Every finding on record at Gateway Transitional Care Center

Based on policy review, observation, record review, and interviews, it was determined the facility failed to a) provide respiratory services as ordered by the physician and b) ensure physician orders and resident care plans identified interventions for oxygen therapy. This was true for 5 of 13 residents (#3, #5, #9, #28, and #59) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: The Centers for Medicare & Medicaid Services website, accessed 7/28/25, stated Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the beneficiary’s medical records will reflect the need for the care provided. The beneficiary’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain: Beneficiary’s name Physician’s name Date of the order and the start date, if start date is different from the date of the order Detailed description of the item(s) (see below for specific requirements for selected items) Physician signature and signature date for items provided on a periodic basis, including drugs, the written order must include: Item(s) to be dispensed Dosage or concentration, if applicable Route of Administration Frequency of use Duration of infusion, if applicable Quantity to be dispensed Number of refills 1. Resident # 3 was admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare following surgery on the digestive system and schizoaffective disorder. Resident #3's physician order dated 4/21/25, documented Oxygen at 0-10 liters via nasal cannula. Titrate to maintain sats above 90% every shift. Resident #3's oxygen order did not document the frequency of use. 2. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including fracture right humerus (long bone in the upper arm) and COPD (a group of lung diseases that blocks airflow and makes it difficult to breathe). Resident # 5's physician order dated 6/17/25, documented Oxygen at 0-10 liters via nasal cannula. Titrate to maintain saturations above 90% every shift. Resident #5's oxygen order did not document the frequency of use. 3. Resident #9 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic viral hepatitis C (an infection that causes liver swelling), dependence on renal dialysis, and acute and chronic respiratory failure with hypoxia (when the lungs cannot adequately oxygenate the blood). Resident #9’s physician’s order dated 2/26/25, documented “oxygen at 0-4 liters via nasal cannula – every shift”. Resident #9’s MAR dated 2/26/25, documented oxygen at 0-4 liters via nasal cannula every shift. Resident #9’s care plan revised 4/11/25, documented oxygen per MD orders. Resident #9’s physician order, MAR, or care plan did not document an indication for use, a baseline SpO2 level, or when to initiate and/or discontinue oxygen therapy. On 7/22/25 at 2:38 PM, the DON stated Resident #9’s oxygen order was written generically because he does not always need oxygen; however, the order should have clarified when to use or discontinue use of oxygen on Resident #9. 4. Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and gait and mobility issues. On 7/21/25 at 2:21 PM, Resident #28’s physician oxygen order documented oxygen at 0 to 10 lpm, every shift PRN to maintain O2 at or greater than 88%. Resident #28’s care plan documented oxygen per MD orders. Resident #28’s daily oxygen saturation logs documented the following: 7/11/25 at 22:34 SpO2 82% on RA per LPN #2 7/7/25 at 18:26 SpO2 67% on O2 per RN #2 4/26/25 at 22:06 SpO2 86% on RA per RN #2 4/26/25 at 15:07 SpO2 86% on RA per LPN #4 Resident #28’s medical record had not contained any documentation of nursing interventions when her oxygen saturation dropped below 88%. On 7/21/25 at 10:48 AM, the DON stated the nursing staff should have addressed Resident #28’s low oxygen saturations below 88% and had not. 5. Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and respiratory failure. The facility's policy for Oxygen Administration, revision date 7/2024, documented oxygen tubing is to be replaced every seven (7) days. Oxygen masks or nasal prongs are to be replaced every seven (7) days. Resident #59's medical record included physician orders for oxygen 0-5 liters per minute via nasal cannula for titrate to maintain above 90% every shift. The order started on 4/11/25. The orders also documented to change oxygen tubing, label and date every seven (7) days as per policy. On 7/24/25 at 8:17 AM, Resident #59's oxygen tubing and humidifier were not dated and Resident #59 stated he did not know when it was last changed. On 7/24/25 at 8:18 AM, the ADON stated Resident #59’s oxygen tubing and humidifier should have been dated when changed and had not been.

Based on observation, record review, and interviews, it was determined the facility failed to assess the risks of transporting residents backwards in Geri-Chairs and had not provided attentive care during resident transports in Geri-Chairs. This was true for 1 of 2 residents (Resident #12) who was observed during transport down the facility's C-Hallway. This deficient practice placed residents at risk for harm when improperly transported and supervision was not provided. Findings include:Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including cerebellar ataxia (a group of neurological disorders that affect the cerebellum, the part of the brain responsible for coordination and balance), cognitive communication deficit, and muscle spasms.On 7/22/25 at 3:37 PM, observed Resident #12 in a Geri-Chair being pulled out of her room backwards. Resident #12 was crying out loudly, kicking her legs, and trying to move about in the chair as the CNA pulled her backwards down the hallway. The surveyor observed the CNA pull the Geri-Chair from the upper left corner of the chair as she led it down the hall and the CNA had not observed the resident during the transport.Resident #12 had three falls involving her wheelchair on 8/10/24, 9/4/24, and 9/13/24 as reported in the facility's Incident and Accident log. Each fall was a result of lack of supervision when Resident #12 was kicking and moving about in her wheelchair. One of the falls resulted in a head injury requiring transportation to the local hospital.On 7/23/25 at 10:43 AM, the DON stated staff must be attentive to Resident #12 during transports in the Geri-Chair and were not.

Based on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include:U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 7/21/25 at 8:18 AM, observed in the kitchen, next to the freezers a garbage can with a hole in the lid.On 7/21/25 at 8:21 AM, the DS #1 stated she was unaware the garbage can should have had a solid lid on it.On 7/23/25 at 3:05 PM, the ED stated the garbage can should have had a solid lid and did not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications for 1 of 6 residents (Resident #83) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include: Resident #83 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (irregular heartbeat that may cause the heart to beat faster) and diabetes.On 7/23/25 at 11:54 AM, observed a bottle of artificial tears on Resident #83's bedside table.Review of Resident #83's medical record contained a Self-Administration of Medications - Initial Evaluation dated 9/15/23, documented for eye drops- Can correctly administer eye drops or eye ointments according to proper procedure Not Applicable. On 7/23/25 at 12:00 PM, LPN #5 stated the artificial tears in Resident #83's room should not have been in his room because he did not have an order for them and a self-administration of medication assessment was not done.

Based on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure resident's call light device in their room was within reach for 2 of 19 Residents (#42 and #84) whose rooms was observed. This deficient practice had the potential to cause harm if residents experienced falls, accidents, or had other needs and could not reach the call light device. Findings include:The facility Call Light/Bell policy dated 8/30/21, documented before leaving the room, staff will place the call light device within the resident’s reach. a. Resident #42 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and hypertension. On 7/21/25 at 2:56 PM, Resident #42 while sitting in her wheelchair stated the call light device had been placed up high on the trapeze bar by staff when they made her bed and now it was out of her reach. On 7/21/25 at 3:00 PM, LPN #1 stated Resident #42's call light device was supposed to be attached to the bed covers to allow easy access for her and was not. On 7/23/25 at 10:23 AM, the DON stated the call light device should have been attached to the bed covers and was not. b. Resident #84 was admitted to the facility on [DATE], with multiple diagnoses including polyosteoarthritis (condition in which multiple joints are affected by inflammation and damage to the tissue that cushions the ends of bones), and obesity. On 7/23/25 at 10:42 AM, Resident #84 while sitting in her wheelchair stated the call light device was wrapped around the overbed light and out of her reach. On 7/23/25 at 10:51 AM, NA #1 stated Resident #84's call light device was supposed to be attached to the blankets for easy access for her and was not. On 7/23/25 at 3:23 PM, the DON stated the call light device should have been attached to her covers and was not.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflect resident's status. This was true for 1 of 19 residents (Resident #47 ) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include: Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect in which an area of the spinal column does not form properly, leaving a section of the spinal cord and spinal nerves exposed through an opening in the back), anxiety, major depression, and PTSD.Resident #47's admission MDS assessment dated [DATE], documented: Section A: -1500 Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Yes.-1510 Level II PASRR conditions: Serious Mental Illness = No.Section I: Psychiatric/Mood Disorder: -I6100. Post Traumatic Stress Disorder (PTSD) = No.0n 7/23/25 at 2:01 PM, Social Services Supervisor stated PTSD should have been on Resident #47's admission MDS assessment and was not.

Based on clinical record review, policy review, and staff interviews, the facility failed to include a resident's mental and psychosocial needs in their Baseline Care Plan. This was true for for 1 of 19 residents reviewed for baseline care plans (Resident #47). Findings include:The facility's Comprehensive Person-Centered Care Planning policy revision date April 2025, documented it was the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meets professional standards of quality care.Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect in which an area of the spinal column does not form properly, leaving a section of the spinal cord and spinal nerves exposed through an opening in the back), anxiety, major depression, and PTSD.Record review of Resident #47's Baseline care plan, Section 1.a. Cognition, was not answered for focus, goal, or intervention. On 7/23/25 at 2:05 PM, Social Services Supervisor stated Resident #47's anxiety, depression, and PTSD diagnoses should have been on her baseline care plan but was not.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 5 of 19 residents (#3, #28, #47, #59, #82) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Comprehensive Person-Centered Care Planning policy, revision date 4/2025, documented the comprehensive care plan would be reviewed and/or revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. a.Resident #3 was admit to the facility on 4/21/25, with multiple diagnoses including surgical aftercare following surgery on the digestive system and schizoaffective disorder. Resident #3's comprehensive care plan documented the following: - Food preferences: Gravy on meat, enjoys green and yellow vegetables, wheat bread, fruit, ice cream, milk. Dated 5/21/24 -Advance to regular diet. Ensure patient is tolerating well. Date 4/22/25 -Patient prefers full liquid diet. Dated 5/16/25 Resident #3's physician order dated 4/27/25, documented, Full liquid diet, thin liquids consistency. On 7/22/25 at 1:41 PM, the DON stated Resident #3 gets bowel blockages real easy so she is on liquid diet. Her care plan should have been updated. b. Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and gait and mobility issues. Resident #28’s care plan dated 7/11/24, documented she was on Enhanced Barrier Precautions (EBP). On 7/21/25 at 11:06 AM, when visiting with Resident #28 in her room, the surveyor noted the lack of EBP posting and EBP PPE outside or inside of her room. On 7/23/25 at 9:27 AM, RN#1 stated she was not sure if Resident #28 was on EBP because she had not been on this hall for a while. RN #1 confirmed there was no EBP sign posting or EBP PPE outside or inside Resident #28’s room. On 7/23/25 at 10:43 AM, RN #1 stated the DON had just let her know the EBP had been discontinued. On 7/23/25 at 2:19 PM, the DON stated Resident #28’s EBP had been previously discontinued, and the care plan should have been updated and had not been. c. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect in which an area of the spinal column does not form properly, leaving a section of the spinal cord and spinal nerves exposed through an opening in the back), anxiety, major depression, and PTSD. Review of Resident #47's comprehensive care plan, revision date 10/15/24, documented she required assistance with ADL self care. Her care plan did not document she requested no male caregivers. On 7/22/25 at 3:47 PM, the ADON stated Resident #47 did request no male caregivers due to her history and it was not documented in her care plan and should have been. d. Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and respiratory failure. Resident #59’s care plan was not updated with the new oxygen parameter orders. On 7/23/25 at 8:11 AM, the ADON stated the recent change of oxygen parameters for Resident #59 were not listed on his care plan and the care plan should have been updated. e. Resident #82 was admitted to the facility on [DATE], with multiple diagnoses including compression of brain (condition in which something increases the amount of pressure pushing on the brain) and aphasia (language disorder that affects ability to communicate). On 7/24/25 at 8:00 AM, observed a fall mat on the floor at Resident #82’s bed side. On 7/24/25 at 8:03 AM, fall mat had not been documented on Resident # 82's care plan. On 7/24/25 at 8:12 AM, LPN #5 stated the fall mat intervention was not listed on Resident #82’s care plan. On 7/24/25 at 8:15 AM, the ADON stated the fall mat had not been documented on Resident #82’s care plan and the care plan should have been updated.

