every other day). -09/08/13 right buttocks-opened-implemented wound cleansers with [MEDICATION NAME] and skin prep, change QOD. -09/10/13 Added [MEDICATION NAME] (nutritional supplement) to BID (twice a day), Vitamin C and Zinc x 14 days." Resident #3's Braden Scale for Predicting Pressure Sore Risk, dated 06/27/13, scored low risk at 18. Resident #3's 9/13 "All active orders for September 2013" (Recapitulation) contained in part the following: -02/26/13 ALT (alternating) Air Mattress -03/18/13 Weekly skin checks-PMs...Specific days of week: Mon., 1400-2200. -04/15/13 Wound Care: buttocks-Topical-every shift every day, 0600-1400, 1400-2200, 2200-0600. Cleanse area with wound cleanser, apply stoma powder, and cover with saran wrap. -08/13/13 Left buttocks: Cleanse area with foaming body cleanser; apply stoma adhesive powder to bilateral buttocks and small piece of saran wrap only to open area to left buttocks. TID (three times a day) 0700, 1600, 1900. The care plan had two focused areas with conflicting interventions: For the problem "Alteration in comfort: DJD, severe pain in shoulders, knees, hips and left foot ...."Intervention dated 5/22/11 documented, "Res will sit in recliner stating it is hard to get in and out of bed. Complains cannot lay flat in bed and has to have head of bed elevated to tolerance, prefers sitting/sleeping in recliner ...." There was no stop date for this intervention. -intervention dated 9/9/13 after review by the IDT (Interdisciplinary team) in response to treatment plan. "Resident now has open area to R buttocks, no change to L Buttocks....IDT response to treatment plan: [REDACTED]. RSD had informed Resident if she does not sleep in her bed then the chair will be removed from her room." Progress Notes dated 7/30/13 by Nursing documented, "Lengthy discussion with Res about sleeping in chair vs. bed. Resident argued that she never told anyone that she 'would' sleep in her bed, but that she would think about it. Res states 'The Dr. said to sleep where I was comfortable.' At HS (hour of sleep) Res was assisted into her recliner per her request. Call light within reach." The progress notes also documented: 9/10/13 "Res lying in bed this am." 9/10/13 "RSD spoke with Res this AM. She said she had slept in her bed last night and would continue to do so but would rather be in her recliner. RSD states she was able to keep her recliner and discussed again that she would have more skin breakdown if she were to choose to sleep in the recliner again. Recliner will remain in her room." 9/12/13 "Res has allowed staff to assist her into bed at HS for that last 3 nights ...Res does complain of pain when transferring both into and out of her bed ..." On 9/12/13 at 9:3 am. Resident #3 stated, "They said if I sleep in my bed it will become healed. I talked with Doctor and he said it may not heal but it could get better. I sleep better in my chair. I have slept in my chair off and on for 3 years." The surveyor reviewed a list of "Document all Ulcers, Wounds, and Other Skin Problems" in the facility's electronic medical record data base. The following information was printed for the surveyor. The measurements of the wounds were as follows: 8/6/13 the left buttocks was 1 x 0.3 cm 8/27/13 the left buttock was 0.5 x 0.3 cm 9/8/13 right buttocks were opened. (No measurement found) 9/12/13 at 10:20 am, the wound was observed. The right wound measured 1 cm x 1 cm circular shape, red with split skin. The left buttocks measured 1 cm x 1 cm circular in shape and approximately ? to ? cm deep. On 9/12/13 at 4:17 pm, 2 surveyors discussed with the DON, Resident #3's skin conditions and reopened pressure ulcers. No information was received that altered the findings. 2. