Every finding on record at Eagle Rock Health and Rehabilitation of Cascadia

Based on record review, review of facility policies, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 2 of 6 residents (#25 and #38) reviewed for medication administration. This deficient practice created the potential for harm when significant medication administration errors were made during medication pass. Findings include:The facility's Medication Administration policy dated 9/10/25, documented a medication error refers to any observed or identified mistake in the preparation or administration of medications or biologicals that does not follow:- The prescriber's written order- The manufacturer's instructions for safe use- Recognized professional standards and guidelines, including those set by state regulations and national healthcare organizations.Staff responsible for medication administration should follow the ten (10) rights to medication administration: a. Right Medication, verify the medication against the provider's order and the Medication Administration Record (MAR). b. Right Resident, Use identifiers (photo on the MAR along with verbal confirmation) - if the resident cannot identify themselves use a second staff member to confirm. c. Right Dose, confirm the dose with the MAR and the provider's order.Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes.A facility's Medication/Treatment/Lab Error Report dated 7/20/26, documented that medications belonging to Resident #38 were administered by LPN #1 to Resident #25 after the breakfast meal on 7/20/26 around 10:00 AM. The following medications were administered:- Carafate 1 gram,- cephalexin 1000mg,- Multivitamin,- pantoprazole 40mg, (Resident #25 also had this medication ordered)- clozapine 200mg.Resident #25's July 2026, medication administration record (MAR) documented he had been given all of his medications the morning of 7/20/26. These medications are as follows:- Calcitriol Oral Capsule (Calcitriol) Give 0.25 mcg by mouth one time a day- Docusate Sodium Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth in the morning related to SLOW TRANSIT CONSTIPATION- Finasteride Oral Tablet (Finasteride (Alopecia)) Give 5 mg orally one time a day related to BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS- Furosemide Oral Tablet (Furosemide) Give 80 mg by mouth one time a day related to EDEMA- Lisinopril Oral Tablet (Lisinopril) Give 20 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION- oxyBUTYnin Chloride ER Oral Tablet Extended Release 24 Hour 10 MG (Oxybutynin Chloride) Give 10 mg orally one time a day for bladder spasms- Pioglitazone HCl Oral Tablet 45 MG (Pioglitazone HCl) Give 45 mg orally one time a dayrelated to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY- Triamterene-HCTZ Oral Tablet 37.5-25 MG (Triamterene & Hydrochlorothiazide) Give 1 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION- Keppra Oral Tablet (Levetiracetam) Give 500 mg orally two times a day related to CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS- traMADol HCl Oral Tablet 100 MG (Tramadol HCl) Give 100 mg by mouth two times a day for pain management per physician's order- Sodium Chloride Oral Tablet 1 GM (Sodium Chloride) Give 1 tablet by mouth three times a day related to HYPOOSMOLALITY AND HYPONATREMIAOn 8/13/26 at 10:05 AM, LPN #1 stated she had not given Resident #25 any of his morning medications following the initial medication error and the MAR had been checked as administered in error.ON 8/13/26 at 10:40 AM, the DON stated that LPN #1 had administered Resident #38's medications to Resident #25 in error on 7/20/26.On 8/13/26 at 1:27 PM, the Medical Director stated he had concerns about how medication errors occurred in the first place at the facility and that he had been working with the facility regarding their medication errors. Resident #38 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including right foot fracture and bipolar disorder.Resident #38's physician order for clonazepam read as follows:- clonazePAM Oral Tablet 1 MG (Clonazepam) Give 1 tablet by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9) -Start Date-7/17/26 1400-D/C Date-8/7/26 1505- clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED (F41.9) -Start Date-7/17/26 1900 -D/C Date- 8/7/26 1506.A facility's Medication/Treatment/Lab Error Report dated 7/29/26, documented that LPN #2 had administered 1 MG of clonazepam to Resident #38 at bedtime.On 8/13/26 at 10:45 AM, the DON stated that LPN #2 had administered 1 MG clonazepam to Resident #38 when it should have only been 0.5 MG clonazepam.

Based on staff interview, record review, policy review, and the State Operations Manual, Appendix PP, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for the facility and 1 of 2 residents (Resident #25) reviewed for medication administration. This deficient practice created the potential for harm should inappropriate care and/or treatment be provided based on inaccurate information in the residents' clinical record. Findings include: The facility's Medication Administration policy, revision date 9/10/25, documented all staff authorized to administer medications must follow the 10 Rights of Medication Administration to ensure resident safety, reduce medication errors, and maintain compliance with federal and state regulations. Procedures 2.f. Right Documentation i. Document promptly after administration in the Resident's medical record.The State Operations Manual, Appendix PP, dated 7/23/25, documented S483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including left hemiplegia (loss of function to one side of the body), dysphagia (inability or difficulty in swallowing), and diabetes. On 8/12/26 at 11:10 AM, during record review of Resident #25's July 2026 medication administration record, the following medications had been documented as administered to Resident #25 on the morning of 7/20/26:Ammonium Lactate External Cream 12% - administered at 7:15 AM to left arm and legCetirizine HCl 10 mgClopidogrel Bisulfate 75 mgDocusate Sodium 100 mgFerrous Sulfate 325 mgFinasteride 5 mgFurosemide 80 mgLantus 5 units - administered at 7:13 AM subcutaneously to right armLisinopril 20 mgOxybutynin Chloride ER 10 mgPantoprazole Sodium 40 mgPioglitazone HCl 45 mgTriamterene - HCTZ 37.5-25 mgKeppra 500 mgTramadol HCl 100 mgSodium Chloride 1 GmCalcitriol 0.25 mcgOn 8/13/26 at 10:56 AM, LPN #1 stated she had only administered Resident #25's insulin on the morning of 7/20/26 and should not have documented all morning medications had been administered because the medications had been placed back in the medication cart for administration after Resident #25 returned from breakfast. After Resident #25 returned to his room from breakfast he had not received the other medications, and the medications had been wasted.On 8/13/26 at 11:04 AM, the Clinical Resource RN stated LPN #1 should not have documented Resident #25's medications had been administered until after the resident had taken each medication.

Based on policy review, record review, and staff interviews it was determined the facility failed to ensure pertinent health information was provided to the receiving health facility for 5 of 9 residents (Resident #1, #3, #7, #11, and #28) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include:Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Progressive Supranuclear Ophthalmoplegia (Steele-Richardson-Olszewski syndrome) (a rare brain disorder causing progressive damage to balance, eye movement, and mobility) and pulmonary embolism (a blockage in a lung artery). An eINTERACT Transfer Form Version 5.0 dated 12/7/25, documented Resident #1 was discharged to the hospital for pain on right side of head after a fall. Resident #1's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for his 12/7/25 discharge. An eINTERACT Transfer Form Version 5.0 dated 12/20/25, documented Resident #1 was discharged to the hospital for bruising to back of head after a fall. Resident #1's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for his 12/20/25 discharge. An eINTERACT Transfer Form Version 5.0 dated 2/17/26, documented Resident #1 was discharged to the hospital for evaluation after falling and hitting head. Resident #1's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for his 2/17/26 discharge. Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Parkinson's disease (a progressive loss of nerve cells causing muscle weakness and tremors) and chronic kidney disease. An eINTERACT Transfer Form Version 5.0 dated 2/22/26, documented Resident #3 was discharged to the hospital for laceration on right leg. Resident #3's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 2/22/26 discharge. An eINTERACT Transfer Form Version 5.0 dated 3/26/26, documented Resident #3 was discharged to the hospital for laceration to left 3rd toe. Resident #3's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 3/26/26 discharge. The facility's Discharge or Transfer policy revision date 8/30/25, documented the facility will ensure the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting is provided in accordance with federal guidance. Resident #7 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including bipolar and anxiety. An eINTERACT Transfer Form V5 (an electronic tool that helps long-term care facilities effectively communicate critical resident information when transferring them to an acute care hospital) dated 9/21/25, documented Resident #7 was discharged to the hospital. Resident #7's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 9/21/25 discharge. An eINTERACT Transfer Form V5 dated 9/25/25, documented Resident #7 was discharged to the hospital. Resident #7's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 9/25/25 discharge. An eINTERACT Transfer Form V5 dated 10/19/25, documented Resident #7 was discharged to the hospital. Resident #7's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 10/19/25 discharge. An eINTERACT Transfer Form V5 dated 11/2/25, documented Resident #7 was discharged to the hospital. Resident #7's medical record had not included documentation that required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 11/2/25 discharge. 4. Resident #11 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD (a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea. An eINTERACT Transfer Form V5 dated 11/16/25, documented Resident #11 was discharged to the hospital for shortness of breath. Resident #11's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for his 11/16/25 discharge. An eINTERACT Transfer Form V5 dated 2/23/26, documented Resident #11 was discharged to the hospital for pain, diarrhea, and elevated heart rate. Resident #11'smedical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for his 2/23/26 discharge. An eINTERACT Transfer Form V5 dated 3/7/26, documented Resident #11 was discharged to the hospital. Resident #11's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for his 3/7/26 discharge. 5.Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including heart failure and COPD. An eINTERACT Transfer Form V5 dated 11/15/25, documented Resident #28 was discharged to the hospital due to altered mental status. Resident #28's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 11/15/25 discharge. An eINTERACT Transfer Form V5 dated 3/19/26, documented Resident #28 was discharged to the hospital due to chest pain. Resident #28's medical record had not included documentation that the required pertinent medical information including care plan goals and advance directive information was provided to the receiving hospital for her 3/19/26 discharge. On 4/2/26 at 10:54 AM, the CNO stated the nurses had completed the eINTERACT charting in Point Click Care but had not documented what forms were sent to the hospital with them and should have.

Based on interview, policy review, and staff interview, it was determined the facility failed to complete a baseline care plan for 2 of 2 residents (#4 and #70). This failure created the potential for harm when staff were not provided direction of care for resident. The facility also failed to provide a resident's baseline care plan to the resident or his/her representative for 5 of 7 residents (#7, #9, #11, #21, and #28) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan. Findings include:The facility's Baseline Care Plans policy, revised 9/3/25, documented the facility will initiate a baseline care plan for each resident within 48 hours of admission. The facility reviews and provides the resident and/or their representative with a summary of the baseline care plan and physician(provider) orders and in a language that the Resident and/or representative can understand. The medical record should contain evidence that the summary/orders were given to the Resident and/or Representative. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (a long-term, progressive inability of the lungs to oxygenate the blood sufficiently) and dementia. Resident #4's baseline care plan was signed and locked on 2/9/26, four days after being admitted to the facility. On 4/1/26 at 12:46 PM, the CNO stated Resident #4's baseline care plan should have been completed and locked within 48 hours of being admitted to the facility and had not been. Resident #70 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and need for assistance with personal care. Review of Resident #70's medical record had not document a baseline care plan. On 4/1/26 at 10:40 AM, the CNO stated Resident #70 did not have a baseline care plan. Resident #7 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including bipolar and anxiety. A Quarterly MDS assessment, dated 4/2/26, documented Resident #7 was cognitively intact. Resident #7's CSCD-Care Plan 48 Hour form dated 8/14/25, had not documented she or her resident representative received a copy of the baseline care plan. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a group of lung diseases that block airflow and make it difficult to breathe) and chronic kidney disease. A comprehensive MDS assessment, dated 2/24/26, documented Resident #9 was cognitively intact. Resident #9's medical record had not included documentation that a baseline care plan was provided and discussed with her or her resident representative. Resident #11 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD and obstructive sleep apnea. Resident #11's medical record had not documented that a baseline care plan was provided and discussed with him or his resident representative. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including interstitial lung disease (a group of over 200 disorders causing inflammation or scarring in the lung tissue between air sacs, making it difficult to breathe and get oxygen into the bloodstream) and heart failure. Resident #21's medical record had not documented that a baseline care plan was provided and discussed with him or his resident representative. Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including heart failure and COPD. Resident #28's medical record had not documented that a baseline care plan was provided and discussed with him or his resident representative. On 4/1/26 at 4:26 PM, the CNO stated there was no documentation that the residents or their representatives had received a copy of their baseline care plans.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and were secure and inaccessible to unauthorized staff and residents; this was true for 2 of 2 medication carts inspected and 1 of 1 treatment carts observed. This failure created the potential for residents to receive expired medications with decreased efficacy, the potential for adverse effects if residents self-administered medications inappropriately, and the potential for residents to obtain prescribed wound care supplies used for other residents and presented the risk for cross-contamination of wound care products stored in the treatment cart. Findings include:The facility's Medication Storage In The Facility policy effective date May 2019, documented the following: - All medications dispensed by the pharmacy are stored in the container with the pharmacy label. -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal (See Section IE: DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES), and reordered from the pharmacy (See IC#: ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS FROM THE DISPENSING PHARMACY), if the current order exists. - Certain medications or package types, such as IV solutions, multiple dose injectable vials, opthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require and expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. - No expired medication will be administered to a resident. - All expired medication will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 4/1/26 at 6:43 AM, medication storage observed of the Yellowstone Hall medication cart with LPN #1 present observed the following:- a bottle of eye drops with the illegible label and an open date of 12/20/25.- a bottle of eye drops with the illegible label and an open date of 2/20/26.- a bottle of glucose strips with no open date. On 4/1/26 at 6:56 AM, LPN #1 stated the eye drops are good for 30 days after opening and should have been wasted. The label is also faded and can't be read so the drops should not be used. The glucometer strips are good for 30 days after opening and should be thrown away since they were not dated when they were opened. On 4/1/26 at 9:47 AM, the CNO stated the eye drop bottles should be dated with open date and he would have to check the pharmacy policy on how long they are good for. On 4/1/26 at 3:22 PM, observed the treatment cart unlocked outside room [ROOM NUMBER]. On 4/1/26 at 3:28 PM, LPN #3 stated the treatment cart had medicated creams in it and should have been locked. On 4/2/26 at 9:57 AM, medication storage observation completed of the Mesa Falls Hall medication cart with RN #5 present observed the following: - undated bottle glucose test strips On 4/2/26 at 10:04 AM, RN #2 stated the test strips should have been dated when open and she was not sure how long they were good for after opening.

Based on record review, observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 1 resident (Resident #12) and the facility observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include: The facility's Oxygen Administration, Safety, Storage & Maintenance policy, revision date 8/4/23, documented under Infection Control: - Change oxygen supplies weekly and when visibly soiled. - Store oxygen and respiratory supplies in bag labeled with resident's name when not in use.The facility's Inhalant (Nebulizer) Medication Administration policy revision date 9/16/25, documented the facility was to:- Follow standard of practice for medication administration, including the rights and infection prevention intervention, in addition to documentation requirements in the medical record.- Rinse nebulizer cup and mouthpiece/mask with warm water after use.- Air dry all parts on a clean paper towel in a designated area.The [NAME] TRUE METRIX Pro Glucose Meter manual, undated, documented: With ONLY PDI Super Sani Cloth Wipes (or any disinfectant product with the EPA* reg. no. of 9480-4), rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. (*Environmental Protection Agency.) 3. To Disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes. Make sure no liquids enter the Test Port or any other opening in the meter.The following was observed for oxygen supplies storage: On 3/30/26 at 8:14 AM, Resident #37's CPAP was observed lying on his dresser, not covered. On 3/30/26 at 8:54 AM, Resident #14's nebulizer mask was observed hanging on her walker, not covered. On 3/30/26 at 9:00 AM, Resident #20's oxygen nasal cannula lying on the floor. On 3/30/26 at 9:11 AM, RN #6 stated Resident #20's oxygen tubing should not have been on the floor, it should have been in the oxygen bag, and the nebulizer should not be stored on the walker. On 3/30/26 at 9:12 AM, Observed RN #6 place Resident #20's oxygen tubing in her oxygen bag without cleaning it and then she placed her nebulizer mask on the dresser. On 3/30/26 at 9:22 AM, Resident #28's BIPAP mask was observed lying on the dresser, not covered. Resident #28's oxygen tubing was observed draped over her wheelchair, not covered. On 3/30/26 at 9:37 AM, Resident #9's VPAP mask was observed lying over the machine, not covered. On 4/1/26 at 11:19 AM, the IP stated a resident's oxygen tubing should be bagged when not in use and not on the floor. The nebulizer masks should be cleaned and dried after each use then put away. CPAP/BIPAP/VPAP should be cleaned and set up to be used at night. The following was observed for blood glucose monitoring: On 4/1/26 at 7:07 AM LPN #1 checked Resident #45's blood sugar using a glucometer and then wiped down the glucometer using a Sani wipe (disinfecting wipe) and then placed the glucometer back in the baggie. On 4/1/26 at 7:10 AM, LPN #1 stated the glucometer was used for multiple residents. LPN #1 stated the dry time for the sani wipe is 2-minutes but she did not realize it had to remain wet for 2 minutes. Resident #12 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease process causing decreased lung functionality), depression, and cardiomegaly (an enlarged heart). Resident #12's physician oxygen order dated 3/9/26, documented oxygen 3 LPM continuously per nasal cannula via O2 concentrator and/or tank. On 4/2/26 at 10:37 AM, observed Resident #12 in her room not wearing her oxygen nasal cannula. On 4/2/26 at 10:42 AM, observed CNA #13 enter Resident #12's room, CNA picked up the oxygen nasal cannula off the floor and assisted Resident #12 in placing her nasal cannula. On 4/2/26 at 10:45 AM, CNA #13 stated the oxygen nasal cannula and tubing should have been discarded and replaced before giving it to Resident #12. On 4/2/26 at 1:55 PM, the CNO stated oxygen supplies should be discarded and replaced weekly as ordered or when the supplies have been found on the floor and had not been.

Based on observation, policy review, and interviews it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 2 of 2 Residents (#23 and #70) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Findings include:The facility's Dignity policy dated 9/12/25, documented each resident has the right to be treated with dignity and respect. Under 2. Promoting resident independence and dignity while dining, such as avoiding: h. refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered.Resident #70 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and need for assistance with personal care. On 3/30/26 at 12:02 PM, CNA #13 had removed Resident #70's shirt without pulling the privacy curtain. Resident #70's roommate was on her side of the room at this time and had observed Resident #70's shirt being removed. On 3/30/26 at 12:15 PM, Resident #70 stated she usually pulls the curtain so her roommate cannot see her being changed but she forgot. On 3/30/26 at 12:19 PM, CNA #13 stated she should have provided privacy to Resident #70 before she took her shirt off. Resident #23 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including enterocolitis due to clostridium difficile (a severe, often antibiotic-associated inflammation of the intestines caused by toxin-producing bacteria) and chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness). On 3/30/26 at 2:53 PM, observed from the hallway, Resident #23's catheter bag, without a privacy bag or cover, was hanging on the left side of her bed, with the door open to her room and visible from the hallway. On 3/31/26 at 11:03 AM, RN #1 stated Resident #23's catheter bag had not been covered because the resident had just gotten back into her room, and the CNA must have forgotten to cover the bag. On 4/1/26 at 12:42 PM, the CNO stated Resident #23's catheter bag should have been covered or in a privacy bag and had not been.

Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 1 of 3 residents (Resident #12) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications. Findings include:Resident #12 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease process causing decreased lung functionality), depression, and cardiomegaly (an enlarged heart). A physician order dated 11/27/25, documented Resident #12 was to start Aripiprazole 5 mg by mouth one time per day. On 4/1/26 at 9:48 AM, the CEO presented the surveyor with Resident #12's signed Psychoactive Medication Informed Consent document dated 1/16/26, listing Aripiprazole 5mg, Buproprion 150mg, and Fluoxetine 40 mg.On 4/1/26 at 9:49 AM, the CEO stated, Resident #12 should have signed a Psychotropic Medication Acknowledgement Consent prior to administration of Aripiprazole but had not.

Based on observation, resident and staff interviews, record review, and policy review it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 1 of 1 resident (Resident #59) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident. Findings include: The facility's Self-Administration of Medication policy revised 9/16/25, documented residents may self-administer medications when it is determined to be safe and appropriate.the assessment will include whether bedside storage is appropriate.if self-administration is approved, a physician's order will be obtained and the care plan updated.Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including paraplegia (paralysis of the lower extremities) and depression. On 3/30/26 at 10:07 AM, observed in Resident #59's room one bottle of Artificial Tears eye drops and one bottle of Prednisolone Acetate eye drops sitting on resident's side table. On 3/30/26 at 10:22 AM, LPN #1 stated Resident #59 should not have had the Artificial Tears and Prednisolone Acetate eye drops at his bedside. On 3/30/26 at 1:27 PM, review of Resident #59's medical record documented the IDT self-administration assessment dated , 3/17/26, under A. Assessment Criteria 15. Can correctly administer eye drops or eye ointments according to proper procedure, 'Not applicable' was highlighted. On 3/30/26 at 2:06 PM, Resident #59's medical record included physician orders for:- Prednisolone Acetate ophthalmic suspension 1%, start date 3/19/26- Artificial Tears ophthalmic solution 0.2-0.2-1%, start date 3/20/26 On 3/31/26 at 5:17 PM, the CNO stated Resident #59 should not have had eye drops at his bedside and had not been approved by IDT for self-administration of eye medications.

Based on record review and staff interview it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 22 residents (Resident #8) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the residents wishes were not followed or documented regarding their advance care planning. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (paralysis of upper and lower limbs) and depression.On 3/31/26 at 9:02 AM, Resident #8's medical record contained a POST but had not documented an advance directive or documentation the facility informed or provided written information concerning the right to formulate an advance directive.On 3/31/26 at 10:48 AM, the Administrator provided the surveyor with a document titled, Understanding Advance Directives, with documented resident verbal consent and cosigned by two staff members dated 3/31/26. On 3/31/26 at 10:49 AM, the Administrator stated the facility only had POST documents for Resident #8.

Based on observations and interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 2 of 22 resident rooms (#211 and #212), shower rooms, and other areas throughout the facility which were observed. This deficient practice created the potential for diminished quality of life and resident safety. Findings include:The following areas were observed for clean and homelike environment: On 3/30/26 at 4:09 PM, observed Resident room [ROOM NUMBER]:Room door frame protective molding torn with sharp jagged edges. On 3/31/26 at 2:08 PM, observed Resident room [ROOM NUMBER]:Electrical wall outlet broken with jagged edges. On 4/1/26 observed:a.Grand Teton Hall - Shower room tile floor with broken tile and missing grout at entry door. b.Palisades Hall - Shower room wall heater with broken and rusted areas to the front and sides of the heater. The heater base broken with jagged edges and partially disconnected from the floor. The tile floor with dark black residue in the grout and around the floor drain. Several broken floor tiles in the middle of the shower room with open divets and dark black residue in the opened exposed areas. c.Mesa Hall - Shower room wall heater cover removed and lying on the floor next to the heater. Wall heater with exposed wire on the bottom side of the heater. On 4/1/26 at 4:23 PM, CNA #14 stated the shower rooms do not look like they have been cleaned and should have been. On 4/2/26 at 10:26 AM, accompanied by the Maintenance Director observed Palisades Hall shower room stall with large amount of dark strands of hair in the drain and on the shower stall floor. On 4/2/26 at 10:30 AM, the Maintenance Director stated he was unaware of the needed repairs to room [ROOM NUMBER]'s door frame molding, room [ROOM NUMBER] electrical outlet, the heaters needed to be repaired, and the shower rooms do not look like they have been cleaned and should have been.

Based on record review and staff interview, it was determined the facility failed to ensure residents' hospital discharge instructions were reviewed upon admission to the facility to assure physician orders were in place to meet their medical needs. This was true for 2 of 2 residents (#9 and #37) whose records were reviewed. This failure placed these residents at risk of delayed respiratory care and assessments. Findings include:1. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (tissues are deprived of adequate oxygen causing shortness of breath) and obstructive sleep apnea.On 3/30/26 at 8:14 AM, observed in Resident #37's room, sitting on his dresser, a CPAP machine (a mask and air pump to keep airways open during sleep).On 3/30/26 at 8:16 AM, Resident #37 stated he uses the CPAP machine at night.On 4/2/26 at 10:48 AM, the CNO stated Resident #37 did not have an order for his CPAP, it was not on his care plan or on his MDS and should have been. 2. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including COPD and Chronic Kidney Disease.On 3/30/26 at 9:37 AM, observed in Resident #9's room, next to her bed, an AVAP machine (a non-invasive ventilator that automatically adjusts pressure support to maintain a target tidal volume, ensuring consistent breathing support for patients with chronic respiratory failure).On 3/30/26 at 9:43 AM, Resident #9 stated she uses the AVAP machine at night to help her breath while she sleeps.Review of Resident #9's hospital Transfer Orders dated 2/9/26, documented, AVAP Max IPAP 16-19 cmH20 Min IPAP 6-9 cmH2) Max EPAP 12-14 cmH2) Min EPAP 6-12 cmH20 Rate 8-12 BPM Tidal volume 380 ml O2 bleed in at 2-8 liters with humidification to maintain spo2 89-90% Q shift on at HS and off in AM.On 3/31/26, Resident #9's medical record had not documented a physician orders for her AVAP machine use.On 4/1/26 at 10:49 AM, the CNO stated the AVAP was not on Resident #9's orders and should have been.

Based on observation, interview, and record review, it was determined the facility failed to complete a significant change in condition or status assessment MDS within 14 days to accurately reflect the resident's status. This was true for 1 of 1 resident (Resident #4) whose medical record was reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments. Findings include:Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (a long-term, progressive inability of the lungs to oxygenate the blood sufficiently) and dementia.Resident #4's physician order dated 2/19/26, documented End of Life Care: Hospice Services.Resident #4's care plan documented hospice care started 2/19/26.On 3/31/26 at 5:10 PM, the MDS coordinator stated the facility had not completed a significant change in condition or status assessment MDS within 14 days of Resident #4 starting on Hospice care and should have.On 4/1/26 at 12:44 PM, the CNO stated the significant change in condition or status assessment MDS should have been completed on Resident #4 within 14 days of starting on Hospice care and had not been.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR I), was completed correctly for 1 of 1 resident (Resident #13) reviewed for Level 1 PASARR screenings. This failure created the potential for harm if residents required, but did not receive specialized services for mental health while residing in the facility. Findings include:The facility's Pre-admission Screening and Resident Review (PASRR) Process dated 8/29/25, documented under Procedure1. Ensure Level I PASRR screening has been completed on potential admissions prior to admission. 2. A negative Level I screen permits admission to proceed and end (the) PASRR process during the initial admission process. 3. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II. 3a. When a Level II PASRR screening is warranted, it should be obtained (as well as determination letter) prior to admission.Resident #13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including post-traumatic stress disorder and joint replacement surgery aftercare.Resident #13's Level 1 PASRR dated 3/3/26 and 3/13/26, had not documented he had Post-Traumatic Stress Disorder and anxiety disorders which would have triggered the need for a Level II PASRR.Resident #13's medical record dated 3/3/26, documented medical diagnosis of Post-Traumatic Stress Disorder, Chronic.On 3/30/26 at 12:00 PM, Resident #13 medical record had not documented a Level II PASRR had been completed.On 3/31/26 at 2:00 PM, the Resident Support Services Assistant stated the Level II PASRR dated 3/30/26, had just been completed and faxed to Mental Health for review.

Based on observation, policy review, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #13) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include:The facility's Comprehensive Care Plan and Conferences policy dated 9/3/25, documented the care plan will reflect the residents' individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes.Resident #13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including post-traumatic stress disorder and joint replacement surgery aftercare.Resident #13's medical record dated 3/3/26, documented medical diagnoses of Post-Traumatic Stress Disorder, Chronic.On 3/31/26 at 2:09 PM, Resident #13's care plan had not addressed his Post-Traumatic Stress Disorder diagnosis with any focus or interventions/tasks. On 4/1/26 at 12:47 PM, the CNO stated Resident #13's Post-Traumatic Stress Disorder diagnosis should have been care planned and had not been.

Based on observation, interview, policy review, and record review, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 22 residents (#2 and #12) whose care plans were reviewed. This placed residents at risk for 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 Resident Care Plan Revisions policy, revision date 9/3/25, documented.updates to the care plan will occur as needed based on the residents' response to interventions or changes in condition. Resident #2 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fracture of the right tibia (lower leg bone) and anxiety. On 3/30/26 at 8:19 AM, Resident #2's physician order dated 3/6/26 - Edema Management Right lower leg: edema, apply Tubi grip on AM, off PM. On 3/30/26 at 11:33 AM, observed Resident #2 sitting in her room not wearing a Tubi grip to her right lower leg. On 4/1/26 at 3:38 PM, during interview Resident #2 stated her right lower leg is swollen and has been for a while. On 4/2/26 at 10:33 AM, observed Resident #2 sitting in her room not wearing a Tubi grip to her right lower leg. On 4/2/26 at 11:06 AM, reviewed Resident #2's care plan with no documentation regarding Tubi grip to right lower leg. On 4/2/26 at 11:07 AM, Resident #2's TAR reviewed with no documentation regarding Tubi grip to right lower leg. On 4/2/26 at 1:17 PM, the CNO stated Resident #2's care plan and TAR should have been updated when the resident received physician orders for the Tubi grip and had not been. Resident #12 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease process causing decreased lung function), depression, and cardiomegaly (an enlarged heart). Resident #12's medical record documented physician order dated 3/9/26, Oxygen at 3LPM continuously per nasal cannula via O2 concentrator and/or tank. On 4/1/26 at 4:22 PM, review of Resident #12's care plan documented Oxygen Settings: -O2 via nasal prongs at 0-4L prn to maintain saturation at 90% or greater - date initiated 2/10/25.-Oxygen 2L/min continuously via NC - date initiated 6/24/25. On 4/1/26 at 4:25 PM, the CNO stated Resident #12's care plan should have been updated with the oxygen order dated 3/9/26, and had not been.