Based on facility standing orders, record review, and staff interview, it was determined the facility failed to follow a) facility bowel care standing order of delivering specific medications to residents who have not had a BM due to constipation for 1 of 1 resident (#28) whose record was reviewed for bowel care and b) obtain a physician's order for insertion of an IV and dressing changes. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's standing order and potential harm if a resident had an IV inserted without consulting the physician. Findings include: The facility standing order (undated) documented Dulcolax suppository PRN for constipation, Fleet Enema PRN for constipation, and Milk of Magnesia 30 mg Q4 hours PRN for constipation. a. Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and gait and mobility issues. Resident #28’s medical record under CNA tasks Bowel movement/Bowel continence documented she had a bowel movement (BM) on 6/22/25 at 16:33 and not again until 6/27/25 at 16:59 which was 120 hours later. Resident #28’s medical record under CNA tasks Bowel movement/Bowel continence documented she had a BM on 7/3/25 at 14:44 and not again until 7/10/25 at 6:06, which was 180 hours later. Resident #28’s medical record documented she normally had at least one BM each day. Resident #28’s physician order dated 6/31/23, documented Sennosides Docusate Sodium Oral Tablet 8.6 - 50 mg, give 1 tablet by mouth for bowel maintenance. Resident #28’s June 2025 and July 2025, MAR documented Sennoside Docusate Sodium Oral Tablet was administered each day in June and July 2025. Resident #28’s MAR had not documented the use of the three facility standing order medications for constipation during June or July 2025. Resident #28’s care plan dated 7/19/23, documented the following intervention: - Toilet Use: Requires supervision staff participation to use toilet. On 7/23/25 at 10:30 AM, the DON stated nursing staff should be following the facility standing order by given medications for constipation and the physician should be contacted for residents who do not have a bowel movement within 72 hours and had not. b. Resident #89 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the right acetabulum (hip) and COPD (a group of lung diseases that block airflow and make it difficult to breathe). On 7/22/25, observed Resident #89 with an IV inserted in his right arm. On 7/23/25 at 3:50 PM, a record review of Resident #89's medical record did not document orders for his IV or IV dressing changes. On 7/23/25 at 4:17 PM, the DON stated Resident #89's IV was started on 7/22/25, and he should have had orders for the IV and dressing changes in his medical records but did not.

Based on observation and staff interview, it was determined the facility failed to ensure nursing staff removed meal trays from resident rooms in a timely manner for which they had the knowledge, skills, and competencies. This was true for 1 of 1 resident (Resident #28) whose breakfast meal tray was observed in her room prior to lunch. This had the potential to create dissatisfaction with meals and decrease residents' quality of life. Findings include:Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and gait and mobility issues.On 7/21/25 at 7:58 AM, observed Resident #28's uneaten breakfast meal tray on her overbed table.On 7/21/25 at 11:06 AM, observed Resident #28's uneaten breakfast meal tray still on her overbed table over 3 hours since it had been delivered. Resident #28 stated she does not know why the nursing staff sometimes wait to pick up the breakfast tray when they deliver the lunch meal tray.On 7/22/25 at 3:54 PM, the DON stated the meal trays should be picked up within 2 hours of delivery and had not been.

Based on review of the State Operations Manual, Appendix PP, staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a nurse aide successfully completed a State approved training and competency evaluation program within 4 months of being hired. This was true for 4 of 10 nurse aides whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility. Findings include:On 7/23/25, personnel files for 10 Nurse Aides (NAs) were reviewed. Four of the 10 NAs had not completed a State approved training and competency evaluation program within 4 months of being hired. - NA #2 was hired on 12/11/24. Had not completed a course- NA #3 was hired on 1/10/25. Had not completed a course- NA #4 was hired on 11/12/24. Had not passed test. Must take course again.- NA #5 was hired on 11/7/24. Had not completed a course. On 7/23/25 at 2:00 PM, the Executive Director stated NA #2, NA #3, NA #4, and NA #5 were not certified nursing assistance and the facility needs to get better about ensuring NAs become certified within the required 4 months of hire date.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 6 residents (Resident #68) observed to receive medication during the survey. This had the potential to affect the resident's health if she did not receive the medications that were ordered. This resulted in a facility medication error rate of 6.9%. Resident #68 was admitted to the facility on [DATE], with multiple diagnoses including fractured left humerus (long bone in the upper arm) and diabetes.Resident #68's physician order dated 6/13/25, documented Cranberry Oral Tablet. Give 500 mg by mouth one time a day for supplement.Resident #68's physician order dated 6/13/25, documented Multivitamin Oral Tablet. Give 1 tablet by mouth one time a day for supplement.On 7/23/25 at 9:25 AM, observed LPN #6 administer Cranberry oral 450mg tablet and Multi-vit with minerals to Resident #68.On 7/23/25 at 9:36 AM, LPN #6 stated the Cranberry tablet was the wrong dose and the Multiple vitamin was the wrong medication and she would have to get the orders clarified with the doctor.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure stored medications had not passed their expiration date and ensure medication carts were kept locked when not attended by authorized staff in an area where residents could access it. These failed practices affected a) 1 of 3 medication storage rooms creating the potential for residents to receive expired medications with decreased efficacy and b) 1 of 4 medication carts which had the potential for residents to gain access and ingest medications that can cause significant adverse outcomes. Findings include:The facility’s Pharmacy Services Drug Storage policy dated 10/24, documented medication and treatment carts will be kept locked when unattended. On 7/21/25 at 11:00 AM, observed the Hall-B medication cart had been left unlocked and unattended. On 7/21/25 at 11:08 AM, LPN #1 stated the Hall-B medication cart had been left unlocked when unattended and should not have been. On 7/23/25 at 10:55 AM, the DON stated medication carts should not be left unlocked when unattended and had been. On 7/23/25 at 9:00 AM, a vial of Novolog solution with the expiration date of 1/9/25, was observed in the A/B Hall medication room. On 7/23/25 at 9:02 AM, LPN #5 stated the Novolog was expired and should have been discarded.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to ensure food items were dated, labeled, and stored at a safe temperature. These deficient practices had the potential to impact all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code Section 3-501.17 stated, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, states refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. Review of the facility's Foods Brought by Family or Visitor policy revision date January 2019, documented food items should be labeled with date it was prepared, if known, and a discard/use by date.a. Resident #28 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and gait and mobility issues. On 7/21/25 at 7:58 AM, observed Resident #28’s uneaten breakfast meal tray on her overbed table. On 7/21/25 at 11:06 AM, observed Resident #28’s uneaten breakfast meal tray still on her overbed table over 3 hours since it had been delivered. Resident #28 stated she does not know why the nursing staff sometimes wait to pick up the breakfast tray when they deliver the lunch meal tray. On 7/22/25 at 3:54 PM, the DON stated the meal trays should be picked up within 2 hours of delivery and had not been. b. On 7/21/25 at 8:15 AM, observed in the kitchen with the Dietary Supervisor #1 (DS) present: -Three bags of English muffins not dated. -A box of frozen sliced carrots not covered. On 7/21/25 at 8:25 AM, DS #1 stated the bags of English muffins should have been dated and the frozen carrots should have been covered and had not been. On 7/23/25 at 1:49 PM, the following were observed in the dry food storage area with DS #1 and RD present: - - Six cans of evaporated milk with a use by date 2/6/25 On 7/23/25 at 2:43 PM, the following were observed in the resident unit refrigerators, with RD present: - Three cans of Glucerna with an expiration date of February 2025. - A container of applesauce with an expiration date of May 2025. - A box of pizza not dated. On 7/23/25 at 2:49 PM, the RD stated the food items should have been discarded from the refrigerators.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not store oxygen supplies in a sanitary manner. This was true for 4 of 9 Residents (#5, #47, #72, and #84). These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including fracture right humerus (long bone in the upper arm) and COPD (a group of lung diseases that block airflow and make it difficult to breathe). On 7/21/25 at 9:07 AM, observed Resident #5's nasal cannula draped on bedside table without a cover. 2. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect in which an area of the spinal column does not form properly, leaving a section of the spinal cord and spinal nerves exposed through an opening in the back), anxiety, major depression, and PTSD. On 7/21/25 at 9:13 AM, observed in Resident #47's room, her CPAP mask was on the floor, next to her bed. Resident #47 stated the staff got her out of bed this morning and must have not put the CPAP mask on her dresser. 3. Resident #72 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and emphysema (a chronic lung disease that damages the air sacs in the lungs making it difficult to breathe). On 7/21/25 at 9:16 AM, observed Resident #72's oxygen tubing and nasal cannula hanging on the wall, not covered. On 7/22/25 at 2:27 PM, the DON stated the oxygen supplies and the cpap tubing and mask should not have been on the floor, and should have been stored appropriately when not in use. 4. Resident #84 was admitted to the facility on [DATE], with multiple diagnoses including polyosteoarthritis (condition in which multiple joints are affected by inflammation and damage to the tissue that cushions the ends of bones) and obesity. A physician order dated 6/20/24, documented Resident #84 was to have her don her CPAP mask (provides positive airway pressure to help breathing) at night when sleeping to ensure adequate oxygenation. On 7/21/25 at 2:16 PM and 7/22/25 at 10:43 AM, Resident #84's CPAP mask and tubing were observed on a pile of linens and pillows in the chair next to Resident #84's bed. The equipment was not bagged. On 7/22/25 at 2:29 PM, the DON stated the CPAP equipment should not have been in the chair and should have been stored appropriately and placed in a bag when not in use.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen was maintained in a sanitary manner when sanitizer solutions were had inadequate strength, rust was observed on the inside of the ice machine, and the dishwashing area contained caulking that was peeling off with food particles entrapped creating a surface that was uncleanable on the stainless counter. These deficiencies had the potential to affect all 76 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The initial kitchen inspection was conducted on7/8/24 from 9:45 AM through 10:28 AM with the DS. The following was observed: a. The stainless-steel counter where the dish machine sprayer hose was located was observed with a brown and black rubbery substance (caulking) partially adhered to two pipes coming up through the stainless counter and was also partially adhered to the stainless counter around where the pipes penetrated the counter. There were food particles adhered under the partially affixed caulking. The partially adhered excess caulking created a surface that was not cleanable. DA #1 and the DS stated there was a leak in the pipes and maintenance staff applied the caulking around the pipes to seal the leak. DA #1 stated the leak was ongoing since approximately October 2023. The DS stated the leaking pipes were a problem since she started in her position in December 2023. b. Three buckets of wiping rag sanitizer solution (Oasis 146 Multi-Quat Sanitizer) were tested by the DS using quat test strips. The two sanitizer buckets for wiping cloths that were currently in use by dietary staff to sanitize kitchen surfaces were inadequate in parts per million (ppm) of quaternary ammonia (quat). The first bucket did not have any sanitizer present in the solution and read zero ppm. The solution in the second bucket read 100 ppm per the test strip, both sanitizer levels verified by the DS. The DS stated there might be a problem with the test strips. The DS filled a new bucket with the Oasis 146 Multi-Quat solution that was dispensed from a hose in the three-sink pot washing area. The ppm of the freshly mixed bucket of quat solution was 200 ppm; the DS stated this was the correct level and verified the test strips were working. The DS stated the desired level of quat was 200 ppm. c. The interior of the ice machine had a plastic panel in which the ice would touch as ice was made and fell into the interior ice bucket. The panel was attached on one side with a significantly rusted screw; the screw on the other side was missing. The DS stated she was not aware of the rusted screw and verified ice would make contact with the rusted screw when tumbled into the interior ice storage area. 2. A second kitchen inspection was conducted on 7/10/24 at 4:50 PM with the DS. The following was observed: a. Two buckets of wiping rag sanitizer solution, currently in use, were tested by the DS using quat test strips. One of the sanitizer buckets for wiping cloths was inadequate in ppm of quat. The bucket of sanitizer solution was tested by the DS and it read 100 ppm of quat. The DS tested a second bucket and it was at the proper concentration of 200 ppm of quat, verified by the DM. [NAME] #1 stated she changed the buckets of sanitizer solution about an hour ago. The DS took an empty bucket to the spigot for the Oasis 146 Multi-Quat Sanitizer and dispensed a new bucket. The DS checked the level of the newly mixed bucket of solution and the concentration was 250 ppm indicating the solution was being mixed and dispensed out of the hose at the correct concentration and that the test strips worked properly. The DS stated the concentration of quat in the wiping rag buckets decreased over time indicating the buckets should be changed regularly which may have accounted for the drop in concentration in the first bucket to 100 ppm. b. The ice machine was observed and had been fixed with new screws. The rusted screw was gone; there was a small area of rust remaining around the area where the new screw was affixed to the metal plate. The DS stated the rusted screw had been replaced. c. The caulking around the pipes and on the counter in the dish washing area had been removed. The DS stated the leak was repaired and excess caulking removed, getting rid of the nasty stuff on the counter. During an interview on 7/9/24 at 10:46 AM, the Administrator stated the new Maintenance Director fixed the pipe and removed the caulking in the dish pit following the surveyor's observation on 7/8/24. The Administrator stated the Maintenance Director had first become aware of the problem with leaking pipes in the dish pit area on 7/5/24. During an interview on 7/10/24 at 6:11 PM, the Registered Dietitian stated the sanitizer solution should be at a minimum concentration of 150 PPM to effectively sanitize surfaces. On 7/11/24 at 10:00 AM, the Maintenance Director and Administrator were interviewed. The Maintenance Director stated he was in his position as Maintenance Director for approximately four months and Maintenance Staff worked as his assistant. The Maintenance Director stated he came to work on 7/5/24 and fixed the leak in the pipes in the dish pit area on that date after being notified of the leak. The Maintenance Director stated the caulking on top of the counter and attached to the pipes were there for a while and previously was applied by Maintenance Staff. The Maintenance Director stated he had not removed the excess caulking on 7/5/24 when he fixed the leak. The Maintenance Director stated there was food constantly in that area (where the pipe leaked and caulking was located) due to debris from the sprayer. The Maintenance Director stated the ice machine broke last week and they called a contractor who came and put new washers in the machine. During an interview on 7/11/24 at 7:33 AM, the DS stated when she tested the sanitizer level in the buckets of Oasis 146 Multi-Quat solution on 7/8/24 and 7/10/24, she had not held the test strip in the sanitizer solution long enough accounting for the inadequate levels recorded on the test strips. The DS verified the test strips read adequate levels of sanitizer in the newly mixed buckets on 7/8/24 and 7/10/24 and in one bucket on 7/10/24 using the same technique and holding the test strip in the solution for the same amount of time, indicating the test strips were in the solution long enough to get a reading.