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #6's 8/27/13 annual MDS coded moderately impaired cognition, at risk for developing pressure ulcers, and no unhealed pressure ulcers. Section V of the MDS triggered for pressure ulcer and indicated the care area was care planned. Resident #6's Care Plan (CP) contained a 8/30/13 focus area, moderate risk for skin breakdown. One of the focus interventions was. "assist (Resident #6) with positioning, "floating heals {sic} (heels) using pillows..." On 9/10/13 at 2:45 p.m., CNA #1 and CNA #6 were observed assisting Resident #6 to lie down in her bed. A pillow was placed under the resident's legs and a blanket was placed over the resident's body. The CNAs adjusted the head of the bed and lowered the bed to the resident's request. The CNAs finished assisting the resident and were about to leave the room. At this time, the surveyor ask CNA #6 why the pillow was placed under the resident's legs. The CNA replied, "To float her heels." The surveyor asked the CNA to lift the blanket so the resident's heels could be observed. When the CNA lifted the blanket, both the right and left heels were in direct contact with the surface of the pillow. The CNA moved the pillow back towards the resident's torso away from the heels and said, "They are floated now." On 9/13/13 at 10:00 a.m., the Administrator and the DON was informed of the observation. The facility did not provide any additional information related to the observation.

Based on observation, resident and staff interview, record review, review of facilitry incident reports (IR) and a report to the State regarding a 1/9/11 fall, the facility failed to consistently implement care planned interventions to prevent falls. This was true for 1 of 3 sample residents (#3) reviewed for falls. Resident #3 fell and sustained a right hip fracture that required hospitalization . Resident #3 was harmed when she experienced elevated levels of pain that required new and/or increased pain medications/interventions to manage pain related to the hip fracture. Findings included. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], for [DIAGNOSES REDACTED]. Resident #3's admission MDS assessment, dated 1/18/11, documented: * Independent cognition - decisions consistent/reasonable; * Understands others and usually understood by others; * Total dependence for bed mobility/dressing/eating/toileting/personal hygiene/bathing; * Upper and lower extremity impairment on both sides; * Almost constant pain made it hard to sleep at night and limited day-to-day activities; * Pain intensity 7 on a numeric rating scale; * Pain described as severe; * Fall with fracture within the last month prior to admission; and * Fracture related to a fall within previous 6 months. The resident's most recent quarterly MDS assessment, dated 12/13/10, documented: * No pain. Resident #3's April 2011 recapitulation of physician's orders [REDACTED]. * Duragesic (Fentanyl) 50 mcg/hr (micrograms per hour) transdermal patch every 72 hours (3 days), ordered 3/22/11; * Ibuprofen 600 mg (milligram) PO (by mouth) every 8 hours PRN (as needed), ordered 1/12/11; * Absorbine Jr. (Junior) liquid topically three times a day PRN, ordered 1/12/11; * Norco 10-325 mg 1 or 2 tablets PO every 4-6 hours PRN, ordered 1/21/11; * Tylenol 650 mg (milligrams) PO every week (resident's request) with Avonex 30 mcg IM (intramuscular) injection 1 time per week (for MS), ordered 1/12/11. Resident #3's Care Plan documented the following, in part: * "High Risk For Falls: paralysis R/T (related to) multiple sclerosis - muscle spasms." This problem was identified 1/12/11. Interventions included, "Low bed to be kept to the lowest level when not receiving cares with wheels off floor. B) Landing strip on the right. ..." * "Alteration in comfort: right intertrochanteric nondisplaced hip fracture, back spasms, weakness/fatigue R/T multiple sclerosis with paralysis...joint and hip pain, generalized pain..." This problem was identified 1/12/11. Interventions for the problem included, "... (2) 03/07/2009 (Resident's name) can alert staff to pain issues: 1) Have (resident's name) rate her pain using 0/10 scale... (3) 01/12/2011 Positioning preferences are subject to change per res(ident) current status and PT (physical therapy) recommendations B) PT recommends right leg in 0 degree extension periodically throughout the day (1/14/11)... (4) 01/20/2011 3 assist to reposition. B) When done positioning, stand at foot of bed and look for extremity (sic) alignment/adjust as needed. C) To position: do not let right knee cap roll in or roll outward. Keep knee cap straight up. Try to keep right hip stretched out flat. D) To roll: Place pillow between knee and keep leg in alignment... 