Based on record review, policy review, and staff interview it was determined the facility failed to ensure physician orders were followed. This was true for 2 of 3 residents (#3 and #21) reviewed for quality of care. This failed practice placed residents at risk for discomfort and adverse effects, including potential for infection. Findings include:The facility's Standing Order - Bowel Protocol, signed date 12/18/25, documented: -Bowel Protocol Step 1: Senna 8.6mg 3 tablets PO at HS for constipation lasting >72 hours. -Bowel Protocol Step 2: Bisacodyl (Dulcolax) 5mg 3 tablets PO at HS for constipation lasting >96 hours.-Bowel Protocol Step 3: Bisacodyl (Dulcolax) suppository 10mg 1 suppository rectally at 10:00 for continued constipation morning after tablets.-Bowel Protocol Step 4: Fleets enema rectally at 12:00 for continued constipation 2 hours after suppository.-Special instructions: If no BM produced within 2 hours of enema, Call MD for further instruction.The facility's Infusion Therapy Responsibilities and Scope of Practice policy, revision date July 2016, stated:- Nursing Responsibilities in Infusion Therapy* Performing functions and procedures that are consistent with current standards of care, facility policies and procedures, and that are within the scope of the state nurse practice act. * Understanding of aseptic and sterile techniques and maintaining infusion equipment and medications in a way to avoid contamination. - Nursing Functions Specific to Infusion Therapy * Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, site rotation (for short peripheral catheters only), changing IV tubing and needleless connection devices. - Infusion Services/Product Provider Responsibilities in Infusion Therapy * Following stringent infection control procedures during preparation and distribution of infusion therapy products. Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Parkinson's disease (a progressive loss of nerve cells causing muscle weakness and tremors) and chronic kidney disease. Resident #3's medication administration record documented Resident #3 had the following medication orders; Senna Tablet 8.6 mg – give 1 tablet by mouth as needed for Bowel Protocol Step #1 – if no BM in 72 hours (Day 3). Order date 2/26/25. Bisacodyl Oral Tablet Delayed Release 5 mg – give 5 mg by mouth as needed for Bowel Protocol Step #2 – No BM in 96 hours (Day 4). Order date 2/26/25. Bisacodyl Rectal Suppository 10 mg – insert 1 suppository rectally as needed for Bowel Protocol Step #3 - if no BM by 10:00 following day after (Day 5) oral Bisacodyl. If no BM after 2 hours of suppository, give Fleet enema. Order date 2/26/25. Fleet Enema Rectal Enema (Sodium Phosphates) – insert 1 application rectally as needed for Bowel Protocol Step #4 – if no result 2 hours after suppository administer Enema. If no BM within 2 hours of enema, call MD for further instructions. Order date 2/26/25. On 3/30/26 at 2:01 PM, Resident #3's medical record documented she had a BM on 3/17/26 at 13:16 and not again until 3/22/26 at 13:58, over 96 hours later with no bowel management medications documented on the MAR as being administered between 3/20/26 and 3/22/26. On 3/30/26, Resident #3's medical record had not documented in the nursing progress notes that her physician had been contacted 3/21/26 through 3/22/26, regarding no BM for over 96 hours. On 4/2/26 at 10:41 AM, the Regional Clinical Specialist stated nursing staff had documented Resident #3's bowel care medication refusals for 3/20/26 and 3/21/26 on the Bowel Care List worksheet and had not documented on the MAR or in the progress notes and should have. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including interstitial lung disease (a group of over 200 disorders causing inflammation or scarring in the lung tissue between air sacs, making it difficult to breathe and get oxygen into the bloodstream) and heart failure. On 3/30/26 at 8:26 AM, observed a PICC line to Resident #21's right upper extremity. The dressing to his PICC line site had not been dated. The edges of the PICC line dressing were loose. The PICC line tubing had not been secured. On 3/31/26 at 9:33 AM, LPN #2 stated there was no date on Resident #21's PICC line dressing and it should have been dated. LPN #2 also stated she was not working when the PICC line was put in and was not sure if it was still being used. Review of Resident #21's medical record documented a physician's order dated 2/25/26, for Ertapenem Sodium Injection Solution Reconstituted 1 GM (broad-spectrum antibiotic). Use 1 gram intravenously in the morning for sepsis r/t pneumonia until 3/1/26. On 3/31/26 at 9:38 AM, RN #4 stated she could not find orders for Resident #21's PICC line. She also stated the PICC line may have been discontinued but either way the PICC line should of been removed or had orders for it.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #59) reviewed for enteral tube use. This created the potential for harm if complications developed from improper medication administration via enteral access device practice. Finding include:The facility's Medication Administration Enteral Assess Device policy, release date 9/16/25, directed staff to follow the general professional standards for safe administration of medications and verify tube placement per facility protocol.Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and dysphagia (difficulty swallowing).Resident #59's physician's order dated 1/21/26, documented Enteral Tube: May Crush meds or use liquid form via tube. Check tube placement via auscultation prior to medication administration. On 4/1/26 at 9:00 AM, observed RN #2 administered 30 milliliters of water in Resident #59's enteral tube. RN #2 then placed 20 milliliters of hydroxyzine HCl liquid (anti-anxiety medication) in his enteral tube. RN # 2 then flushed Resident #59's enteral tube with 30 milliliters of water. RN #2 did not verify tube placement prior to medication administration.On 4/1/26 at 9:12 AM, RN #2 stated she was not sure what the facility's policy was on checking tube placement and residual prior to administering medication.On 4/1/26 at 9:46 AM, the CNO stated the facility's g-tube policy does not state to check residual or placement before feedings or medication administration. Placement is checked with a x-ray when it is put in only.

Based on observation, policy review, manufacturer's PAP user manual, interview, and record review, the facility failed to ensure 3 of 4 Residents (#12, #13, and #53) received respiratory services as prescribed by the physician. This created the potential for residents to experience respiratory difficulties and impaired breathing. Findings include:The facility's BiPAP/CPAP Administration policy dated 9/12/25, documented the facility will provide non-invasive ventilation (NIV) using BiPAP or CPAP therapy in accordance with physician orders and professional standards of practice.[NAME] PAP therapy user manual undated, documented under oxygen safety information, when using oxygen with this system, a [NAME] Respironics pressure valve must be placed in-line with the user circuit between the device and the oxygen source. The pressure valve helps to prevent the back flow of oxygen from the user circuit into the device when the unit is off. Failure to use the pressure valve could result in a fire hazard. When using oxygen with this system, turn the device on before turning on the oxygen. Turn the oxygen off before turning the device off. This will prevent oxygen accumulation in the device. Explanation of the Warning: When the device is not in operation and the oxygen flow is left on, oxygen delivered into the tubing may accumulate within the device's enclosure. Oxygen accumulated in the device enclosure will create a risk of fire.Resident #12 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease process causing decreased lung functionality), depression, and cardiomegaly (an enlarged heart). Resident #12's physician oxygen order dated 3/9/26, documented oxygen 3 LPM continuously per nasal cannula via O2 concentrator and/or tank. On 3/30/26 at 9:27 AM, observed Resident #12 in her room not wearing her oxygen nasal cannula. On 4/1/26 at 3:27 PM, observed Resident #12 in her room not wearing her oxygen nasal cannula. On 4/2/26 at 10:37 AM, observed Resident #12 in her room not wearing her oxygen nasal cannula. On 4/2/26 at 12:52 PM, the CNO stated Resident #12 should have had her oxygen nasal cannula on continuously as ordered and had not. Resident #13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including post-traumatic stress disorder and joint replacement surgery aftercare. 3/30/26 at 11:26 AM, observed with RN #3 present, Resident #13's oxygen concentrator was turned on with 3 1/2 lpm being bled into the CPAP device however the CPAP device was not turned on. A [NAME] Respironics pressure valve had not been installed on Resident #13's PAP device. Resident #13's TAR for CPAP setting were documented as CPAP Settings: CPAP with 2L/min at HS. CPAP settings at 7cm H2O, Ramp: 15 via full face mask CPAP- Fill humidifier with purified water at HS, every night shift related to obstructive sleep apnea (ADULT) dated 3/14/26. Resident #13's physician oxygen order dated 3/27/26, documented oxygen @ 3 liters via NC every shift related to obstructive sleep apnea (ADULT). On 3/30/26 at 8:45 AM, observed Resident #13 had not been using his O2 when visited. On 3/31/26 at 11:00 AM, observed Resident #13 had not been using his O2 when visited. On 3/31/26 at 11:10 AM, RN #2 stated Resident #13 does not use his oxygen during the day and asked if there was an order for him to do so. Resident #53 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including acute osteomyelitis of right ankle and foot (serious, often chronic bone infection (usually Staphylococcus aureus) requiring prompt treatment to prevent permanent damage) and lumbar vertebra fracture. On 3/30/26 at 1:01 PM, observed Resident #53 had not been using the oxygen when the surveyor visited. Resident #53's medical record documented SpO2 on 3/29/26 at 10:21 of 88%, and on 3/30/26 at 10:57 of 88%, with both times documented he had not been on his supplemental oxygen and was using room air only. Resident #53's physician oxygen order was for 2 lpm continuously per nasal cannula to keep oxygen saturations at or above 90%. Resident #53's care plan documented monitor respiratory status and oxygen saturation, and oxygen at 2 LPM continuously per nasal cannula to keep oxygen saturation at or above 90%. On 4/2/26 at 10:46 AM, the CNO stated nursing staff should have made sure Resident #13 and Resident #53 were using their oxygen per physician's order, Resident #53's oxygen should not be allowed to bleed into the PAP device when it was not in use, and he was not aware of the requirement of the [NAME] Respironics pressure valve and was not aware if any PAP devices in the facility had the pressure valve.

Based on policy review, observation, record review, and interviews, it was determined the facility failed to provide adequate pain management. This was true for 1 of 1 resident (Resident #53) whose medical record was reviewed. This failure created the potential for residents to experience continual pain and distress. Findings include:The facility's Pain Assessment and Management policy dated 9/2/25, documented under Procedure, Pain Management, 2. The facility should address/treat the underlying causes of the pain, to the extent possible, a. developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management.Resident #53 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including acute osteomyelitis of right ankle and foot (serious, often chronic bone infection (usually Staphylococcus aureus) requiring prompt treatment to prevent permanent damage) and lumbar vertebra fracture.Resident #53's physician order dated 2/11/26, and 3/20/26, documented Hydrocodone-Acetaminophen Oral Tablet 5-325 MG, every 4 hours as needed.Resident #53's care plan dated 11/10/25, documented facility will attempt non-pharmacological pain intervention as part of treatment plan.On 3/30/26 at 1:38 PM, Resident #53's MAR documented no attempt to use non-pharmacological pain management prior to administering pain medications on 3/17/26, 3/18/26, 3/20/26, 3/23/26, 3/24/26.On 4/1/26 at 3:50 PM, the CNO stated Resident #53 should have had non-pharmacological pain management offered prior to administering the hydrocodone medication and had not been.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 4 residents (#1 and #3) reviewed for medication errors. This deficient practice created harm for one resident (Resident #1) who was hospitalized , and the potential for harm for one resident (Resident #3), due to receiving the wrong medications. Findings include: The facility's Medication Errors policy and procedure, release date 11/28/2017, documented a medication error as the administration of drugs or biologicals which is not in accordance with prescribers' orders, manufacturers specifications, and accepted professional standards. Significant Medication Error as one which causes the resident discomfort or jeopardizes his or her health and safety. 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), high blood pressure, and dysphasia (difficulty swallowing). A progress note dated 8/4/24 at 11:30 PM, by LPN #1, documented Resident #1 was transferred to the hospital via EMS (Emergency Medical Services) with noted changes in condition (altered mental status, decreased oxygen levels, and decreasing blood pressure) after being administered Resident #2's medication. On 8/13/2024 at 10:22 AM, LPN #1 was interviewed, she stated, on the evening of 8/4/24, she was assigned to work a hall unfamiliar to her. She recalled LPN #4 informing her during hand-off report, of Resident #2's room change within the same hall. LPN #1 stated, later that shift during her medication pass, she prepared Resident #2's medications by crushing them and adding them to applesauce. The medications included: - Benztropine Mesylate, 1 mg, an anti-tremor Parkinson's medication - Bupropion HCl, 75 mg, an anti-depressant - Clonazepam, 1 mg, a long-acting tranquilizer for anxiety - Donepezil HCl, 10 mg, an Alzheimer's medication to treat dementia - Doxycycline Hyclate, 100 mg, an antibiotic - levothyroxine, 50 mcg, a hormone to treat hypothyroidism (contraindicated in those with high blood pressure) - Memantine,10 mg, medication to treat dementia. She took the prepared medications to Resident #2's previous room which was empty. She then stored the medications in the medication cart until she could locate Resident #2's new room. LPN #1 stated she continued her medication rounds and prepared Resident #1's evening medications which included one Lipitor tablet (a cholesterol-lowering medication), which she refused. When LPN #1 returned the Lipitor to the medication cart, she noticed the medications she had prepared earlier for Resident #2, who had the same first name as Resident #1. LPN #1 stated she confused Resident #1 for Resident #2 and took the prepared medications, stored for Resident #2, to Resident #1, who accepted and took the medications. LPN #1 stated, a few minutes later, she noticed Resident #2's new room across the hall and realized she had given her medications to the wrong resident. Hospital notes, dated 8/5/24, documented Resident #1 was brought in due to receiving the wrong medications at the skilled nursing facility. The hospital documented Resident #1 had atrial fibrillation (a type of irregular heart rhythm which prevents blood from flowing properly to the lower chambers of the heart), tachycardic (fast heart rate) and hypotension (low blood pressure) when she arrived at the hospital. On 8/13/24 at 12:39 PM, the DNS and Regional Clinical RN were interviewed together and confirmed that Resident #1 was given Resident #2's medications then transferred to the hospital for further monitoring. 2. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease, chronic kidney disease, fibromyalgia, and diabetes. A Medication Error Report, dated 8/13/24, documented a medication error occurred on 8/11/24 at 6:20 PM when LPN #3 reported she may have given Resident #3 the wrong insulin. Resident #3's insulin order was for NovoLog (a rapid-acting insulin) per sliding scale at meals and bedtime, and LPN #3 may have given Lantus (a long-acting insulin) instead. She immediately reported the suspected error to Resident #3's physician who ordered blood sugar monitoring every 6 hours for 24 hours. On 8/13/24 at 5:33 PM, LPN #3 was interviewed regarding the medication error. She stated she checked Resident #3's blood sugar and followed up by giving her an insulin dose, then was not sure if she administered Lantus or Novolog so she notified the physician immediately and started to monitor Resident #3 for adverse symptoms. Resident #3's record documented she did not require further medical interventions for a change in condition. On 8/13/24 at 12:39 PM, the DNS and Regional Clinical RN were interviewed and confirmed LPN #3 was not sure which insulin she gave Resident #3 on 8/11/24.

Based on observation, review of nurse schedules, staff interview, and policy review, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19 infections. This failure placed all staff in the facility, and all residents on the non-COVID units in the facility, in immediate jeopardy of serious harm, impairment, or death related to COVID-19 infection. Findings include: 1. The CDC website, accessed on 10/26/20, included a section titled Responding to Coronavirus in Nursing Homes, which stated facilities were to assign dedicated healthcare professionals (HCP) to work only on the COVID-19 positive unit. The website also included Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which stated dedicated means HCP are assigned to care only for COVID-19 positive patients during their shift. The facility's Cohorting Plan, updated 10/12/20, documented the Red Zone housed residents who were COVID-19 positive, the Green Zone housed residents who were COVID-19 negative, and the Gray Zone housed residents who were under a 14-day quarantine. It further stated when possible, staff should be dedicated to the Red Zone and the facility should avoid assigning staff working in the Red Zone to the Green or Gray Zone. This policy and guidance was not followed. Staff were observed working in the COVID-19 positive unit, the COVID-19 negative unit, and the quarantine unit as follows: - On 10/21/20 at 9:24 AM, LPN #1 exited the COVID-19 positive unit. She doffed (took off) her PPE and entered the COVID-19 negative unit. On 10/21/20 at 10:59 AM, LPN #1 exited the COVID-19 positive unit into the COVID-19 negative unit. She doffed her PPE, then entered Resident #3's room in the COVID-19 negative unit. On 10/21/20 at 11:37 AM, LPN #1 was in the hall of the quarantine unit and said she was the nurse that shift for the COVID-19 positive unit, the quarantine unit, and another hall with COVID-19 negative residents. She said she went back and forth to each of the units throughout her shift and had already been in the COVID-19 positive unit twice that day and had worked with residents in the COVID-19 negative and quarantine unit too. - On 10/21/20 at 10:37 AM, CNA #1, who was previously observed in the COVID-19 positive unit and the COVID-19 negative unit, was in the quarantine unit and entered Resident #8's room. On 10/21/20 at 10:40 AM, CNA #1 said she was working the COVID-19 positive unit and assisted in the COVID-19 negative unit and quarantine unit. She said she went back and forth to each of the units throughout her shift assisting residents with their needs. The Nurses' Schedule, dated 10/2/20 to 10/21/20, documented one licensed nurse and two CNAs were assigned to work Station 3 which included the COVID-19 positive unit, part of the COVID-19 negative unit, and the quarantine unit. On 10/21/20 at 9:40 AM and 11:00 AM, the Administrator said the facility did not have dedicated staff for the COVID-19 positive unit. He said there were two residents in that unit until the day before when one of the residents was transferred to the hospital. He said the same nurse and CNA who worked in the COVID-19 positive unit also worked in the COVID-19 negative unit and the quarantine during the same shift. The Administrator said facility staffing was, Nowhere near the critical level. On 10/21/20 at 3:15 PM, the ICP said she had discussed with administration about having dedicated staff for the COVID-19 positive unit and she said she was told by the Administrator there was not enough staff. She said the same nurse and CNA who worked with residents in the COVID-19 positive unit also worked in the COVID-19 negative unit and the quarantine unit during the same shift. 2. The CDC website, accessed on 10/26/20, included a section titled Preparing for COVID-19 in Nursing Homes, which stated HCP working in quarantine units were to wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. The section also stated, Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. The CDC website also included a section titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which stated HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. HCP are to wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. The facility was located in a county with a positivity rate in the red as reported to the CMS.data.gov website for the week ending 10/21/20, website accessed on 11/4/20. This meant there was high community activity or spread of COVID-19. The facility's Cohorting Plan, updated 10/12/20, directed staff in the Green Zone (COVID-19 negative unit) to wear surgical masks with or without eye protection when taking care of these residents and in the Gray Zone (quarantine unit) to wear surgical masks, eye protection, a gown, and gloves when taking care of these residents. The facility's plan did not include the use of N95 masks for residents in the quarantine unit following guidance by the CDC. This policy and guidance was not followed. a. A sign was posted, just past the facility's lobby, which stated Green Zone (COVID-19 negative unit) and directed staff to wear a surgical/procedure mask at all times. Staff were observed wearing cloth face masks in the facility, as follows: - On 10/21/20 at 9:54 AM, the Maintenance Director was in the COVID-19 negative unit while wearing a cloth mask. The Maintenance Director said he had on a cloth mask with two layers. He said he could go into residents' rooms in the COVID-19 negative unit with the cloth mask. He said he would wear a surgical mask or N95 mask with eye protection when going into residents' rooms in the quarantine unit. - On 10/21/20 at 10:00 AM, the LSW was in the COVID-19 negative units wearing a cloth mask. She said she went into residents' rooms in the COVID-19 negative units with the cloth mask. The LSW said she went into rooms in the quarantine unit with a cloth mask and added a face shield or goggles. - On 10/21/20 at 12:05 PM, the ICP was wearing a cloth facemask. b. The quarantine unit had a sign outside in the hallway directing staff to use PPE when caring for residents in this unit. The sign directed staff to wear surgical/procedure masks and eye protection and to wear gloves and a gown as needed. The sign did not meet CDC guidance or follow the facility's policy. Staff were observed as follows: - On 10/21/20 at 10:28 AM, PTA #1 had on a surgical mask and eye protection and put on gloves and went into Resident #7's room. PTA #1 did not put on a gown. On 10/21/20 at 11:22 AM, PTA #1 said she did not put on gown while helping Resident #7 with therapy. PTA #1 said she thought she only needed to put on a gown if she was assisting her with toileting. - On 10/21/20 at 10:37 AM, CNA #1, was in the quarantine unit and was wearing a surgical mask and eye protection and went into Resident #8's room. She did not put on a gown. Just inside the room CNA #1 performed hand hygiene, put on gloves and made the bed. While making the bed her clothing touched the sheet and the bed at several places on her torso and her hip area. On 10/21/20 at 10:40 AM, CNA #1 said she did not wear a gown when she made Resident #8's bed. CNA #1 said she would only need to wear a gown in the Gray Zone if she was providing personal cares like toileting or changing incontinent briefs. - On 10/21/20 at 11:31 AM, LPN #1 had just completed passing medications in one of the COVID-19 negative units and went into the quarantine unit. In the quarantine unit LPN #1 prepared Resident #7's medications and placed them in a medication cup with her bare hands. LPN #1 had on a surgical mask and eye protection. LPN #1 did not put on gloves or a gown prior to entering Resident #7's room. LPN #1 handed the cup of medications to Resident #7 with her bare right hand. Resident #7 took the cup, swallowed the medications and gave the cup back to LPN #1. LPN #1 then threw away the cup, performed hand hygiene and left the room. On 10/21/20 at 11:37 AM, LPN #1 said she did not wear a gown or gloves when she administered Resident #7's medication. LPN #1 said she would only need to wear a gown or gloves in the Gray Zone if she was providing personal cares like toileting or changing incontinent briefs. On 10/21/20 at 11:24 AM, CNA #2 and CNA #3 said in the quarantine unit they only had to wear a gown and gloves in residents' rooms if they were providing personal cares like toileting. On 10/21/20 at 3:15 PM, the ICP said she was not aware staff should not be using cloth masks while in the facility. She said staff were expected to wear surgical masks when in residents' rooms or caring for residents. The ICP said staff were educated to wear eye protection while in resident rooms in the quarantine unit and in the COVID-19 positive unit. She said she expected staff to wear gloves and a gown when caring for residents in the quarantine unit. The ICP also said nurses should wear gloves when administering medications in the quarantine unit. On 10/21/20 at 5:20 PM, the DON said she was not aware staff should not be wearing cloth masks while in the facility. She said staff were expected to wear surgical masks when in residents' rooms or when caring for residents. 3. The CDC website, accessed 10/28/20, included a section titled Using Personal Protective Equipment (PPE), dated 8/19/20, which instructed healthcare personnel on donning PPE, as follows: *Perform hand hygiene before putting on PPE. *Put on an isolation gown and tie all the ties on the gown. *Put on an N95 filtering respirator or higher. *Put on face shield or goggles. *Put on gloves. The section also instructed HCP how to doff PPE, as follows: *Remove gloves. *Remove gown. *Perform hand hygiene. *Remove face shield or goggles. *Remove N95 respirator. The facility procedure for donning and doffing PPE, revised 2/1/18, stated the removal order for PPE was gloves, face shield, gown, and N95 mask and then to wash or sanitize hands immediately after removing all PPE. This policy and guidance was not followed. On 10/21/20, at 10:05 AM, CNA #1 was at the PPE cart for the COVID-19 unit. She donned PPE in the following order: N95 mask, shoe coverings, gown, face shield, then gloves. CNA #1 did not perform hand hygiene prior to donning her PPE. On exiting the COVID-19 unit she doffed her gloves and put on new gloves without performing hand hygiene, doffed the N95 mask, then donned a surgical mask and went into the COVID-19 negative unit. At 10:15 AM, CNA #1 was asked if she did hand hygiene before donning her surgical mask. She stated Woops, darn. When asked if she should do hand hygiene before putting on gloves she stated that she should have. At 10:50 AM, RN #1 went to the PPE cart for the COVID-19 positive unit and stated she was going to check on Resident #1. She donned her face shield, wearing it upside down on top of her head, and donned an N95 mask. RN #1 then grabbed a gown and tied the neck of her gown prior to putting it on, when she put it on the gown drooped down to her mid chest and gaped around her shoulders. She did not tie the waist tie. RN #1 then put on gloves, without performing hand hygiene, and entered the unit. At 10:59 AM, RN #1 exited the COVID-19 positive unit wearing the face shield and N95 mask. She performed hand hygiene doffed her face shield but kept it in her left hand, doffed her N95 mask and put on a surgical mask. She then redonned the face shield, wearing it upside down on top of her head, and entered the COVID-19 negative unit. When asked about donning PPE and hand hygiene she stated she followed facility policy and she kept her face shield with her on top of her head when in the COVID-19 negative unit to have it readily available for use there. At 11:08 AM, Housekeeper #1 went to the PPE cart outside the COVID-19 positive unit and selected PPE. She doffed the surgical mask she was wearing and donned an N95 mask, a gown, face shield, and shoe coverings. She then entered the COVID-19 positive unit. When she exited, she was asked about donning PPE. She stated that because she does housekeeping she dons and doffs PPE differently and she was taught by the housekeeping supervisor to do PPE in the order she had. On 10/22/20 at 3:15 PM, the ICP stated staff should not be wearing the face shields on top of their head and should be performing hand hygiene prior to donning gloves. She stated they were not taught to don PPE the way that was observed. The facility failed to ensure designated staff were assigned to work only the COVID-19 positive unit each shift, ensure staff wore all appropriate PPE when entering resident rooms who were on quarantine, and ensure staff wore all appropriate PPE for source control in the facility. These deficient practices placed staff and residents who had tested negative for COVID-19, at imminent risk of COVID-19 infection and subsequent serious harm, impairment, or death related to the infection. On 10/21/20 at 5:20 PM, the Administrator and the DON were informed of a determination of Immediate Jeopardy. The facility was provided with written notification. On 10/22/20 at 2:26 PM, the facility provided a plan to remove the identified immediacy. The facility alleged the plan to remove the immediacy was to be implemented on 10/22/20 at 6:00 AM. The plan was accepted on 10/22/20 at 2:33 PM. The facility's IJ removal plan included: -Designated staff were assigned to the COVID-19 positive unit and those staff would not work the other units during their shift. -Staff would wear all PPE in residents' rooms in the quarantine unit. -All staff would wear masks (not cloth) and eye protection while in the facility. On 10/22/20 at 4:00 PM, the Administrator and DON were verbally informed the immediacy was removed based on onsite verification the IJ removal plan was implemented. 4. The facility's Isolation Precautions policy, revised 8/18/20, directed staff to post signage on the door or wall outside of the resident's room indicating the type of precautions and required PPE. This policy was not followed. The quarantine unit had a retractable fabric strip at waist level that stretched from wall to wall across the hallway separating it from the COVID-19 negative area. A sign was posted outside of the quarantine unit which directed staff to wear surgical/procedure masks and eye protection. The sign directed staff to wear gloves and a gown as needed. There were no signs on or near the doors of the residents' rooms. On 10/21/20 at 3:15 PM, the ICP said the resident rooms in the quarantine unit had signs at one point but were recently taken down when the large signs were made prior to entering the unit.

Based on observation, interview, and record review, it was determined the facility failed to: *Adequately assess residents for injuries immediately following falls and monitor for latent signs of injuries after falls. This was true when a resident experienced a fall and was not assessed or monitored appropriately after the fall. This failed practice resulted in harm to 1 of 11 sample residents (#3) when the resident was subsequently diagnosed with [REDACTED]. *Assess residents blood pressure using an accurate and appropriate blood pressure measuring device. This was true when a resident (#11) was found to have an elevated blood pressure reading when checked using a blood pressure measuring device that was not provided by the facility. This failed practice created the potential for harm if residents received inappropriate medical treatment due to inaccurate blood pressure readings. *Follow physician orders [REDACTED].#10). This failed practice created the potential for harm if abnormal oxygen saturation and lung sounds remained undetected and untreated. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The United States Department of Health and Human Services Agency for Healthcare Research and Quality in October 2014 (http://www.arhq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspsman2.html), documented the nursing standard of practice following a resident fall at a nursing home included an evaluation of resident injuries immediately post-fall and monitoring the resident for the next 72 hours. Resident #3's 4/4/17 annual MDS (Minimum Data Set) assessment documented she was cognitively intact and required extensive assistance with transfers/two plus persons physical assist. When moving from seated to a standing position, the resident was not steady and required human assistance to stabilize. Resident #3's 5/25/17 significant change in status and 8/25/17 quarterly MDS assessments documented she was cognitively intact and was totally dependent with transfers/two plus persons physical assist. On Saturday, 5/13/17 at 9:30 am, a fax documented Resident #3's physician was notified that the resident was assisted to the floor when being transferred .Knees buckled. No injury. A response fax from the physician, dated 5/15/17, documented Noted. I subsequently heard she injured her ankle/legs .x-rays ordered (and) awaiting reading. On 5/13/17 at 9:33 am, an Incident Progress Note documented Resident #3 was being transferred from the bed to wheelchair, her pants were pulled up and her legs gave out. The resident was assisted to the floor. On 5/14/17 at 1:26 pm, an eAdmin Record Progress Note documented Resident #3's [MEDICATION NAME] Tablet Give 1000 mg (milligrams) by mouth every 6 hours as needed for pain . PRN (as needed) Administration was: Effective (the resident) stated pain is better. The note did not document the location or severity of Resident #3's pain. On 5/13/17 at 1:33 pm, an eAdmin Record Progress Note documented Resident #3'[MEDICATION NAME] Tablet 500 mg Give 1000 mg by mouth every 6 hours as needed for pain . The note did not document the location or severity of Resident #3's pain, or whether the medication was effective at alleviating the pain. On 5/13/17 at 1:36 pm, Progress Note documented Resident #3's Late Entry: When assisting resident to wheelchair from floor leg(s) where (were) placed under resident and assisted up without any pain. No other nursing assessments were documented between 1:36 pm 5/13/17 and 10:00 pm on 5/14/17. On 5/14/17 at 10:00 pm, a Health Status Progress Note documented Resident #3 refused to get out of bed due to pain in her left leg, right leg and ankle, and her right great toe was bruised and swollen. The physician was contacted by phone and x-rays were ordered of the left leg, right leg, and right great toe. On 5/15/17, an X-ray report documented Resident #3's had fractures of the left proximal and distal fibula and distal tibia (lower leg), right proximal fibula, base of the first proximal phalanx (great toe) on the left foot, and base of the first proximal phalanx on the right foot. On 5/15/17 at 2:55 pm, a Progress Note documented Resident #3 was transferred to the hospital for treatment of [REDACTED]. On 5/15/17 at 5:45 pm, a hospital note documented Resident #3's fractures of the left tibia and fibula, right tibia, base of the left great toe, possible subacute or healing [MEDICAL CONDITION] fifth metatarsal (bone in the foot), possible non-displaced fracture involving the base of the right great toe, and probable subacute healing fractures of the right third and fourth metatarsals. It was documented the resident had a Nursing home fall resulting in multiple fractures bilaterally of the lower extremities. The resident was admitted to the hospital for management of the fractures. On 5/15/17, an Investigation Interview documented the LPN observed Resident #3's feet later (on 5/13/17) after the fall because the resident complained of some pain in her left foot. The resident's feet were a little swollen at that time but nothing that was abnormal for her . No bruising was present; however, there was a line on the great toe of her left foot. The resident was given Tylenol for pain and the LPN said the resident might be a better candidate for a two person assist rather than a one person assist . The investigation did not document any further assessment or interventions for Resident #3's pain complaints, swelling, or skin discoloration. There was no documentation that Resident #3's range of motion was assessed immediately after the fall, that she was monitored for further signs of injury in the hours subsequent to the fall, or the physician was contacted by phone until the resident refused to get out of bed due to pain at 10:00 pm the next day. On 10/23/17 at 4:53 pm, LPN #1 said she evaluated the resident after the fall on 5/13/17. LPN #1 said the resident was found on the floor, a skin assessment and vital signs were performed with no abnormal findings, and the resident was transferred to a chair and monitored. LPN #1 did not remember how the fall happened, and said two people would have been better rather than a one person assist. Resident #3 was harmed when she had an assisted fall on 5/13/17 at 9:33 am, and was not assessed for injury per professional standards of practice for over 36 hours following the fall. There was no documentation the physician was aware of the faxed notification of Resident #3's fall until two days after the fall, and the resident's legs and feet were not assessed for changes in her range of motion or by x-ray during that time. Resident #3 was diagnosed with [REDACTED]. Resident #3 required admission to the hospital for management of the fractures two days after she fell . 2. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #11's 10/27/17 Medication Review Report documented [MEDICATION NAME] Tablet (blood pressure medication) 10 mg (milligrams) once a day and hold if blood pressure less than 110 systolic (top number) or less than 60 diastolic (bottom number). On 10/24/17 at 9:35 am, RN (Registered Nurse) #1 checked Resident #11's blood pressure using a small white automatic blood pressure device on the resident's left wrist. The blood pressure reading was 243/100. RN #1 re-checked Resident #11's blood pressure on his right wrist using the same blood pressure device. The blood pressure reading on the right wrist was 209/96. RN #1 said she would re-check the resident's blood pressure manually (with a stethoscope and blood pressure cuff that is inflated by hand). On 10/24/17 at 10:17 am, RN #1 said she should notify the physician of Resident #11's blood pressure reading. On 10/24/17 at 10:20 am, RN #1 called Resident #11's physician and left a message for the nurse or physician to call back regarding the resident's elevated blood pressure. On 10/24/17 at 10:25 am, RN #1 re-checked Resident #11's blood pressure manually on the resident's right arm and said the blood pressure reading was 140/82. RN #1 said she did not believe the blood pressure reading from the automatic blood pressure device was accurate. On 10/24/17 at 10:32 am, RN #1 said she would check the battery in the small white blood pressure device and re-check a blood pressure on another individual to make sure the machine was working correctly. She said if the machine was working erroneously she would not notify the physician of the initial blood pressure readings for Resident #11. On 10/24/17 at 2:25 pm, the Director of Nursing Services (DNS) said if the blood pressure reading was high when the nurse used the automated blood pressure machine, she would expect the nurse to re-check the blood pressure manually. She said the automated blood pressure machine reading seemed inaccurate and she would not expect the nurse to report the results obtained from the automated blood pressure machine; however, she would expect the nurse to report to the physician if the resident's blood pressure medication was not effective. On 10/24/17 at 3:47 pm, the DNS said it is best practice to check blood pressure manually but our policy says it's okay to use a machine. She said she would look for the manufacturer's instructions for the blood pressure machine that was used on Resident #11. On 10/24/17 at 3:00 pm, the DNS said the nurse used her personal blood pressure machine to check the resident's blood pressure and the manufacturer's instructions were not available. The DNS said the facility does not supply automated blood pressure machines and each medication cart has manual blood pressure equipment. The DNS said the nurses are expected to use manual blood pressure equipment and would no longer be allowed to use their own automated blood pressure machines. 3. Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #10's 10/26/17 Medication Review Report documented [MEDICATION NAME] Nebulization Solution (a liquid breathing medication that is inhaled as a mist) 1 (One) dose inhale orally via nebulizer three times a day .Document pulse and lung sounds pre & post administration and record the total time (min) nursing spent with resident on treatment. Resident #10's 10/26/17 Medication Record documented the [MEDICATION NAME] Nebulization Solution was administered each day from 10/6 - 10/25/17. Documentation of the minutes, heart rate, and lung sounds before and after [MEDICATION NAME] was either not done or was incomplete for 37 of 54 administrations. On 10/26/17 at 4:00 pm, LPN #3 was observed administering the [MEDICATION NAME] Nebulization Solution to Resident #10 without checking the resident's pulse or lung sounds prior to the medication. When asked about the order to monitor the resident's pulse and lung sounds prior to and after the [MEDICATION NAME], LPN #3 said the order was not followed and it should be. On 10/26/17 at 4:05 pm, Resident #10 said the [MEDICATION NAME] administration was done about 15 minutes ago and her breathing was fine. She said the nurse did not check her lungs or pulse oximetry (a device that shows the resident's pulse and oxygen level).