Based on observation, policy review, record review, and staff interview, the facility failed to ensure the required nursing staff posting accurately reflected the actual staff hours to care for the 76 current residents and failed to ensure the posting included an updated census for each shift. This failure had the potential to inaccurately inform any resident, family member, or visitor to the facility of the available nursing staff caring for residents. Findings include: On 7/9/24 at 3:05 PM, a posted nurse staffing was not observed in the R and D/C hall Nurse's Stations. There were white boards located at or near the nurse's stations with staff assignments for the halls. On 7/9/24 at 3:15 PM, the DNS showed the nursing staff posting for 7/8/24 and 7/9/35 on the wall across from the A/B Nurse's Station. The postings included the date, the number of CNAs, RNs, and LPNs, and the anticipated hours to be worked. The nursing staff posting did not include the actual number of hours worked for each nursing staff category or the updated census to account for any admissions, discharges, or transfers to acute care. On 7/11/24 at 8:30 AM, the nurse staffing posting on the wall across from the A/B Nurse's Station had the anticipated hours for 7/10/24 and 7/11/24. During an interview on 7/11/24 at 1:10 PM, the Administrator and RNC stated there was no policy regarding the nurse staff posting and confirmed where it was currently posted by the A/B Nurse's station residents and visitors for the R and D halls would probably never see it.

Based on observation, record review, and resident and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 19 residents (Resident #39) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments. Findings include: Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke. a. During an interview with Resident #39 on 7/8/24 at 11:15 AM, in response to the question if he had any issues with his teeth, gums, or dentures, Resident #39 stated he did not have teeth and wanted dentures. A Nutrition - Admission Evaluation, dated 2/20/20, documented Resident #39 was edentulous (lacking teeth) of both the upper and lower jaws. Annal MDS assessments dated 7/20/23, and 4/20/24, and a significant change of status MDS assessment, dated 5/7/24, did not include documentation Resident #39 had no natural teeth or tooth fragment(s) (edentulous). During an interview on 7/10/24 at 1:12 PM, the MDS Coordinator confirmed that Resident #39's MDS assessments were incorrectly coded and should have included Resident #39 was edentulous. b. A physician order, dated 4/23/24, documented Resident #39 was to be admitted to hospice care. A significant change of status MDS assessment, dated 5/7/24, did not include documentation Resident #39 was on hospice care or that he had a terminal prognosis (life expectancy of six months or less). During an interview on 7/10/24 at 1:19 PM, the MDS Coordinator confirmed Resident #39 should have been coded for a terminal prognosis and on hospice, that was the intent of the significant change assessment. During an interview on 7/11/24 at 5:06 PM, the DNS stated it was an expectation that MDS assessments would be coded accurately.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 4 residents (Resident #33) reviewed for quality of care. This created the potential for Resident #33 to have decreased caloric intake and weight loss when physician's orders were not followed to provide a specific dietary supplement. Findings include: Resident #33 was admitted to the facility on [DATE] with multiple diagnoses including dementia, adult failure to thrive, and dysphagia (impaired swallowing) after a stroke. A quarterly MDS assessment, dated 6/13/24, documented Resident #33 was 61 inches tall (5 feet, 1 inch) tall and weighed 85 pounds. The assessment documented Resident #33 experienced a significant unplanned weight loss. The assessment further documented Resident #33 was severely cognitively impaired. A Weight Summary, dated 9/30/22 - 7/9/24, documented on 7/2/24 Resident #33 weighed 83.6 pounds and had a body mass index (BMI) of 16.4 indicating she was underweight. The summary documented on 4/11/24, Resident #33 weighed 106.2 pounds and had lost 22.6 pounds since that time. A physician order, dated 5/29/24, documented Resident #33 was to be provided a Mighty Shake to be administered three times a day to Resident #33 for weight loss. Resident #33's care plan, dated 9/17/22, documented Resident #33 had a nutritional problem. Interventions included to provide Resident #33 a Mighty Shake three times a day. During an interview on 7/8/24 at 10:02 AM, the DS stated the dietary staff made house shakes from a recipe and served them instead of Mighty Shakes. The DS stated there were no Mighty Shakes in the facility several months ago the facility switched from using Mighty Shakes to making and providing house shakes. The DS stated the dietary staff served the house shakes at meals and put the shakes on residents' trays during tray line meal service. Review of the undated Recipe Analyzer Results for House Shake provided by the facility, documented the house shake provided 166 calories in a four-ounce serving. Review of the undated Hormel Foods Product Fact Sheet for Mighty Shake, documented there were 220 calories in a four-ounce serving. Resident #33 was served 498 calories daily from the Health Shakes instead of 660 calories daily from Mighty Shakes. During dining observations in the dining room on 7/8/24 for lunch from 11:31 AM through 12:54 PM, on 7/9/24 for breakfast at 8:43 AM, and on 7/10/24 at 12:31 PM, Resident #33 was served the house shake with her meals. During an interview on 7/10/24 at 5:19 PM, the RD verified the dietary department served house shakes instead of Mighty Shakes. The RD verified that Mighty Shake was a specific name brand product. The RD stated she did not have the nutritional analysis for the house shake and did not know if the nutritional content was the same. The RD stated the residents' orders had not been adjusted to reflect that residents were receiving a different product than what was prescribed (Mighty Shake). During an interview on 7/11/24 at 8:55 AM, the RD stated Mighty Shake provided 220 calories per serving whereas the house shake provided 166 calories. The RD verified the house shake was not equivalent in calories to Mighty Shake and provided less calories. During an interview on 7/11/24 at 12:43 PM, the ADN and LPN #4 who was the charge nurse, stated it was important for orders to match the medication/supplement being administered, and if an order did not match, it should be clarified with the physician. The ADNS and LPN #4 verified Resident #33 received the house shake and not Mighty Shake as prescribed.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#10 and #24) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's Bed Hold policy, dated 12/2023, states It is the policy of this facility to inform the resident or resident's representative in writing of the right to exercise the bed hold provision of 7 days upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on therapeutic leave. In the event of an emergency transfer, the second notice will be provided within 24 hours. A copy of this notification shall become a part of the resident's health record at the time of transfer. 1. Resident #24 was originally admitted to the facility on [DATE], and readmitted on [DATE] and 4/17/24 with multiple diagnoses including sepsis (extreme reaction to an infection that can lead to organ failure, tissue damage and death if not treated promptly), diabetes, respiratory failure (develops when the lungs cannot get enough oxygen into the blood making it difficult to breathe), hemiplegia and hemiparesis (paralysis and or weakness on one side of the body) following a stroke, and Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). a. A progress note, dated 4/12/24 at 5:05 PM documented Resident #24 had hypotension (low blood pressure) and respiratory issues and was sent out to the hospital emergency department with a critical lab value. The note documented Resident #24's first two emergency contacts were not available, so a friend was notified. A social services progress note, dated 4/12/24 at 4:19 PM stated, a bed hold notification was delivered to Resident #24's daughter via telephone. b. A progress note, dated 7/7/24 at 10:27 AM, documented Resident #24 was sent to the hospital with respiratory issues and a critical lab value. The note stated, Call placed to emergency contacts 1 and 2 with no answer. Message left with callback information to both. Review of the Bed Hold Notification provided by the DNS for Resident #24's 7/7/24 transfer documented the bed hold was provided on 7/8/24 at 3:15 (no AM or PM) with the name of the facility representative. When asked when the written bed hold notice was provided to Resident #24 and her representative, the DNS stated the notices were not provided in writing. During an interview on 7/11/24 at 12:56 PM, the Community Relations Liaison staff member (CLS) was asked about the 7/7/24 written bed hold notice for Resident #24 and her representative, that had her signature. The CLS stated she did not do the bed hold notices and when queried if provided by mail or email, the CLS stated nope, just calling them. 2. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure, Parkinson's Disease, and repeated falls. Resident #10's record documented he was his own responsible party and his sister was listed as his emergency contact. An annual MDS assessment, dated 2/3/24, documented Resident #1 was cognitively intact. A progress note, dated 4/7/24 documented Resident #10 was sent to the local hospital related to not feeling well increased temperature, and an episode of projectile vomiting. The note documented Resident #10's sister was notified by phone of his transfer to the hospital. The note also documented Resident #10's sister would be notified by phone of any additional changes. Resident #10's record did not include documentation a bed hold notice in writing was provided to him or his sister. During an interview on 7/11/24 at 11:02 AM, regarding provision of a written bed hold notice upon a resident's emergent transfer, LPN #2 stated if the resident was cognizant, he would have the resident sign it, and if the resident asked, he would make a copy. LPN #2 then unsuccessfully attempted to find the form at the facility's A/B hall Nurse's Station. Unable to find the bed hold notice form, LPN #2 went to speak to the DNS. At 11:22 AM, LPN #2 provided a blank bed hold policy and stated, the form was in the admission packet and he did not give the notice to a resident or their representative. During an interview on 7/11/24 at 11:18 AM, when asked if residents and representative are provided a written bed hold notice, LPN #3 stated, I notify social services and they handle the bed hold.