5) 01/12/2011 Nsg (nursing): Administer pain meds (medications) as ordered: ... C) Baclofen as ordered. Recently increased R/T (related to) increased muscle spasms per new admit. ... Wants to be asked every 4 hours if she needs pain medication. ... 20) Indwelling Foley Catheter... D) D/C (discontinue) Foley when (resident's name) pain from right hip fracture is more comfortable..." Review of a 1/9/11 IR revealed Resident #3 had a fall at 5:30 a.m. It documented, in part: * Describe What Happened: "Res noted on floor beside bed (R) side of bed, upper body leaned against several pillows from bed. ... Res states 'the pillows started to fall and I slid with them." * Immediate Corrective Action: "...Res c/o (complained of) pain to (R) hip 7/10 with movement 4/10 at rest. Pain to (R) ankle 4/10..." * Was call light in reach? "Yes" Was call light on? "Yes" * Any medication or physical/cognitive change in last 3 days? "No" and "No" * Patient condition before incident: "Alert" * Time of last known contact with staff: "0525 (5:25 a.m.) * Any equipment involved? "Bed pillows slipped out from under Res legs/buttocks." * Environmental factor? "landing strip up against wall under window" * Recommendations: "Res sent to ER (emergency room ) for eval(uation), res has fx (fracture) (R) trochanter (and) was admitted to hospital for possible surgery 1-11-11. 1-10-11 Res life flighted to (another City) for surgery, family did not want to wait till 1-11-11 for surgery." Resident #3's December 2010 Pain Record documented her pain level on all three shifts (noc = nights, AM = days, and PM = evenings). A 0-10 scale was used to rate the pain. Zero indicated no pain, ten indicated worst pain. The resident's pain was documented at zero on all shifts, except as follows: * 12/1 = 6 on night shift (noc), 12/4 = 6 (noc), 12/6 = 5 (noc), 12/13 = 7 (noc), 12/14 = 8 (noc), 12/17 = 5 (noc), 12/20 = 7 (noc), and 12/27 = 8 (noc). Note: In December, Resident #3's pain was documented at 5 - 8 (moderate to severe) on 8 of 93 shifts and at zero (no pain) on 85 of those 93 shifts. The December 2010 Pain Record also documented Alternate Interventions/number of shifts they were implemented related to Resident #3's pain: * Positioning: 7 times; * Heat/Cold: 0 times; and * Massage: 0 times. The December 2010 Pain Record also documented Resident #3 received the following medications/doses related to pain: * Scheduled Tylenol 650 mg: 12/5, 12/12, 12/19, and 12/26 (with the Avonex IM); * Scheduled Acetaminophen (generic Tylenol) 500 mg: 12/1 through 12/31 = three per day; * PRN Ibuprofen 600 mg 1 tablet: 12/1, 12/4, 12/6, 12/12, 12/13, 12/14, 12/17, 12/20, and 12/27 = one per day; and * PRN Absorbine Jr topical: 12/1 and 12/4 = one per day. Note: In December 2010, Resident #3 received 4 doses of scheduled Tylenol 650 mg, 93 doses of scheduled Tylenol 500 mg, and 2 doses of Absorbine Jr. Resident # 3's clinical record contained 2 Pain Records for January 2011. The January 2011 Pain Record, for the time period 1/1 to 1/9/11, documented Resident #3's pain as follows: * 1/1 through 1/8 = 0 (none for all 3 shifts); and * 1/9/11 = 7 (noc). Note: In January, Resident #3's pain was documented at zero on all shift prior to the fall on 1/9/11 at 5:30 a.m. The January 2011 Pain Record, for the time period 1/1 to 1/9, documented zero Alternate Interventions were utilized in January. The January 2011 Pain Record, for the time period 1/1 to 1/9/11, also documented Resident #3 received the following medications/doses related to pain: * Scheduled Tylenol 650 mg: 1/2 (one per week with the Avonex IM); * Scheduled Acetaminophen 