Based on observation, staff interview, resident interview, and record review, it was determined the facility failed to ensure adequate supervision and assistance, as assessed, was provided during transfers for residents at risk for falls. This was true for 1 of 11 sample residents (#3) and resulted in harm to Resident #3, who sustained fractures to both lower extremities from a fall during a transfer in her room. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's 4/4/17 annual MDS (Minimum Data Set) assessment documented she was cognitively intact and required extensive assistance with transfers/two plus persons physical assist. When moving from seated to a standing position, the resident was not steady and required human assistance to stabilize. The triggered care areas included ADL (Activities of Daily Living)/functional rehabilitation potential and falls. Resident #3's ADL care plan interventions, initiated 7/12/16, documented she was unable to ambulate and required 1 staff limited support for transferring between surfaces. Resident #3's risk for falls care plan interventions, initiated 11/14/13, documented the resident was to wear non-skid footwear when transferring or mobilizing in W/C (wheelchair) and had a raised edge mattress on her bed. Resident #3's physical device care plan interventions, initiated 5/4/16, documented the resident used anti-lock/roll brakes, bed against the wall, bilateral assist bars on bed, and a scooped mattress due to her risk for falls. On 5/13/17 at 9:33 am Incident Progress Note documented Resident #3 was being transferred by one staff person from the bed to wheelchair, her pants were pulled up and her legs gave out. The resident was assisted to the floor and no injuries were noted. A 5/15/17 Investigation Interview of the CNA (Certified Nursing Assistant) documented Resident #3 was lowered to the ground during a transfer on 5/13/17 at approximately 8:45 am. As the CNA assisted Resident #3 to get up for breakfast, she assisted the resident to stand up and the resident held onto the CNA with her hands around the CNA's neck. During the transfer, the CNA pulled up the resident's briefs and pants, the resident's knees gave out, and she was lowered to the floor. The CNA called for assistance on the walkie-talkie, received no response, and left the resident unattended as she went to the dining room to summon the nurse. The resident was assessed by the nurse and assisted to a chair. The CNA did not think the care plan documented the resident was a two-person assist, but it would have been nice to have a second person. The CNA thought the resident's legs just got too tired to stand any longer and knew that she has been kinda iffy while standing. The CNA said she should have had a second person to assist her during the transfer. A 5/15/17 Investigation Interview of the LPN documented she assessed Resident #3's feet later in the day after the fall because the resident complained of some pain in her left foot. The resident's feet were a little swollen at that time but nothing that was abnormal for her . No bruising was present; however, there was a line on the great toe of her left foot. The resident was given Tylenol for pain and the LPN said the resident might be a better candidate for a 2 person assist rather than a 1 person assist . A 5/14/17 at 10:00 pm Health Status Progress Note documented Resident #3 refused to get out of bed due to pain in the left lower extremity, right lower extremity and ankle, and the right great toe was bruised and swollen. The physician was notified and x-rays were ordered of the lower extremities and right great toe. A 5/15/17 X-ray report documented Resident #3 had fractures of the left proximal and distal fibula and distal tibia (lower leg), right proximal fibula, base of the first proximal phalanx (great toe) on the left foot, and base of the first proximal phalanx on the right foot. A 5/15/17 at 11:41 am Communication/Visit with physician progress notes [REDACTED]. (The) Resident will be non-weight bearing for now . A 5/15/17 at 1:34 pm Communication/Visit with physician progress notes [REDACTED]. A 5/15/17 at 2:55 pm Other Progress Note documented Resident #3 was transferred to the hospital for treatment of [REDACTED]. A 5/15/17 at 5:45 pm hospital note documented Resident #3's fractures of the left tibia and fibula, right tibia, base of the left great toe, possible subacute or healing fracture of the left fifth metatarsal (bone in the foot), possible non-displaced fracture involving the base of the right great toe, and probable subacute healing fractures of the right third and fourth metatarsals. It was documented the resident had a Nursing home fall resulting in multiple fractures bilaterally of the lower extremities. On 5/19/17 at 1:47 am, an Admission/Readmission-Other Progress Note documented Resident #3 returned from the hospital with both lower extremities splinted and wrapped, and she had a walking boot. The resident was hospitalized from 5/15-5/18/17 and sustained multiple fractures to both lower extremities. The resident required a total lift for transfers, was non-weight bearing on her left leg and was able to pivot transfer on the right leg. Resident #3's physical mobility care plan interventions, initiated 5/19/17, documented non-weight bearing on the left leg with right foot pivot transfers and the resident required total lift assistance for mobility. Resident #3's care plan was updated on 6/27/17 related to multiple fractures of the bilateral lower extremities and weight bearing as tolerated with walking boot on the left lower extremity when out of bed. The care plan documented an intervention, initiated on 6/27/17, that the resident required 2 staff/total lift for transfers. On 10/23/17 at 12:12 pm, Resident #3 was observed in the dining room with a black boot on her left lower leg. On 10/23/17 at 4:53 pm, LPN #1 said she evaluated the resident after the fall on 5/13/17. LPN #1 said the Resident #3 was found on the floor, a skin assessment and vital signs were performed with no abnormal findings, and the resident was transferred to a chair and monitored. LPN #1 did not remember how the fall happened, and said 2 people would have been better rather than a 1 person assist. Resident #3 was harmed when the facility failed to provide two-person assistance for transfers as assessed in her MDS. There resident was lowered to the floor during a one-person transfer and sustained multiple fractures which required hospitalization and resulted in a decline in her ADLs.

Based on staff interview, record review, and review of the facility's abuse policy and procedure, it was determined the facility failed to investigate and report four allegations of abuse to the State Agency involving 1 of 12 sampled residents (#3). The Administrative staff's lack of protective response and investigation of the reported allegations placed Resident #3 and the remaining fifty residents at the facility at risk for abuse/harm. The facility's failed practice resulted in Immediate Jeopardy to residents' health and safety. The facility was notified verbally of the Immediate Jeopardy on 8/12/16 at 5:17 pm and in writing on 8/15/16 at 1:41 pm. Findings include: The facility's Abuse Policy and Procedure contained the following information: * When a staff member receives an allegation of abuse and neglect .the staff member will then report it to the supervisor. The charge nurse or licensed nurse will be notified immediately, assess the situation .and complete an initial investigation. If this is an injury of unknown origin he/she will attempt to determine the cause of the injury. * Notify the administrator immediately of any incidents of alleged or suspected abuse and injury of unknown origin. * Notify the designated agencies in accordance with state law, including the state survey and certification agency. * Notify the physician and family regarding the facts of the situation. * The investigation team (social worker, administrator, and the director of nursing services) will review all incidents no later than the next working day following the incident. * The investigation may include interviewing staff, residents or other witnesses to the incident. You may want to have each person write his or her memory of the event. If possible, get signed statements from any witnesses. * The social worker or designated staff will report the results of all investigations to the state survey and certification agency and other officials within five working days of the incident. * The social worker and other staff, as appropriate will provide ongoing support and counseling to the resident and family as needed. Resident #3 was admitted to the facility with multiple diagnoses, including major [MEDICAL CONDITION] without psychotic features, generalized anxiety disorder, and mild, late onset [MEDICAL CONDITION]. Resident #3's MDS assessments for Brief Interview Mental Status (BIMS) included: * 11/10/15 - BIMS = 14 or cognitively intact * 2/10/16 - BIMS = 15 or cognitively intact * 5/6/16 - BIMS = 10 or moderate impairment * 7/12/16 - BIMS = 15 cognitively intact Resident #3 received counseling services from an outside provider, whose progress notes included the following: * 3/21/16 - (Resident #3) had a red mark on her head and over her right eye. 'I think someone beat me up!' She said she did not know what happened. Talked with staff and it was noted that Resident #3 had neither fallen or been hit, but she had slept on her head with her arm under her forehead causing a red mark that staff reported to be 'clearing up. Resident #3's medical record did not include documentation that the red area was identified and monitored prior to the counseling session. * 5/10/16 - (Resident #3) told me another resident had 'hit me and cracked some ribs.' She said she had felt afraid of this .I checked out (Resident #3's) report and found out it was not true. She appeared to be upset and I did try to calm her . * 5/16/16 - (Resident #3) was noted to have a bruise on her forehead and said, 'It came from another resident hitting me.' (Resident #3) spoke of 'avoiding him.' Staff reported she had fallen and had not been hit. An Incident Report dated 4/30/16, 16 days prior to the identification of the bruise, documented Resident #3 had fallen but did not state she had hit her head. * 7/25/16 - (Resident #3) reported she had 'seen someone from Dallis (sic). She told me, 'Don't go with him!' She would not say what was bothering her, but she seemed to not want anything to do with him. (Resident #3) appeared to feel afraid of the person from Dallis (sic). She was able to talk about different things, but she was very concerned about the person. The facility's completed abuse investigations and incident reports from August 2015 to August 2016 did not include investigations related to the above allegations of abuse. Resident #3's clinical record from February 2016 to August 2016 did not include documentation related to the identified allegations of abuse. The State Agency's reportable incident faxes from March 2016 to August 11, 2016, did not include notification from the facility related to the identified allegations of abuse. On 8/12/16 at 11:15 am, the DNS stated she did not review the counselor's notes. She said the SSD reviewed the counselor's notes and notified her of any problem or concern. On 8/12/16 at 1:00 pm, the DNS and SSD were interviewed together. The SSD stated she skimmed through the counselor's notes, but did not read the whole note. When asked if they were aware of the allegations of abuse made by Resident #3, the DNS and SSD stated, We were not aware of the allegations until now. They stated the allegations should have been identified as allegations of abuse, investigated, and reported to the State Agency. On 8/12/16 at 1:12 pm, the LCSW from the counseling service was interviewed. When asked if he had reported the identified allegations to the SSD he stated, I know that we talked about them; however, I am not sure if it was that day it happened, that week, or a couple of weeks. He stated he had reported each incident to the nursing staff when it was brought to his attention by Resident #3. On 8/12/16 at 5:17 pm, the Administrator stated he was unaware of the allegations, otherwise they would have been investigated. The facility failed to ensure the identified allegations of abuse were thoroughly investigated. This failure directly impacted Resident #3 and had placed the remaining fifty residents at the facility at imminent risk of abuse.

Based on observation, interview, and record review, it was determined the facility failed to ensure appropriate assessments were completed, or a new care plan was developed, prior to issuing a notice of involuntary discharge to a long-term resident. This was true for 1 of 1 resident (Resident #3) sampled for involuntary discharge. Resident #3 experienced psychosocial harm when she became apprehensive that the stress of being forced to move from her long-time home in the facility would hasten her demise. Findings included: Resident #3 was admitted to the facility on [DATE], and had resided in the facility since that time except for a hospitalization between 3/27/16 and 4/8/16, with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented Resident #3 was independent in daily decision making, had minimal depression, displayed hallucinations and delusions, and rejected care 1 to 3 days of the 14-day assessment period. Resident #3's behavior monitors for October 2016 documented target behaviors of hallucinations, resistance to care, excessive call light use, and suicidal ideation. The monitors documented hallucinations were present on 4 of 36 shifts between 10/1/16 and 10/18/16. No other target behaviors were documented on the behavior monitors for those dates. On 10/19/16, a [MEDICAL CONDITION] Medication Review form documented Resident #3 had no episodes of refusing care, repeated use of call light, or suicidal ideation/self-harm. The form documented 6 episodes of hallucinations people are going to harm her. The form documented recommendations of a psychiatric re-evaluation of her medications related to increased behaviors, and to seek alternative placement to meet her psychiatric needs. Resident #3's Progress Notes documented episodes of altered thought processes on 10/19/16 and 10/22/16. In both instances the notes documented Resident #3 was easily assured of her safety with interventions from staff. On 10/28/16 at 5:53 pm, Resident #3's Progress Notes documented the LSW talked with Resident #3's family about transfering the resident to another facility. The note documented the family's response as, .'Absolutely not. I want her to stay at (this facility). (Facility #2's Administrator) highly suggested that we do not transfer her and statistics show that at her age people usually die within 30 days after a transfer. So we are talking life and death here. And I've talked to (Resident #3's physician) and he is in agreement that (Resident #3) should not be transferred as it would be more detrimental for her.' Notified administrator. Will continue working on discharge options for (Resident #3). On 11/4/16 at 12:38 pm, Resident #3's record documented a verbal communication with her primary care physician. The communication documented, in its entirety, 30 day discharge notice to be given for resident to (discharge) to a long-term psychiatric hospital or care center, as the facility can no longer meet the resident's psychiatric needs. The verbal communication form was signed by the physician. There was no further assessment from Resident #3's physician, and no assessment from a psychiatrist regarding unmet psychiatric needs. There was no documentation of recent behavioral changes for Resident #3, assessment of the root cause of those changes, or care plan updates regarding behavioral changes or unmet psychiatric needs. On 11/7/16, Resident #3's Individual Therapy progress note documented she was cooperative with an appropriate affect and pleasant mood. Her thought processes were documented as intact and her thought content was documented as non-psychotic. Active symptoms were documented as, Doing well at this time. On 11/9/16, a Notification of Transfer or Discharge form in Resident #3's record documented the resident would be discharged on [DATE] as the facility was unable to meet psychiatric needs. The form provided boxes for the resident to check she would either agree to move and waive her right to 30 day notice, or she requested the full notice period before the move occured. The box next to the request for the full notice period was checked. The spaces for the resident's signature, resident's representive's signature, and employee signature were all blank. On 11/14/16, an Individual Therapy progress Note documented Resident #3 told me that a resident 'pulled my leg last night.' The note documented the resident .appeared to be confused and afraid. Talked (with) Social Services (and) reported my findings. (Resident #3) has received a 30 day notice to find a facility that can adequately meet her needs. She noted her leg hurt. The note documented her attitude as cooperative, her affect flat, her mood fatigued, her thought process obsessive, and her thought content bizarre. Active symptoms were documented as [MEDICAL CONDITION], anxiety, and depression. On 11/15/16 at noon, Resident #3's IP stated the facility presented the 30 day discharge notice during a care conference on 11/9/16. The IP stated the facility previously broached the topic of an involuntary discharge with family, but it was not clear why the resident could not remain at the facility. The IP stated the facility previously asked a long-term psychiatric facility to assess the resident for admission, but it had declined to admit the resident as she was behaviorally stable. The IP stated the facility's LSW informed the family the discharge was necessary because the resident at times made allegations of abuse, and the facility did not have enough staff to investigate them; the Administrator confirmed that statement. The IP stated Resident #3's family was concerned because the resident had lived in the facility for a number of years, considered the facility her home, and being forced to change residences at this stage in her life could kill her. The IP stated Resident #3 had seen her psychiatrist that morning and the psychiatrist told Resident #3 and the IP that the resident was appropriately placed in the current facility and did not need placement with additional psychiatric support. The facility documented no allegations of abuse from Resident #3 between 10/28/16 and 11/14/16. One allegation was reported on 11/14/16. On 11/15/16 at 1:40 pm, LN # 1 stated she had worked at the facility for approximately 4 years, and had cared for Resident #3 during that time. LN # 1 stated Resident #3 had no recent behavioral changes that she noticed, and was at baseline. On 11/15/16 at 2:45 pm, Resident #3 was observed sitting in a wheelchair in her room. Resident #3 was facing her over bed table, with a letter from the facility rescinding the 30 day discharge notice, dated 11/14/16, on top of a stack of books. Resident #3 discussed the books she was currently reading and stated she had lived at the facility for a long time. Resident #3 stated she had previously been in a different retirement home, but realized she needed more help. Resident #3 stated she suffered from [MEDICAL CONDITION], Alzheimer's, and that other disease, pointing to her head. Resident #3 stated, I had to consider where I wanted to spend the rest of my days. Resident #3 stated she and her family surveyed all of the nursing homes in the area, and selected this particular facility as her final residence. Resident #3 reported she was happy and content with her choice, but recently the facility had given her some trouble about staying because of my other disease, again pointing to her head. Resident #3 stated, I don't want to move. It will kill me. On 11/15/16 at 3:45 pm, the LSW stated the facility issued the involumtary discharge notice on 11/9/16 at a care conference, with Resident #3, her family, and the Ombudsman present. The LSW stated the facility issued the notice due to more frequent statements that she is not feeling safe, which she said indicated the facility was unable to meet Resident #3's psychiatric needs. The LSW was unable to show evidence through nursing, social services, or phyisican documentation of behavioral increases prior to the notice being served. The LSW stated the facility was still developing a baseline for Resident #3's normal behaviors. The LSW stated the facility had not worked with Resident #3's psychiatrist to develop threshholds of behaviors related to the resident's meltal illness; how many of those behaviors were typical for the resident; or how the facility could determine when the number or persistence of the behaviors indicated the resident was psychiatrically unstable. The LSW stated the resident had not been seen by a psychiatrist since August 2016, at which time the psychiatrist indicated Resident #3 would need to be seen on an outpatient basis once every three months. The LSW stated she called the psychiatrist's office on 11/2/16 to make a quarterly appointment for Resident #3, but the office had not called back by 11/3/16, so the facility decided to proceed with the involuntary discharge based on the lack of response from the psychiatrist's office. The LSW stated the psychiatrist had not been involved with the determination of unmet psychiatric needs in the facility. The LSW stated she had not assessed the resident prior to initiation of the discharge notice because her daughter didn't want me to. The LSW stated the psychiatrist's office called back on 11/5/16 to schedule an appointment for Resident #3, and the appointment had taken place earlier that day. On 11/16/15 at 9:15 am, the Administrator stated the facility issued the involuntary discharge letter to Resident #3 due to statements of fear. The Administrator said the statements occurred all the time and were increasing. The Administrator stated the statements were documented in Resident #3's Social Services notes, Nursing Notes, and Behavior Monitors. When informed of the lack of documentation in those areas of Resident #3's record, the Administrator stated, Well, you (the State Agency) gave us an (Immediate Jeopardy) on her during the first survey (August 2016). The Administrator stated the facility requested a long-term psychiatric facility evaluate Resident #3 for possible admission and they said she would not fit in with their population. The Administrator stated after the facility spoke with Resident #3's family and discovered their opposition to that transfer, the facility identified a second discharge location, and issued an involuntary notice so the resident could have her psychiatric needs met. Please see F157 as it pertains to physician notification, and F250 as it pertains to the provision of Social Services for Resident #3. Resident # 3 was harmed when she experienced fear that an involuntary discharge notice would result in her premature demise. The facility documented the discharge was necessary due to unmet psychiatric need, however the physician documented an awareness the facility intended to issue the discharge notice, but did not document an assessment to evaluate the nature or extent of Resident #3's alleged behavioral changes, or to rule out possible medical factors underlying those changes. Resident #3 had was not assessed by either her psychiatrist or the facility LSW before the discharge notice was issued, and no new care plan interventions were developed and implemented in an effort to avoid the discharge.

Based on staff and resident interview and record review it was determined the facility failed to provide medically realted social services to recognize continued and worsening signs of depression after the discontinuation of an antidepressant medication; implement and revise the resident specific care plan related to depression; and ensure safety notifications were made to a qualified professional to rule out suicidal ideation, intent, or plan. This was true for 1 of 8 (#3) sampled residents. Resident #3 sustained psychosocial harm when she experienced a pattern of feeling better off dead, which escalated after the her antidepressant was discontinued, without notification or assessment of a qualified professional and without revision of the care plan to address these feelings. Findings include: Resident #3 was admitted to the facility with multiple [DIAGNOSES REDACTED]. A Behavioral Committee Drug Review, dated 1/26/16, documented Resident #3 was cognitively intact, was currently taking Zoloft 100 mg daily for mild depression and the depression was stable. Resident #3's Quarterly MDS, dated [DATE], documented: - Cognitively intact. - Verbalized feeling tired or having little energy for 7-11 days; poor appetite or overeating for 7-11 days; moved/spoke more slowly than usual or was fidgety and moved around more than usual for 2-6 days; and had mild depression. -Resident #3 denied she experienced thoughts she would be better off dead, or hurting herself in any way during the previous 14 days. Resident #3's current Mood care plan documented the following interventions: - Monitor, record, and report to health care provider, as needed, risk for harm to self: Suicidal plan; past attempt at suicide; risky actions (stockpiling pills, saying good-bye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgement, or safety awareness. (Initiated 11/15/13) - Non-pharmalogical interventions for depression/self-isolation: Senior counseling weekly, encourage her to participate in activities, reminisce with her about her life/job experiences such as homemaking and speech therapist, and encourage familiar television shows. (Initiated 11/15/13) Resident #3 was admitted to the hospital on [DATE] with multiple medical issues and was re-admitted to the facility on [DATE]. Resident #3 did not have Zoloft included on the re-admission orders [REDACTED] From 4/9/16 through 4/11/16, due to a medication error, Resident #3 received Zoloft 100 mg daily. The Medication Administration Record (MAR) from 4/12/16 through 5/22/16 documented the Zoloft was place on hold. Resident #3 did not receive an anti-depressant for at least 40 consecutive days. Resident #3's progress notes documented: On 4/8/16, .(Resident #3 is not speaking (and) appears withdrawn. (She) closes her eyes when staff approach her . On 4/22/16, Uses call light in excess. Will push call light button repeatedly while receiving staff assistance and after staff leaves her room. When staff assessed her needs, she often lies there with her eyes closed and won't respond. On 5/5/16, (Resident #3's family member) came to visit, due to (Resident #3) using her cell phone to continually call her. (In addition), the resident continued to use call light button when awake and repeatedly pushing it even when staff were in the room assisting her. On 5/16/16, Resident calling her daughter continually and pushing call light continually .Daughter called the facility and asked to have residents phone placed on (the) top shelf of (her) bookcase. When entering (the) resident's room resident was on (the) phone. (The phone) was then given to this nurse and placed on (the) top shelf (of the bookcase). A Behavior Committee Drug Review, dated 4/20/16, documented Resident #3 was cognitively intact and experienced mild depression. The review form did not address whether the facility monitored and evaluated Resident #3 for mood changes and/or increased suicidal ideation after the Zoloft 100 mg was placed on hold. On 5/6/16, a care plan change note documented Resident #3 told the Social Service director that she was having thoughts of harming herself and the facility initiated 15-minute checks, however the resident's clinical record did not document the physician, the contracting LCSW, and/or the NP had been notified to rule out suicidal ideation, intent, or plan. Resident #3's Comprehensive MDS assessment, dated 5/6/16, documented: - Verbalized having little interest or pleasure in doing things for 7-11 of 14 days, felt down, depressed, or hopeless for 7-11 of 14 days, tired or had little energy for 7-11 of 14 days, poor appetite or overeating for 2-6 days; felt negative about herself for 7-11 of 14 days, trouble concentrating on reading or watching television, experienced thoughts she would be better off dead, or hurting herself in some way for 12-14 of 14 days; and experienced moderately severe depression. - The safety notification documented on the MDS as made, but there was no evidence any notification was done beyond the person who completed the assessment. On 5/12/16, the Social Service Director (SSD) documented Resident #3 still had thoughts of harming herself, and continued on 15-minute checks. The LSW did not document whether Resident #3 had suicidal intent, or a plan. Resident #3's clinical record did not document the physician, the contracting LCSW, and/or the NP had been notified to further assess whether the Resident #3 experienced suicidal ideation, intent, or plan. Resident #3's clinical record from 4/8/16 through 5/12/16 did document the facility was monitoring and tracking Resident #3's suicidal thoughts determine if a pattern was present. In addition, the record did not document attempted interventions with outcomes to determine which interventions were successful and/or which interventions needed to be revised. Resident #3's LCSW Progress Notes, dated 5/10/16, 5/16/16, 5/30/16, 6/13/16, 6/27/16, 7/25/16 and Treatment plans, dated 5/25/16 did not document the LCSW had been notified regarding Resident #3's psychosocial distress manifested by expressed hopelessness, worthlessness, and suicidal ideations. In addition the progress note did not document the LCSW had addressed Resident #3's depression during his weekly visits. On 5/18/16, the SSD documented Resident #3 was re-assessed for continued 15-minute checks, as the resident stated she continued to have thoughts of harming herself. 15-minute checks were continued at that time, but Resident #3's clinical record did not document the physician, the contracting LCSW, and/or the NP had been notified to rule out suicidal ideation, intent, or plan. On 5/20/16, a fax sent to Resident #3's physician documented, (Resident #3) has been having suicidal ideations since 5/6/16 (was re-assessed on 5/12/16 and 5/18/16) and remained on 15-minute checks for suicidal ideations. Her Zoloft 100 mg . has been on hold since 5/1/16 (NOTE: The resident's clinical record documented Zoloft had been on hold since 4/12/16). (Resident #3 remained in a state of) moderately severe depression. Do you think it would benefit her to start the Zoloft again? NOTE: The facility failed to recognize a pattern regarding Resident #3's expressions of suicide, complete further assessments, and implement further interventions, other than 15-minute checks from 5/6/16 to 8/3/16. In addition, Resident #3's clinical record did not address her prolonged period of psychosocial distress, to the point of hopelessness, worthlessness, suicidal ideation, without social service interventions. Resident #3's Treatment Plan, dated 5/25/16, documented, Resident #3 required continued treatment from the LCSW to keep her, mental health symptoms in check and (Resident#3) needs consistent monitoring by staff and through therapy. The LCSW documented Resident #3's visits would be decreased from weekly to monthly visits. It was unclear how this determination was made based on Resident #3's continued expressions of suicidal ideations documented in her clinical record. On 5/23/16, a physician order [REDACTED]. On 6/23/16, the Nurse Practioner (NP) documented, (Resident #3) indicated that her moods were a little depressed. (Resident #3) stated she struggled with feelings of hopelessness and worthlessness daily. When asked about thoughts of suicide or death, she did not respond which may have been the result of not hearing the question. Resident #3's Quarterly MDS assessment, dated 7/12/16, documented: - Verbalized feeling tired or having little energy for 2-6 days; felt bad about herself for 2-6 days; moved/spoke more slowly than usual or was fidgety and moved around more than usual for 2-6 days; thoughts that she would be better off dead, or hurting herself in some way for 7-11 days; and experienced mild depression. - The safety notification documented on the MDS as made, but there was no evidence any notification was done beyond the person who completed the assessment. A nurse's note, dated 8/1/16, documented, (Resident #3's family member) called and reported to the nurse that the resident had called her and stated she was going to kill herself. (Resident #3) was placed on every 15 minute checks. An 8/3/16 Nurse's Note documented, Physician noted that he reviewed the suicide watch note (related to Resident #3). On 8/12/16 at 1:00 pm, during an interview with the DNS and SSD, when asked if the facility had recognized a pattern in Resident #3's continued and worsening signs of depression after the discontinuation of the Zoloft, the DNS stated the SSD was responsible for assessing Resident #3's mental health and would notify nursing staff if needed. The SSD stated the facility had not attempted to determine if there was a pattern. When asked if the care plan interventions were reviewed/revised; if other interventions were considered in addition to the 15-minute checks; and or further basements were completed after Resident #3 experienced prolonged periods (from May 2016 to July 2016) of psychosocial distress as manifested by hopelessness, worthlessness, and suicidal ideations, the SSD did not respond. The DNS stated, I see what you are saying. The facility was asked and did not provide evidence the safety notification was made or further assessments were conducted to ascertain the resident's status in terms of suicial ideation, intent, or plan. When asked if the facility had attempted to rule out suicidal ideation, intent, or plan, the SSD stated she was not sure. Resident #3 was harmed when the facility failed to ensure medically related social services were provided to a resident with ongoing statements of feelings of harming herself. The facility did not ensure notifications were made to the resident's physician, nurse practitioner, or her counselor.