Based on observation, interview, and record review, it was determined the facility failed to ensure thickened liquids and/or diet texture alterations were provided as ordered when served to residents. This was true for 3 of 6 sample resident (#s 11, 12, and 13) with orders for thickened liquids and/or diet texture alterations. Residents #11, #12 and #13 were in immediate jeopardy (IJ) of serious harm, impairment, or death when: a. Resident #11 received nectar thick rather than honey thickened liquids; b. Resident #12 received regular texture food rather than mechanical soft; and Resident #13 received mechanical soft food with mixed textures and crust on bread rather than no mixed texture foods and no crust. On 10/11/17 at 9:10 pm, the facility's Administrator was notified verbally and in writing of the IJ situation. Specifically, the facility failed to: * Ensure physician orders [REDACTED]. * Ensure the food prepared and delivered to residents was consistent with physician's dietary orders prior to residents eating or drinking food and/or beverages. * Ensure thickened liquids were provided at the consistency ordered by the physician. * Identify incorrect mechanical soft diet textures and incorrect mixed diet consistencies before they were served to residents. The combined effect of the above failed systems placed Residents #11, #12, #13, and all other residents on thickened liquids and/or altered textured diets, at immediate risk for serious harm, impairment, and/or death. Findings include: The website American Speech Language Hearing Association at https://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults/ documented the signs and symptoms of dysphagia (swallowing difficulty) may occur during or right after eating or drinking and may include a wet or gurgly sounding voice during or after eating or drinking, taking extra effort and/or time to chew and/or swallow, food or liquid leaking from the mouth or getting stuck in the mouth, pneumonia or chest congestion after eating, and weight loss or dehydration. The facility's Modified Consistency Diets Nutrition Care Manual, dated 1/2014, referenced The Academy of Nutrition and Dietetics Association, described honey thick fluids as fluids that pour like honey and are too thick to drink through a straw. Examples of honey thick liquids are honey and tomato sauce. The Idaho Diet Manual, 11th Edition, 2015, described honey-thick consistency as a continuous 'string' when poured and included examples such as commercial thickener or product to achieve honey-thick consistency. Nectar-thick liquids were described as discontinuous 'beads' when poured and included examples such as fruit nectars and vegetable juice. Mechanical soft diet was described as .designed to provide a texture modification of the regular diet for patients with chewing or swallowing difficulty. Meats are in the ground form . Regarding mechanical soft diet vegetables, the diet manual documented, Tender cooked or canned vegetables; vegetable juice; finely chopped raw vegetables if tolerated. and All should be 1/2 inch in diameter. 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's 11/2/16 annual MDS (Minimum Data Set) assessment documented the resident required supervision while eating and one person physically assisting during meals. There were no signs or symptoms of aspiration and the resident was on a mechanically altered diet. The resident was receiving RNA (Restorative Nursing Assistant) services to help her with eating and/or swallowing. Resident #11's 7/7/17 and 10/4/17 Dietary Quarterly Evaluation documented the resident required tray set-up, divided plate, Consistent Carbohydrate Diet (CCD) puree texture, and honey fluid consistency. Resident #11's 7/9/17 quarterly MDS assessment documented the resident required supervision and set-up help for eating. The MDS documented the resident had signs and symptoms of aspiration such as loss of liquids/solids from the mouth, holding food in the mouth/cheeks or residual food in the mouth, and coughing or choking during meals or when swallowing medication. The MDS documented she continued to receive RNA services for assistance with eating and/or swallowing. Resident #11's nutrition risk care plan documented interventions to provide the diet as ordered-CCD pureed diet and honey thick liquids, initiated on 5/29/13, and staff to assist resident with eating, initiated on 2/1/16. Resident #11's Order details, dated 7/11/17 at 2:34 pm, documented NPO (nothing by mouth) and pureed diet texture with honey thick fluid consistency. It also documented All pureed food to be pudding thick to assist swallowing . On 10/12/17 at 8:10 am, the Administrator stated Resident #11 was as risk of choking on any food and the Speech Therapist had recommended the resident to be NPO. The Administrator stated the resident had refused to be NPO and refused tube feeding so they ordered the safest diet possible until the family could be consulted. Resident #11's 7/12/17 IDT (Interdisciplinary Team) Progress Note documented a family meeting was held on 7/12/17 regarding Resident #11's increased aspiration risk with eating and drinking and the recommendation of NPO. The note documented education was provided to the resident and her son regarding the risks verses benefits and the resident decided to continue eating a pureed diet and declined tube feeding. The physician said that (the) pt (patient) is at risk in both situations (pureed diet or feeding tube.) Following the IDT meeting, Resident #11's diet order was changed to a CCD pureed texture and honey thick liquid consistency on 7/13/17. Resident #11's 9/15/17 Speech Therapy SLP (Speech Language Pathology) Evaluation and Plan of Treatment documented the resident referred herself for a swallowing evaluation due to increased signs and symptoms of aspiration during meals. The resident exhibited signs of aspiration during trials of honey-thick liquids from a cup, but did not exhibit signs and symptoms of aspiration when honey consistencies were presented with a teaspoon. The evaluation did not contain evidence the staff was educated on providing Resident #11's fluids with a teaspoon. Resident #11's nutrition risk care plan, dated 5/29/13, did not contain documentation the care plan was updated on 9/15/17 with the speech recommendation to provide the honey thick fluids with a teaspoon. Resident #11's 9/26/17 Speech Therapy Encounter Note documented the speech therapist educated staff about thickened liquids and the resident's diet level, and collaborated with staff to ensure (the) patient receives honey-thick consistencies at meals to decrease (the) risk of aspiration. Resident #11's 10/11/17 Speech Therapy Encounter Note documented the resident received deep pharyngeal neuromuscular stimulation (electrical stimulation to the throat area) to improve her swallowing function. The resident demonstrated signs and symptoms of aspiration with pureed textures during therapy and was instructed to take smaller bites. The resident remained on aspiration precautions, honey thick liquids and a pureed diet. On 10/11/17 at 5:21 pm, Resident #11 was observed in the dining room consuming the evening meal and was gagging on nectar thickened liquids. CNA #1 and CNA #2 were at the table with the resident. CNA #1 used her radio to call for nurse to dining room. The ADON (Assistant Director of Nursing) arrived in the dining room at 5:24 pm as well as several other staff members. On 10/11/17 at 5:55 pm, Resident #11 was frequently coughing and drooling at the table in the dining room. A glass that contained an amber-colored liquid was on the table in front of the resident. CNA (Certified Nursing Assistant) #2 provided the resident with a second glass that contained a brown liquid. The resident continued to exhibit coughing and drooling as she consumed the drinks. Upon examination, the liquids in front of the resident appeared to readily pour from the cup as Resident #11 brought the cup up to her mouth and the liquid poured into her mouth. Resident #11 was not provided her fluids with a teaspoon. The resident's meal ticket on the table next to her documented CCD-Pureed, Honey Thick, and drinks in a mug. Resident #11's meal ticket did not specify she was to receive her fluids with a teaspoon. CNA #2 said the resident preferred to drink from a glass instead of a mug. When asked if the resident's drinks were honey thick, CNA #2 said the drinks were not honey thick and they should be. CNA #2 said he should have made sure the drinks were honey thick before they were provided to the resident. CNA #2 removed Resident #11's drinks from the table to add additional thickener and returned once he had completed this task. The resident left the table a short time after that. On 10/12/17 at 8:05 am, Resident #11 was observed in the dining room consuming breakfast. The resident's meal ticket documented CCD-Pureed, Honey Thick, Drinks in a mug. The resident was lifting a mug of white liquid to her mouth and coughed. Resident #11 was not provided her fluids with a teaspoon. The white liquid consistency appeared thickened to a honey consistency and more readily adherent to the mug, and CNA #1 confirmed it was honey thick. A container of commercially packaged honey thick water was near the resident's table and the contents resembled the liquid in the resident's mug. The resident said she preferred to have her drinks in a glass because a mug can be hard to hold. CNA #2 told the resident her drink has to be in a mug because it's on the order. On 10/12/17 at 8:50 am, CNA #1 asked the resident if she wanted her drink to be in a glass, and the resident said she would like her drink to be in a glass. On 10/12/17 at 8:52 am, the Clinical Resource Nurse provided Resident #11 with a glass of white liquid, which she poured from a container of commercially prepared honey-thick water. The resident took a drink of the white liquid in the glass and coughed. The resident did not exhibit any overt distress and exhibited less coughing and less drooling than at dinner the previous night. The white liquid appeared to be the appropriate consistency for honey-thick. 2. Resident #12 was admitted to the facility in 2011 and readmitted in 2013 with multiple [DIAGNOSES REDACTED]. A 9/19/17 quarterly MDS assessment further documented the resident had dysphagia, moderately impaired cognition but able to understand others and was understood by others, and supervision and set up help only with eating was needed. The resident's care plan included the following focus areas and their associated interventions: * At nutrition risk, revised 1/14/16 - Provide and serve diet as ordered, mechanical soft texture. * Alteration in chewing and swallowing ability as demonstrated by occasional pocketing food and sometimes spitting food out that is partially chewed up ., initiated and revised 6/27/13 * Diet to be followed as prescribed mechanically chopped meats to puree with gravy. Monitor for need to change diet. The resident's 10/2/17 Order Summary Report of Active orders included mechanical soft diet, dated 5/6/15. At 5:35 pm on 10/11/17, during the evening meal in the main dining room, Resident #12 was served a whole slice of roast turkey, approximately 1/2 to 3/4 inches thick, placed on bread and covered with gravy. In addition, the plate contained cooked whole broccoli florets with stems, each about 3 inches long and 2 inches wide. Resident #12 was sitting at the table and pushing the food around on his plate, he attempted to pick up a piece of the meat and bread and the food fell on to his plate. The resident's meal ticket documented mechanical soft diet with ground roast turkey for open-faced sandwich and sliced broccoli cuts. At 5:40 pm, when asked if the texture of Resident #12's food was correct, the DON said he did not know. The DON directed the surveyor to ask CNA #1, who was in charge of ensuring residents' meals were served at the appropriate texture and consistency. At 5:45 pm, CNA #1 cut the roast turkey with gravy on bread into 3/4 inch by 1/2 inch pieces but left the broccoli florets whole. The CNA said the turkey was okay because it was processed. CNA #1 and a surveyor went to where the facility's 2014 Diet Manual was stored and reviewed its contents regarding mechanical soft diets. The manual documented mechanical soft diets consists of ground meats, with soft fruits and vegetables, and most bread products. The manual did not mention processed meats. The manual documented that naturally large vegetables, such as broccoli or cauliflower florets, should be sliced or chopped. CNA #1 was observed speaking to the Clinical Resource RN about the content of the diet manual. CNA #1 left the meal tray in front of Resident #12 and stated she thought he could eat the food just fine. At 6:05 pm on 10/11/17, the CDM said Resident #12's meat should be ground but that it was not ground. The CDM removed the plate and took it to the kitchen. Moments later, the CDM returned with a plate of ground roast turkey with gravy on bread and whole broccoli florets/stems which he placed in front of the resident. The resident began eating the open face sandwich right away. When asked about the whole broccoli florets/stems, the CDM said it was okay because the broccoli was soft enough. At 6:10 pm, the CDM, who was in the kitchen, was informed the resident's broccoli needed to be sliced. Resident #12 ate the whole broccoli floret/stems. Resident #12 consumed all the open-faced turkey sandwich after the consistency was corrected. 3. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/1/17 quarterly MDS assessment documented Resident #13 had a moderate cognitive impairment, had a communication language barrier and required a mechanically-altered diet. Resident #13's physician's orders [REDACTED]. No mixed consistencies. No crust on bread, dated 3/1/17. Resident #13's Nutrition Care Plan, dated 5/29/13, documented the risk for nutritional decline related to difficulty chewing. Interventions included staff monitoring/ documenting/ and reporting to the physician any signs and symptoms of dysphagia and her need for a mechanical soft diet. The care plan did not identify the specific physician ordered restrictions Resident #13 required. Resident #13's 10/11/17 Dinner Meal Ticket documented she was to receive a Mechanical Soft diet with No Crust on the Bread. The meal ticket included ground roast turkey for open faced sandwich, mashed potatoes- no gravy, sliced broccoli cuts and raspberry yogurt. The meal ticket did not identify the need for the no mixed consistencies. On 10/11/17 at 6:15 pm, Resident #14's dinner plate included a ground turkey open faced sandwich. The sandwich consisted of ground turkey was on top of a slice of wheat bread, which had crust on the bread, no gravy and was a mixed consistency with the bread and the meat. The broccoli florets were whole and included the stems. The stems measured to approximately 3 inches long and the florets were approximately 2 inches wide in diameter. The broccoli was not sliced or cut. The resident's dinner tray also included raspberry yogurt contained chunks of fruit in the yogurt, which was a mixed consistency. Resident #13 was observed consuming two bites of a bread/meat mixture but had stopped eating the meat and bread. On 10/11/17 at 6:20 pm, the CDM observed Resident #13's dinner meal plate and stated she did not like gravy. The CDM did not identify the improper mixed consistencies of the meat on top of the bread, the crust on the bread, or large pieces of broccoli as identified in her physicians orders. On 10/11/17 at 6:25 pm, Resident #13 was observed pushing food around on her plate and was observed consuming a couple more bites of yogurt and mashed potatoes. Resident #13 did not consume the meat or bread mixed consistency and left the dining room without consuming the majority of her dinner meal. On 10/11/17 at 6:25 pm, the Clinical Resource RN stated the food for Resident #13 was not appropriate for her diet order. She stated whoever delivers the tray was to verify the meal was consistent with the physician orders. She stated the meal ticket did not identify that the meal was not to include mixed consistencies. The Clinical Resource RN stated the meal ticket had mixed consistencies, crust on the bread and the broccoli was not cut up. On 10/11/17 at 6:30 pm, the CDM stated the bread should have been crust free and the meal ticket did not document no mixed consistencies. The CDM stated the meat on top of the bread was a mixed consistency. He stated the broccoli was soft and did not need to be cut or chopped. On 10/11/17 at 6:40 pm, CNA #1 stated the process of meal verification started in the kitchen with the cook and the assistant who helped the cook. She stated after they plated the food and verified the meal; the person passing the tray would verify the accuracy of the food. She stated any staff member could pass a tray which could include nursing staff, administrative staff, business office, activities, and others. She stated the meal tray for Resident #13 was not how the physician had ordered it. Resident #13's 10/12/17 Breakfast Meal Ticket documented she was to receive a Mechanical Soft diet with No Crust on the Bread, and no mixed consistencies. The food listed on the meal ticket included ground sausage patty and raspberry or peach yogurt On 10/12/17 at 8:20 am, Resident #13's breakfast meal tray was delivered by CNA #2 and it included ground sausage patty with gravy over the top of the ground meat, which created a mixed consistency. The tray contained raspberry yogurt with chunks of fruit in the yogurt which was a mixed consistency. On 10/12/17 at 8:21 am, the ADON examined the breakfast meal tray for Resident #13 and told CNA #2 to remove the yogurt from Resident #13's tray because it contained pieces of fruit in the yogurt. CNA #2 removed the yogurt and the ADON and CNA #2 left Resident #13 to consume her meal without identifying the meat and gravy as a mixed consistency. Resident #13 ate approximately 2 bites of the meat with gravy mixture. Resident #13 ate approximately 25% of her oatmeal and drank her milk. On 10/12/17 at 8:35 am, the ADON removed Resident #13's plate of ground sausage and gravy and stated she pulled the plate due to its mixed consistency. This was 15 minutes after the plate was delivered and she had taken two bites of the food. 4. The facility identified 15 other residents with orders for mechanically altered diet textures and or thickened liquids which included sampled residents (#3, #8, #10, and #17). The facility failed to ensure the health and safety of residents whose nourishment included mechanically altered diet textures, mixed consistencies and/or thickened liquids, were not in imminent risk of serious harm, impairment, or death from choking or aspiration. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: On 10/11/17 at 9:10 pm, the facility Administrator, DON (Director of Nursing), and ADON (Assistant Director of Nursing), Clinical Resource Nurse, and the Administrator in Training were notified verbally and in writing of the IJ and of the need to develop and implement a plan to remove the immediacy. On 10/12/17 at 1:00 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The facility reviewed its Practice Guidelines on Therapeutic Diets/consistencies with members of the IDT to include the Certified Dietary Manager (CDM) to incorporate prompt monitoring to begin on 10/12/17 for the breakfast meal and all meals thereafter to ensure that proper therapeutic diets/consistencies were being served. This review was completed on 10/11/17 at 9:30 pm. Food was prepared to match all therapeutic diets/consistencies. The cook read the ticket while plating the items then passed the plate to the aide who placed the ticket on the tray. The aide double checked the items the cook placed on the plate and compared to the ticket. If there were any discrepancies the aide returned the plate to the cook for correction. The dietary aide passed the tray to an assigned clinical staff member who verified that it matched the ticket and food that has been plated for therapeutic diet consistency. After verification, the tray was passed to a co-worker for delivery to the resident. This process was also followed for the hall carts. Dietary staff prepared pre-thickened beverages located in the dining room and hall carts as needed in designated bins labeled with the consistencies. The DON was educated by the speech therapist on 10/12/17 at 7:10 am on recognizing the differences in textured diets and liquid consistencies. The above actions were verified and the Immediate Jeopardy removed prior to the survey exit conference completed on October 13, 2017.

Based on observation, record review, and interviews, it was determined the facility failed to ensure a resident with a history of healed pressure ulcers who was at risk for developing pressure ulcers (PUs) did not develop avoidable PUs. This was true for 1 of 5 (#6) residents sampled for hi-risk PUs. Resident #6 was harmed when she developed a Stage III PU to the left lateral hip, the right medial knee, the left medial knee, right inferiolateral shin, and a SDTI (Suspected Deep Tissue Injury) to the right cuneiform (bone just proximal to the first metatarsal (toe) bone). Findings included: Resident #6 was originally admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's annual 1/22/13 MDS coded: -Minimum of one person physical assistance for ADLs, -At risk for PUs, One or more unhealed PUs at Stage I or higher, -No Unhealed Stage I PU, -Stage I or greater, scar over bony prominence, or a non-removable dressing/device -two Stage II PUs, date of oldest Stage II PU 12/15/12, -No Stage III, Stage IV, or Unstageable- Slough and/or eschar, -No SDTIs, -No worsening PUs since prior assessment, Stage II, III, IV -Healed PUs present on the prior assessment -Number of current PUs not present on prior assessment, None -No moisture associated skin damage (MASD) -Treatments: pressure reducing device for chair and bed and ulcer care, -Indwelling catheter, -Hospice, -Moderate pain, received scheduled pain medication, no prn medication, and no non-medication interventions. Note: Resident #6's most recent quarterly MDS was in progress at the time of the survey. Resident #6's 1/23/13 PU Care Area Assessment (CAA) documented, in part: "-Analysis of Findings, has current PUs on her ankle and knee...right lateral ankle stage II PU 0.4 by 0.3 by 0.0 Left medial knee stage II PU 0.6 by 0.6 by 0.0 currently at a stage I and has [MEDICATION NAME] tissue... -[MEDICATION NAME] Risk Factors...immobility ... -Conditions that Present Complications or Increase Risk for Pressure Ulcers ...terminal illness...pain... -Treatments and other Factors that Cause Complications or Increase Risk ...history of healed PUs...indwelling catheter tubing... -Care Plan Considerations...dependent upon staff for mobility, ADLs, has contractures, meal percentages are not good and is on medications that can dry skin out and can cause rashes...Will careplan {sic} for this problem to continue resolve {sic} current PUs and prevent any further skin breakdown." Resident #6's Physician order [REDACTED]. -12/15/11, [MEDICATION NAME] 300 mg po tid (milligrams by mouth three times a day), 8:00 a.m., 12:00 p.m., and 8:00 p.m. for pain -12/28/11, [MEDICATION NAME] 10-325 mg po bid (two times a day) 6:00 a.m. and 11:00 a.m. for chronic pain -1/16/12, APAP 325 mg po prn for pain -8/24/12, [MEDICATION NAME] 50 mcg/hr (micrograms per hour) [MEDICATION NAME] for pain -2/7/12, Offload bilateral feet and heels with pillows for skin breakdown risk reduction. -2/15/12, Cleanse site to Right (R) outer ankle with NS. Pat dry. Apply skin prep cover with protective dressing change every 3 days (Q3days) and prn until resolved. -8/15/12, Cleanse Left (L) medial knee with NS, pat dry, cut alginate to fit then cover with optiform or equivalent dressing. Change Q3D et. (every 3 days and) prn until resolved. -3/17/13, Apply zinc based barrier cream to bilateral buttocks and lower back M.A.D. (Moisture Associate [MEDICAL CONDITION]) area then dust entire area with powder prn with cares daily until resolved. -3/17/13, Cleanse R medial knee SDTI site with NS, pat dry, apply skin preparation, apply [MEDICATION NAME], cover with protective dressing. Change QOD (every other day) et prn until resolved. -3/17/13, Cleanse SDTI site to R medial cuneiform (bone just proximal to the first metatarsal bone) with NS, pat dry, apply skin preparation and monitor QD for change in condition until resolved - QD Everyday, 8:00 a.m. -3/17/13, Cleanse stage two blistered areas with NS, pat dry, apply [MEDICATION NAME] and ag+ (silver) alginate to open areas then cover with protective dressing. Apply skin prep to intact blisters then cover with protective dressing. Change QOD et. prn until resolved. -3/17/13, Monitor red blanchable areas QD - left lateral ankle, right medial shin, right lateral ankle, left lateral hip, right 4th toe, and right 5th toe. -3/17/13, Monitor SDTI areas and apply skin prep QD and monitor QD until resolved, left lateral shin, right superiolateral shin, right inferiolateral shin, left lateral hip, and left lower lateral pinna (ear area). Resident #6's 1/21/13 "Braden Scale for Predicting Pressure Sore Risk" form documented a total score of 12.5. The total score scale identified 10-12 as high risk, 13-14 as moderate risk. Resident #6's Care Plan (CP) included, in part, CP PU Focus area, (Resident #6) has history of PUs and potential for PU development related to immobility. "Resident with stage I to right medial knee. Stage II area to left medial knee, left trunk x2, left armpit x3. SDTI to left lateral lower leg, right medial cuneiform, right inferior lateral shin, right superior lateral shin, left lateral hip, left lateral distal pinna as of 3/17/13." Date initiated: 2/10/12 NOTE: Resident #6's PU CP Focus area identified a total of thirteen different PU and SDTI areas on Resident #6's body as of 3/17/13. The CP did was not individualized with the onset dates for each of the above identified areas. The documentation provided evidence the onset date was 3/17/13 for all thirteen different PU and SDTI areas on Resident #6's body. PU Focus Interventions included, in part, - Assess/record/monitor wound healing daily with care and wound nurse to record weekly for times of wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD for when (resident) has wounds. - "(Resident #6) needs assistance to turn/reposition at least every 2 hours, more often as needed or requested." - Monitor/document/report to MD prn (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length x width x depth), stage. - "Staff will place pillow or thin blanket between (Resident #6's) knees to reduce pressure factor to bony prominences." - "Treat pain as per orders prior to treatment/turning etc. to ensure (Resident #6's) comfort." - "Utilize pillows for positioning et (and) offloading off pressure areas et bony prominence." CP ADL Focus area identified Self Care Performance Deficit related to, in part, limited ROM, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] 2/23/12. Date initiated: 2/10/12. One of the ADL interventions was, "Skin Inspection: Provide frequent skin inspection with cares, showers and weekly skin checks. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse." NOTE: The CP ADL Focus area did not identify the significance between the two dates of 2/23/12 and 2/10/12. CP Comfort Care Focus area, end stage disease process. Admission to Hospice program. Date initiated: 8/2/12. Two of the Comfort Care interventions were, "Turn and reposition in frequent intervals and prn. Evaluate resident's verbal and nonverbal cues to assess the degree and severity of pain." Resident #6's "Weekly Skin Evaluation" (WSE) forms, signed by a LPN, contained handwritten entries as follows: 3/1/13, "dressing" inside of left knee, "wraps" both left and right foot. 3/8/13, "dressing" inside of left knee, "(indistinguishable word)" left foot. 3/15/13, "dressing" inside of left knee, "dressings" both left and right foot. 3/23/13, "dressing" inside of both the left and right knee, "dressing" both the left and right foot, "dressing" outside of left hip. 3/30/13, "dressing" outside of left hip, "dressing" inside of left knee and right knee, "dressing" left and right foot. NOTE: As identified on the PU Care Plan, Resident #6 had a total of thirteen different PU and SDTI areas identified. However, the WSE forms, dated 3/23/13 and 3/30/13, did not identify the different PU and SDTI areas as was on the PU Care Plan. Resident #6's March 2013 Treatment Record contained, in part, "Order dates: 3/17/13; -Cleanse stage two blistered areas with NS, pat dry, apply [MEDICATION NAME] and ag+ alginate to open areas then cover with protective dressing. Apply skin prep (preparation) to intact blisters then cover with protective dressing. Change QOD et. prn until resolved. -Cleanse SDTI site to right medial cuneiform with NS, pat dry, apply skin prep and monitor QD for change in condition until resolved. -Monitor red blanchable areas QD for change in condition and apply skin prep QD et prn until resolved. -Monitor SDTI areas and apply skin prep QD and monitor QD until resolved. -Apply zinc based barrier cream to bilateral buttocks and lower back M.A.D. areas then dust entire area with powder prn with cares daily until resolved. -Cleanse Right medial knee SDTI site with NS, pat dry, apply skin prep, apply [MEDICATION NAME], cover with protective dressing. Change QOD et. prn until resolved." On 4/24/13 at 10:15 a.m., the surveyor informed the DON, ADON, Clinical Resource Representative (CRR), and Administrator the survey team had serious concerns about the number of open areas areas (thirteen) on Resident #6's skin on 3/17/13. The surveyor requested information as to Resident #6's current skin issues, when the skin issues began, measurements, assessments completed, and evidence the skin issues (PUs and SDTIs) were unavoidable. The CRR stated the facility had volumes of documentation that would provide evidence the facility repositioned and turned Resident #6 on a regular basis to prevent pressure ulcer recurrence. On 4/24/13 at 2:30 p.m., two surveyors observed LN #8 and a medical doctor (MD) providing wound care for Resident #6. The MD said he received a call from the facility to help the facility treat Resident #6's wounds, this was his second visit to the facility, he worked at a local wound care center, and treated patients with wounds on a daily basis. During the above observation, the survey team observed the treatments given to Resident #6 for the left lateral hip, inside of both the right and the left knee, right lateral shin, and right great toe. Resident #6 had 2 open areas to the inside of the left knee (left superior and inferior medial), one open area to the inside of the right knee (right medial), a scabbed area on the right lower outer leg (right inferior lateral shin), an area on the outside of the left hip (left lateral hip), and an area at the joint of the right great toe (medial aspect at the base of the right great toe, cuneiform). The left superior medial knee had a visible protrusion which the MD said was a bone spur. The MD and LN #8 measured the bone spur site, 0.4 cm (centimeters) length, 0.3 cm width, and 0.4 cm depth. The surveyors asked the MD what could have caused all these skin issues. The MD stated, "I think one night someone did not move her and her skin blew up (broke open)." When the MD said this, LN #8 looked in the direction of the MD, moved her head up and down, nodding, signifying agreement. The MD also stated Resident #6's right medial knee had undermining at one time. As the MD and LN #8 provided wound care, Resident #6 grimaced. The MD made a comment Resident #6 was brave. The surveyors asked LN #8 when Resident #6 was last medicated. The LN stated, "I believe at her last scheduled administration time. I think around 12:00 p.m." -At 3:10 p.m., LN #8 stated, "I received a phone call on 3/17/13 from the weekend wound nurse. I came in and found these open areas to her skin. There was no off-loading device in place between legs and feet while (Resident #6) was lying on her left side and the catheter tubing was over her right lower leg causing pressure to the right lateral shin." The MD and the LN obtained measurements of: Left superior medial knee bone spur site as identified above; Right medial knee, "1.6cm length, 1.4cm width, and 0.7cm depth;" Left inferior medial knee, "2.8cm length, 1.8cm width, and 0.25cm depth;" and the left outside (lateral) hip area was darkened, indented with eschar edges loosening slightly and active bleeding. A dressing was observed at the base of Resident #6's great right toe (cuneiform). The right lateral shin had a raised border with eschar. LN #8 stated, "The left hip progressed to a Stage III. The area (darkened area left lateral hip) was where the PU was. In a month's time it has shrunk considerably." On 4/24/13 at approximately 3:00 p.m., the facility provided additional information that included, in part, -PNs, dated 8/6/12 at 7:00 p.m. through 4/23/13 at 3:25 p.m. The PNs did not provide evidence the resident refused to be repositioned due to discomfort or pain or cried out in pain whenever she was moved or repositioned. The PNs did provide evidence: "11/1/12 11:06 a.m., MDS Careplan meeting results: currently has no open wounds. Has a small scab on right lateral ankle that is mostly healed now..." Electronically signed by the MDS Coordinator. "2/8/13 6:26 p.m. Residents {sic} Right lateral ankle Stage I pressure site is resolved but still considered at risk...Left medial knee stage I pressure site measures 0.6cm x 0.4cm x 0.0cm..." Electronically signed by LN #8. "2/14/13 1:57 p.m., Residents {sic} Right lateral ankle Stage I pressure site is resolved but still considered at risk..." Electronically signed by LN #8. "3/7/13 22:28 (at 10:28 p.m.) Note Text: LE (late entry) week of 2/17/13 Residents {sic} right lateral ankle Stage I pressure site is resolved but still considered a risk. Site is covered with a protective dressing. Heels are off-loaded using pillows. Left medial knee stage I pressure site is resolved but still considered at risk. Site is covered with protective dressing. Pillow is placed between legs to keep pressure off of this area to prevent injury." Electronically signed by LN #8. "3/10/13 04:37 (4:37 a.m.)...denies c/o (complaints of) break thru {sic} pain this shift...resident is repositioned q2h (every 2 hours) for comfort and heels elevated..." "3/16/13 10:00 (10:00 a.m.)...Feet and ankles are floated bilaterally at this time. Wraps and bandages in place over sores." NOTE: The PNs provided evidence the resident was routinely repositioned every two hours and no complaints of pain except on 1/23/13 at 3:02 p.m., "...did cry out with some pain with movement being turned side to side but when done she said pain went down." NOTE: The PNs did not include nursing staff entries from 3/16/13 at 10:00 a.m. until 3/18/13 at 13:59 (1:59 p.m.). "Late Entry 3/18/13 13:59 (1:59 p.m.)" The entry did not specify the original date for the late entry. "Wound nurse assessed patient while checking on protective dressing. Several new wounds were found during this assessment. These wounds include Left lateral ankle is red blanchable areas that measure 3.9cm x 1.8cm. 0cm. Right medial cuneiform area SDTI site measures 1.9cm x 1.8cm x utd (unable to determine). Right medial shin red blanchable site measures 2.5cm x 2.0cm x 0cm. Right lateral ankle red blanchable site measures 0.6cm x 1.7cm x 0cm. Right inferior lateral shin SDTI site measures 3.0cm x 2.8cm x utd. Right superior lateral shin SDTI site measures 1.5cm x 2.5cm x utd. Right medial knee stage I pressure site measures 5.3cm x 2.0cm x 0cm. Left medial knee stage II pressure site measures 4.8cm x 2.0cm x<0.1cm (less than 0.1 cm). Left lateral hip red blanchable area measures 6.0 cm x 10.0cm x 0cm With SDTI site in center that measures 4.5cm x 4.3cm x utd. Bilateral medial buttocks and lower back moisture associated [MEDICAL CONDITION] site measures 27.5cm x 15.8 cm x 0cm. Left lateral trunk inferior stage II pressure clear fluid filled blister site measures 4.8cm x 3.0 cm x <0.1cm. Left lateral trunk superior stage II pressure clear fluid filled blister site measures 1.0cm x 1.1cm x <0.1cm. Left armpit superior stage II pressure clear filled blister site measures 4.9cm x 1.7cm x <0.1cm. Left armpit middle stage II pressure clear fluid filled blister site measures 7.4cm x 3.0cm x <0.1cm. Left armpit inferior stage II pressure clear filled blister site measures 5.8cm x 2.4cm x <0.1cm. Left lateral distal pinna SDTI site measures 1.5cm x 1.3cm x utd. Right 5th toe anteriolateral aspect red blanchable area measures 0.5cm x 0.5cm x 0cm. Right 4th toe anteriolateral aspect red blanchable areas measures 0.4cm x 0.6cm x 0cm..." Electronically signed by LN #8. -March 2013 Incident Report Tracking form dated 3/3/13 through 3/29/13. Highlighted in green on the first page was, "3/17/13, Resident #6...Day Sunday, shift 1200, Type Skin, Injury Pressure areas; M.A.D. (Moisture Associated [MEDICAL CONDITION])..." The second page identified, "Resident #6, reason Left hip amd {sic} left knee with sites. MAD to bottom..." The surveyor asked if there was an incident report generated and also to review the incident report. Later the same day, the Administrator and the DON said the incident report was done but they were unable to locate the report. Please refer to F225 as it related to lack of investigation of injuries. -A one page document titled, "Care Plan History" at the top right that documented in part, "Original Care Plan Item, Description, Staff will place pillow or thin blanket between Resident #6's knees to reduce pressure factor to bony prominences, Created 1/2/2013, Created by LN #8." -A one page document titled, "Dietary" in the top right that provided evidence the resident refused snacks on 3/6, 3/10, 3/12, 3/13, 3/15, 3/16, and 3/17/13. On 4/25/13 at 12:15 p.m., LN #8 stated, "(On 3/17/13) I got a call (from the weekend wound nurse) because she was fresh out of training. She had already started the dressing changes, I arrived at the facility, and we did a full skin assessment. I know she had areas on her leg prior to that catheter tubing laying on her leg. When I came in she had a purple area on her left hip. She has had red areas on either hip depending on which side she was laying on." The LN stated, "I do not remember a conversation when the MD from the wound center said the open areas were caused by someone not turning her. I stepped out of the room and the MD may have said that while I was out of the room. I do not remember saying her left lateral hip progressed to a Stage III. I do not remember saying Resident #6 was laying on her left side and the catheter tubing caused pressure against her lower right leg." On 4/25/13 at 3:45 p.m., the facility provided the surveyors with additional documentation regarding Resident #6's open skin areas. One of the documents was a statement from the resident's primary physician, dated 4/25/13, addressed to the State inspectors that documented in part, "...she cries out when she is moved at all...She has always voiced her wishes that the staff did not have to move or reposition her because of the pain...recurrent skin ulcerations are unavoidable...even the slightest pressure or shear for her results in skin problems because of the skin failure...she will continue to have skin problems despite air mattresses and pillows and cushions and being moved frequently..." On 4/26/13 at 10:45 a.m., the survey team requested additional documentation from the facility: -Evidence the facility addressed, "(Resident #6) cries when she is moved at all, she has always voiced her wishes that the staff did not have to move or reposition her because of pain, and despite air mattress and pillow and cushions and being moved frequently, the resident continues to have skin breakdown." The above information was requested based on Resident #6's physician's statement dated 4/25/13. -All physician progress notes [REDACTED]. -All wound care MD progress notes. -All wound measurements for any open areas that developed since December 2011 and treatment sheets for those wounds. -All Interdisciplinary Team (IDT) notes from January 2012 to current. -Care plans initiated after December 2011. On 4/26/13 at 11:30 a.m., the Administrator, the DON, and the ADON were informed of the finding. Resident #6's developed pressure areas and SDTIs on 3/17/13 as evidenced by the resident's Care Plan, Treatment Record, Physician Orders, and Incident Report Tracking form. On 4/29/13 at 3:30 p.m., the Administrator contacted the Bureau of Facility Standards and stated the facility had 300 pages of documents for surveyor review. The Administrator was asked to overnight the information to the Bureau. On 4/30/13 at approximately 3:00 p.m., the Bureau received additional documentation from the facility. - Resident #6's physician's progress notes documented, in part, "12/27/11...complains of more pain whenever she is moved whether to turn her or transfer her to wheelchair..." The 12/27/11 progress note documented the physician prescribed medication for Resident #6's pain. "3/29/12...says the chronic pain is tolerable..." "9/4/12...still hurts with movement but doesn't think she needs a change of pain medication...follow pain...follow skin problems..." "10/9/12...follow closely to be sure no pain or distress..." "10/30/12...due to skin problems with pressure she mostly stays in bed...Stage 2 pressure areas mostly healed again but recurrent problems..." "12/27/12...pain in her left hip when moved but that is chronic. She is comfortable when she can lay still...She has a new pressure areas between her knees...says - hurts to move her..." NOTE: Resident #6's current Care Plan did not include interventions for: Resident #6 cried out when she was moved at all. Resident #6 always voiced her wishes that the staff did not have to move or reposition her because of the pain. Resident #6's Care Plan did not address skin failure as a focus area, or the recurrent skin ulcerations were unavoidable, or even the slightest pressure or shear for Resident #6 resulted in skin problems because of the skin failure. - The wound care MD's 4/17/13 progress note documented, in part, "Stage 2 PU on left medial knee...Stage 3 PU after debridement on right medial knee...." - Weekly Skin Monitoring forms. The facility did not provide Weekly Skin Monitoring forms for the month of March 2013. The 4/14/13 form documented, in part for Resident #6, "Date of onset 3/17/13. R (right) medial cuneiform...Current Stage, SDTI...R inferiolateral shin...Current Stage, III...R medial knee...Tunnel...L (left) medial knee...Current Stage, III...L lateral hip...Current Stage III." -Interdisciplinary (IDT) Skin Review Notes, dated 3/24/12 through 10/19/12, documented Resident #6 was treated by the facility for open skin areas. The 10/19/12 IDT Skin Review Note documented, in part, the only area of concern was, "...R lateral ankle not open...1.4 length x 0.6 width x 0. Improved..." -The Care Plans provided did not include dates to indicate when the Care Plans were put into place, did not identify when the Care Plans were printed, therefore the survey team was not able to determine when the Care Plans were initiated or revised.