500 mg: 1/1 through 1/8 = three per day; and * PRN Ibuprofen 600 mg: 1/6 and 1/9 = one per day. Note: Resident #3 received 2 doses of scheduled Tylenol 650 mg, 24 doses of scheduled Tylenol 500 mg, and 2 doses of Ibuprofen from 1/1 to 1/9/11. The January 2011 Pain Record, for the time period 1/12 to 1/31/11, documented Resident #3's pain every shift as follows: * 1/12 = 10 (PM); * 1/13 = 8 (noc), 6 (AM), and 8 (PM); * 1/14 = 9 (noc), 7 (AM), and 7 (PM); * 1/15 = 8 (noc), 10 (AM), and 7 (PM); * 1/16 = 7 (noc), 6 (AM), and 8 (PM); * 1/17 = 7 (noc), 6 (AM), and 8 (PM); * 1/18 = 10 (noc), 9 (AM), and 9 (PM); * 1/19 = 7 (noc), 6 (AM), and 9 (PM); * 1/20 = 8 (noc), 9 (AM), and 5 (PM); * 1/21 = 9 (noc), 8 (AM), and 5 (PM); * 1/22 = 5 (noc), 6 (AM), and 5 (PM); * 1/23 = 6 (noc), 5 (AM), and 5 (PM); * 1/24 = 7 (noc), 5-6 (AM), and 6 (PM); * 1/25 = 6 (noc), 5-6 (AM), and 6-7 (PM); * 1/26 = 6 (noc), 8 (AM), and 5 (PM); * 1/27 = 5 (noc), 5 (AM), and 5 (PM); * 1/28 = 5 (noc), 5 (AM), and 6 (PM); * 1/29 = 6 (noc), 6 (AM), and 6 (PM); * 1/30 = 7 (noc), 7 (AM), and 7 (PM); and * 1/31 = 0 (noc), 7 (AM), and 1 (PM). Note: After the 1/9/11 fall/right hip fracture, Resident #3's pain level was documented at 5-10 (moderate to severe) on every shift, except two. The January 2010 Pain Record, for the time period 1/12 to 1/31/11, documented Alternate Interventions/number of shifts implemented related to Resident #3's pain: * Positioning: 42 times; * Heat/Cold: 8 times; and * Massage: 0 times. The January 2011 Pain Record, for the time period 1/12 to 1/31/11, also documented Resident #3 received the following medications/doses for pain: * Scheduled Tylenol 500 mg: 1/12 through 1/15 = one per day and 1/17 through 1/19 = one per day; * PRN Hydrocodone 5/325, 1 tablet: 1/12 = one, 1/13 = two, and 1/17 = one; * PRN Hydrocodone 5/325, 2 tablets: 1/13 = two, 1/14 = four, 1/15 and 1/16 = five per day, 1/17 and 1/18 = four per day, 1/19 = five, and 1/20 = three; * PRN Norco 10/325, 2 tablets: 1/20 = two, 1/21 = five, 1/22 = six, 1/23 through 1/28 = five per day, 1/29 = six, 1/30 and 1/31 = four per day; * PRN Ibuprofen 600 mg, 1 tablet: 1/17 = two, 1/18 = one, 1/20 = three, 1/21 = two, 1/22 and 1/23 = one per day, 1/26 = one, 1/27 = three, and 1/28 through 1/30 = one per day; * PRN Absorbine Jr.: 1/12, 1/20, 1/22, 1/30, and 1/31 = once per day. Note: After the 1/9/11 fall, Resident #3 received Hydrocodone 5/325 - 1 tablet times 4 doses, Hydrocodone 5/325 - 2 tablets times 32 doses, Norco 10/325 - 2 tablets times 55 doses, Ibuprofen 600 mg times 17 doses, and Absorbine Jr. times 5 doses. A physician progress notes [REDACTED]. The patient has been receiving pain medication to help control discomfort. ... Assessment/Plan: 1. status [REDACTED]. She has needed Hydrocodone to help with perceived breakthrough symptoms. We will increase her Duragesic to 50 mcg to see if we can provide better stable day-to-day control. ..." Note: Duragesic, a long acting opioid analgesic, was added to Resident #3's pain management regimen, and in February 2011, Duragesic was increased. A physician progress notes [REDACTED]. Last x-ray shows no significant healing or change. ... She has fair pain control with current medication but with activity she does have some breakthrough pain up to a 7 out of 10. ..." The April 2011 Pain Record, for the time period 4/1 through 4/12, documented Resident #3's pain as follows: * 4/1 = 4 (noc), 4 (AM), and 7 (PM); * 4/2 = 5 (noc), 4 (AM), and 4 (PM); * 4/3 = 7 (noc), 7 (AM), and 7 (PM); * 4/4 = 6 (noc), 7 (AM), and 7 (PM); * 4/5 = 7 (noc), 7 (AM), and 7 (PM); * 4/6 = 5 (noc), 8 (AM), and 7 (PM); * 4/7 = 6 (noc), 7 (AM), and 7 (PM); * 4/8 = 5 (noc), 8 (AM), and 5 (PM); 4/9 = 5-7 (noc), 7 (AM), and 5 (PM); * 4/10 = 8 (noc), 7 (AM), and 4 (PM); * 4/11 = 7 (noc), 8 (AM), and 8 (PM); and * 4/12 = 5 (noc), 7 (AM), and 5 (PM). Note: Resident #3's pain level was rated as 4-8 (moderate to severe) in April. The April 2010 Pain Record, for the time period 4/1 through 4/12/11, documented