Based on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure: a) Residents did not develop new avoidable pressure ulcers; b) Physician orders [REDACTED]. c) Pressure ulcers were consistently assessed and monitored to promote healing; d) Interventions were revised when existing pressure ulcers deteriorated; and; e) A medical device was properly positioned to prevent development of a Stage IV pressure ulcer. These deficient practices were true for 1 of 4 residents (#2) sampled for pressure ulcers and resulted in harm when three Stage IV pressure ulcers further deteriorated and Resident #2 developed three new unstageable pressure ulcers. Findings include: Resident #2 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS), Care Plan (CP), Wound Data Collection form (WDC), Wound Clinic Notes (WCN), Wound Clinic Orders (WCO), Treatment Administration Records (TAR), Progress Notes (PN), Dietary Notes (DN), Dietician Assessment (DA), and the facility's pressure ulcer policy and procedure documented the following. * Resident #2's quarterly MDS assessment, dated 2/22/16, documented she: - Was Cognitively intact - Required extensive assistance of one staff for bed mobility - Was totally dependent on two or more staff for transfers - Had impairment to bilateral lower extremities - Had one Stage II pressure ulcer present on admission - Had three Stage IV pressure ulcers present on admission - Did not have unstageable pressure ulcers - Did not have suspected deep tissue injuries - Required a pressure reducing device for her chair and bed, turning and repositioning program, nutrition or hydration interventions to manage skin problems, and pressure ulcer care * Resident #2's quarterly MDS assessment, dated 5/24/16, documented differences in the number and stage of pressure ulcers on admission. It stated she: - Had one Stage III pressure ulcer present on admission; - Had two Stage IV pressure ulcers present on admission; * The facility's wound and pressure ulcer policy stated: - An individualized repositioning schedule was required for a resident unable to position herself/himself and was to be based on nutrition, hydration, incontinence, diagnoses, mobility, and observations of the resident's skin over a period of time. - When a pressure ulcer was identified, the Registered Nurse should record the type of wound and the degree of tissue damage on the Wound RN assessment. The licensed nurse was to record the location of the wound, measurements, and ulcer/wound characteristics. - Dietary staff would be automatically notified. - The interdisciplinary team should determine any modifications necessary to the resident's care plan. Interventions were to focus on physical, mental, and psychosocial concerns that could be affected. - Pressure ulcers should be assessed at least weekly and include measurements, characteristics of the ulcer, presence of pain, and current treatments. * Resident #2's physician orders [REDACTED]. - Keep weight off affected area/limb at all times; - Bed rest and up only for meals and bathroom; - Wear blue heel booties or foam heel lifts at all times on bilateral lower extremities as tolerated to protect feet from skin breakdown; - Turn and reposition every two hours; - Avoid positioning directly on pressure wound site; and - Limit side lying to 30 degree tilt; and limit head of bed elevation to 30 degrees in bed. * Resident #2's skin care plan for August 2016 documented: - Foam wedge to be placed between knees when up in a wheelchair and pillows for positioning off buttocks when in bed. - Educate to causes of skin breakdown and the importance of remaining off the areas of pressure wounds. - Assist to turn/reposition at least every 2 hours, remind to shift position as needed, and encourage to be in wheelchair only for meals and in bed the rest of the time. - Provide air bed with low air loss mattress, wheelchair cushion, and blue boots on both feet while in bed. - Provide supplemental protein, amino acids, vitamins, minerals to promote wound healing. - Do not leave sling behind resident in wheelchair. * Resident #2's medical record documented the following wounds were facility acquired: - Wound #3 was acquired on 10/6/14; - Wound #5 was acquired on 12/8/14; - Wound #8 was acquired on 8/4/15; - Wound #9 was acquired on 11/23/15; - Wound #10 was acquired on 12/21/15; - Wound #11 was acquired on 3/23/16; - Wound #12 was acquired on 7/7/16; and - Wound #13 was acquired on 8/4/16. Resident #2's record included the following documentation regarding wounds #3, #5, #8, #11, #12, and #13: a) Wound #3 - Stage IV distal left ischial (lower buttocks) pressure ulcer which deteriorated: * WCN/WCO - 11/24/15: The wound increased in diameter and measured 2.0 cm x 1.4 cm x 2.0 cm. The wound clinic assessed the wound and determined Resident #2's wheelchair cushion was over-inflated, which contributed to the deterioration of the wound. The note documented Resident #2 was repositioned in her electric wheelchair and air was released from the wheelchair cushion until proper inflation was reached. The manufacturer's specifications for use of the wheelchair cushion documented, DO NOT sit on an improperly inflated cushion. Under-inflated and over-inflation of the cushion sections reduce or eliminate the cushion's benefits and could increase risk to the skin and other soft tissue. Physician orders [REDACTED]. Resident #2's wound measurements were documented as the length x width x depth of each wound, in that sequence. For reference, 1 inch is equal to 2.54 cm, and 4 inches is equal to 10.16 cm. * WCN - 12/29/15: The wound measured 1.5 cm x 1.5 cm x 2.0 cm. * WCN - 1/19/16: The wound measured 3.0 cm x 1.6 cm x 2.5 cm. * WCN - 1/28/16: The wound measured 3.0 x 2.0 cm x 5.0 cm. * A Dietician Assessment (DA), dated 2/22/16, documented Resident #2 weighed 68 kg (150 pounds) and her estimated protein requirement was 1.0 gram of protein per kilogram (kg). Resident #2 at this time was assessed with [REDACTED]. * WCN - 3/10/16: Dressing changes were decreased to once daily and as needed. * WCN - 3/15/16: The dressing was intact and dated 3/10/16, indicating Resident #2's wound dressing had not been changed daily, as ordered. The periwound (area around the wound) was irritated/red with a rash and maceration (softening and breaking down of the skin resulting from prolonged exposure to moisture), had a mild odor, and a moderate amount of yellow/brown drainage. The wound had not been measured. * WCN/WCO - 3/23/16: The periwound was moist, red, and with a rash. The wound measured 2.4 cm x 1.1 cm x 0.4 cm. New orders included a dietary consult related to inadequate protein intake and decreased [MEDICATION NAME] and [MEDICATION NAME] levels. * DN - 3/23/16: The RD spoke with Resident #2 about her low [MEDICATION NAME], magnesium, and potassium levels and discussed food interventions for each deficient lab value. Resident #2 stated she wanted 2 glasses of whole milk with each meal and milk offered with snacks. She stated she liked most protein rich foods, ''but they didn't like her. The note did not include the reason Resident #2 was unable to tolerate protein rich foods, protein alternatives available to her, or that the need for increased protein intake was to promote wound healing. * WCN - 3/30/16: The periwound was excoriated with a mild odor, the dressing was bunched up on arrival today and the wound measured larger at 3.0 cm x 2.0 cm x 1.7 cm. * WCN/WCO - 4/4/16: The dressing was intact, very moist and measured 3.0 cm x 2.8 cm x 2.8 cm, the periwound was pink with skin irritation, the tissue was shiny red, friable (easily tears, fragments, or bleeds when gently palpated or manipulated), and palpable to the bone. b) Wound #5 - Stage IV sacral (low back directly above tailbone) pressure ulcer which deterioriated, bone palpable: * WCN - 12/29/15: The wound measured 2.7 cm x 1.4 cm x 2.0 cm. * WCN - 1/19/16: The wound measured 3.0 cm x 2.0 cm x 1.3 cm and had increased slough (a layer of dead tissue, typically yellow, separated from the surrounding underlying tissue). * WCN - 1/28/16: The wound measured 2.3 cm x 1.8 cm x 1.2 cm. * WCN - 3/10/16: The wound measured 2.8 cm x 1.0 cm x 1.0 cm. * WCN - 3/15/16: The dressing removed by the wound clinic was dated 3/10/16, indicating the dressing had not been changed daily, as ordered. The wound measured 2.0 cm x 1.1 cm x 0.4 cm. * WCN - 3/23/16: The wound measured 2.0 cm x 1.1 cm x 0.4 cm. * WCN - 3/30/16: The wound measured 2.0 x 1.5 cm x 0.4 cm. * WCN/WCO - 4/4/16: The wound measured 2.4 cm x 1.0 cm x 0.8 cm, the dressing was intact and very moist, the tissue was red and friable, and the sacral bone could be felt. c) Wound #8 - Stage III right ischial pressure ulcer deteriorated to Stage IV with bone exposed: * WCN - 12/29/15: The wound measured 0.7 cm x 0.3 cm x 2.0 cm; unable to visualize wound bed due to characteristics of wound; and periwound was light pink and irritated, which appeared to be from friction. * WCN - 1/19/16: The wound measured 2.0 cm x 1.5 cm x 4.0 cm, had a strong odor, moderate amounts of dark brown drainage, and there was slough present in the wound bed. The periwound was moist, red, very tender, and hard. * WCN - 1/28/16: The wound measured 2.5 cm x 3.0 cm x 3.8 cm, had a strong odor; necrotic (dead tissue), purulent (pus) drainage; induration (hard mass); and circumferential [DIAGNOSES REDACTED] (redness) that measured 6.0 cm x 9.0 cm. * WCN/WCO - 3/10/16: The wound measured 11.8 cm x 5.0 cm x 4.6 cm; the dressing was not intact on arrival; the wound had a strong odor; the muscle and bone were exposed; and the [DEVICE] track pad (foam applied directly into the wound bed) was secured on the resident's buttocks, which created the potential for pressure injury. Resident #2 returned to the facility with orders for staff to change the dressing 2-3 times a week and as needed. * WCN - 3/15/16: The wound measured 9.3 cm x 4.0 cm x 4.0 cm, had a strong odor and the muscle and bone were exposed. The wound dressing was dated 3/10/16, when the resident was last seen by the wound clinic for wound care, indicating the dressing had not been changed, as ordered. * WCN - 3/23/16: The wound measured 8.8 cm x 3.4 cm x 3.2 cm; had a strong odor; and the [DEVICE] was intact, but had leaked on arrival. * WCN/WCO - 3/30/16: The wound measured 10.0 cm x 5.0 cm x 3.0 cm with undermining (erosion under the wound edges); had a strong odor; and the [DEVICE] was turned off when the resident arrived at the wound clinic. (Resident #2) reported the [DEVICE] had been leaking so much lately that 'it was ruining my underwear. The entire base of the wound was exposed bone, bone darkly discolored and desiccating (moisture was removed from the bone and it was drying out) superiorly. The order for the facility was to change the [DEVICE] dressing every other day and as needed. If the vacuum registered a leak alarm, the WCN/WCO instructed facility staff to change the dressing immediately to maintain negative pressure to the wound at all times. Facility staff were also instructed to not turn the vacuum unit off for any reason other than dressing changes. * TAR - 4/1/16, 4/2/16, 4/3/16: Resident #2 went 3 days, from 4/1/16 to 4/4/16, without a wound dressing change. * WCN - 4/4/16: The wound measured 8.5 cm x 4.0 cm x 3.2 cm; had a strong odor; a large amount of drainage; the [DEVICE] track pad was not attached at the inferior edge of the wound; the ischial bone was prominent and soft; perimeter granulation tissue was spongy in areas and friable with scattered slough. * TAR - The dressing change scheduled for 4/10/16 was not completed until 4/11/16. d) Wound #11 - Unstageable left inferior (low) buttock/left perineum (area between the anus and vulva or scrotum) pressure ulcer developed in facility: * WCN - 3/23/16: New unstageable pressure ulcer on Resident #2's left inferior (low) buttock. The wound had black eschar and measured 1.7 cm x 1.2 cm. New area of pressure that could be coming from (Resident #2's) catheter when she sits. Orders for the facility to inspect/ensure Resident #2 was not sitting on the catheter tubing. * WCN - 3/30/16: The left inferior buttock wound measured 3.0 cm x 3.8 cm x 0.1 cm and had bridged with wound #3 (left ischial wound). * WCN - 4/4/16: The wound measured 3.5 cm x 4.0 cm x 0.1 cm, was red and very moist, and perineal care to the labia was needed, a 0.5 cm x 0.5 cm area of slough to the left labia looked like it was from pressure related to her catheter. e) Wound #12 - Deep tissue injury to the middle of the left lower leg which developed into an unstageable wound: * NN - 7/7/16: A CNA informed the License Nurse (LN) Resident #2 had a suspicious area to her left lower extremity. The LN evaluated the area and identified a quarter sized non-blanching black area on the resident's leg that was surrounded by redness, induration, and was hot to the touch. Concerned it is the start of a pressure ulcer and soft tissue infection. No documented wound measurements. * NN - 7/8/16: Order for Keflex 500 mg three times daily related to signs and symptoms of soft tissue infection to left lower extremity and wound care evaluation. * WCN/WCN - 7/11/16: New deep injury to Resident #2's left medial lower leg. The wound clinic did not include measurements. Orders from the wound clinic to the facility included daily wound treatment and dressing changes. * TAR - On 7/9/16 the facility received orders from the wound clinic for dressing changes to the wound, however, the orders were not transcribed to Resident #2's TAR until 7/14/16. Therefore, treatment of [REDACTED]. * WCN - 7/25/16: The wound measured 10.0 cm x 6.0 cm x 0.1 cm; the wound bed was covered with eschar; signs and symptoms of infection were present as evidenced by purple streaks observed distally to wound (away from the center). Orders included [MEDICATION NAME] (antibiotic) 1 gram and that Physician #1 would follow-up on 7/26/16 to address the left lower extremity wound. Resident #2's clinical record showed she did not receive the [MEDICATION NAME] on 7/26/16 or 7/27/16, and had not been evaluated by Physician #1. * MAR - 7/27/16: Order for [MEDICATION NAME] 1 gram daily for seven days. * WCN/WCO - 8/4/16: The wound was unstageable (obscured full-thickness wound with skin and tissue loss) and measured 10.4 cm x 5.5 cm x 0.3 cm. Orders included [MEDICATION NAME] (antibiotic) 300 mg IV every 24 hours for seven days related to lower leg extremity [MEDICAL CONDITION] and referral to a plastic surgeon due to lack of wound improvement. * WCN - 8/8/16: Documented the wound measured 11.5 cm x 6.0 cm x 0.6 cm. The physician removed the eschar covering the wound bed and sent it to the lab for evaluation. Once the eschar was removed, slough was observed over the majority of the wound bed. f) Wound #13 - Unstageable left heel pressure ulcer developed in the facility: * WCN - 8/8/16: Resident #2 had a new unstageable pressure ulcer on the left heel measuring 5.0 cm x 5.0 cm x 0.1 cm that had bridged to several smaller areas of pressure on the lateral (side) and posterior (back) ankle. On 8/9/16, at 9:15 am, Resident #2 stated she was seen by the wound clinic for her wounds and that she felt frustrated and discouraged. She stated the facility found a new pressure sore on her left lower the previous month that started very small and then grew to what is was now. Resident #2 stated she thought the wound might be related to the catheter tubing placed between her legs, which were contracted and had decreased sensation, and she would not have felt the tubing. On 8/15/16, at 1:50 pm, the DNS stated the floor nurses and MDS coordinator were responsible for care plans. The DNS stated the RD was responsible for nutritional care and had not related any concerns regarding Resident #2's nutrition. The DNS stated she was not aware of the wound clinic physician's orders [REDACTED]. * Please refer to F325 as it relates to the facility's failure to ensure Resident #2's nutritional needs were met.

Based on record review, review of I&As, and staff interview, it was determined the facility failed to ensure a resident at risk for falls was adequately assessed, and interventions were implemented, and monitored for effectiveness, to prevent repeated falls. This was true for 1 of 5 (#11) residents sampled for falls. This failed practice resulted in harm to Resident #11 when over the course of two months she experienced nine falls, two of which involved injury, including one fall that resulted in a laceration to her ear requiring sutures. Findings include: Resident #11 was admitted to the facility with multiple diagnoses, including gout, cervicalgia (neck pain), [DIAGNOSES REDACTED] (an abnormal, asymmetrical head or neck position), and pain. Quarterly MDS assessments, dated 5/23/16 and 8/10/16, documented Resident #11 was independent with bed mobility, transfers, ambulation, and locomotion; required limited assistance of one person for dressing, toileting, and hygeine; had no impairment in upper or lower extremities; had not received physical therapy or restorative therapy; and had received occupational therapy from 6/3/16 to 7/1/16 for left wrist pain. Resident #11's current fall care plan documented: * Licensed nurses and social services would educate her about safety reminders and what to do if a fall occurred. The safety reminders and what to do if a fall occurred were not included on the care plan. * The activities department and physical therapy would encourage Resident #11 to participate in activities which promoted exercise, physical activity for strengthening and improved mobility such as yoga. * Licensed nurses would monitor Resident #11 for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function. * A Registered Nurse would review and modify environmental hazards that could cause or contribute to a fall. Resident #11's I&A reports, and nurses' notes from 4/8/16 to 8/1/16, documented: * On 4/8/16 at 12:20 pm, Resident #11 was found on the floor in her room and stated she lost her balance while trying to walk towards her walker and landed on her bottom. The time between last staff member and resident contact before fall was at 10:00 am. The facility documented the fall was an isolated incident and no corrective actions were taken to prevent future falls. * A nurses' note, dated 4/15/16, documented the RN/MDS nurse spoke with Resident #11 regarding fall prevention and offered her restorative therapy. The nurse documented, (Resident #11) politely refused stating this was an isolated incident, and that she just needs to slow down and take her time. * On 5/23/16 at 10:20 pm, Resident #11 was found on the floor in her room and stated she was (reaching) trying to hang a picture on the wall (lost her balance) and fell scraping her left leg on the arm chair. Resident #11 sustained abrasions to her left knee and left lower leg. The area on the form to document the time between last staff member and resident contact before fall was blank. The form documented Resident #11's dose of Depakote had been changed within the previous 30 days (5/13/16). Corrective actions implemented to prevent future falls included encouraging Resident #11 to remove the stacks of magazines from the floor and to ask for assistance and allow maintenance to help. * On 6/4/16 at 3:30 pm, Resident #11 was found on the floor in her room without her walker in front of her and stated she was too tired and missed the bed! The area on the form to document the time between last staff member and resident contact before fall was blank. Corrective actions implemented to prevent future falls included employee education. The content of the education was not included. Resident #11 was talked to about the use of the walker in front of her especially when she was so tired. * On 6/23/16 at 10:50 am, Resident #11 was found on the floor in her room and stated she was walking with her walker and couldn't remember what she was doing when she fell . The form identified there were numerous newspapers and papers scattered over the floor. Corrective actions implemented to prevent future falls included educating Resident #11 about the hazards of collecting and storing newspapers on the floor in her room and keeping the floor cluttered. In addition, maintenance and social services were notified, but the form did not document what their involvement would include. * On 6/30/16 at 5:15 am, Resident #11 was found on the floor in her room and stated she was asleep in the chair and slipped out onto the floor. Resident #11 complained of right knee pain and the inside of her right ankle was red. The corrective action to prevent future falls was to obtain a urine analysis and blood work. The urinalysis was negative for bladder infection. * On 7/9/16 at 7:45 am, Resident #11 was found on the floor in her room and it was determined she fell asleep in the chair and fell forward onto the floor. A corrective action was taken to prevent future falls by looking at more blood work. * On 7/10/16 at 4:45 pm, Resident #11 was found on the floor in her room. Resident #11 was not sure how she ended up on the floor. There were no corrective actions implemented. * On 8/1/16 at 10:45 pm, Resident #11 was found on the floor in her room and stated she couldn't remember what happened. Resident #11 sustained a laceration to her right ear and complained of neck pain. Resident #11 was transported to the emergency room at a local hospital. An emergency room report, dated 8/1/16 at 11:26 pm, documented Resident #11 presented with jaw pain which began earlier today. Patient was bending over to pick up the newspaper off the floor when she fell , hitting the right side of her face on the ground. Reports bleeding from her left ear . Resident #11 sustained a small laceration to her right ear which required sutures. A nurses' note, dated 8/11/16 at 4:30 pm, documented Resident #11 was found on the floor with her raised toilet seat sitting next to her on the floor and stated she fell asleep. On 8/15/16 at 2:40 pm, the DNS stated after each fall Resident #11 received increased supervision, including 15-minute checks continuing for 72 hours. The DNS stated Resident #11 was moved to a room closer to the nurses' station for increased supervision and she became very upset over the move. The DNS stated she did not remember if Resident #11 was involved in the decision making process about changing rooms, but the facility felt it was best to move her. When asked if therapy services were consulted to evaluate Resident #11 after any of the falls, the DNS stated on 8/13/16 the facility received an order from the physician for Physical Therapy to evaluate and treat Resident #11. Resident #11 did not receive supervision and/or services necessary to prevent falls. This failure resulted in injuries, including a laceration requiring sutures.

Based on observations, staff interview, and record review, it was determined the facility failed to ensure antidepressant therapy was not discontinued when residents presented with signs and symptoms of severe depression. This failed practice resulted in harm when Resident #3, expressed suicidal ideation on at least four occasions after her long standing antidepressant medication was discontinued without a gradual dose reduction. Additionally, the facility failed to confirm Resident #3 was exhibiting aggressive behaviors related to dementia prior to initiating a medication ordered to address those types of behaviors. Findings include: 1. Resident #3's psychological evaluation, dated 8/22/14, documented she had severe and recurrent major [MEDICAL CONDITION] and problems with interpersonal relationships accompanied by strong feelings of loneliness. A Behavioral Committee Drug Review, dated 1/26/16, documented Resident #3 was cognitively intact; had mild depression; was stable; and her target behaviors included paranoid ideations and hallucinations. Medications included [MEDICATION NAME] 100 mg daily for depression. Resident #3's Quarterly MDS, dated [DATE], documented: - Cognitively intact. - Verbalized feeling tired or having little energy for 7-11 days; poor appetite or overeating for 7-11 days; moved/spoke more slowly than usual or was fidgety and moved around more than usual for 2-6 days; and had mild depression. Physician order [REDACTED]. Resident #3's current Mood care plan documented the following interventions: - Monitor, record, and report to health care provider, as needed, risk for harm to self: Suicidal plan; past attempt at suicide; risky actions (stockpiling pills, saying good-bye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgement, or safety awareness. (Initiated 11/15/13) - Non-pharmalogical interventions for depression/self-isolation: Senior counseling weekly, encourage her to participate in activities, reminisce with her about her life/job experiences such as homemaking and speech therapist, and encourage familiar television shows. (Initiated 11/15/13) Resident #3 was admitted to the hospital on [DATE] with multiple medical issues and was re-admitted to the facility on [DATE]. The re-admission orders [REDACTED] A Progress Note, dated 4/8/16, documented Resident #3 was readmitted to the facility and the [MEDICATION NAME] was not included on the re-admission orders [REDACTED] The Medication Administration Record [REDACTED]. The MAR from 4/12/16 through 5/22/16 documented the [MEDICATION NAME] was place on hold. A Behavior Committee Drug Review, dated 4/20/16, documented Resident #3 was cognitively intact and experienced mild depression. The review form did not address whether the facility monitored and evaluated Resident #3 for mood changes and/or increased suicidal ideation after the [MEDICATION NAME] 100 mg was placed on hold. On 5/6/16, a care plan change note documented Resident #3 told the Social Service director that she was having thoughts of harming herself and the facility initiated 15-minute checks. Resident #'3 clinical record documented the physician had not been notified on 5/6/16 about the resident's suicidal thoughts, or that the facility had assessed, evaluated, and/or monitored the resident for a suicidal plan and/or the means to commit suicide as directed by the mood care plan. Resident #3's Comprehensive MDS assessment, dated 5/6/16, documented: - Verbalized having little interest or pleasure in doing things for 7-11 of 14 days, felt down, depressed, or hopeless for 7-11 of 14 days, tired or had little energy for 7-11 of 14 days, poor appetite or overeating for 2-6 days; felt negative about herself for 7-11 of 14 days, trouble concentrating on reading or watching television, experienced thoughts she would be better off dead, or hurting herself in some way for 12-14 of 14 days; and experienced moderately severe depression. - The safety notification documented on the MDS as made, but there was no evidence any notification was done beyond the person who completed the assessment. On 5/12/16, the Social Service Director (SSD) documented Resident #3 was re-assessed for [MEDICAL CONDITION], still had thoughts of harming herself, and continued on 15-minute checks. Resident #'3 clinical record documented the physician had not been notified on 5/13/16 about the resident's suicidal thoughts, or that the facility had assessed, evaluated, and/or monitored the resident for a suicidal plan and/or the means to commit suicide as directed by the mood care plan. On 5/13/16, the Director of Nursing documented Resident #3 had no thoughts of harming herself. Resident #3's clinical record from 5/14/16 to 5/17/16 did not document staff performed any additional evaluation and/or assessment of the resident's increased suicidal and/or self-harm ideation. On 5/18/16, the SSD documented Resident #3 was re-assessed for continued 15-minute checks, stated she continued to have thoughts of harming herself, and would remain on 15-minute checks. On 5/20/16, a fax sent to Resident #3's physician documented, (Resident #3) has been having [MEDICAL CONDITION] since 5/6/16 (was re-assessed on 5/12/16 and 5/18/16) and remained on 15-minute checks for [MEDICAL CONDITION]. Her [MEDICATION NAME] 100 mg . has been on hold since 5/1/16 (NOTE: The resident's clinical record documented [MEDICATION NAME] had been on hold since 4/12/16). (Resident #3 remained in a state of) moderately severe depression. Do you think it would benefit her to start the [MEDICATION NAME] again? A physician order, dated 5/23/16, documented staff were to resume administering [MEDICATION NAME] 100 mg daily. The clinical record documented Resident #3 had not received [MEDICATION NAME] since 3/24/16, except for three days, 4/9/16 through 4/11/16. On 5/23/16, the SSD documented Resident #3 was re-assessed for [MEDICAL CONDITION] and she stated she was no longer suicidal. The 15-minute checks were discontinued at this time. On 6/23/16, the Nurse Practioner (NP) documented, (Resident #3) indicated that her moods were a little depressed. (Resident #3) stated she struggled with feelings of hopelessness and worthlessness daily. When asked about thoughts of suicide or death, she did not respond which may have been the result of not hearing the question. Resident #3's Quarterly MDS assessment, dated 7/12/16, documented: - Verbalized feeling tired or having little energy for 2-6 days; felt bad about herself for 2-6 days; moved/spoke more slowly than usual or was fidgety and moved around more than usual for 2-6 days; thoughts that she would be better off dead, or hurting herself in some way for 7-11 days; and experienced mild depression. - The safety notification documented on the MDS as made, but there was no evidence any notification was done beyond the person who completed the assessment. The clinical record did not include documentation the physician had been notified on 7/12/16 about the resident's thoughts of suicide, or that the facility had assessed, evaluated, and/or monitored the resident for a suicidal plan and/or the means to commit suicide as directed by the mood care plan. On 7/20/16, the SSD documented, Psychosocial well-being discontinued as Resident #3 has not made statements of having little interest in doing things. A nurse's note, dated 8/1/16, documented, (Resident #3's family member) called and reported to the nurse that the resident had called her and stated she was going to kill herself. (Resident #3) was placed on every 15 minute checks. On 8/2/16, the NP documented, (Resident #3) says she is ok (sic). She continues to have the agitation she was experiencing last month, but feels she is more able to cope with it and is able to answer questions appropriately. On 8/2/16 a Nurse's Note documented, No attempts (by Resident #3) to injur (sic) self through this shift . On 8/3/16 a Nurse's Note documented, Physician noted that he reviewed the suicide watch note (related to Resident #3). A social service note, dated 8/9/16, documented, (Resident #3) reassessed for suicidal ideation. She was asked if she was having thoughts of harming herself and she stated no (sic). Every 15 minute checks were discontinued. On 8/12/16 at 1:00 pm, when asked if the physician had been notified upon completion of the MDS assessments and Resident #3's expression of suicidal ideation, the SSD and DNS did not respond. Please refer to F 157. 2. Resident #3's Comprehensive and Quarterly MDS assessments, dated 5/6/16 and 7/12/16 respectively, documented the resident: - Did not display physical, behavioral, and/or other behavioral symptoms towards others. - Did not reject evaluation or care that were necessary to achieve the resident's goals for health and well being. A physician order, dated 5/31/16, documented the resident was to receive [MEDICATION NAME] 5 mg at bedtime for aggressive behaviors related to dementia. No aggressive behaviors were documented in the resident's clinical record prior to the initiation of this medication. Resident #3's MARs dated 5/26/16 to 8/9/16 documented she received [MEDICATION NAME] 5 mg at bedtime related to aggressive behaviors. Resident #3's outpatient mental health NP progress notes, dated 5/31/16, 6/23/16, and 8/2/16, did not identify concerns regarding aggressive behaviors related to dementia. A Behavioral Committee Drug Review, dated 7/25/16, documented [MEDICATION NAME] was ordered for aggressive behaviors related to [MEDICAL CONDITION], however the review did not identify specific aggressive behaviors. On 8/12/16 at 1:00 pm, the DNS and SSD did not respond when asked to explain why Resident #3 was started on [MEDICATION NAME] for aggressive behaviors when none had been documented as present. When asked if Resident #3 was monitored for adverse reactions related to the [MEDICATION NAME], the SSD and DNS again did not respond.