Based observation, policy review, staff and resident interview, and record review, it was determined the facility failed to provide the necessary care and services to prevent the development of new pressure sores and promote healing for existing pressure sores. This was true for 1 of 4 residents (Resident #20) sampled for pressure sores. The deficient practice resulted in harm for Resident #20 when: *Resident #20 did not receive dressing changes as ordered to a Stage IV pressure wound to his sacrum and buttocks. This wound increased in size and depth. *Resident #20 developed at least six stage three pressure sores that were not present upon admission. *The locations of Resident #20's pressure wounds were not accurately monitored or documented. At least 11 of the 12 wounds that were identified between 6/11/13 and 7/1/13 were not consistently documented on from week to week. *Resident #20 was on a scoop mattress, instead of the pressure relieving air mattress specified in his care plan. *Wound documentation was not coordinated with hospice staff. *Heel protectors and pillows to prevent contact with the mattress were not provided per Resident #20's plan of care. Findings include: The facility's "Policy and Procedure - Clinical Best Practices" for Skin Monitoring and Management, Revised 5/2007, 9/2009, and 7/2010, documented, in part: -"It is understood that a resident may experience pain associated with the presence of a wound...Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain...prior to treatment..." -"Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area...all wound or skin treatments should be documented in the resident's clinical record at the time they are administered..." -"...In order to...prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches...Stabilize, reduce, or remove any underlying risks. Monitor impact of interventions and modify interventions as appropriate...Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc.)...obtain a physician order [REDACTED]. -"Continue preventive measures as appropriate, including but not limited to: Pressure reduction...Re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after 14 days or any time a wound is worsening..." -"Monitoring...daily via medication administration and treatment administration records. Ensure all orders have been implemented as ordered." Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20's most recent MDS, dated [DATE], coded: *BIMS of 8, indicating moderately impaired cognitive skills. *Extensive assistance of 2 or more persons required for bed mobility, dressing, and personal hygiene. *Total dependence on two or more persons for toileting *Did not transfer, ambulate, or otherwise move about the unit. *No rejection of care. *Impaired range of motion in both lower extremities. *Unhealed pressure ulcers present, at risk of developing further ulcers. *Six Stage III pressure ulcers present, none had been present at the time of admission to the facility. *One Stage IV pressure ulcer present, which had been present at the time of admission. *Stage IV pressure ulcer measured 25 centimeters (cm) long, 31 cm wide, 8 cm deep. *Six Stage III pressure ulcers (PU) and two Stage IV pressure ulcers which were not present or were present at a lesser stage on the prior assessment. *Pressure reducing devices for chair and bed, nutrition and hydration interventions, and pressure ulcer care in place for treatment. *No pain in the 5 days prior to the assessment. *Two or more falls without injury since the time of admission. Resident #20's care plan documented: -Focus of, "Has a terminal prognosis r/t multiple chronic decubitus ulcers", initiated 3/22/13. Approaches of, "Assess resident coping strategies and respect resident wishes", and, "Work with nursing staff to provide maximum comfort for the resident." -Focus of, "Potential for severing femoral artery r/t being exposed due to open wound on buttock." Initiated 6/25/13. Interventions of, "FYI - there are dark towels in the cabinet above the closet in case the artery breaks," and, "Is is (sic) recommended that he be bed rest only. Provide with repositioning every 2-4 hours and prn for comfort." -Focus of, "Stage IV ulcer to buttocks with exposed fascia, bone, muscle, and femoral artery. Has drainage and foul odor caused by prolonged exposure related to: incontinence, lack of sensation, cognitive impairment, non-adherence with therapeutic regime, chronic non-healing wound [MEDICAL CONDITION] in wound. Expected decline in wound and placed for Hospice care." Initiated 3/22/13. Interventions of, "Communicate with Hospice nurse on when dressing changes are to be performed and by whom, " "Medicate for pain as needed prior to dressing changes. FYI: due to decrease sensation to lower body he has not expressed pain during wound changes but still has potential for pain," and, "Provide tx (treatment) as ordered by MD and refer to TAR for changes." -Focus of, "Potential additional skin and wound deterioration related to:\no sensation to LEs (lower extremities) \hospice diagnosis." Initiated 3/22/13. Interventions of, "Provide measures to decrease pressure/irritation to skin: Pressure relieving Air mattress, heel protectors, pillows for positioning", and "Keep air mattress cover clean, dry, and free of wrinkles. Monitor that it has the correct setting." -"At risk for falls r/t Unaware of safety needs, paralysis, and no sensation of legs." Initiated 3/29/13. Interventions of, "bed to be in low position away from wall and scoop mattress to be placed to bed." NOTE: While Resident #20's care plan contained initiation dates for the Focus areas, there were no dates to determine when each intervention was added or revised. Please see F280 as it pertains to care plan revisions and F514 as it relates to accuracy of records. Physician's Progress Notes documented: -5/31/13, "...receiving palliative care with hospice due to massive sacral/gluteal tissue destruction from non-healing ulcers...Pt (patient) has episodes of pain and [MEDICAL CONDITION] care is only palliative trying to keep clean, dry, clear of infection and odor...arranged wound change schedule, hospice in AM, facility in PM." -6/28/13, "...massive non-healing sacral ulcer...will continue to do best given these limited options..." Resident #20's All Active Orders for June 2013 form (Recaps) documented: -"SN (Skilled Nurse) at facility to change dressing on buttock and sacral area. -NOCS (night shift) Everyday, 1830-0630 (between 6:30 PM and 6:30 AM)." Order date was documented as 6/13/13. Resident #20's Treatment Administration Record (TAR) for June 2013 documented, "SN at facility to change dressing on buttock and sacral area. Order Date 6/13/13. NOCS (night shift) every day." The TAR was blank for 6/13/13, 6/14/13, and 6/15/13, with the first facility dressing change documented on 6/16/13. On 6/7/13, a facility Skin Assessment for Resident #20 documented, "Pt (patient) has several open areas. Please reference Treatment record. Pt is being treated by hospice and wound care for open areas." On 6/19/13, a Braden Scale for Predicting Pressure Sore Risk for Resident #20 coded, "12", indicating the resident has at High Risk for pressure ulcers. Resident #20's Nurse's Progress Notes documented: -6/13/13 at 2:38 AM, "Drsg to coccyx changed..." NOTE: From an anatomical perspective, the coccyx, sacrum, and buttocks are different parts of the body. -6/14/13 and 6/15/13, no dressing changes documented. -No refusals of care 6/14/13 - 6/17/13 -Air mattress in place on 6/14/13, but a scoop mattress on 6/19/13, with no explanation as to when or why the change was made. -6/24/13 at 2:10 AM, "Changed Pt's Dressing to buttocks. Wound being changed by hospice nurse during the daytime. Pt wound was bleeding more today than last weeks dressing changes. Pt was given 1 mg [MEDICATION NAME] prior to dressing change to help decrease pain." NOTE: The facility did not document evening dressing changes to Resident #20's sacrum and buttocks per MD order on 6/13/13, 6/14/13, or 6/15/13. -6/28/13 at 1:23 AM, "During dressing change resident began screaming and became agitated believing we were 'packing' the wound bed. (RN #8) wound nurse with me at the time and tried to calm resident and reassure but he remained agitated. Has been screaming most of the evening about things like getting water, plugging in speakers, etc. Calling staff in about every 5 to 10 minutes. When this nurse asked him to consolidate some items into a single trip he again began to scream and use multiple expletives. He continues to scream to this time. This nurse informed him he could have his door open and not scream or closed and scream. He told this F... that." NOTE: There was no documentation Resident #20 was assessed for pain before or during this dressing change. 7/4/13 at 7:00 AM, "Pt slept well through the night, he had no complaints of pain. Pt dressing to coccyx area was changed at 0015 (12:15 AM) on 7/4/13..." -7/7/13 at 6:08 PM, "Dressing to buttocks changed. two person assist. Rt. (Resident) expressed discomfort during the procedure. Wound bed red, moist...some exudate present on old dressings, plus bm (bowel movement)..." -7/8/13 at 11:50 PM, "Pt had complaints of moderate pain this evening. Pt was given PRN [MEDICATION NAME] with effectiveness. Pt dressing was changed at 2330 (11:30 PM)." NOTE: This entry did not specify which of Resident #20's dressings was changed. "Skin Pressure Ulcer Weekly" (SPUW) forms: NOTE: The facility's SPUW forms displayed a diagram of a human body with various parts of the body numbered 1-52. The form prompted the user to identify each wound location with a corresponding number on the body diagram. Each week, Resident #20 was noted with a total of between 6 and 8 PUs. Facility documentation of the location of the PUs was inconsistent from week to week, with some, but not all, wounds being assigned a number for identification. Additionally, some, but not all, wounds were documented weekly. Resident #20's SPUWs documented 12 different descriptions of his pressure ulcers. For the purpose of ease of reading this citation, the surveyor has numbered the pressure ulcers as wounds #s 1 - 12: In addition, per SPUW forms and staff interview, the hospice nurses for Resident #20 were assessing and measuring his wounds, then provided that information to RN #8, who then documented that information into Resident #20's record. Please see interviews below. SPUW's documented the following between 6/11/13 and 7/1/13: a. Regarding Pressure Ulcer #1: -6/11/13: Description documented as, "Bilateral Buttocks and sacrum stage IV pressure ulcer with exposed bone, fascia, muscle, tendons, and arteries." Size: 24.0 cm X 29.0 cm X 7 cm. The wound was documented as having large amounts of serosanguinous exudate with a foul odor. The wound bed was described as "Pink/Beefy Red." Surrounding skin color was documented as "Normal for Skin" with "Peripheral Tissue [MEDICAL CONDITION]." Resident #20 was described as having no pain. The "Additional Documentation" area of the form documented, "...The dressing is changed twice daily. Hospice staff changes dressing every am (morning) and facility nursing staff changes dressing (at) HS (bedtime) daily..." -6/17/13: Description as, "Bilateral buttocks and sacrum stage 4 pressure site present on admit." Size: 25 cm X 32 cm X 8 CM. "Exudate type" was documented as, "Serosanguinous." "Exudate Amount" was documented as, "Copious." The odor was documented as, "Foul." The Wound Bed was, "Black/Brown (Eschar)." The surrounding skin color was, "White/Gray Pallor." The Surrounding tissue/wound edges was documented as, "Peripheral tissue [MEDICAL CONDITION]." Additional documentation was, "Dressing is changed Q am (every morning) by hospice staff and Q pm (every evening) by facility staff..." NOTE: Between 6/11/13 and 6/17/13, Resident #20's wound to his buttocks and sacrum had grown in size and depth. The facility did not have documentation the dressing had been changed per MD order on 6/13/13, 6/14/13, or 6/15/13. The amount of exudate had increased from "large" to "copious." The wound bed had deteriorated from "pink/beefy red" to "black/brown eschar." Skin color surrounding the wound had deteriorated from, "normal for skin" to "white/gray pallor." Nevertheless, two days after this assessment of Resident #20's wound, the facility documented Resident #20 as being on a "scoop" mattress, rather than the air mattress he had previously been documented as using. 