Alternate Interventions/number of shift implemented related to Resident #3's pain: * Positioning: 42 times; * Heat/Cold: 8 times; and * Massage: 0 times. The April 2011 Pain Record, for the time period 4/1 through 4/12/11, also documented Resident #3 received the following medications/doses for pain: * Scheduled Duragesic 50 mcg patch every 3 days: 4/2, 4/5, 4/8, and 4/11; * PRN Norco 10/325 1 tablet: 4/1 = three, 4/2 and 4/3 = four per day, 4/4 = one, 4/5 through 4/7 = four per day, 4/8 = 3, 4/9 and 4/10 = five per day, and 4/11 and 4/12 = three per day; * PRN Norco 10/325 2 tablets: 4/11 = two and 4/12 = one; * PRN Ibuprofen 600 mg 1 tablet: 4/1 and 4/2 = one per day, 4/3 = two, 4/4 through 4/6 = one per day, 4/7 = two, 4/8 = one, 4/10 = two, 4/11 and 4/12 = two per day; * PRN Absorbine Jr: 4/1 and 4/2 = one per day, 4/3 and 4/4 = two per day, 4/5 = one, 4/6 = two, 4/8 and 4/9 = one per day, 4/10 = three, and 4/11 and 4/12 = one per day; * PRN Aspercreme to joints: 4/1 and 4/2 = one per day, 4/3 and 4/4 = four per day, 4/5 = three, 4/6 = four, 4/7 = two, 4/8 = three, 4/9 through 4/12 = two per day. Note: In April 2011, in addition to the scheduled Duragesic 50 mcg, Resident #3 received Norco 10/325 - 1 tablet 43 times, Norco 10/325 - 2 tablets 3 times, Ibuprofen 600 mg 16 times, Absorbine Jr. 16 times, and Aspercreme 30 times. On 4/12/11 from 12:20 to 12:40 p.m., Resident #3 was interviewed. The resident stated she fell and broke her right hip in early January when her pillows slipped off the bed. The resident stated her pain was "not much" before the fall but after the fall she had a "lot of pain." The resident stated the pain was "a little better now, especially if staff "pre-medicate me before they turn me." The resident stated the pain increased with movement. She stated that before the fall/hip fracture, she was able to go out of her room but, "It's kinda hard to do that now." On 4/12/11 at approximately 11:40 a.m., LN #9 was observed applying a topical medication to Resident #3's waist/hip areas. LN #9 stated the medication was administered for pain. On 4/14/11 at 10:05 a.m., CNA #12 and CNA #13 were observed providing a bed bath and repositioning Resident #3. CNA #12 stated, "We have to be very careful turning and positioning her or she will have pain. She has lots of pillows. She tells us where to put them." On 4/14/11 at 10:20 a.m., the DON was asked for the report sent to the Bureau of Facility Standards (BFS) regarding the 1/9/11 incident. That afternoon, the DON provided a copy of a 32 page facsimile (fax) that was faxed to the BFS on 1/13/11 regarding Resident #3's fall/right hip fracture. The fax cover page stated the facility had notified the BFS of the 1/9/11 incident by telephone on 1/10/11. The faxed documents included a summary of the incident, one page of Resident #3's fall care plan, dated 12/7/10, a one page Temporary Care Plan for falls, dated 1/9/11, a Personnel Action form, a Consultation report, and a variety of inservice training materials including a "One-on-One" inservice. The the summary of the incident stated the LN on duty "...reported that the bed had to be lowered about 4 - 6 inches when they picked (resident's name) up from the floor to the bed. When asked if the landing strip was on the floor (LN's name) answered that the landing strip was not on the floor. (LN's name) stated following the fall we need to get a landing strip; (resident's name) replied there is already one here against the wall. ..." The report also stated the CNA who cared for the resident at the time of the fall, "...described she had answered call light for (resident's name) as she needed her legs repositioned as they were sliding off the bed towards the wall. (CNA's name) stated that she lifted (Resident #3's) legs up and straightened them out, she adjusted the pillows for positioning and asked (resident's name) if they were all right. (Resident#3's name) stated they were okay and (CNA's name) left the room to answer another call light. When (CNA's name) came