Based on observation, resident and staff interview, record review, and review of the facility's [DIAGNOSES REDACTED] procedure, it was determined the health and safety of 5 of 5 sample residents (#s 1, 2, 3, 4, and 5), two random residents (#s 14 and 17), nine other residents with a [DIAGNOSES REDACTED]. a) failed to ensure physician's orders for [DIAGNOSES REDACTED] (blood glucose below 70) met accepted standards of professional practice for Resident #1 and #2. Their orders instructed [MEDICATION NAME] injection or Glucose gel/paste for a blood glucose (BG) less than 80, and Resident #1's orders instructed BG checks twice a day with sliding scale (SS) insulin as needed, which the facility did at 8 am and 9 pm during their normal morning and bedtime medication (med) pass times, rather than fasting before breakfast and dinner as the physician intended; b) failed to consistently implement interventions and recheck BG levels multiple times when Resident #2 experienced [DIAGNOSES REDACTED]; c) failed to notify the physician when Resident #2's insulin was repeatedly held, refused or the dosage was changed; d) failed to ensure Resident #s 1-5's physician's orders included parameters for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (BG above 110); e) failed to check the BG and administer insulin at the correct time for Resident #14; f) failed to ensure a [MEDICAL CONDITION] procedure/guideline was in place for Resident #s 1-5 and all other diabetic residents and any resident who could experience [MEDICAL CONDITION]; g) failed to notify the physician when Resident # 2, #3 and #5 experienced [MEDICAL CONDITION]; and, h) failed to ensure an insulin pharmacy label matched Resident #17's physician's orders. Additionally, Resident #5's blood pressure was not consistently measured as ordered to monitor for hypertension. The failure created the potential that undetected hypertension may not be treated, if indicated. The American Diabetes Association's (ADA) article, [DIAGNOSES REDACTED] (Low Blood Glucose), last edited 9/16/14, defined [DIAGNOSES REDACTED] as, "...a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70 mg/dl (milligrams/deciliter)...may also be referred to as an insulin reaction, or insulin shock...The only sure way to know whether you are experiencing [DIAGNOSES REDACTED] is to check your blood glucose...Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma, and death...left untreated, [DIAGNOSES REDACTED] may lead to a [MEDICAL CONDITION] or unconsciousness... [MEDICATION NAME] is a hormone that stimulates your liver to release stored glucose into your bloodstream when...blood glucose levels are too low... [DIAGNOSES REDACTED] unawareness occurs more frequently in those who: * frequently have low blood glucose episodes (...can cause you to stop sensing the early warning signs of [DIAGNOSES REDACTED]) * have had diabetes for a long time * tightly control their diabetes (...increases...chances of having low blood glucose reactions)... Other Causes of Symptoms(:) Other people may start to have symptoms...when their blood glucose levels are higher than 70 mg/dl. This can happen when...blood glucose levels are very high and start to go down quickly. If this is happening, discuss treatment with...health care provider." The ADA's article, [MEDICAL CONDITION] (High Blood Glucose), last edited 9/16/14, defined [MEDICAL CONDITION] as, "...technical term for high blood glucose (blood sugar)...happens when the body has too little insulin or when the body can't use insulin properly... Checking your blood and then treating high blood glucose early will help...avoid problems associated with [MEDICAL CONDITIONS] can be a serious problem...fail to treat [MEDICAL CONDITION], a condition called ketoacidosis...could occur...Ketoacidosis is life-threatening and needs immediate treatment..." The ADA's article, Checking Your Blood Glucose, last edited 3/3/15, documented the following regarding blood glucose target ranges, "Blood glucose targets are individualized based on: * duration of diabetes * age/life expectancy * comorbid conditions * known CVD (cardiovascular disease) or advanced microvascular complications * [DIAGNOSES REDACTED] unawareness * individual patient considerations. The American Diabetes Association suggests the following targets for most nonpregnant adults with diabetes. More or less stringent glycemic goals may be appropriate for each individual. * A1C (laboratory test to measure glucose control over the previous 2-3 months): 7% * A1C may also be reported as eAG: 154 mg/dl * Before a meal (preprandial plasma glucose); 70-130 mg/dl * 1-2 hours after beginning of the meal (Postprandial plasma glucose): less than 180 mg/dl..." On 3/26/15 at 3:50 p.m., the Administrator and DNS were informed verbally and in writing of the Immediate Jeopardy (IJ) situation. They were provided examples of residents who had not received proper and timely care and treatment for [REDACTED]. On 3/27/15 at 6:45 p.m., the facility provided the survey team with an acceptable abatement plan and the IJ was abated. The abatement plan included a procedure for insulin to be administered within a certain time limit before a meal service, a review of the orders for all diabetic residents with clarification of the orders to include the [DIAGNOSES REDACTED] Incident Procedure, physician contact for hypo- and [MEDICAL CONDITION] parameters, a change within PCC (Point Click Care, the facility's electronic medical record computer program) from AC/HS (before meals and bedtime) to the start time of meals so that residents receive their meal within 30 minutes of insulin administration, and training of all nurses on duty regarding the aforementioned changes as well as timely interventions, recheck BGs after interventions, and physician notification with other nurses to be educated before starting their shift. Findings included: Note: On 3/25/15 at 3:00 p.m., the survey team requested the facility's policies and procedures regarding hypo- and [MEDICAL CONDITION]. On 3/26/15, a Hypoglycemic Incidents Procedure, dated September 2012, was provided. The facility's Hypoglycemic Incidents Procedure documented, "1. On admission or when a resident is newly diagnosed with [REDACTED]. 2. For blood glucose levels 70 and below, or physician's guidelines, as long as resident is able to swallow...: a. Give a rapidly absorbed carbohydrate* such as 1) 4 oz (ounces) of orange, apple or grape juice OR 2) 6 oz of regular soda *These amounts are equal to 15 grams of carbohydrate. b. Repeat blood glucose test after 15 minutes. c. Repeat administration of carbohydrate if necessary. d. Follow with longer-acting carbohydrate protein such as: 1) Cheese and crackers 2) Milk and fruit 3) Sandwich e. Notify physician. f. Monitor blood glucose levels every 15 minutes until blood glucose level is above 70. 3. For blood glucose levels 45 or below as long as resident is able to swallow: a. Give glucopaste / glucogel / tube per physician's order. (15 gm. is standard; however need to check physician's order) b. Repeat blood glucose test after 15 minutes. c. If continues 45 or below, repeat glucopaste or glucogel after 15 minutes...if resident remains alert to swallow. d. Notify physician immediately...on-call for attending physician or the medical director; if not available contact the emergency room for further direction. 4. If...unable to swallow and has an order for [REDACTED]. [MEDICATION NAME] should be given per physician's order and physician notified per policy. b. Monitor blood glucose levels every 15 to 30 minutes until blood glucose level is above 70. 5..." 1. Resident # 2 was admitted to the facility on [DATE] and readmitted [DATE] with multiple [DIAGNOSES REDACTED]. Note: On 8/28/14 at 12:30 pm, Resident #2 experienced a life threatening episode of [DIAGNOSES REDACTED] when his BG measured 30. He was documented as being lethargic, pale, and confused after a fall from his wheelchair. Juice was given, rather than Glucopaste/gel per the facility's Hypoglycemc Incident Procedure. However, the resident's BG was not rechecked after the juice was given. Then, at 12:44 pm, a [MEDICATION NAME] 1 mg SC injection was administered. Fifteen minutes later his BG was 63. However, no other interventions or BG rechecks were documented. In addition, there was no documented evidence the physician was notified of the hypoglycemic event or that [MEDICATION NAME] SC was administered. In addition, on 3/7/15 at 9:34 pm, an LN attempted to administer [MEDICATION NAME] 1 mg per SC injection when the resident's BG was 63. However, the resident refused the injection. The [MEDICATION NAME] injection could have raised the resident's BG so much that Humalog insulin would have been necessary. Note: The facility's Hypoglycemc Incident Procedure instructed [MEDICATION NAME] by injection for a BG of 45 or lower if the resident was unable to swallow. There was no documented evidence the resident was unable to swallow when he refused the injection. Note: The survey team first noted diabetic management problems that occured in August 2014; however, the problems persisted and were still evident during the March 2015 survey. Resident #2's significant change and two most recent quarterly MDS assessments, dated 8/11/14, 10/30/14 and 1/29/15 respectively, documented intact cognition with a BIMS score of 15 and that insulin was administered 7 of 7 days in the look back period. The resident's current Medication Review Report included the following orders/start dates related to diabetes: * [MEDICATION NAME] 18 units by subcutaneous (SC) injection twice a day - 8/4/14; * Humalog insulin SC per sliding scale before meals and at bedtime: BG of 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-400 give 8 units, 401 + (plus) give 10 units, and above or equal to 401 give 10 units - 10/23/14; * BG check PRN (as needed) for signs/symptoms of [DIAGNOSES REDACTED] - 10/28/14; * [MEDICATION NAME] emergency kit 1 milligram inject 1 dose SC PRN "low blood sugar" - 7/24/14; and, * Glucose Gel 40 % give 1 dose by mouth PRN [DIAGNOSES REDACTED] - 10/28/14. The resident's care plan for DM included the following interventions and dates: * "Monitor/document/report to health care provider PRN s/s (signs/symptoms) of [DIAGNOSES REDACTED]: Sweating, tremor, increased heart rate...pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait." Initiated 5/27/14; * "Snack/food...midmorning daily." Initiated 8/29/14, revised 2/11/15; * "Monitor/document/report to health care provider PRN for s/s of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (difficult breathing and often preceding diabetic coma), [MEDICATION NAME] breath (smells fruity), stupor, coma." Initiated 2/20/14; and, * "Educate resident/family: Diabetes complications and preventions. (Resident's name) requests to be awakened when resting for BG checks and do not hold [MEDICATION NAME] administration when BG is low." It was initiated and revised 5/27/14. The aforementioned orders and care plan did not include any parameters for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] or when to notify the physician if the resident's BG was too low or too high. Additionally, neither the physician's orders nor the care plan included or referred to the [DIAGNOSES REDACTED] Incidents Procedure. The resident's August 2014 MAR documented the resident's scheduled [MEDICATION NAME] was held 8 times and refused twice; and, that his BG was 495 on 8/12 at 11:00 a.m. In addition, the August 2014 MAR documented the resident's BG levels were less than 70 on 8/7 at 7 am = 47, 8/10 at 7 am = 48, 8/17 at 9 pm = 56, 8/19 at 7 am = 41, 8/24 at 7 am = 45, 8/26 at 7 am = 44, and 8/27 at 7 am = 59 and at 4 pm = 62. Resident #2's August 2014 Progress Notes (PNs) included the following documentation: 8/7 at 7:53 am - "Blood sugar 47, resident ate candy bar and 240 ml (milliliters) of milk." * A recheck BG was not documented. 8/8 at 8:56 pm - "[MEDICATION NAME] per resident request, stated he'd had an 'insulin reaction' for past two mornings." * The 9:00 pm BG was documented as 202. 8/9 at 8:56 pm - "[MEDICATION NAME] per nursing judgement d/t (due to) low bs (blood sugar) in am and BS at 91." * The BG of 91 was within the accepted normal range. In addition, there was no documentation of any signs and symptoms (s/s) of [DIAGNOSES REDACTED] or that the physician was notified that [MEDICATION NAME] was held for a "low" BG. 8/10 at 9:03 pm - "[MEDICATION NAME] per nursing judgement d/t low blood sugars in am, was at 42 this morning." * An intervention and recheck BG was not documented when the BG was 42. 8/10 at 9:04 pm - "HumaLOG...Held d/t resident's request, resident concerned about drop in BS in am, and did not want to take HS (bedtime) snack to keep BS up at night." * The 9:00 pm BG was documented as 172. 8/14 at 8:51 pm - "[MEDICATION NAME] per resident request, stated he doesn't have [MEDICATION NAME] (sic) at night to prevent drop of BS in am." * The BG scheduled for 9:00 pm was documented as 133. 8/15 at 9:06 pm - "[MEDICATION NAME] per nursing judgement and per resident request." * The 9:00 pm BG was documented as 149. 8/17 at 9:14 pm - "[MEDICATION NAME] for a blood glucose of 56, Snack provided. Rechecked in 15 minutes. now 65 and climbing." * No other intervention or recheck BG was documented when the BG was 65. * 8/17 at 11:21 pm - "...received his meds (medications) and blood glucose checked, it is 56. [MEDICATION NAME] has been withheld and pt (patient) given a snack of milk and a candybar per his request...15 minutes after snack. Blood glucose is rechecked and has come up to 65. Pt reports feeling fine. Will continue to monitor..." * No documented evidence of any further intervention or BG recheck. 8/18 at 5:33 am - "Blood Glucose is 47 this morning after holding his insulin last nigtht (sic), given orange juice and a cheese stick, will recheck in about 15 minutes." * A recheck BG was not documented; however, the 7:00 am BG check (almost 1 1/2 hours later) documented the BG was 130. In addition, there was no documented evidence of any s/s of [DIAGNOSES REDACTED] or why his BG was checked at 5:33 a.m., almost 1 1/2 hours before the breakfast meal was scheduled to start at 7:00 a.m 8/19 at 6:41 am - "(R)es. bs was 41 at 0605 (6:05 a.m.), night shift gave juice, cheese...rechecked at 0640 (6:40 a.m.) @ (at) 88." * The BG was rechecked 35 minutes, not 15 minutes, after the intervention. 8/19 at 8:52 pm - "[MEDICATION NAME] below 150, held per nursing judgement and d/t resident requet (sic)." * The BG scheduled for 9:00 pm was documented as 136. 8/23 at 9:15 pm - "HumaLOG...Resident refused d/t drop in BS previous am, BS was 257." * There was no documented evidence the physician was notified about the refusal. 8/24 at 9:14 pm - "[MEDICATION NAME] d/t nursing judgement. When administered on 8/23, BS dropped to 43 in am." * The 7:00 am BG on 8/23 was documented as 45 in the August MAR. However, there was no documented evidence that any interventions or BG rechecks were done. 8/25 at 10:09 pm - Late Entry "...blood glucose levels continue to be very low in the mornings. pt (sic) refusing Humalog for sliding scale at all and wants us to cut the amount of [MEDICATION NAME] he takes. Have asked the doctor to review his blood sugars and adjust the doses accordingly, will continue to monitor..." * There was no documented evidence that the facility followed-up with the physician. 8/28 at 12:30 pm - "...found on floor...doesn't remember falls or nurse in the room at 1100 (11:00 a.m.) to check blood sugar...blood sugar post fall was 30, gave resident juice and PRN [MEDICATION NAME]." And, "...told he should consume a snack in the morning after therapy due to insulin working better in the tissue after exercise...Verbalized understanding...Will be reinforced by therapy." * The 11:00 am BG (an hour before the scheduled meal service) was documented as 73. However, by 12:30 p.m., the BG was 30. Nothing was documented about the resident's level of consciousness when the BG was 30. However, the first intervention documented was juice, which indicated the resident was conscious and able to swallow. There was no documentation about why juice, rather than Glucose Gel 40% was not administered as ordered for [DIAGNOSES REDACTED] if the resident was able to swallow. Additionally, the facility's Hypoglycemic Incident Procedure which instructed Glucopaste or Gel for a BG of 45 or below if the resident was able to swallow, was not followed. 8/28 at 12:44 pm - "[MEDICATION NAME] Emergency Kit 1 MG Inject 1 dose subcutaneously as needed for low blood sugar. Residents blood sugar was 30, resident is lethargic, pale, and confused, will continue to monitor." * There was documentation that the resident was unable to swallow at this time. 8/28 at 1:00 pm - "...blood sugar is 63." * No other intervention or recheck BG was documented. 8/28 at 8:17 pm - "HumaLOG...pt refused based on severe drops in his blood glucose levels. Would also only take 6 units of the [MEDICATION NAME] (sic)." * No documentation that the physician was notified about the refusal and dosage change. 8/29 at 10:31 am - "Care Plan change made to ensure resident gets a snack midmorning after therapy to ensure blood sugar does not drop too low." 8/30 9:22 pm - "[MEDICATION NAME] d/t low BG of 98." 8/31 9:36 pm - "HumaLOG...Resident refused d/t recent a.m. [DIAGNOSES REDACTED] episodes." There was no documented evidence that interventions were consistently implemented when the resident was hypoglycemic or that his BG was rechecked 15 minutes after an intervention was implemented for [DIAGNOSES REDACTED]. Also, there was no documented evidence the physician was notified of the frequent episodes of [DIAGNOSES REDACTED], that [MEDICATION NAME] and Humalog insulin were held or refused repeatedly from 8/7/14 to 8/25/14 (18 days) and from 8/28 to 8/31 (4 days), that different doses of the insulin medications were administered per the resident request, or when the BG was over 400. In addition, there was no documented evidence the facility followed-up with the physician after notification about [DIAGNOSES REDACTED] on 8/25/14 or informed the physician of severe [DIAGNOSES REDACTED] 3 days later, on 8/28/14, when the resident's BG dropped to 30. The resident's MAR for 3/1/15 - 3/24/15 documented the resident's BG was greater than 400 as follows: 3/7 at 11:00 am = 449, 3/11 at 7:00 am = 438, 3/13 at 11:00 am = 484, 3/14 at 7 am = 405, 3/19 at 4:00 pm = 416, and 3/22 at 4:00 pm = 416. However, there was no documented evidence the physician was notified when the resident's BG was over 400 in March 2015. The March 2015 MAR and/or PNs also contained documentation that the resident refused the HS dose of [MEDICATION NAME] 21 times, 3/1, 3/3-3/6, 3/8-3/10, 3/12-3/14, and 3/18-3/27; requested a different dose of [MEDICATION NAME] on 3/11 at 9:45 pm, and "7 units" rather than the ordered 18 units was administered; and, the resident refused the Humalog insulin per the s/s when his HS (9:00 pm) BG measured 140 to 516 on 3/1-3/6, 3/8, 3/10-3/14, 3/16, 3/23, and 3/27. However, there was no documented evidence the physician was notified when the insulin medications were refused or when a different dose than ordered was administered. The March 2015 MAR also contained documentation that the resident's BG levels were less than 70 on 3/6 at 7 am = 63, 3/7 at 9 pm = 63; and 3/15 at 9 pm = 57. The MAR included the orders for [MEDICATION NAME] SC and Glucose Gel 40 % by mouth as needed for [DIAGNOSES REDACTED]. However, the only documented intervention for [DIAGNOSES REDACTED] was on 3/7 at 9:34 pm when the resident refused an attempted [MEDICATION NAME] 1 mg SC injection. The March 2015 PNs also documented the following: 3/6 - There were no entries when the resident's BG was documented as 63 at 7:00 am. on the MAR, which indicated that no interventions were implemented and the BG was not rechecked. 3/7 at 10:16 pm - "...blood glucose was low at 2100 (9:00 pm) was 63 pt was given juice, crackers and cheese and banna (sic) at 2300 (11:00 pm) was 198..." * The March 2015 MAR documented that the resident refused a [MEDICATION NAME] SC injection at 8:35 pm when the BG scheduled for 9:00 pm was 63. In addition, the BG recheck was done 2 hours, not 15 minutes, after the intervention with food for [DIAGNOSES REDACTED]. 3/12 at 11:55 pm - "...BG at HS: 516...would only allow 6 U (units) of Humalog..." * Again, there was no documented evidence the physician was notified about the extremely high BG or that a different dose of Humalog was administered. 3/15 at 10:15 pm - "...Lethargic, generalized weakness. C/O (complaint of) 'I can't think straight"...Reports he hasn't been feeling well and that he did not eat well for supper. Hands are shaking. Blood sugar low at 57. Tx (treatment) for his low blood sugar provided. Resident able to eat w/ (with) assistance. Requires being fed. Will f/u (follow up) on blood sugar in 30 min(utes)..." * What the "Tx" was was not documented and a BG recheck was not documented. On 3/26/15 at 2:20 pm, the DON was interviewed and asked about orders for [MEDICATION NAME] SC or Glucopaste/gel for residents with a BG less than 80. The DON said, "The nurse should follow the [DIAGNOSES REDACTED] policy." On 3/26/15 at 3:35 pm, the DON was asked if the facility had a policy or protocol for [MEDICAL CONDITION]. She said the facility did not have a [MEDICAL CONDITION] policy and that the nurses would, "Use standard practice if (BG) over 400, call MD (Medical Doctor)." On 3/27/15 at 12:15 pm, the Medical Director (MD) was interviewed by telephone about diabetic management in the facility. When asked about the Hypoglycemic Incident Procedure, the MD said he was familiar with the procedure and had approved it, but he was not involved in creating it. When asked about orders for [MEDICATION NAME] SC or Glucopaste/gel for BG levels less than 80, the MD said "70 to 110" was the normal BG range and the intent was that staff would monitor a resident whose BG was under 80 and recheck the BG as needed. He said staff should "use their best judgement" and that "80 would be an area they look at as a potential issue going on." Regarding residents without specific orders for interventions for [DIAGNOSES REDACTED], the MD stated, "If the facility has a protocol then follow it and then if there are questions talk to the doctor." Regarding orders for BG checks and SS insulin twice a day, the MD stated, "I would do a fasting blood sugar before breakfast and then before dinner." Resident #2 was in immediate jeopardy when the facility failed to provide adequate diabetic management as evidenced by the facility's attempt to administer a [MEDICATION NAME] SC injection when the resident's BG was 63 and the resident was able to refuse the injection; the facility did not follow the physician ordered intervention for Glucose Gel, or the Hypoglycemic Incident Procedure, when his BG was 30 and juice, not Glucose Gel, was administered; the facility did not provide consistent or appropriate interventions or follow-up monitoring when the resident experienced numerous episodes of extremely low and extremely high BG levels; and, the facility failed to notify the physician when the resident's BG levels were less than 70 or over 400 and when the resident refused antidiabetic medications or requested different doses of the medications. 2. Resident #3 was admitted to the facility on 2013, and readmitted [DATE], 5/16/14, and 2/7/15 with multiple [DIAGNOSES REDACTED]. The resident's current Medication Review Report included an order for [REDACTED]. The March 2015 e-MAR contained documentation that the resident's BG was over 400 on 3/10 at 9:00 pm = 442, 3/11 at 4:00 pm = 445 and 9:00 pm = 412, 3/17 at 9:00 pm = 435, and 3/23 at 4:00 pm = 426. Review of the resident's electronic medical record revealed there was no documented evidence the resident's physician was notified when the BG was over 400. On 3/26/15 at 6:10 pm, the Administrator, DON, and Director of Social Services were notified of the BG issue. On 3/27/15 at 1:00 pm, LN #8 was asked if the physician was notified when the resident's BG was over 400. The LN said she would do some research and get back with the surveyor. On 3/27/15 at 4:45 pm, LN #8 stated, "No, we did not find any documentation the nurses notified the physician (when the resident's BG was over 400)." The facility did not provide any further information about the issue. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident's #1 Annual MDS assessment, dated 10/10/14, and Quarterly MDS assessment, dated 1/8/15, documented the resident was severely cognitively impaired with a BIMS score of 3. The care plan for diabetes mellitus, initiated 10/29/13, documented the following interventions: *Observe for signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, muscle cramps, abdominal pain, rapid/deep breathing, fruity smelling breath, change in level of consciousness; and, *Observe for and report to nurse signs and symptoms of [DIAGNOSES REDACTED]: sweating, tremor increased heart rate, pale skin, nervousness, confusion slurred speech, lack of coordination and staggering gait. NOTE: The care plan did not contain acceptable blood glucose parameters, [DIAGNOSES REDACTED] or [MEDICAL CONDITION] interventions or refer to the facility's policy and procedure. The 3/24/15 Medication Review Report (Recapitulation Orders) documented the following physician orders: *Humalog Solution Inject as per sliding scale: If 200-250 = 2 units; 251-300 = 4 units; 301 - 350 = 6 units; 351-400 = 8 units, subcutaneously two times a day for diabetes, with a start date of 9/30/13; *[MEDICATION NAME] Emergency Kit 1 MG Inject 1 gram intramuscularly as need for Blood Glucose < 80. Give if unable to swallow, with a start date of 9/30/13; *Glucose 15 Gel 40%, give 15 gram by mouth as needed for blood glucose < 80 and food contraindicated. Give 15 Gms PO (per oral). If unable to swallow give [MEDICATION NAME], with a start date of 9/30/13; and, *Blood glucose check as needed for s/sx of [DIAGNOSES REDACTED], with a start date of 10/28/14. The March 2015 MAR documented BG (Blood Glucose) levels were scheduled at 8 AM and 9 PM. NOTE: The orders directed staff to give [MEDICATION NAME] intramuscularly before giving a high carbohydrate snack. Blood glucose checks were ordered twice per day and lacked direction when BG levels should be drawn, e.g., fasting or before meals. There was no direction in the physician order what to do if the BG levels were above 400. Additionally, the facility did not have a [MEDICAL CONDITION] policy. On 3/26/15 at 2:20 PM, the DON stated BG levels are scheduled per the doctor's order and, unless the physician ordered a specific time, it would default to the AM and HS med pass. When asked if a nurse should question a BG level done after the resident ate a meal, the DON stated it would depend on how stable the resident was, but, typically BG levels were fasting. When asked if a BG should be done at 9 PM, after dinner and an evening snack, the DON stated, "I don't see that would be a big problem." When asked if the scheduled times should have been clarified with the physician, the DON stated, "I believe the physician ordered it as he wanted it to be." When questioned about the 9/30/13 orders for Glucose 15 Gel 40 %, to give 15 grams by mouth, and the [MEDICATION NAME] Emergency Kit order, to give 1 gram intramuscularly for a BG < 80, if the resident was unable to swallow, the DON stated, "It was probably typed in wrong, I'll have to look it up." When asked about the order for Glucose 15 Gel 40 % for BG levels < 80, the DON stated the nurses should follow the facility's [DIAGNOSES REDACTED] policy. NOTE: The facility's procedure for Hypoglycemic Incidents documented, "For blood glucose levels 70 and below, or physician's guidelines, as long as resident is able to swallow (observe for gag reflex with tongue blade): a. give a rapidly absorbed carbohydrate* such as: 1) 4 oz. of orange, apple or grape juice OR 2) 6 oz. of regular soda. *These amounts are equal to 15 grams of carbohydrate." It was unclear if the facility was to follow the guidelines for BGs below 80 or the policy guidelines of below 70. On 3/26/15 at 4:00 PM, the Administrator and DON were informed of the concerns regarding blood glucose issues. On 3/27/15 at 12:15 PM, the resident's physician stated he knew the facility had a [DIAGNOSES REDACTED] policy in place but was not involved in creating it. When asked about ordering BGs on a BID basis, the physician stated he did not order BG's BID and one of his partners must have issued that order. He stated if he ordered BGs twice per day he would order a fasting blood sugar before breakfast and then before dinner. When asked about giving Glucose Gel for a BG below 80, the physician stated he would expect nurses to use their best judgment. When asked why he would use 80 as a parameter when the American Diabetes Association listed 70-110 as normal parameters, the physician stated he used 80 as an area the nurses should look at since there could be a potential issue going on and they should recheck it at 80. For residents who have BG orders and/or sliding scale orders, but have no interventions for [DIAGNOSES REDACTED] or [MEDICAL CONDITION], the physician stated the facility should implement the protocol for low BGs. 4. During a medication pass observation on 3/24/15 at 3:17 p.m., LN #4 was observed administering insulin 2 units per sliding scale (SS) to resident #14. The LN said she had "just done" the resident's BG (blood glucose) "right before" 2 surveyors arrived and that the BG was 173. As the LN administered the insulin, she added, "This is for dinner." LN #4 was interviewed immediately afterward. When asked about the SS insulin in relation to meal times, LN #4 stated, "She just ate some yogurt so it's okay to give the insulin. If it was 8-10 units then I would worry but its only 2 units." Refer to F 333, Significant Medication Error, for details about this deficient practice. Note: The facility's lunch meal service was set for 12:00 to 1:00 p.m. and the dinner meal service was set for 5:00 p.m. to 6:00 p.m. Therefore, the resident's BG check was done and SS Humalog insulin was administered approximately 1 hour and 45 minutes before the evening meal was scheduled to start. On 3/26/15 at 2:00 pm, the DON was asked if there was a policy, procedure or guidelines for the timeframe a BG check should be done and when sliding scale insulin should be given. The DON stated, "Usually an hour window before or after the established time." When asked if she percieved a problem with insulin being given almost 2 hours before a meal, she stated, "Yeah, there's potential for a problem." On 3/26/15 at 6:10 pm, the Administrator, DON, and Director of Social Services were notified of the issue. The facility did not provide further information about the issue. 5. During a medication pass observation on 3/26/15 at 11:10 am, the pharmacy label on Resident #17's Humalog insulin was noted to be different from the physician's orders. The label on the resident's Humalog insulin read, "Inject 8 units subcutaneously (SC) three times a day before meals." LN #1, however, administered Humalog 4 units. She said she administered 4 units per the resident's sliding scale orders for a blood sugar level of 221. Immediately afterward, the LN was asked about the difference between the pharmacy label and the amount of Humalog insulin administered. The LN said, "It's different." The LN then looked in the computer and found the physician orders for the aforementioned SS Humalog insulin, it was dated 9/30/2013. The LN said there were no other orders for Humalog insulin. Refer to F 431 for details about the pharmacy labeli

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents were not harmed through severe weight loss. This was true for 1 of 10 residents (#1) sampled for weight loss and resulted in harm when Resident #1 lost 11-percent of her body weight in a three month period, and 19-percent of her body weight over six months. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS assessment, dated 10/10/14, documented the resident had severe cognitively impairment with a BIMS score of 3, needed supervision, one person assistance when eating, and weighed 143 lbs. The quarterly MDS assessment, dated 1/8/15, documented the resident had severe cognitively impairment with a BIMS score of 3, needed setup help only to eat, and weighed 127 lbs. The ADL Care Plan, initiated 10/17/13 and revised on 4/29/14, documented an intervention to remind, cue and provide assistance to the resident as needed to eat. The Nutritional Care Plan, initiated on 10/18/13, documented the following interventions: *Invite resident to activities that promote additional intake. Family encouraged to eat meals with resident, revised 1/6/14; *Prefers to sit in her room or with front office staff during meals/snacks; *Offer meals in the dining room each meal, offer walk to dine; *Often prefers to eat in her room or with office staff, revised 10/22/14; *Assist with obtaining special equipment as needed. Plastic spoon with meals. Offer finger foods, revised 1/14/15; *Snack/food #3 offer fluids and a finger food for snacks, revised 1/26/15; *Weigh weekly. MD states weight loss expected and unavoidable, revised 2/11/15; Note: The record did not include an assessment or explanation for the [DIAGNOSES REDACTED]. "expected and unavoidable." *Give fortified foods per dietary plan. Offer foods one at a time, revised 2/18/15; and, *Snack/food #1 mandarin oranges with breakfast. Resident will also be offered bran, prune, applesauce mixture with breakfast to promote bowel regularity daily, revised 2/18/15. The resident's Weights Summary Report documented the following weights: *10/18/14 142.5 *1/4/15 127 *10/26/14 140 *1/10/15 127.3 *11/1/14 140.2 *1/19/15 127 *11/7/14 135 *1/25/15 126.2 *11/15/14 133.2 *2/1/15 116 *11/23/14 125.6 *2/8/15 114 *11/29/14 126 *2/14/15 113.4 *12/8/14 125.5 *2/21/15 112.2 *12/13/14 124.1 *3/1/15 111.6 *12/21/14 126.2 *3/7/15 112.6 *12/27/14 127.5 *3/14/15 111.5 *3/21/15 115.4 Resident #1 was observed throughout the survey week of 3/23/15 appeared thin and cachectic (loss of weight and muscle mass). On 3/24/15 at 9:16 AM, CNA #5 was observed delivering a breakfast tray to Resident #1's BST (bedside table). CNA #5 awakened the resident, asked if she needed anything else and left the room. The resident leaned up on her left elbow, ate the mandarin oranges and drank approximately half of her milk. She did not touch the scrambled eggs, potatoes, or bacon, or drink the milk shake, which was on the breakfast tray. The resident lied down and closed her eyes. CNA #5 was not observed to remind, cue, or assist the resident to eat or offer foods one at a time as care planned. On 3/24/15 at 10:05 AM, a staff member came into the resident's room and asked if she had been served breakfast. The resident replied, "Yes." The staff member asked if the resident wanted anything else until noon, and the resident replied she was fine. On 3/24/15 at 10:25 AM, a chocolate shake with a straw was observed on the resident's BST. The resident was in bed sleeping. On 3/24/15 at 11:25 AM, the resident was awake in bed with the chocolate shake, which was still full, and a full water pitcher on the BST. On 3/24/15 at 12:45 AM, the resident remained in bed, the chocolate shake and water jug remained on the BST and were both full. The hall lunch trays had not been delivered. The meal monitor for 3/24/15 documented the resident ate 26-50% of breakfast at 9:03 AM, refused lunch at 1:32 PM, ate 0-25% (snack) at 2:56 PM and refused the evening snack. On 3/25/15 at 8:35 AM, the RD provided a nutrition timeline and stated eating was more of a social aspect for Resident #1 and she ate best at lunch or when family were present. She stated the resident needed encouragement to go to the dining room. When asked about the intervention to remind, cue and assist the resident as needed to eat, the RD stated, "I would expect a CNA to assist in cueing and reminding the resident to eat. Absolutely, since she has had significant weight loss since Christmas. Actually, her weight loss started in November." On 3/25/15 at 9:00 AM, the OM stated Resident #1 liked her and they normally had lunch together, but she hadn't seen her the day before. The OM stated the resident, who had worked in an office, liked to watch for her daughter or son to arrive, and liked the activity. Note: There was no documentation of a plan for the resident to have her meals in the office when the OM was unavailable. On 3/25/15 at 4:45 PM, LN #4 was observed asking the resident if she wanted a can of Ensure and the resident requested Vanilla flavor. On 3/25/15 at 5:30 PM, the resident was observed in bed with a can of Vanilla Ensure; a water pitcher on her BST was not within reach. On 3/25/15 at 6:10 PM, LN #4 was asked if the resident was able to reach the Ensure and water pitcher on the BST. She stated, "No, the resident can't reach it. Usually the resident needs to be encouraged and when I walk by I tell her to take a sip." LN #4 then moved the BST closer to the resident's bed. The resident sat up in bed and took a drink of the Ensure. Note: Once the BST with the water pitcher and Ensure was moved within the resident's reach, she took a drink. The meal monitor for 3/25/15 documented the resident ate 0-25% of breakfast at 9:03 AM, 0-25% of lunch at 1:00 PM, and did not contain documentation for the evening meal or the evening snack. On 3/26/15 at 9:05 AM, the resident was observed sitting in her WC in the dining room being assisted to eat by a CNA. The surveyor observed the resident ate approximately 75% of her meal. On 3/26/15 at 12:30 PM, the resident was observed sitting in her WC with a lunch tray in the office eating lunch with the OM. The meal monitor for 3/26/15 documented the resident ate 26-50% of her breakfast at 10:36 AM, ate 51-75% of her lunch at 12:43 PM and refused food/supplement at 2:51 PM and 9:52 PM. The evening snack monitor documented the resident ate 0-25% at 9:58 PM. Note: When assisted to eat, the resident showed an increased percentage in the amount of food eaten, as evidenced by the 26-50% eaten at breakfast, and when eating lunch with the OM, the resident ate 51-75%. Review of the physician's progress notes revealed: *10/19/14-The resident weighed 143 lbs. and weight was stable; *12/15/14-The resident weighed 124 lbs., had previously weighed in the 140's, and would be put on a weight assessment program; and, *2/7/15-The resident weighed 116 lbs., was down 11 lbs. (No comparative date or weight documented), and would again discuss with staff steps taken to control her weight. Note: No documentation was found which defined a weight assessment program or that one was implemented. No documentation was found of a discussion with staff on how to control the resident's weight. Review of the Medication Review Report for March 2015 (recapitulation orders), documented an order, dated 11/12/14, for 1 can of Ensure daily with dinner related to diabetic management and an order, dated 12/16/14, for House Supplement three times a day for weight loss, poor appetite/intake, offer 240 cc (cubic centimeters) house supplement with snacks. Note: No documentation was provided by the facility that it was tracking the success of interventions which had been attempted. No documentation was provided the speech therapist had been involved or who recommended the intervention to offer foods one at a time. Additionally, no documentation was found in the resident's care plan of the RD's recommendation of adding chocolate with meals, that staff knew of the RD's recommendation or when it was discontinued. During the survey process, chocolate was not observed to be served to the resident. On 3/25/15 at 9:15 AM, the RD provided a Nutrition Timeline for the resident and stated on 11/15/14 the resident weighed 133.2 lbs. and had significant weight loss (6.5%) based on the 30 day weight of 142.5 lbs. taken on 10/11/14. She stated the resident was placed on Ensure, pudding, Nutrition At Risk (a weekly interdisciplinary meeting to address weight loss), along with lab work. On 12/2/14, the RD recommended chocolate with meals to help stimulate the resident's appetite. On 12/15/14, the RD stated that chocolate with meals as an appetite stimulant had not increased her oral intakes but the resident wanted to continue taking chocolate with meals. On 12/15/14, the resident's physician approved the RD recommendations to increase the Ensure to TID (three times daily). The resident had some weight gain in January with three weeks of stable weight at 127 lbs. However, the resident lost 10 lbs. in one week, recording a weight of 126.2 lbs. on 1/25/15 and 116 lbs. on 2/1/15. She stated the resident's weight dropped another 2 lbs. on 2/8/15. The RD faxed a communication to the resident's physician on 2/9/15 regarding the weight concern, and informed the physician that the resident was not interested in eating and not responding to nutrition interventions. She asked the physician the following numbered questions: "#1) Will you address her weight loss? #2) Would you say that her weight loss is expected and unavoidable? Thanks!" The physician's faxed response documented, "Weight loss is expected and unavoidable." The RD did not provide a summary of the current interventions or make the physician aware of what interventions had been tried before asking the physician for a weight loss [DIAGNOSES REDACTED]. In response to the faxed request from the RD on 2/9/15, the physician did not document why weight loss was unavoidable. Additionally, his progress notes did not address unavoidable or expected weight loss concerns. A progress note on 2/25/15 at 2:38 PM, by the LSW, documented, "MD states that he will address pain relief as a potential reason for decline in weight loss." This progress note was nearly three weeks after the 2/9/15 faxed response by the physician in which he responded to the RD's request for a [DIAGNOSES REDACTED]. No documentation was found which indicated the physician investigated pain relief as a potential reason for the resident's weight loss. On 3/25/15 at 9:15 AM, the RD stated she felt the facility had done all it could to prevent weight loss. The RD was made aware of the observations where the resident had the food tray placed on her BST, and had not been reminded, cued or received assistance as needed to eat. The RD shook her head from side to side. The surveyor explained the facility identified interventions, but did not ensure the resident received the help she needed. The RD was unable to explain why the interventions identified by the facility were not carried out during the surveyor's observations. On 3/25/15 at 9:55 AM, CNA #5 stated breakfast hall trays were normally delivered between 9:30-10:00 AM and she had setup Resident #1's breakfast tray on 3/24/15. She stated the resident ate all of her mandarin oranges and most of her milk. She stated the resident didn't really eat and that it was she who charted on the meal monitor. She stated she delivered the lunch tray and set it up as well. She stated Resident #1 wasn't hungry and didn't eat anything for lunch. CNA #5 stated every CNA charted differently, with most staff charting what the resident ate off her plate. However, CNA #5 stated, she charted the percentage of what the resident ate of everything, not just on her plate. CNA #5 stated she charted the resident ate 25% so she picked 0-25%. When shown the meal monitor where she charted 26-50%, CNA #5 stated Resident #1 ate only the mandarin oranges. When asked if she ever stayed in the room and reminded, cued or assisted the resident to eat, CNA #5 stated, "She is independent to eat, unless they changed it and didn't tell me." Record review of the Kardex Report used by CNA's and provided on 3/25/15, documented the resident, "Requires reminding, and cueing, assistance as needed to eat." On 3/27/15 at 3:35 PM, LN #8 stated the staff did not often cue, remind, or assist the resident to eat. At 5:10 PM, LN #8 stated Resident #1 had lost a substantial amount of weight. She stated the resident's physician was aware of her severe weight loss and had mentioned it to LN #8 but, "he didn't give us any advice." The facility failed to ensure the resident was reminded, cued, and assisted to eat as needed as care planned. Resident #1 experienced severe weight loss of 9.3 lbs. or 6.5% in one month, from 10/18/14 to 11/15/14. She continued to experience severe weight loss of 15.5 lbs. or 11% in three months and 27.1 lbs. or 19% in six months. No documentation was found which defined a weight assessment program or that one was implemented. No documentation was found of a discussion with staff on how to control the resident's weight. No documentation was provided by the facility that it was tracking the success of interventions which had been attempted. On 3/27/15 at 5:30 PM, the Administrator and DON were informed of the aforementioned weight loss concerns. No further information was provided by the facility which resolved the issue.

Based on observation, staff interview, and record review it was determined the facility did not ensure 1 of 4 sampled residents (#4) was safe from hazards when a resident was transported from the dining room without wheelchair pedals, caught her foot on an elevated threshold and carpet between the dining room and hallway which caused her harm when she fractured her right tibia and fibula. In addition, the elevated threshold between the Rehabilitation alcove and hallway created a potential trip hazard for residents who could become injured. Findings include: 1. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The Resident's Quarterly MDS dated [DATE] coded the Resident: *Was severely cognitively impaired with a BIMS of 7, *Did not reject care, *Used a wheelchair, *Locomotion off the unit required extensive one person assistance, *Experienced occasional pain. The Resident's Mobility Impairment Care Plan dated 5/29/13, documented in part as an intervention, "W/C (wheel chair) for mobility." Note: The care plan did not indicate to leave foot pedals off. The Resident's MAR from 7/1 to 8/3/13 documented an order on 12/20/11 for, "Fentanyl (Duragesic) 25 MCG Transdermol Q (every) 3 days" for pain. The Resident's Interdisciplinary Progress Note dated by an LN on 8/3/13 at 6:15 PM, documented, "Resident coming out of dining Rm (room). Ft (foot) caught on threshold & forced knee to go more forward & ft to go under w/c. Taken to Rm VS (vital signs) were taken & ice applied to R(ight) knee. Both knees checked. Both equal in size. Pain med(ication) given. Family notified. Upon return to her room- her knee was again checked & found to be swollen @ knee...She was transported by ambulance to (local hospital)..." The Resident's History and Physical from a local hospital dated 8/3/13 documented in part, "...presents with a right tibial/fibular plateau fracture. The patient had an accident with her wheelchair yesterday in the nursing home. The fracture was sustained...She has already been seen by Dr. (Physician's name). He feels that placing her into a brace is appropriate and that she should not be a surgical candidate." A facility Investigation Interview and Notes on 8/6/13 at 1:15 PM, documented in part an interview with LN #1 who witnessed the incident with the Resident: -"She (the Resident) was being wheeled from the dining room to the hallway as they crossed the threshold her sneaker grabbed on the carpet and that kept the foot in one place- the right sneaker. The c.n.a. continued to push the wheelchair and her right leg bent under the chair. When (Resident #4) cried out the c.n.a. stopped and backed her up." -"Why did it happen? The sneaker grabbed the carpet. The resident prefers to not use foot pedals." -"In your opinion, how could this event have been avoided? Use of foot pedals." Note: Evidence in the Resident's medical record could not be found to indicate the resident refused wheelchair pedals nor was there evidence regarding any discussion with the responsible party about the risk versus benefits of using pedals. A facility Investigation Interview and Notes with a blank date and time, documented in part an interview with LN #2 who witnessed the incident with the Resident. "(C.N.A. #3) was pushing (Resident #4)'s wheelchair out of the doorway, and (Resident #4) hollered out. (C.N.A. #3) stopped and backed up to see what had happened...(C.N.A. #3) was not rolling the resident too fast in the wheelchair, or doing anythingin (sic) my opinion to harm the resident. She immediately stopped when the resident yelled out." A facility Investigation Interview and Notes on 8/7/13 at 4:45 PM, documented in part an interview with C.N.A. #3 regarding the incident with the Resident: -"I was wheeling (Resident #4) through the dining room doorway, she put her foot down and I stopped and asked her what was wrong, because she won't wear foot peddals (sic) and she said her leg hurt and so I said that we would get her some pain medication from the nurse. So I wheeled her back to her room and then she called again and said that her leg was still hurting so I called the nurse and that is when the nurse said that she thought that her leg was fractured. I wasn't pushing her fast or anything and when she put her foot down, I stopped immediately." -"Why did it happen? Because she put her foot down." -"In your opinion, how could this event have been avoided? If (Resident #4) would have allowed foot peddals (sic) to be put on her chair it could have been prevented. I hope that it is care planned for her to have them from now on, or else I am not pushing her." On 9/3/13 at 3:15 PM the entry way from the hallway to the Idaho dining room was observed. A 2 inch wide metal threshold covered the area where the vinyl dining room floor and the hallway carpet met. The threshold peak was approximately 1/4 of an inch higher than the carpeted floor. The resident's pain medication was increased twice after the fracture. The Resident's physician's orders [REDACTED]./12/13, the physician increased the 50 MCG Fentanyl patch to 75 MCG. The Resident's August 2013 TAR dated 8/9/13 documented, "Hinged leg brace." On 8/11/13 the TAR documented, "Drsg (dressing) R medial leg. Cover (with) Bacitracin, then cover (with) Mepilex foam. Use 1 layer Kerlix then replace thigh-high sock." The Resident's Wound Flow Sheet Attachment dated 8/14/13 by an LN, documented, "Right calf has hematoma, noted moderate serous drainage on foam, Kerlix and stocking." On a sheet of white paper dated 8/19/13, Resident #4's physician documented in part, "I will set up appointment with a plastic surgeon at (local hospital) wound clinic in near future." The Resident's Mobility Impairment Care Plan dated 8/27/13, documented in part as an intervention, "Foot Pedals on W/C at all times." On 9/4/13 at 9:40 AM LN #1 was interviewed regarding the incident. When asked to give an account of what happened she said the C.N.A. wheeled the resident from the dining room and over the threshold and stated, "it's a bad bump-hard for everyone to get over." She also stated the threshold was, "not a smooth transition." When asked about the wheelchair foot pedals she stated, "I've never seen her use foot pedals...Her foot pedals were underneath her bed." On 9/4/13 at 9:55 AM LN #2 was interviewed regarding the threshold and she stated, "Some residents can't get up the steam...they need a boost to get over it." LN #2 then acted out trying to get over the threshold as if she was in a wheelchair. On 9/4/13 at 10:05 AM CNA #3 was interviewed regarding the incident. She said the metal threshold was, "...coming up," and the Resident's foot got caught on the metal and her foot planted on the floor. When asked why the Resident's foot pedals were not attached to the wheelchair, she stated, "She tells you verbally she doesn't want foot pedals." On 9/4/13 at 10:18 AM the Administrator (who was Acting DON at the time of the incident) was interviewed. She said it was her understanding the Resident could self propel while in her room and liked the foot pedals off so she could fit her feet underneath her bedside table. When asked if the Resident's foot pedal preference had been on the care plan, she stated, "It probably should be." When asked about any refusals by the resident regarding the foot pedals, she stated, "I was not involved or aware of refusals, that was just her preference." When asked about the threshold issue, she said the flooring was old, was in the process of being replaced and a wider threshold had been ordered to be installed the following week. On 9/4/13 at 10:45 AM the Acting DON was interviewed regarding the Resident's right leg hematoma. She said the side of the hematoma had ruptured at the fracture site with red blood drainage and was aware the Resident's physician had planned to get a consultation with a plastic surgeon regarding the site. On 9/4/13 at 10:50 AM during a tour with the Environmental Services Director (ESD) and the Administrator, the threshold at the Idaho dining room was measured by the ESD. He measured a 3/16th of an inch upgrade or incline from both the carpet and the vinyl to the top of the threshold and the threshold peak was 1/4 of an inch higher than the carpeted floor. He said the facility was in the process of ordering a different threshold, "...with a flatter wider threshold to get rid of the bump." When asked when he became aware of the issue with the threshold, he stated it was, "Brought to my attention like the day before (the incident involving Resident #4)." When asked what interventions were tried to smooth out the bump, he said he tried to nail down the threshold tighter and he replaced the vinyl flooring next to the threshold, without success. He also said he could not find a commercially available wider threshold to smooth out the transition. The facility failed to prevent Resident #4 from harm when staff failed to attach foot pedals to her wheelchair and the Resident caught her foot on an elevated metal threshold and carpet, which resulted in the Resident's fractured leg. On 9/4/13 at 11:30 AM, the Administrator was informed of the issue. No further information was provided by the facility. 2. On 9/3/13 at 2:00 PM the entry way from the hallway to the Rehabilitation alcove area was observed. A 2 inch wide metal threshold covered the area where the vinyl alcove floor and the hallway carpet met. The threshold peak was approximately 1/2 of an inch higher than the carpeted floor. On 9/4/13 at 10:05 AM CNA #3 was interviewed regarding the Rehabilitation alcove threshold, she stated, "Where the flooring and threshold meet, it's coming up...All the employees know it's coming up." She said she had even tripped on the threshold in question. When asked if management or maintenance knew about the hazard, she stated, "I think they know about it." On 9/4/13 at 10:18 AM the Administrator was interviewed regarding the facility's thresholds. She said the flooring was old, was in the process of being replaced and wider thresholds had been ordered to be installed the following week. On 9/4/13 at 10:50 AM during a tour with the ESD, the Rehabilitation alcove threshold was observed. He said, similar to the threshold issue in the Idaho dining room, the alcove threshold was in the process of being replaced and would have an extended gradual slope when the work was complete. On 9/4/13 at 11:15 AM, the Administrator informed the survey team she had spoken to the contractor working on the threshold project and had received a firm commitment from the contractor as to the day he would install the thresholds.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop avoidable pressure ulcers. This was true for 2 of 3 sampled residents (#s 1 & 10) reviewed for pressure ulcer prevention and treatment. Specifically, * Resident #1 was harmed when he developed unstageable pressure ulcers to the right and left heel and a Stage II pressure ulcer to the dorsum of the right foot. In addition, Resident #1's record failed to document the assessment of an ulcer on the right medial ankle. * Resident #10 was harmed when she developed unstageable pressure ulcers to the left heel and the left fifth metatarsal. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 8/8/12, coded: * BIMS of 13 indicating cognitively intact * No behaviors and no rejection of care necessary to achieve health and well-being * Required extensive assistance of two or more persons for bed mobility, transfer and toilet use * No unhealed pressure ulcers at Stage I or higher * Pressure reducing device for bed and turning/repositioning program Resident #1's quarterly MDS assessment, dated 10/26/12, coded: * BIMS of 14 indicating cognitively intact * No behaviors and no rejection of care necessary to achieve health and well-being * Required extensive assistance of two or more persons for bed mobility, transfer and toilet use * 1 Stage 2 pressure ulcer that was not present on admission/entry or reentry * 2 unstageable pressure ulcers that were not present on admission/entry or reentry * Length/width/depth (l/w/d) of pressure ulcer with largest surface area: 4.0 cm x 3.0 cm x 0.3 cm * Most severe type of pressure ulcer: Necrotic tissue (Eschar) Resident #1's Initial Interdisciplinary Data Collection Tool, dated 8/1/12, did not document any pressure areas to the feet. The resident's Braden Scale For Prediction Pressure Sore Risk included the following: * 8/1/12: Score of 16 - Mild Risk. The Intervention Guide documented, "Frequent turning (... q (every) 2 hours)...protect heels ...manage friction and shear." * 8/8/12: Score of 14 - Moderate Risk. The Intervention Guide documented, "Frequent turning with a planned schedule...protect heels ...manage friction and shear." * 8/15/12: Score of 13 - Moderate Risk. The Intervention Guide documented, "Frequent turning with a planned schedule...protect heels ...manage friction and shear." * 8/30/12: Score of 14 - Moderate Risk. The Intervention Guide documented, "Frequent turning with a planned schedule...protect heels ...manage friction and shear." * 10/5/12: Score of 12 - High Risk. The Intervention Guide documented, "Frequent turning with a planned schedule, Supplement with small shifts in position...protect heels, manage friction and shear." * 10/27/12: Score of 13 - Moderate Risk. The Intervention Guide documented, "Frequent turning with a planned schedule...protect heels ...manage friction and shear." The facility provided 6 care plans for Resident #1: 2 were dated 8/1/12, 3 were dated 8/21/12 and 1 was dated 11/6/12. All of the care plans included the problem, dated 8/1/12, "Alteration in metabolic balance r/t (related to) diabetes." Interventions included, "Inspect feet daily and notify LN of any abnormalities such as blisters, cracks in the skin etc. Do not trim nails, will be done by LN." a. Right heel pressure ulcer present on 8/18/12. Resident #1's two care plans, dated 8/1/12, included the following problems and interventions present before the development of the right heel pressure ulcer: * 8/1/12 - Mobility impairment: Assist with repositioning every 2-3 hours * 8/1/12 - Potential for alteration in resident identified for nutrition at risk: Monitor for skin breakdown and low Braden Scale * 8/1/12 - Skin integrity impairment r/t wound on left foot (5th metatarsal): Rigid foam boot to affected extremity left foot, Position resident to decrease pressure to affected area * 8/1/12 - Potential for alteration in skin: Elevate legs between meals and after dinner as resident will allow, Assist to reposition every 2 hours off back turning side to side (8/15/12), pad bony prominences. * 8/1/12 - Alteration in comfort r/t left foot ulcer: Offer to assist resident to lie down and position foot for comfort (8/11/12) * 8/1/12 - Alteration in metabolic balance: Inspect feet daily and notify LN of any abnormalities such as blisters, cracks in the skin.. Resident #1's Daily Skilled Note, dated 8/18/12 at 11:30 am, documented, in part, "Wound Assessment - new area of breakdown noted on resident's R(ight) heel. Resident has had heels elevated by pillows due to refused blue boots. ...Heellift (sic) boot was placed on R foot to be worn at all times." A FAX Communication to Physician form, dated 8/18/12 at 1:00 pm, documented, "Resident (#1) has refused to get up out of bed & now has a pressure sore to R (right) heel. ..." Resident #1's Wound Flow Sheet form for the right heel ulcer documented on 8/18/12: Pressure Ulcer, Full Thickness, Unstageable - Necrotic Tissue. L/W/D was 4.0 cm x 3.5 cm x unknown depth, 25% slough, 75% eschar, minimum serosanguinous drainage, no pain or odor. Resident #1 was seen at a Wound Clinic on 8/21/12. The Wound Clinic notes documented, in part: "Ulcer, Heel and midfoot, Right Heel...minimum amount of bloody exudate, full thickness wound with exposed partial thickness and eschar, has beefy red granulation and is covered with a necrotic eschar...2.4 cm x 3.5 cm x 0.3 cm...The patient was educated about floating heels off of bed to relieve pressure to area. ...Short term (goal) pressure will be relieved through offloading..." Subsequent Wound Flow Sheet documentation and Wound Clinic notes for Resident #1 documented the facility and Wound Clinic were treating the right heel ulcer with slow resolution of the ulcer. The Wound Flow Sheet documented on 12/6/12 that the right heel ulcer was a pressure ulcer, unstageable, 4.0 cm x 3.0 cm x 0.1 cm, 0-25% granulation, 75-100 % eschar, minimum serosanguinous drainage with no odor or pain. On 12/11/12 at 10:45 am, LN #7 and LN #8 were observed changing the dressing to Resident #1's right heel. The DON was also present. The resident's right heel was floated off the bed using a pillow. The old dressing was removed. The right heel was observed to have a round area of eschar with a small brown area adjacent to the right medial border of the eschar. Serosanguinous drainage was present. The right heel ulcer was not measured by the staff changing the dressing since the measurements were done once a week by the wound nurse (see above measurements for 12/6/12). On 12/12/12 at 10:00 am, the Wound Nurse and the DON were asked about the right heel ulcer. The Wound Nurse said the resident had no pressure relieving device on the right foot. The DON stated the resident had a "blue boot" on the right foot. She described the blue boot as a foam boot that provided padding, but did not have any offloading capabilities. The Wound Nurse said that Resident #1 did not like to wear the blue boot and did not like to keep his heels floated on a pillow. The Wound Nurse said that Resident #1 would "talk the CNAs into taking them (blue boots and pillow) off." She said the CNAs "didn't come to me, but I found out and then went in and he had already developed the right heel ulcer." The Wound Nurse said the CNAs were told at their CNA meetings that "they needed to communicate these things (to me)." Resident #1's Daily Skilled Notes, Interdisciplinary Progress Notes, Social Service Notes and MAR/TAR were reviewed from 8/1/12 to 8/18/12 when the right heel pressure ulcer was discovered. A single entry on the Daily Skilled Note, dated 8/16/12 6:00 am - 6:00 pm, documented, in part, "Cont(ues) to refuse repositioned Q 2 hrs (every 2 hours)." There were no documented care plan problems or interventions related to refusal of care. There was no documentation that the right foot was inspected daily as directed in the care plan. There was no documentation that the right heel was care planned to be offloaded or floated. b. Left heel ulcer present on 9/17/12 Resident #1's three care plans, dated 8/21/12, included the following problems and interventions present before the development of the left heel pressure ulcer on 9/17/12: * 8/21/12: Mobility impairment: Assist with repositioning every 2-3 hours, Bed Mobility: 2 assist, Reposition to right side and back. * 8/21/12: Skin Integrity impairment: Rigid foam boot to affected extremity left foot, heelift boot to right foot at all times (10-3-12), Position resident to decrease pressure to affected area, Resident is often refused with wearing boots, encourage and educate to wear, suggest pillows to float heels if resident requests boots off. * 8/21/12: Potential for alteration in skin: Assist to reposition every 2-3 hours off back turning side to side, Pad bony prominences, Air bed (8/22/12) * 8/21/12: Alteration in comfort r/t left foot ulcer: Offer to assist resident to lie down and position foot for comfort, Reposition resident frequently to improve comfort. * 8/21/12: Alteration in metabolic balance: Inspect feet daily and notify LN of any abnormalities such as blisters, cracks in the skin... * 8/21/12: Potential for alteration in resident identified for nutrition at risk: Monitor for skin breakdown and low Braden Scale. Resident #1's Interdisciplinary Assessments and Summary Reviews form, dated 8/29/12, documented, in part, "...Resident wears a rigid cushioned walking boot on his L foot & a heelift boot on his right foot for pressure reduction. " Resident #1's Wound Clinic Notes, dated 9/17/12, documented, in part, "New pressure injury noted to Left heel today dressed and protected per orders. ...Pressure Ulcer left heel...date problem was noted - 9/19/12 ...exudate...absent, full-thickness wound with exposed eschar is covered with a necrotic eschar...Stage III ...Patient was educated on repositioning off affected area. ...Short term (goal) Pressure will be relieved through offloading." NOTE: The Wound Clinic Note on 9/19/12 did not document the size of the pressure ulcer. Subsequent Wound Clinic Notes did not document the size of the left heel pressure ulcer, but documented on 9/26/12 and on 10/3/12, "...The posterior heel (left) reveals a flacid (sic) ulcer that is non infected." Resident #1's Daily Skilled Note, dated 10/3/12, documented the first facility note regarding the left heel pressure ulcer, "Resident has wounds to R & L(eft) heels...His dressings are changed in the wound clinic...two times per week....Resident has an air mattress. He wears a rigid boot to off load pressure on his L foot & wears a heellift (sic) boot on his R foot. He often asks the CNAs to remove his boots because he does not want to wear them. He has been educated about the importance of wearing the boots to prevent pressure to his heels. Will encourage resident to be complaint. If he wants the boots off for a while will suggest pillows beneath legs to float heels..." On 10/31/12 at 10:50 am, a Daily Skilled Note documented, "Resident continues (with) 4 wounds on his R & L feet...There appears to be eschar in the heel wounds..." Resident #1's November 2012 MAR indicated [REDACTED]. There was no documentation regarding the left heel ulcer including the size of the ulcer, drainage, wound margins, tunneling or odor until the dressing was changed again on 11/17. The Wound Flow Sheet documented on 11/17/12 that the left heel had a pressure ulcer that was unstageable and 3.0 cm x 4.0 cm x (no depth) in size. There was 0-25 % granulation and 75-100% eschar present, minimal serosanguinous drainage, no odor and no pain. On 12/11/12 at 10:45 am, LN #7 and LN #8 were observed changing the dressing to Resident #1's left heel. The DON was also present. The resident's left heel was floated off the bed using a pillow. The old dressing was removed. The left heel was observed to have a round area of brown/black eschar/slough, encircling a red area on the left heel. Within the red area, there was a smaller deeper colored red area. Serosanguinous drainage was present. The left heel ulcer was not measured by the staff changing the dressing since the measurements were done once a week by the wound nurse. NOTE: The left heel pressure ulcer was assessed on 12/6/12 to be 5.0 cm x 4.0 cm x 0.8 cm with 75-100 % granulation, 0-25% slough, with serosanguinous drainage, with no odor and some pain requiring the administration of pain medication. Resident #1's Daily Skilled Notes, Interdisciplinary Progress Notes, Social Service Notes and MAR/TAR were reviewed from 8/1/12 to 9/19/12 when the left heel pressure ulcer was discovered. There was no documentation that the left foot rigid boot was removed and the left heel was inspected daily as directed in the care plan. On 12/12/12 at 10:25 am, the Wound Nurse and the DON were interviewed regarding the left pressure ulcer. The Wound Nurse said, "I didn't even know about that one initially. The Wound Clinic reported it on 9/17 (2012)." The Wound Nurse said Resident #1 was seen at the wound clinic until 11/16/12 and then the facility started documenting the left pressure ulcer characteristics. NOTE: The resident's MAR indicated [REDACTED]. c. Pressure ulcer dorsum of right foot. On 9/14/12, Resident #1's Wound Clinic Note documented, in part, "Pressure ulcer, right dorsum...exudate...absent, partial thickness wound... has pink granulation...1.8 cm x 0.7 cm x 0.2 cm...Stage II. Resident #1's Daily Skilled Note, dated 10/3/12, documented, in part, "Wound Assessment - Resident has wounds to R & L heels, R dorsum..." On 10/31/12 at 10:50 am, a Daily Skilled Note documented, in part, "...The R dorsum is between Stage I & II at this time..." There were no other notes in the record or Wound Flow Sheets that documented any characteristics of the right foot dorsum pressure ulcer. On 12/11/12 at 10:45 am, LN #7 and LN #8 were observed changing the dressing to Resident #1's right heel. The DON was also present. When the right heel dressing was removed, 2 small scabbed areas were observed on the dorsum of the right foot. The areas were not measured, but appeared to be approximately half an inch long. On 12/12/12 at 10:25 am, the Wound Nurse and the DON were interviewed regarding the pressure ulcer on the dorsum of the right foot. The Wound Nurse said the areas could have been from strap of the foam boot that was on the right foot. The Wound Nurse said she had no wound tracking sheets for this ulcer. The DON stated she would review Resident #1's record for any documentation regarding the assessment of this ulcer. The facility provided no other documentation after 10/31/12 regarding the condition of the pressure ulcer on the dorsum of the right foot. d. Right medial ankle pressure ulcer Resident #1's Physicians Orders form documented, "Leave dressings dry and intact until next visit to wound care. (R heel, L lateral 5th toe, R dorsum and L heel). Ulcer: R Medial Ankle. Remove old dressing. Cleanse w/NS (with normal saline). Cleanse the peri-ulcer area w/NS. Normal Saline. Use [MEDICATION NAME] 7 as primary dressing. Use hydrasorb foam as secondary dressing. Apply [MEDICATION NAME] size G. This order to be carried out Sunday 9/30/12. Pt (patient) will return to clinic 10/2/12 for reassessment." Resident #1's MAR indicated [REDACTED]. There was no other documentation in Resident #1's record concerning this ulcer. On 12/12/12 at 10:10 am, the Wound Nurse and the DON were asked about the right medial ankle ulcer. The Wound Nurse stated she was not aware of this ulcer. The Wound Nurse and the DON were shown the documentation in the resident's record regarding the treatment of [REDACTED]. She said the LN could not remember the ulcer or the treatment. The DON, LN #8 and the Wound Nurse examined Resident #1's right medial ankle and stated there was no pressure ulcer currently present. The DON provided no other information regarding this pressure ulcer. Resident #1 was harmed when he developed unstageable pressure ulcers to his right and left heels. The facility failed to provide any documentation that the resident's feet were inspected daily, as care planned. There were no care planned interventions to float or offload the resident's heels before the resident developed the right heel ulcer. There was no facility documentation regarding the condition of the pressure ulcer on the dorsum of the right foot or the ulcer on the right medial ankle including the size of the ulcer, drainage, odor, and condition of the area surrounding the wound. The facility failed to document the condition of the left heel ulcer with dressing changes on 11/2, 11/10, and 11/13. On 12/14/12 at 10:00 am, the Administrator was informed of the issue. The facility provided no other information or documentation that resolved the concern. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10's Initial Interdisciplinary Data Collection Tool, dated 7/27/12, documented the following: -"Redness slow to blanch" on both her right and left heels, and -No pressure ulcers. Resident #10's Comprehensive Care Plan, dated her day of admission 7/27/12, included the following: -Mobility impairment which required 2 person assistance with bed mobility, to be done every 2 hours. -Potential for alteration in skin R/T (related to) aging process. "Plans and approaches" for this area included "Pressure relieving booties while in bed," "Assist to reposition Q (every) 1-2 hours" (NOTE: For this approach, the number "1" was crossed out, dated 8/8/12. The remaining approach was for Resident #10 to be repositioned every 2 hours), and "Use turn sheet to reposition." NOTE: There were no documented changes in the mobility impairment or alteration in skin care plans areas until 8/28/12, 10 days after her pressure ulcer was first noted in her medical record. Resident #10's Admission MDS assessment, dated 8/3/12, documented the following: -BIMS of 4 (severely impaired decision making skills). -No rejection of care. -Extensive assistance of 2 persons required for bed mobility, transfers, toilet use, and dressing. -Extensive assistance of 1 person required for wheelchair mobility, eating, and personal hygiene. -At risk for developing pressure ulcers. -No unhealed pressure ulcers Stage I or higher. Resident #10's Pressure Ulcer CAA, dated 8/9/12, documented, "(Resident #10) does have risk factors of pressure and shear, moving feebly and requiring staff assist for adequate offloading. She is currently wheelchair bound...her activities of daily living have declined, as well as declines in mobility before admit...Pressure relieving booties are used in bed. A turn sheet is used, and she is repositioned each 2 hours." NOTE: There was no documentation in Resident #10's care plan to direct staff that Resident #10 was at risk of shear or needed staff assistance to offload her heels. There was no mention in her care plan her heels should be offloaded. There was no documentation of the specific type of pressure relieving booties to be used. There was no documentation as to what measures should be taken to protect Resident #10's heels in her wheelchair or recliner. On 8/18/12, Resident #10's Wound Flow Sheet documented a 2.0 cm (centimeter) x 2.0 cm Stage II pressure ulcer to her left foot base. Resident #10's Interdisciplinary Progress Notes (PN) documented the following: -8/18/12 at 10:30 AM, "Wound assessment-Resident presents (with) a red heel (and) a 2.0 x 2.0 blister in the foot base. Area nonblanchable skin on back of heel (and) base. A heellift boot was applied to foot to be worn until area is resolved. [MEDICATION NAME] applied to intact blister. 5th toe appears red and swollen to 1st joint..." -8/19/12 at 9:45 AM, "[MEDICATION NAME] intact to (left) heel, foam boot on (left) foot." -8/20/12 at 2:10 PM, "Order received for intact blister on left heel base-[MEDICATION NAME] (change) q (every) 5 days or PRN (as needed) until resolved." -8/27/12 at 10:30 AM, "[MEDICATION NAME] applied to (left) heel blister that is now flat (and) extends to curve of the heel." -8/29/12, no time noted, "Wound assessment-(left) heel blisters still intact, area has more fluid et (and) is 6 cm x 4 cm et closed..." -9/5/12 at 3:15 PM, "Order received to give Keflex 500 mg PO BID x 7 days for (left) heel. She may also be seen by the wound clinic..." -9/5/12 for the 6AM to 6PM shift, "Cleanse (left) heel wound (with) NS (normal saline), apply non-stick dressing et (and) wrap (with) Kerlix, (change) each day until she can be evaluated by wound clinic." 9/6/12 at 2:00 PM, "...drsg (changed) (left) heel, heel red (with) small and serous drainage..." 9/9/12 at 1:30 PM, "New dsg (dressing) to (left) heel. Wound is open (with) s/sx (signs and symptoms) drainage around sore..." 9/12/12 at 12:30 PM, "To wound clinic (at) (wound clinic name)." 9/12/12 at 2:45 Pm, "New dressing on (left) heel (with) a therapeutic boot on." On 9/26/12, a PN from the wound clinic documented Resident #10 had 2 pressure ulcers, as follows: -Wound #1 - Unstageable pressure ulcer to the left heel, 8 cm long x 7 cm wide x .01 cm deep. -Wound #2 - Unstageable pressure ulcer to the left fifth metatarsal head, 1.9 cm long x 1.2 cm wide. Ongoing wound clinic notes documented the following wound characteristics: Wound #1: -10/3/12, 8 cm x 7.5 cm, unstageable -10/10/12, 4.3 cm x 4.8 cm x 1.2 cm, unstageable (Necrotic tissue) -10/17/12, 4.3 cm x 4.8 cm x 1.2 cm, unstageable (Necrotic tissue) -10/22/12, 4.8 cm x 4.2 cm x 0.5 cm, unstageable (Necrotic tissue) -10/25/12, 5 cm x 4.5 cm x 0.2 cm, unstageable (Necrotic tissue) -10/29/12, 6 cm x 6 cm x 0.2 cm, unstageable (Necrotic tissue) -11/2/12, 8 cm x 8 cm, Stage 4 -11/5/12, 5 cm x 5 cm x 0.3 cm, Stage 4 -11/19/12, 6.8 cm x 5.5 cm x 1.3 cm, Stage 4 -12/3/12, 6 cm x 7 cm x 1.5 cm, Stage 4 Wound #2: (Necrotic tissue) -10/3/12, 2 cm x 1.7 cm, unstageable -10/10/12, 1.8 cm x 1.8 cm, unstageable -10/17/12, 1.8 cm x 1.8 cm, unstageable -10/22/12, 2 cm x 1.5 cm, unstageable -10/25/12, 2 cm x 2 cm x 0.1 cm, unstageable -10/29/12, 1.5 cm x 1.5 cm x 0.2 cm, unstageable -11/2/12, 2 cm x 2 cm, unstageable -11/5/12, 2 cm x 2 cm, unstageable -11/19/10, no measurements, unstageable -12/3/12, 1 cm x 1.6 cm x 0.3 cm, unstageable Care plan updates for Resident #10 included: - 8/8/12, the approach under "Mobility Impairment" was changed from, "2 assist Q 2 hours" to, "1-2 person assist Q 1-2 hours." NOTE: This change indicated resident required less assistance than was coded in her MDS assessment from 8/3/12. -8/8/12, the approach under "Potential for Alteration in Skin Integrity," "Encourage resident to frequently shift in w/c" was crossed out. NOTE: Both of the above changes to Resident #10's care plan were made 10 days prior to documentation of the appearance of a pressure ulcer to her left heel. On 12/13/12 at 2:40 PM, the DON and the RN Case Manager were interviewed regarding the pressure areas on Resident #10's left foot and heel. The RN Case Manager, who wrote the initial PN when the heel wound was discovered, stated, "Other than what's in the note, I don't know much more about it. There was another case manager in charge of that unit when it happened. I know she (the resident) had been at the podiatrist about a week beforehand, for her toe." The DON stated, "I'm not sure what was in place to prevent it. I would have expected at least blue boots." The DON was unsure what interventions would have been in place for offloading Resident #10's heels prior to the pressure ulcers developing. The DON stated that since the development of the pressure ulcers, "The care plan has been changed out. There should be padding now. They should be floating her heels." The DON also stated they had begun to check Resident #10's blood glucose levels to see if that was a factor, and Resident #10 had been started on [MEDICATION NAME]. NOTE: Resident #10's record documented blood glucose checks began on 11/22/12, 96 days after her pressure ulcers were documented, and [MEDICATION NAME] was started on 11/28/12. Resident #10 was harmed by the facility's deficient practice when she developed a Stage II pressure ulcer to her right heel and an unstageable pressure ulcer to her fifth left metatarsal head. The pressure ulcer on her left heel later developed into a Stage IV pressure ulcer. On 12/14/12 at 10:00 AM, the Administrator and DON were informed of these findings. The facility offered no further information regarding these pressure ulcers.