out of other resident room, (Resident #3's name) call light was on again and she entered the room to find (Resident#3) on the floor beside the bed with her head at the foot of the bed and her feet at the head of bed direction. ... (CNA's name) was aware that landing strip was not in place when asked and indicated that it was not in use." The report further stated, "...; DON reviewed nurse notes and there is no indication that muscle spasm has occurred during past three months that could cause pillows to topple. Aides have described using more than multiple pillows to position (Resident #'s name) per her preference and that additional pillows are required to stabilize the pillows used for positioning. Nursing (and) Aide Skilled roster sheet indicated that (resident's name) should have landing strip on right side of bed. Landing strip matt (sic) is in (Resident #3's) room leaned against the wall. ... History and Physical from (Name of hospital) admission indicated that fall was related to severe multiple sclerosis and multiple spastic contractions of her muscles supposedly led to her falling out of bed." The summary of the report also stated, "(Resident #3's name) was admitted to (a local hospital) for fracture of right trochanter and was later transported to (another hospital in a another city) for treatment as surgeon was not available in (local town) until Tuesday. ... (Resident's name) was determined to not be a surgical candidate due to osteoporosis, elected to not have surgery and is returning to (facility) for pain management." In the Plan to Prevent in Future, and the Conclusion, the report documented, "Written disciplinary actions to be completed for aide providing cares...for not following written care plans and physician orders [REDACTED]. (and) ... Her low bed was in not in either low or high position but approximately 4 - 6 inches from lowest position." The 12/7/10 fall Care Plan documented two of the interventions as, "... low bed ... (and) landing strips on rights." The Personnel Action (PA) form documented, "Failure to utilize safety devices as physician ordered and as care planned" and "(CNA's name) did not place physician ordered/care planned landing strip on (R) side of bed - (resident's name) slid from bed and fall resulted in fractured (R) trochanter with surgical intervention to repair - Bed was not placed in lowest position." The PA also contained the following handwritten comments, "(1) Complete 'Providing Excellent Customer Service' read/quiz (2) 'Elder Abuse' read/quiz (3) 'Managing Difficult Behavior in Others' (4) Read sign (and) return Safety regulations P (and) P (policy and procedure). (5) Read, sign (and) return Low Mattress Low Platform P (and) P." Note: There were no staff names/signatures/initials, or dates, on any of the aforementioned inservice materials, quizzes, and policies. In addition, none of the questions on the quizzes were answered. The One-on-One Inservice documented, "All skilled staff are required to complete the attached quiz and return to DON...by January 21, 2011. ... Not using safety devices that are ordered/care planned are not an option..." The One-On-One Inservice document contained a typed list of facility staff names, and spaces for each staff member's signature. However, all of the spaces for the staff signatures were blank. The 1/11/11 Consultation report documented in part, "A right intertrochanteric hip fracture... possible surgical repair versus nonoperative management including specifically pain management. ..." Resident #3 was harmed when she suffered an increase in pain after the 1/9/11 fall that resulted in a right hip fracture. Resident #3 required a significant increase in pain management, including new and/or increased pain medications and interventions. On 4/14/11 at approximately 6:30 p.m., the Administrator and DON were informed of the concern for harm related to Resident #3's fall, fracture, and pain. No comments were made at the time; and, no further information was received from the facility.