Based on a complaint from the general public, medical record review, and staff interview, it was determined the facility failed to provide indwelling catheter care in accordance with accepted professional standards of practice and infection control, or in conformance with physician orders. This was true for 1 of 2 residents (#3) sampled for indwelling catheter care and resulted in harm to Resident #3, who was provided with a Foley catheter without medical justification, developed "severe" urosepsis after his indwelling catheter was not changed for 59 days, and who ultimately required a suprapubic catheter as a result of "erosion" to the glans penis secondary to the Foley catheter. Findings include: The Idaho Department of Health and Welfare, Bureau of Facility Standards (BFS) received a complaint from the general public on 8/1/12 that alleged the following: * On 5/21/12, the resident was admitted to the hospital with [REDACTED]. The complainant does not know why the catheter was placed in the hospital or for what diagnosis" * The complainant said the MD (physician) ordered the catheter to be changed every "3-4 weeks." The Foley catheter was not changed on schedule; however three facility staff members falsely told an interested family member that the Foley catheter had been changed on schedule. * The complainant stated the identified resident developed urosepsis as a result of the facility's failure to change the Foley catheter as scheduled. * The complainant stated the resident's penis was "split open" by the Foley catheter and that he lost "4-5 towels worth of blood" upon his arrival at the hospital due to the injury. * The complainant stated the resident required a suprapubic catheter due to the urosepsis and injury to his glans penis. Resident #3 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 5/3/12, documented the following: * Intact cognitive skills for daily decision making * No behaviors * Anti-anxiety, antidepressant, and diuretic therapies in use * Frequently incontinent of bladder and bowel with toileting program for each in place * Three physician visits and three new orders within the preceding 14 days A hospital emergency room Clinical Report, dated 5/16/12, documented, "Chief complaint - Abdominal pain. This started about 2-3 days ago and is still present. Review of Systems: The patient has had constipation ..." A hospital History and Physical, dated 5/16/12, documented, "(Resident #3) was brought to the emergency room with abdominal pain, bloating, and some vomiting ... has been struggling with constipation, thought to be secondary to chronic opiate use. He is having a lot of issues with his bladder with frequency and some urgency." A hospital Nurse's Note, dated 5/16/12, documented, "16 fr (French) foley catheter placed. The patient tolerated procedure well. Urine collected; sample sent to lab. Patient transported to CT (computed tomography) by stretcher with monitor and tech(nician)." A hospital CT report, dated 5/16/12, documented, "Moderate stool throughout the colon without evidence of obstruction. No difficulty with urination, pain with urination ...The kidneys demonstrate severe bilateral renal cortical atrophy. There is an exophytic right upper pole renal cyst measuring ... There are multiple smaller bilateral renal (sic) simple renal cysts. There is no hydro[DIAGNOSES REDACTED]. The ureters are normal in course and caliber. There is no evidence of urolithiasis. The urinary bladder is decompressed with a Foley catheter." A hospital Care Plan, dated 5/24/12, documented the following: * "Problem: [MEDICAL CONDITION]." * "Goal: States relief from pain of full bladder and suprapubic area is free of bladder distention (sic)." A hospital discharge summary, dated 5/25/12, documented, "A Foley catheter was placed and is being left in at the time of discharge. The patient is just unable to control his bladder. It has been an issue since he has been in the nursing home and has impaired his ability to get up and move around. He would prefer to have this in place. A Foley catheter will be left in place to be changed every 3 weeks." NOTE: The hospital discharge summary listed Resident #3's admission diagnoses, which included "Stage III [MEDICAL CONDITIONS]," and malignant neoplasm of the prostate gland, but did not include any diagnosis, such as urinary obstruction, [MEDICAL CONDITION], or [MEDICAL CONDITION] bladder for example, for which a long-term indwelling catheter would be necessary. A hospital physician's orders [REDACTED]." The facility's Cumulative [DIAGNOSES REDACTED]." A facility FAX Communication to Physician, dated 5/25/12, documented, "May we have Dx (diagnosis) for Foley cath(eter) use or would you like us to DC (discontinue)?" A faxed response to the facility from Resident #3's physician, dated 5/29/12, documented, "Foley cath(eter) use dx - intractable incontinence." A Physician Telephone Order, dated 5/30/12, documented, "dx for foley clarified: [MEDICAL CONDITION] bladder ..." On 5/30/12, "[MEDICAL CONDITION] bladder" was added to Resident #3's facility Cumulative [DIAGNOSES REDACTED]. NOTE: Mosby's Medical, Nursing & Allied Health Dictionary, 6th ed., defined the following terms: * "Intractable: Having no relief, such as a symptom or a disease that is not relieved by the therapeutic measures used." * "Incontinence: The inability to control urination or defecation." Types of incontinence include "functional, reflex, stress, total, and urge." * "[MEDICAL CONDITION] Bladder: Dysfunction of the urinary bladder caused by a lesion of the nervous system. Treatment is aimed at preventing infection, controlling incontinence, and preserving kidney function by enabling the bladder to empty completely and regularly." NOTE: Medical-Surgical Nursing, 6th edition, by Lewis, Heitkemper, and Dirksen, described the following [MEDICAL CONDITION] bladder types and clinical manifestations: * "Reflexic - Incontinence, frequency, urgency; voiding is unpredictable and incomplete." * "Areflexic - If sensory function intact, feels bladder distension and hesitancy; no control of micturition, resulting in overdistention of bladder and overflow incontinence." * "Sensory - Poor bladder sensation, infrequent voiding, large residual volume." * "Collaborative Care - Diagnostic: history and physical examination [REDACTED]." Resident #3's Comprehensive Care Plan, dated 5/25/12, documented the following: * "Problems/Needs/Concerns: Alteration in elimination r/t (related to) Foley catheter." A handwritten entry, dated 6/5/12, documented, "d/t (due to) [MEDICAL CONDITION] bladder." * "Plans and Approaches: (Handwritten and dated 6/6/12) Change catheter Q (every) 3 weeks." NOTE: A 5/30/12 Physician's Telephone Order, dated 5/30/12, documented the resident's Foley catheter was to be changed every four weeks, rather than every three weeks. A Physician's Progress Note, dated 6/9/12, documented, "(Resident #3 is) with family in T.V. lounge ... He has done remarkable well since leaving hospital. Family has noted a big change in mood (and) general attitude. They feel that since he can now leave his room without fear of incontinence of urine he is more optimistic about life." NOTE: Recapitulated Physician Orders, dated 6/14/12, did not document any mention or interventions for incontinence or Foley catheter care, despite the 5/25/12 order to change Resident #3's Foley cather every three weeks, and the subsequent order on 5/30/12 directing staff to change the resident's Foley catheter every four weeks. Recapitulated Physician Orders, dated 6/28/12, documented, "Intractable incontinence - Foley catheter," despite the Physician's Telephone Order of 5/30/12 documenting a [DIAGNOSES REDACTED]." Resident #3's Comprehensive Care Plan, dated 6/14/12, documented the following: * "Problems/Needs/Concerns: Alteration in elimination r/t Foley catheter d/t (due to) [MEDICAL CONDITION] bladder." * "Plans and Approaches: Catheter care Q shift including perineal care, empty and record cc's (cubic centimeters) of urine Q shift. Change catheter Q 3 weeks." Interdisciplinary Progress Notes (IDT Notes) documented the following: * 5/26/12 - "Foley cath draining clear straw color urine." * 5/28/12 - "Foley catheter in place draining clear yellow urine. Res(ident) states he feels much better (with) catheter in place." * 5/29/12 - "Dx for foley intractable incontinence." * 5/30/12 - "New order to clarify dx for foley ... He has a foley catheter to down drain (with) [DIAGNOSES REDACTED]. * 5/31/12 (10:00 a.m.) - "Foley "down" drain (with) clear yellow urine." * 5/31/12 (3:30 p.m.) - "Visited (one-to-one with) res. Res has recently returned from hospital (with) a catheter. LSW (Licensed Social Worker) visited (with) res about this as he has stated in the past that he didn't want to leave room d/t frequent urination urges. Res stated, 'The catheter helps out a lot (and) I want to be more involved now.' Res feels that the catheter has improved his quality of life." * 6/6/12 - "Foley (down) drain (with) clear yellow urine in collection bag." * 6/11/12 - "There was a hole in the cath bag. It was changed and is now intact." * 6/14/12 - "Foley cath draining clear straw color urine." * 6/16/12 - "Catheter intact." * 6/19/12 - "Foley draining straw color urine." * 6/20/12 - "Catheter intact." * 6/23/12 - "Foley cath draining straw color urine." * 6/24/12 - "Foley (down) drain (with) amber color urine, encouraged to drink more fluids." * 7/2/12 - "Catheter intact, urine normal." * 7/3/12 - "Cath in place, draining clear yellow urine." * 7/14/12 - "Resident pleasant, alert, (and) cooperative - c/o (complains of) catheter discomfort. DD (Down drain bag) emptied (and) leg strap adjusted to take pressure off catheter." * 7/16/12 - "Catheter intact." * 7/17/12 - "Cath change (at) (3:30 a.m.). Tolerated well." * 7/17/12 - "Catheter intact, urine normal. States he 'had a bad night.'" * 7/20/12 - "Resident alert. C/o chills early in shift and seemed mildly confused." * 7/20/12 - "Resident sleeping in bed. Stated, 'Cold, cold, cold.' Checked catheter, intact." * 7/21/12 (4:00 a.m.) - "Res c/o hot cold flashes, denies pain. Slightly increased confusion. Urine cloudy. UA dip showed mod(erate) amt (amount) leukocytes. NSG F/U C&S (Nursing to follow-up with culture and sensitivity test) (and) monitor." * 7/21/12 (3:00 p.m.) - "Resident states he isn't feeling as well today. Foley cath (with) cloudy yellow urine. UA obtained from port on tubing (and) sent to (hospital). Resident is somewhat confused (at) times today." * 7/21/12 (3:30 p.m.) - "Pt (Patient) does not seem quite as mentally clear as typical (and) urine looks a little cloudy. VS (Vital signs) all WNL (within normal limits). (Physician) called (and) UA - C/S (urinalysis and culture and sensitivity tests) ordered. This was obtained (and) sent to (hospital) lab." * 7/21/12 (4:00 p.m.) - Spoke with (Resident #3's interested family member) (and) told her that U-dip (urinalysis) was positive (for infection) - specimen sent around (3:30 p.m.) (and) we were waiting for results." * 7/21/12 (8:00 p.m.) - Resident sitting up in recliner - responded to nurse when asked if he was OK res stated, 'I don't feel good.' Resident SOB (short of breath) - O2 SATs (blood-oxygen saturation level) 74% on 2 LPM (liters of oxygen flow per minute) via NC (nasal cannula) - placed elder on 5 LPM via mask per MD orders ..." * 7/21/12 (11:00 p.m.) - Around (9:30 p.m.) LN into check resident. Resident cold to touch, clammy, non-responsive. Notified charge nurse - O2 SATs 82% - resident placed in bed - (interested family member) notified (at 9:45 p.m.) of resident's condition. (Family member) stated she would come in (and) would decide what to do (with) res. Around (10:00 p.m.) (family member) in to see resident. LN explained to family res(ident's) condition. (Family member) decided to send res to ER for eval & tx (evaluation and treatment). Order received from (physician) - non-emergent ambulance called. Resident sent around (10:45 p.m.)." * 7/22/12 - "Called (and) spoke with nurse at (nearby hospital) - pt was admitted to (hospital) about (11:00 p.m.)- 7/21/12 (and) went to ... ICU (Intensive Care Unit). He is currently on ventilator with blood transfusion in progress. admitting [DIAGNOSES REDACTED]." * 7/25/12 - "Late entry for 7/20/12. Checked resident's catheter placement (and) in place. Penis edges are smooth. Opening large, no redness. Released foreskin back. Released tention (sic) on catheter bag (and) leg strap. He stated, 'That is better.' No other concerns at this time." NOTE: No explanation was provided regarding the reason for this late entry. A Physician's Progress Note, dated 7/22/12, documented, "(Resident #3) was admitted last evening [MEDICAL CONDITION]ly secondary to [MEDICAL CONDITION], chronic [MEDICAL CONDITION], recent bowel obstructions in May, history of [MEDICAL CONDITION] with an indwelling Foley, became delirious, obtunded, required intubation in the ER ... He has been close to anuric. He has a lot of blood clots in urine. We have been flushing his Foley with this 3-way catheter ... we have really gotten no urine output until this afternoon when now for the last couple of hours we have had a 150 (milliliters) of urine. I believe the source [MEDICAL CONDITION] is his urinary tract. He has grown 100,000 [MEDICATION NAME] and 100,000 gram-negative nonlactose fermenter ..." A consulting physician's Progress Note, dated 7/22/12, documented, "(Resident #3's) Foley catheter has been in since that time (previous hospital admission in May 2012 detailed above) (and) has greatly improved the quality of his life, however he has not felt well (family member) says for the last couple of days and said he was 'delirious' a couple of nights ago difficulty breathing and trouble thinking. (The family member) was over there (the facility) today and had lunch with him; however, seemed fine and was conversant, lucid, and then tonight was transported to the ER with a decreased level of consciousness and actually has required intubation ... He lives at (the facility) and has apparently been lucid and since he has had catheter and can stay out of the bathroom they say he has been more physically active. Assessment: [MEDICAL CONDITION] syndrome, probably originating from the urinary tract, although cannot rule out right pneumonia." A hospital Documentation Worksheet, dated 7/23/12, documented Resident #3 was admitted to the hospital with [REDACTED]." The document also listed as [DIAGNOSES REDACTED].) will probably need a suprapubic cystotomy (sic) for long term drainage of the lower urinal tract." A hospital Nurse's Note, dated 7/23/12, documented, "(Resident #3's) penis apparently has a large filet'd (sic) type open wound, which bleed (sic) quite heavily at one point. There is debate about options for cath, including s/p (suprapubic) cath." A Physician's Progress Note, dated 7/23/12, documented, "There is a Foley catheter in the urethra with some erosion of the distal urethra with no active bleeding. The patient is being seen in consultation by urology with ultimate plans for a suprapubic catheter." A 7/23/12 physician's Consultation Report documented, "For the last year or even longer, (Resident #3) has had marked distress with his lower urinary tract and marked frequency and was pretty much confined to his own room at (the facility). He was hospitalized in May with a bowel obstruction and at that time had a Foley catheter placed and was much happier with the catheter in place because it helped eliminate the need for marked frequency. The catheter was left indwelling. It appears that the catheter has caused some erosions of the distal urethra. The patient was admitted to the hospital last evening because of urosepsis and had to be admitted to the intensive care unit. It is difficult to examine the external genitalia because he has not been circumcised, but it appears that the distal portion of the urethra has eroded just proximal to the glans penis. Impression: Recent urosepsis, fairly severe. Need for urethral catheter with erosion of distal urethra just proximal to glans penis. In addition, if the patient rallies and continues to do well and is able to return to the nursing home, it would be best to place a suprapubic cystotmy for long-term drainage of the lower urinary tract." A hospital Nurse's Note, dated 7/25/12, documented, "Late entry for 7/24/12 - Pt has had a foley catheter in past 6 weeks at (the facility) d/t frequent urination. Family has questions about the wound on the penis and when it developed. In discussions (with) the (facility), they report last changing foley cath on 7/16/12 and there has been no documentation of the penis wound. The ICU (Intensive Care Unit) nurse indicated that the wound could have been overlooked, because pt is not circumcised and the wound is underneath the foreskin. No one is sure when the wound first developed." A hospital Operative Report, dated 7/31/12, documented, "A few months ago, urethral catheter was placed because of marked urgency and frequency. The patient was much more comfortable with the catheter. However, he has had some erosion of the distal urethra with the catheter. He was recently admitted with urosepsis. We have felt that he is a candidate for long term catheter drainage and I recommend that a suprapubic tube be placed." A hospital Discharge Summary, dated 8/2/12, documented, "(Resident #3) was admitted with suspected urosepsis. (He) was admitted to the intensive care unit (where) he was intubated ... The issue with the penile erosion was addressed by Urology and it was felt that he would benefit from a suprapubic catheter which was eventually placed on July 31, 2012." NOTE: Resident #3 was again admitted to the hospital on [DATE], and was not available for surveyors to observe, assess or interview during the BFS Complaint Investigation Survey of 8/7/12 through 8/9/12. On 8/8/12, at 8:30 a.m., the facility's Administrator, DON, and Resident #3's Resident Care Manager (RCM #5) were interviewed. When asked what diagnostic assessments were performed that led to a change in Resident #3's May 2012 [DIAGNOSES REDACTED].#5 stated, "That's what the doctor gave us," while the DON stated, "He had a constant need to void. He wouldn't leave his room because he was so embarrassed. We told the doc' at the time that he couldn't use a Foley (catheter) for incontinence. We asked him at the time ... could we consider him with a [MEDICAL CONDITION] bladder. The doc' said, 'I think we could consider that a [MEDICAL CONDITION] bladder,' and he gave us the diagnosis. The benefit to the resident was overwhelming." When asked to explain the complainant's allegations that facility staff falsely informed an interested family member that Resident #3's Foley catheter had been changed on schedule and as ordered by the physician, the DON provided the surveyor with investigation materials that included documented interviews with the three nurses involved in the provision of false information to Resident #3's interested family member. That investigation documented that LPN #6 misinterpreted the resident's MAR indicated [REDACTED]'t inform the interested family member that the catheter had been changed, but only informed that person of when the Foley catheter was next scheduled to be changed (7/16/12); and RN #8 stated she was only referring to the down drain bag when she informed the family member that the resident's catheter had been changed on schedule. The facility's internal investigation documented that Resident #3's Foley catheter was not changed until 7/16/12. Resident #3's MAR for June 2012 included an area in which to document the Foley catheter change that was highlighted by hand-drawn lines on either side of 6/16/12. The area was blank. The resident's July 2012 MAR indicated [REDACTED]. When asked to comment on whether the facility's failure to change Resident #3's Foley catheter, which had been in place from 5/16/12 until 7/16/12 (59 days), the DON stated, "They (physicians) can't determine exactly where or when [MEDICAL CONDITION] occurred." When questioned about the "erosion" to the resident's distal urethra attributed by hospital healthcare providers to the prolonged use of the Foley catheter, the DON stated that Resident #3 was provided pericare immediately prior to his transfer to the hospital and that no wounds of that nature were noted by facility staff. She stated, "That almost sounds like trauma, which would lead me to believe that that would have happened during transfer." On 8/8/12, at 12:40 p.m., CNA #9 was interviewed. CNA #9 stated she was last staff member to provide pericare to Resident #3 prior to his 7/21/12 transfer to the hospital. She stated that she pulled back the resident's foreskin to clean loose stool from the resident and while the skin in that area was red, she did not see any tissue damage to the resident's penis. Federal guidance at 42 CFR 483.25 (d) (1) and (2) states, "The intent of this requirement is to ensure that each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible; an indwelling catheter is not used unless there is valid medical justification; an indwelling catheter for which continuing use is not medically justified is discontinued as soon as clinically warranted; services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter; and a resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. A resident may be admitted to the facility with or without an indwelling urinary catheter (urethral or suprapubic) and may be continent or incontinent of urine. Regardless of the admission status, a comprehensive assessment should address those factors that predispose the resident to the development of urinary incontinence and the use of an indwelling urinary catheter. The facility's documented assessment and staff approach to the resident should be based on evidence to support the use of an indwelling catheter. Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include: [MEDICAL CONDITION] that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible, and which is characterized by: Documented post void residual (PVR) volumes in a range over 200 ml; inability to manage the retention/incontinence with intermittent catheterization; and persistent overflow incontinence, symptomatic infections and/or renal dysfunction. (Additionally), contamination of Stage III or IV pressure ulcers with urine which has impeded healing, despite appropriate personal care for the incontinence; and terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain. Most individuals with indwelling catheters for more than 7 days have bacteriuria. A long term indwelling catheter (greater than 2 to 4 weeks) increases the chances of having a symptomatic UTI and urosepsis. The incidence of bacteremia is 40 times greater in individuals with a long term indwelling catheter than in those without one." The facility failed to ascertain the resident's shifting [DIAGNOSES REDACTED].#3's indwelling Foley catheter for 59 days when it was scheduled to be changed in 28 days; provided inaccurate information regarding that catheter change to the resident's interested party when directly queried on three separate occasions; had the resident under its care at the time he developed "severe" urosepsis that required intubation in a nearby hospital's intensive care unit and required a surgically implanted suprapubic catheter due to an "erosion" of the resident's distal urethra.

Based on observation, staff interview and record review it was determined the facility did not ensure pressure sores were prevented for 3 of 4 sampled resident's (#s 1, 4 & 6) reviewed for pressure sores. Resident #6 was harmed when he developed two Stage II avoidable pressure sores. Resident #1 had recently returned from the hospital after fracturing her hip due to a fall in the facility. She developed an avoidable Stage II pressure sore on her foot at which time a specialized boot was applied. In addition, Resident #4 had a preventative care plan for off loading her heels that was not implemented. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 4/11/11, documented the resident had 2 Stage II pressure sores. The resident was frequently incontinent of urine and bowel. The quarterly MDS, dated [DATE], was not coded for pressure sores, but the resident was coded as continent of bowel and occasionally incontinent of urine. Both MDS assessments indicated the resident required extensive assistance for bed mobility, transfers and all other ADLs. The facility's "Braden Scale For Predicting Pressure Sore Risk" assessment was dated 7/27/11. The resident received a score of 15 (Scores of 15-18 designated as mild risk). The resident's Wound Flow Sheet indicated a Stage II pressure sore on the right ischium was found on 3/15/11. Measurements were taken on 3/16/11 and documented the wound was 1.1 centimeters (cm) in length and 1.0 cm in width. There was no measurement for depth. There was no drainage, wound margins were [DIAGNOSES REDACTED]tous but intact, no tunneling or odor. Pain was indicated. The wound was cleansed and covered with "Poly skin" dressing. The back of the form indicated that a "Stage III cushion" was added to the resident's wheelchair (wc) and the care plan was updated. This was verified on the care plan dated 1/28/11. A hand written entry was added on 3/16/11 that indicated the resident was to use a Stage III cushion in his wc. In addition, the care plan was updated to include transfers every 2 hours and as needed (prn) between the wc, chair, recliner and bed. The facility continued to document on the wound until they indicated it was resolved on 4/8/11. The wound had not increased in size but the resident continued to feel pain, particularly when the wound was touched through 3/29/11. The resident developed a second pressure sore on the left ischium also found on 3/15/11. It was documented as a Stage II. Measurements were documented on the Wound Flow Sheet on 3/16/11. The wound was 0.8 cm in length and 0.2 cm in width. No depth was indicated. There was no drainage, the wound margins were [DIAGNOSES REDACTED]tous but intact. No tunneling or odor were noted. Pain was documented. The wound was cleansed and Poly skin dressing was applied. The care plan was updated to include the same interventions as above. The wound was documented as resolved on 5/9/11. On 3/27/11 the wound did increase in size to a length of 1.5 cm. On 4/3/11 the wound was 2.5 cm in length and 0.9 cm in width. The wound had decreased in size by 4/17/11 to 0.8 cm in length and 0.5 cm in width. There were no other measurements documented after 4/17/11 until it was resolved on 5/9/11. Pain was indicated up to 3/22/11. An "Interdisciplinary Progress Note" was dated 3/16/11. The documentation included, "Wound review: Resident has (two) Stage 2 pressure wounds in same site as old wound on R(ight) & L(eft) ishium (sic)... " The LN Unit Manager for the Helping Hands Unit was interviewed on 8/24/11 at 9:20 am. She was asked what could have been done to prevent pressure sores for Resident #6. She indicated he needed his position changed every 2 hours, some people would require this more frequently. She felt the resident developed wounds related to poor nutrition as he did not want to eat any more and just wanted to drink supplements. She stated that Resident #6 would stay in bed all day if you let him. When staff tell him to get off his back he does not want to and can be resistive for dressing changes. NOTE: Resistance for wound care or turning were not care planned. The resident was observed throughout days 8/22 through 8/25/11 of the survey. He did like to stay in bed a lot but also would sit in his wc in front of the TV in the lounge and occasionally he was in a recliner asleep. He was observed at three meals and did not want to eat, preferring to drink supplement. He sat in his wheel chair when eating. Resident #6 developed 2 recurrent Stage II pressure sores. The record indicated he had a history of [REDACTED]. The care plan did not document the use of an enhanced (Stage III cushion) until he developed the two pressure sores on 3/15/11. There was no direction for transferring the resident between bed, chair, wheelchair and recliner at every 2 hours until after the pressure sores developed. Resident #6 was harmed when he experienced pain as a result of the pressure sores and was at increased risk for further break down and infection. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. dementia, [MEDICAL CONDITION], arthritis and pain. The resident was hospitalized for [REDACTED]. The resident's annual MDS assessment, dated 6/15/11, documented she required extensive assistance for bed mobility and transfers and all other ADLs. The resident was frequently incontinent of bowel and bladder and was not indicated for a pressure sore. The facility's "Braden Scale For Predicting Pressure Sore Risk" assessment was dated 7/21/11 and 8/12/11. The resident received a score of 14 for both assessments. (Scores of 13-14 designated as moderate risk). The resident's care plan, dated 8/10/11, identified the resident's potential risk for skin problems and a blister to the right outer aspect of her heel. Approaches included: *Weekly skin checks. *Lotion to dry skin. *Proper fitting foot wear. *Proper hydration. *Pressure relieving cushion to wc. *[MEDICAL CONDITION] checks every week. *Reposition every 2 hours, use turn sheet. *Resident has had previous pressure sores and is at increased risk. *Pad bony prominences. *Foam tubing around O2 tubing at ear contact. *Blue bootie left foot at bedtime. *Geri-gloves when out of bed. *Heel lift boot on right heel at all times. Copies of two faxes to the resident's physician were in the record. The first was dated 7/27/11 and notified the physician the resident had a Stage II pressure sore in the natal cleft that measured 1.5 cm length x 0.5 cm width. The second fax was dated 7/29/11 and notified the physician of a unstageable blister on the right outer heel. Measurements were 3 cm length x 2.4 cm width. A facility Wound Flow Sheet identified the natal cleft wound on 7/27/11. It was not staged but did document the same measurements as the fax copy above. The margins were intact, there was no tunneling, odor or pain. [MEDICATION NAME] was the treatment indicated. For dates 8/1, 8/2 and 8/3 there were no measurements. On date 8/4/11 the wound was resolved. A "Daily Skilled Note" (nurse note), dated 8/1/11, documented, "Late entry for 7/28/11. Resident's natal cleft area re-evaluated and it is a skin split, not a Stage II pressure ulcer." A facility Wound Flow Sheet identified a right heel closed blister on 7/28/11. It was not staged but documented measurements the same as the fax copy above. The margins were intact, no tunneling, odor or pain. [MEDICATION NAME] II was the treatment designated. There were no documented measurements after the initial date until 8/8/11, for 2.4 cm length x 3.2 cm width. This was 11 days after the pressure sore was found on 7/28/11. A "Pressure Ulcer Healing Chart" (PUSH) was initiated on 8/9/11. Measurements were to be measured at regular intervals using a "PUSH tool." The measurements were documented and graphed. The first documentation on this form was dated 8/9/11, and was the same as on the Wound Flow Sheet for 8/8/11. The next documentation was for 8/16/11 and the pressure sore had increased in size measuring 2.5 cm x 4.0 cm. This was the last documentation on the form. A "Daily Skilled Note" documented on 7/29/11, indicated, "Up in wc, heel lift boot on (R) foot d/t (due to) blister, [MEDICATION NAME] II intact (R)foot...denies and shows no s/s (signs/symptoms) of pain." The resident was observed on all observation days of the survey from 8/22 through 8/25/11 to be up in a tilt back wheelchair during the day and at meals. The resident had a waffle foam large protective boot to her right foot. The LN Unit Manager for Helping Hands Unit was interviewed on 8/22/11 at approximately 1:45 pm. She identified that Resident #1 had a pressure ulcer of recent onset to her right heel. She stated that the resident currently used a specialized boot on her right foot to keep her heel raised. The facility did not prevent an avoidable pressure sore for Resident #1, who was at increased risk for pressure sores, after sustaining a fracture that caused decreased mobility. This was evidenced by the significant change MDS assessment, dated 7/28/11, which documented she had declined and required total care for all ADLs. 3. Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #4's most recent quarterly MDS assessment, dated 5/28/11, documented in part: * Impaired cognition; * Extensive assistance of 2 people for bed mobility and transfers; and * At risk for pressure ulcers (PU). Resident #4's care plan, dated 6/14/11, identified the potential for alteration in the resident's skin as a problem. One approach to this problem was "Bridge heels while in bed." The responsible party, or discipline, was documented as "HHI." Another approach, "Assist to repostion (sic) Q 2-3 hrs (Assist to reposition every 2 to 3 hours)," identified HHD as the responsible party. Resident #4's heels were observed resting on and in contact with the mattress on the following dates/times: * 8/23/11 at 8:35 a.m., 9:00 a.m., 9:55 a.m., 12:00 p.m., and 3:00 p.m. * 8/24/11 at 8:05 a.m., 9:50 a.m., 1:15 p.m., and 1:40 p.m. On 8/24/11 at 1:40 p.m., with the resident's permission, CNA #7 and the surveyor looked at the resident's heels. CNA held up the resident's heels. Both heels were dark pinkish red. And, Resident #4 stated, "Kinda tender" when the CNA touched both heels. CNA #7 placed a pillow under the resident's heels. The resident's heels now rested on the pillow. At 1:45 p.m., LN #1 accompanied the surveyor to Resident #4's room. When the surveyor informed LN #1 the resident's heels were red, the LN looked at the resident's heels. LN #1 moved the pillow farther up under the resident's lower legs which suspended the resident's heels in the air. LN #1 agreed that the resident's heels were slightly red. The LN stated that both of the resident's heels blanched but they were "kinda soft." When asked what "bridge heels while in bed meant", LN #1 stated, "Use a pillow or foam heel protectors." On 8/25/11 at 8:10 a.m., Resident #4 was observed in bed and both heels were noted to be in contact with the mattress. There was no pillow, nor any foam heel protectors, near the resident's feet. At 9:00 a.m., the 300 Unit Case Manager (UCM) accompanied the surveyor to Resident #4's room. The UCM acknowledged that Resident #4's heels were touching the mattress. When asked the meaning of "bridge heels while in bed" the UCM responded, "Use a pillow under the legs to keep the heels off the mattress. Or use blue boots." The UCM instructed CNA #8 to bridge the resident's heels and the CNA immediately placed blue heel protector on each of the resident's heels. The UCM stated the resident's right heel was "a little pink" but that it blanched well." The UCM stated the resident's left heel was "okay." At 9:30 a.m., the DON and the 300 UCM were interviewed about Resident #4's potential risk for skin breakdown and how care plan approaches were implemented. The UCM was asked the meaning of HHI and HHD under the responsible party section of the care plan. The UCM stated HHI meant "Handheld Information" and that it was "Just information for CNAs." She stated that CNAs were not expected to document if HHI was next to an approach. The UCM stated HHD meant "Handheld Documentation" and that CNAs were expected to document when HHD was next to an approach. The UCM and DON were asked if nursing documented that the resident's heels were bridged. The DON stated that there was no place for nurses to document if the approach was done or not. When asked how the facility ensured that approaches assigned as HHI were implemented, the DON stated that nurses "document by exception and document it only if it occurs." The UCM changed the responsible party from HHI to HHD at the "bridge heels while in bed" approach. In addition, the UCM added "blue booties" to the same approach and stated that staff would be made aware of the changes. On 8/25/11 at approximately 4:45 p.m., the Administrator was informed of the concern. No further information was received from the facility.

Based on record review, staff interview, and resident interview, it was determined the facility failed to ensure that a continent resident remained continent while a resident of the facility. The facility, once the resident became incontinent of bladder, also failed to assess for the cause of the resident's incontinence or implement interventions to prevent repeated episodes of incontinence. This was true for 1 of 5 residents (#3) sampled for incontinence and toileting programs. This deficient practice harmed the resident who, according to the resident, staff, and medical records, had not regained or improved his ability to remain continent at the time the facility underwent its annual state licensure and re-certification survey. Additionally, the facility failed to develop individualized toileting programs for residents based on their comprehensive assessments. This was true for 3 of 5 residents (#s 1, 6, and 8) sampled for incontinence and toileting programs. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 1/6/11, documented the following: * Moderately impaired cognitive skills for daily decision making * Extensive assistance of one staff member required for bed mobility, transfers, locomotion in the facility, dressing, eating, and bathing * Extensive assistance of at least two staff members required for toileting * Occasionally incontinent of bowel * Frequently incontinent of bladder Resident #3's most recent quarterly MDS assessment, dated 6/22/11, documented the following: * Moderately impaired cognitive skills for daily decision making * Independent for bed mobility, transfers, locomotion in the facility, and toileting * Continent of bowel and bladder Recapitulated physician orders [REDACTED]." Start date: 4/18/11. NOTE: [MEDICAL CONDITION] was not among Resident #3's [DIAGNOSES REDACTED]. Resident #3's Urinary Care Plan, dated 7/5/11, documented the following: * "Problems/Needs/Concerns: Alteration in elimination r/t (related to) occasionally incontinent of bladder." * "Long/Short Term Goals: Resident will be clean, dry and free of odor thru (sic) 10/5/11." * "Plans and Approaches: Resident is independent in room with all aspects of toileting and will ask for help. Ask Q shift if they have had a BM (bowel movement) and document. Wears med(ium) pull-ups d/t (due to) pm (evening) incontinence (7/29/11). Condom catheter (8/8/11)." Nurse's Notes for Resident #3 were reviewed for 2/5/11 through 8/25/11. Those Nurse's Notes documented only the following entries related to Resident #3's incontinence: * 4/18/11 - "Res(ident) c/o (complained of) incontinence during naps and evening. (Physician) notified. New order rcvd (received). [MEDICATION NAME] 0.4 mg Q evening. Dx (Diagnosis): Incontinence. NOTE: Nursing 2011 Drug Handbook, by Lippincott, Williams, and Wilkins, documents the following related to [MEDICATION NAME]: "Selectively blocks alpha receptors in the prostate, leading to relaxation of smooth muscles in the bladder neck and prostate, improving urine flow and reducing symptoms of [MEDICAL CONDITION] (Benign Prostate Hypertrophy)." Resident #3 was not diagnosed with [REDACTED]. * 4/21/11 - "Resident continues on [MEDICATION NAME]. States, "It has helped a lot with episodes of incontinence. No adverse effects noted." * 7/7/11 - "CNAs report episodes of (increased) inc (incontinent) bladder (and) dribbling. Res(ident) refused to wear pads/attends. Res(ident) did agree to urinal." * 8/4/11 - "Res(ident) continues to wet his bed. Res(ident) stated that it's been happening for the past 10 days and he wants to know if it's him or (whether) something has (changed with) his meds. Res(ident) is wearing pull-ups to help." * 8/8/11 - 10:50 a.m. - "New order received to collect UA (urine for analysis), condom catheter (and) DC (discontinue) [MEDICATION NAME]. Condom cath(eter) to be placed on at HS (bedtime) (and) removed in AM (morning) if resident is continent during the day." NOTE: A FAX Communication to Physician form, dated 8/8/11 at 6:30 a.m., documented, "Within the last 10 days res(ident) has been having excessive incontinent urination, especially at night, soaking his bed. Res(ident) has also expressed that he is extremely concerned about how frequently and severely he is wetting himself. Looking into (Resident #3's) meds he was started on [MEDICATION NAME] on 7/28 and one of the side effects of the med is polyuria. Please advice (sic)." The physician's response was documented orders for a urinalysis, placement of a condom catheter, and for the resident to discontinue receiving [MEDICATION NAME]. * 8/9/11 - "Resident called me into room. He was very confused speaking in nonsensical manner. He said someone had came (sic) into his room (and) said it was time to go. He said the person was hispanic (sic) or oriental. He then put hand into pants (and) said, 'I don't really feel wet.' He said he didn't know what was going on. Notified charge nurse (and) case manager of abnormal behavior." * 8/11/11 - 3:45 p.m. - "UA collected ..." * 8/16/11 - "Rec'd (Received) new order for [MEDICATION NAME] 500 mg IV daily (for) 7 days. Dx: UTI (urinary tract infection). Given 500 mg Rocephen (sic) per IV site, no complications." * 8/17/11 - "Reminded res(ident) to call for assist to place condom catheter..." * 8/18/11 - "Res(ident) has not used condom cath(eter) this shift thus far. Has not requested assist (with) application (and) denies need for assist (with) application of condom cath(eter). (No) ADRs (adverse reactions) from ABX Tx (antibiotic treatment) for UTI. Cont(inues) (with) episodes of inc(ontinent) urine. Did request assist (with) attend (change after) urinating on underwear (and) pants. Receiving AB (antibiotic) for UTI. Denies pain (with) urination (and) taking fluids well." * 8/20/11 - "Ref(used) condom cath(eter). Requested (and) prefers 'pull up' type attends. Has used call light for assist (with changing) attends (and) toileting." The resident's Voided Record was reviewed for 6/2/11 through 8/24/11. That record revealed the following: * One episode of incontinence, on 6/3/11, from 6/2/11 through 7/3/11 * Incontinent 7/4/11 * Incontinent daily from 7/7/11 through 7/13/11, with multiple episodes of incontinence on 7/13/11 * Incontinent 7/17/11 and 7/27/11 * Incontinent daily from 7/28/11 through 8/2/11, and daily from 8/4/11 through 8/7/11 * Multiple episodes of incontinence on 7/29, 7/30, 7/31, 8/2, 8/7, and 8/9 * Incontinent daily from 8/11/11 through 8/24/11, with multiple episodes of incontinence on 8/11, 8/13-16, 8/20, and 8/23 On 8/25/11, at 10:30 a.m., Resident #3 was interviewed. When asked to talk about his new onset of incontinence in the facility, the resident stated, "It comes and goes. I just thought it was nerves or something. I didn't have a bladder problem before. It embarrasses me." When asked whether he felt the facility had adequately responded to the new onset of incontinence, the resident stated, "No, huh uh." On 8/25/11, at 11:10 a.m., the DON was interviewed. When asked about Resident #3's urinary incontinence, the DON stated, "I don't know why he's losing his (ability to control his bladder). I haven't gotten out there to ask staff." Federal guidance at 483.25(d) documented the resident has been harmed when, "Examples of avoidable negative outcomes may include, but are not limited to, decline or failure to improve continence status: As a result of the facility's failure to assess and/or re-assess the resident's continence status, utilize sufficient staffing to implement continence programs and provide other related services based on the resident's assessed needs, and/or to evaluate the possible adverse effects of medications on continence status, the resident failed to maintain or improve continence status." Resident #3 had been ordered [MEDICATION NAME] on 4/18/11 for "[MEDICAL CONDITION]," although the resident was never actually diagnosed with [REDACTED]. The resident was assessed by the facility to be continent of bladder at the time of his quarterly MDS assessment on 6/22/11, and there were no nurse's notes pertaining to incontinence between 7/7/11 and 8/4/11 despite the resident's Voiding Record, which documented daily incontinence from 7/7/11 through 7/13/11 and 7/28/11 through 8/2/11. Resident #3's physician ordered a urinalysis on 8/8/11 at 10:50 a.m., however the facility failed to collect the urine sample until 8/11/11 at 3:45 p.m. and antibiotic therapy was not initiated until 8/16/11 at 9:30 p.m. The facility failed to adequately assess, respond to, or treat Resident #3's new onset of urinary incontinence. This failure by the facility harmed Resident #3, who expressed concern, confusion, and embarrassment as a result of this new decline in his [MEDICAL CONDITION] health. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. dementia, [MEDICAL CONDITION], ureter disorder, arthritis and pain. The resident fell in the facility and fractured her hip which required surgery. She returned to the facility on [DATE]. The resident's annual MDS, dated [DATE], documented that she was on a toileting program and was frequently incontinent of bowel and bladder. The facility "Bladder Assessment" was completed over a two day period, 8/15 and 8/16/11. The assessment documented the resident occasionally told staff when she needed to use the toilet. Her current condition was described as "stable" and not a factor for toileting ability. The form asked the writer to check the probable incontinence type based on the assessment information. The word "functional" was checked. A toilet program was recommended. The proposed schedule was to check and change every 2-3 hours and prn. This was signed by a registered nurse and dated 8/16/11. There was no void pattern established. The current care plan was dated 8/10/11. The resident had a problem identified for elimination related to incontinence of bowel and bladder. Approaches included: *Change resident post incontinence. *Keep skin clean and dry. *Resident uses incontinence products (pull ups). *Check and change every 2-3 hours and as needed (prn). *Toilet upon upon rising, after meals, before sleeping to encourage bowel movement. The resident had a catheter after surgery and her return to the facility. It was discontinued on 8/12/11. The facility did not comprehensively assess the resident to determine an individualized toileting program for her. 3. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial MDS, dated [DATE], documented the resident was frequently incontinent of bladder. This was the same for the quarterly MDS dated [DATE]. The facility bladder assessment form had the first part of the assessment completed and dated 10/8/10. The second page of the assessment indicated a registered nurse should complete the last section of the assessment. The assessment was blank. There was no void pattern developed for the resident. The current care plan was dated 6/24/11 and identified a problem with elimination related to dementia. Approaches included: *Assist to bathroom every 2-3 hours and as needed. Encourage resident to void. *Change resident post-incontinence using barrier cream. *Resident uses incontinence products (pull ups). *Toilet at 12:00 am and 4:00 am. NOTE: This approach had been added to the 11/19/10 care plan and was dated 12/6/10. The direction on the hand written addition for 12/6/10 indicated this should be done as the resident allowed. This was part of a directive that was not on the current care plan. The resident did not have a comprehensive bladder assessment to determine an individualized toileting schedule. There was no indication of an assessment that resulted in the need for night and early morning hour toileting of the resident. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 4/11/11, documented the resident was frequently incontinent of urine. This was the case for the quarterly MDS dated [DATE] as well. The facility bladder assessment form was dated 4/11/11. The first page of the assessment asked the writer what terms or cues the resident used to indicate toileting needs. The documentation for this question was, "'I've got to pee pee' and other colorful terms." The section completed by a registered nurse indicated that the resident had end stage disease and this did affect his toileting ability. The recommended toilet schedule was, "Assist to BR (bathroom) every 2-3 hour and prn." A void trial was not done. The resident's current care plan was dated 6/29/11. Approaches included: *Assist to BR every 2-3 hours and prn, encourage resident to void. *During sleeping hours, allow resident at least one 4 hour period of undisturbed sleep unless current skin breakdown or otherwise delegated by LN. *Resident uses incontinent products - night time attends placed at bedtime, do not disturb T/O (unknown acronym) night except between 3-4:30 am and as needed. *Has toilet riser. The DON was interviewed on 8/23/11 at 10:17 am. She was asked how the facility established individualized toilet programs for residents as the toilet or change every 2-3 hours was a recurring theme in care plans. She stated they use the daily documentation per shift that tells how many times a day the resident was either continent or incontinent. She was asked how they could determine individualized time frames a resident toileted, by the documentation used in the facility. She did not answer. She was asked if the facility ever established a void pattern for residents, and stated that she was not familiar with that procedure. The resident did not have an individualized toilet schedule. There were two directions on the care plan for night time toileting or incontinence care. There was no assessment for the night time schedule.

Based on staff interview, observation, record review and review of facility incident and accident reports it was determined the facility failed to ensure that falls were prevented for 2 of 7 residents (#1 and #8) reviewed for falls. Resident #8 was not supervised and did not have an alarm functioning correctly when the resident fell and fractured her spine, resulting in harm due to significant pain. Resident #1 fell from her wheel chair and was harmed when she fractured her hip and the wheel chair brake had not been applied. In addition, the facility failed to thoroughly investigate the incdents. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as a high fall risk on 10/30/10, 11/1/10, 12/4/10 and 1/5/11. This was documented on the facility, "Falls Data Collection Tool." Any score above 12 equaled high risk for falls. The assessments were all above 12 with the lowest score being 18 after a fall with injury on 11/1/10 that resulted in the resident's inability to stand. The resident's initial MDS, dated [DATE], documented the resident had fallen in the previous 6 months. The current care plan was dated 6/24/11. The resident was identified as a fall risk. Approaches to keep the resident safe included: "Safety devices: Bed alarm, Chair alarm, has seat belt (Velcro) alarm D/T (due to) poor safety awareness." The care plan also directed a one person assist for transfers and bed mobility and not to place foot pedals on the resident's wheel chair unless she was being transported. A facility "Resident/Visitor Incident Report" (I&A) was dated 11/1/10. The report documented a CNA stated that Resident #8 stood up and turned to her right and attempted to ambulate. The CNA also reported the resident's alarm had not sounded right away. When the alarm was checked it was on a two second delay. The resident had right hip pain. All staff were counseled to ensure the sensor alarms and tab alarms were on the proper setting. The report had an investigation section. The report did not say how many staff were on the Helping Hands Unit (a locked unit) when the accident occurred. There was no indication that staff were questioned as to when the resident was last toileted to ascertain if this may have been a contributing factor for the resident standing up. There was no indication as to previous attempts by the resident to stand from her wheel chair prior to the fall or if any medications could have caused loss of balance. The nurse progress notes for 11/1/10, (4:30 pm), documented that the resident had hip pain and was given hydrocodone for pain. The note also indicated the resident had been very restless and attempting to ambulate without assistance. Another note on this date, timed 5:00 pm, documented the resident stood up from the table, turned to walk to right side of her wheel chair and "fell to the floor hard." It was unknown if the resident hit her head. The resident was assessed and the physician was called. The resident was sent to the hospital by ambulance at 5:30 pm. The facility called the hospital at 8:30 pm, and were informed the resident was admitted . The resident returned on 11/3/10 at 4:45 pm by facility transport. The hospital clinical report, dated 11/1/10, documented the resident was found to have a new compression fracture of the lumbar spine (L1). The resident was having right hip pain. The resident was noted to have had a prior hip fracture and X-rays revealed the screws had "backed out a bit." No new fracture was noted in the hip. On 11/2/11 a hospital progress note indicated the resident had a procedure under local anesthesia and "cement was carefully infused throughout the anterior three fourths of the vertebral body without complication." The resident was observed to be restless and frequently self propelled in her wheel chair up and down the hall of the Helping Hands Unit. She also would leave and return to her table several times during meals. This was the case on all observation days of the survey from 8/22/11 through 8/25/11. The facility did not provide adequate supervision to Resident #8 who had been restless and attempting to get up prior to the fall. The alarm was not set correctly. The resident had just received pain medication which could contribute to unsteadiness when she stood up. The facility did not thoroughly investigate for cause and prevention of future falls. The resident was harmed when she experienced pain and a fracture to her spine after she fell . The resident was immobile when she returned to the facility until she recovered. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. dementia, renal insufficiency, arthritis and pain. The resident was hopitalized after fracturing her hip in the facility. She was readmitted on [DATE], after surgical repair of her hip. The facility's "Falls Data Collection Tool" for assessing fall risk documented 7/21/11, the resident was at high risk for falls. (A score of 24 with 12 and over identified as high risk). All prior assessments on 2/15/11, 5/31/11 and 7/17/11 also documented high risk scores. The resident's MDS annual assessment, dated 6/15/11, did not document a history of falls in the prior 6 months. The care plan, dated 8/10/11, documented the resident was at risk for falls. Approaches to keep the resident safe included: *Safety mat to side of bed to reduce risk of injury. *Multiple falling star program. *Safety devices : Bed alarm, (wheelchair) alarm. *After cares lower bed to lowest position. *Assist bars to improve bed mobility and increase safety with transfers. *Raised edge mattress to help identify edge of bed. *Transfer: 2 assist with gait belt. *Partial weight bearing left leg. Other than an additional person to assist with transfers and direction on weight bearing for the resident's left leg, the interventions were the same on the 6/24/11 care plan prior to the resident's fall. The LN Unit Manager in the Helping Hands Unit was interviewed on 8/22/11 at approximately 1:45 pm. She indicated Resident #1 had a recent fall and fractured her hip while in the facility. She said that Resident #1 had a habit of rocking herself and pushing forward in her chair. She said that she had been present when the resident fell and was only about 5 feet from her, passing medications. She stated she had tried to grab the resident but she just slid out of the chair. She indicated that now the resident has a new wheel chair that tilts back, and no longer attempts to get out of the chair. A nurse progress notes dated 7/17/11 (7:10 am), documented, "Resident scooted off wc. Family notified....(Doctor) ordered X-ray left hip... transported to (hospital) per ambulance..." On the same date at 1:00 pm, it was noted the resident was admitted to the hospital. The I&A investigation report, dated 7/18/11, documented the resident fell on [DATE]. The resident had scooted herself to the edge of her wheelchair seat and fell off onto the floor. The wheelchair was "unlocked." The report stated, "She does scoot herself freq(uently) throughout the shift even when placed in glider chair. She is constantly reminded and assisted back in her chair." The corrective action was that a nurse instructed a CNA to place the resident in a glider chair after being transported from her room by wheel chair. This did not make sense as the facility documentation already indicated the resident scooted herself in the glider chair, as well as the wheel chair. There was no indication if any other staff were in the room supervising while the nurse was busy passing medications. The nurse was close (within 5 feet) and had attempted to stop the resident's fall. However, the facility had not investigated how much the brake being off the wheel chair had contributed to the fall for Resident #1 who fractured her hip when she fell . The resident had pain as a result of the fracture and resultant surgery. Although the facility was aware that the resident "scooted" in her chair and required almost constant repositioning, they failed to get a chair evaluation until after the fall with injury occurred. Her condition had declined as evidenced by a significant change MDS, dated [DATE], that indicated she now required total care with all activities of daily living.