6/26/13: Description as, "23, 54, 55, 53 (referring to numbers on the human body diagram on the form) coccyx, left buttock, sacrum stage IV pressure ulcer present upon admit." Size: 22 cm X 27 cm X 8 cm. Exudate type as, "serosanguinous", exudate amount as, "large." Odor was documented as, "foul." Wound bed was documented as, "slough." Surrounding skin color was documented as, "White/Gray Pallor." Surrounding Tissue/Wound Edges as, "Peripheral Tissue [MEDICAL CONDITION]." "Additional Documentation" included, "...Dressing is changed BID (twice per day), AM per hospice nurse, PM per facility nurse...No reports or indications of pain or discomfort." NOTE: Between 6/17/13 and 6/26/13, the wound became smaller in length and width. Nurse's Progress Notes indicated Resident #20 was on a scoop mattress, rather than a pressure-relieving air mattress. 7/1/13 - Site as, "53) Sacrum." Description as, "Sacral/bilateral buttocks stage IV PU site... Size: 22 cm X 34 cm X 8 cm. The "Additional Documentation" area of the form stated, "...Changed BID and PRN. NOTE: These measurements of Wound #1 indicated the wound had grown in size during this week. During this time, facility documentation indicates Resident #20 was on a scoop mattress, rather than a pressure-relieving air mattress. NOTE: There was no documentation the facility had implemented interventions for this Stage IV pressure ulcer as defined in their policy and specified in Resident #20's care plan. There was no documentation the facility had re-evaluated the existing treatments for Resident #20's Stage IV pressure ulcer even though it had not shown improvement, and in fact had shown signs of deterioration, between 6/11/13 and 7/1/13. The facility could not provide documentation that wound treatments were documented in Resident #20's clinical record at the time they occurred. b. Regarding the rest of the Pressure Ulcers. -Wound #2. 6/11/13, site documented as, "45) Right ankle (inner)." Description as, "Right medial ankle stage III pressure site." Size: 2 cm X 2 cm X 1 cm. -Wound #3. 6/11/13, site as, "Other (specify)." Description as, "Right medial foot Stage III pressure ulcer." Size: 3.5 cm X 3 cm X 1 cm. -Wound #4. 6/11/13, site as, "Other (specify)." Description as, "Right lateral distal lower leg previously two Stage III pressure sites are now one Stage III pressure site." Size: 2.5 cm X 2.0 cm X 1.0 cm. NOTE: There was no further documentation for wounds 2, 3, or 4, and no explanation as to whether or not they had healed. -Wound #5. Site documented as, "49) Right heel." Description as, "Right posterior heel Stage III pressure ulcer." Documented on 6/11/13, 6/17/13, and 6/26/13, with improvement noted each week. Not documented on 7/1/13, with no explanation as to what had happened with that wound. -Wound #6. 6/11/13, site as, "42) Left lower leg (front)." Description as, "Left lateral distal lower leg stage III pressure ulcer." Size: 4 cm X 3 cm X 1 cm. NOTE: There was no further documentation on this wound, and no explanation as to whether or not it had healed. -Wound #7. Site as, "37) Right knee (front)." Description as, "Right lateral knee stage III pressure ulcer site." 6/11/13, size: 1.5 cm X 2 cm X 1 cm. 6/17/13, size: 2 cm X 2 cm X 0.5 cm. NOTE: Wound #7 was longer, but not as deep on 6/17/13 as it was on 6/11/13. There was no further documentation on this wound, and no explanation as to whether or not it had healed. -Wound #8. Site as, "Other." Description as, "Right medial mid dorsum stage II pressure site." 6/17/13, size 3 cm X 2 cm X 0.5 cm. Documented again on 6/26/13 with slight improvement in size. -Wound #9. 6/17/13, site as, "41) Right lower leg front." Description as, "Right distal anteriolateral leg stage II pressure ulcer." Size as, "3 cm X 2 cm X 0.5 cm." NOTE: Wounds #8 and #9 did not directly correspond to any wound documented during the week of 6/11/13. See interviews below regarding facility explanation for assessing and measuring wounds. -Wound #10. Site as, "50) left heel." Description as, "Left heel stage II pressure site." 6/17/13, size 3 cm X 3 cm X 0.5 cm. 6/26/13, size 3 cm X 5 cm X 0.5 cm. NOTE: These measurements documented the wound increased in size between 6/17/13 and 6/26/13. This wound was not documented on 6/11/13. See interviews below. -Wound #11. 6/26/13, site as, "43) Right lower leg (rear)." Description as, "Right posteriolateral distal leg stage II." Size: 2 cm X 2 cm X 0.5 cm. NOTE: Wound #11 was not noted on 6/11/13 or 6/17/13, -Wound #12. 6/26/13, site as, "44) Left lower leg (rear)." Description as, "Left posteriolateral lower leg stage II pressure site." Size: 3 cm X 2 cm X 0.75 cm. NOTE: Wound #12 was not noted on 6/11/13 or 6/17/13. There was also a single SPUW for 7/1/13, which listed Wound #1, "all stage II PU's" to Resident #20's right posteriolateral leg, as well as PUs to Resident #20's right heel, left heel, right medial mid dorsum, left lateral distal leg, and right anteriolateral patellar. NOTE: Many of these wounds were not staged. The documentation is unclear as to whether or not these were the same wounds the facility had been monitoring or if they were new wounds. There was also no documentation stating whether some of the wounds being monitored by the facility had improved or resolved since the previous week's assessment. On 7/9/13 at 3:20 PM, the surveyor observed Resident #20 in his room. He was lying in bed, on his back and buttocks, with the head of his bed elevated approximately 30-45 degrees. He was lying in a "scoop" mattress, with built-up edges of the mattress approximately 6 inches in height, on both sides of the head and foot of the bed. There was a sheet on the mattress, but the sheet was askew, having come loose from the edges of the mattress. The sheet had bunched up underneath Resident #20 with several large wrinkles under him where he laid. There was a pillow behind his head, but no other pillows were visible. He was wearing a T-shirt and gym-type shorts, with his legs and feet exposed. His feet were bare. His legs were in a "butterfly" position, with the weight of his legs resting on the outer aspects of his knees, calves, ankles, and feet. His knees, calves, ankles, and feet were positioned directly on the wrinkles in the sheet or the bare mattress. There were multiple skin tears and dressings visible on both of his legs. He was not wearing any kind of heel protection, nor were his heels or ankles being floated. Resident #20 welcomed the surveyor into his room. His mother was sitting in a chair at bedside. The bed was high enough from the floor that the mattress was even with Resident #20's mother's neck and upper chest as she sat in the chair, rather than the low position specified in Resident #20's care plan. On 7/9/13 at 4:45 PM, RN #8, identified as the facility wound nurse, was asked about Resident #20's pressure ulcers. RN #8 stated Resident #20's wounds were assessed and measured by hospice, then hospice reported those findings to RN #8, who then entered the information into Resident #20's record in the facility. RN #8 stated she did not actually assess or measure the wounds herself before entering the data into Resident #20's medical record, but rather relied on the information received from hospice. RN# 8 stated the wound to Resident #20's buttocks and sacrum received daily dressing changes from hospice, and "as needed" dressing changes from the facility. RN #8 stated if Resident #20 needed a dressing change other than the ones provided by hospice, she would come in to the facility and do it herself, even if it meant she had to come in on a weekend, evening, or holiday. On 7/10/13 at 8:20 AM, the two surveyors reviewed Resident #20's TAR for July 2013 with the DNS, ADON, and administrator. The area of the TAR to document the facility nurse had changed Resident #20's dressing to his buttocks and sacrum every evening, was blank except for July 1, 2013. The DNS stated because Resident #20 was a "special case" as far as his wounds, the dressing changes for his sacral wounds had been placed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, the DNS reported, "We can't find the MAR for this wound. We have looked everywhere and will keep looking, but we can't find it anywhere," and "I'm going to go look in the shred box next." The DNS was then asked about the weekly SPUW forms for Resident #20, and the lack of consistency in the documentation of Resident #20's wounds. In particular, the pressure ulcer to Resident #20's left heel which was not documented on 6/11/13, but was documented on 6/17/13. The DNS stated the wound to Resident #20's left heel had "always been there", but was not correctly or consistently documented by the hospice nurse. The Administrator then stated the facility had had a meeting with hospice so they "could all get on the same page." The Administrator stated he could not recall the date of that meeting, and the facility did not make notes of the content of that meeting or the plan moving forward after the meeting occurred. NOTE: Resident #20's hospice record indicated the meeting took place on 6/21/13, two weeks after the facility alleged compliance for F314. On 7/10/13 at 8:40 AM, the surveyors, along with RN #4, looked at Resident #20's July 2013 MAR. There was no area on the MAR indicated [REDACTED]. RN #4 stated, "It's not there now. It was there, at the front, on a page by itself." RN #4 stated she did not do the dressing changes for Resident #20, because she worked day shift, but she did get a report from the nurses who did the dressing changes. On 7/10/13 at 9:45 AM, the surveyors again met with the Administrator, DNS, and the corporate Clinical Resource person (CR). The DNS was asked about the blank areas on Resident #20's June 2013 TAR (6/13/13-6/15/13) for the evening dressing changes to his sacrum and buttocks. The DNS stated, "We missed it. That's why we decided to put it on the MAR." The DNS was then asked about the documentation for the dressing change to that wound beginning 7/2/13. The DNS stated, "It was documented in the nurse's notes." The surveyor and the DNS reviewed Resident #20's nurse's notes together, and found narrative documentation of dressing changes on 7/4/13 to the "coccyx area", 7/7/13 to the "buttocks", and 7/8/13 "dressing change" with no location specified. The DNS was then asked to describe the process for wound dressing changes for Resident #20. The DNS stated Resident #20 had been on hospice since prior to his admission, and hospice had been treating Resident #20's buttocks wound for, "A long time. So for consistency, we let them keep doing it." The DNS was asked if the facility had any responsibility for assessing, measuring, or changing the dressings for any of Resident #20's wounds. The DNS stated, "No. Hospice does that." (NOTE: Resident #20 had a physician's orders [REDACTED].) The DNS and Administrator were asked again about the inconsistencies with the wound documentation for Resident #20's wounds. The Administrator stated, "We've had several meetings with them (hospice) to discuss it (inconsistency in wound documentation.)" The administrator stated he did not recall when the meetings were. The surveyor then informed the Administrator of the documentation in Resident #20's hospice record indicating the meeting took place on 6/21/13, which was after the facility's alleged compliance date. The Administrator stated, "But we met with them before, too." The Administrator, DNS, and CR were informed of the surveyor's concerns of continued non-compliance at F 314. The CR stated, "I understand." On 7/10/13 at 10:15 AM, the surveyors observed a dressing change for Resident #20's buttocks and sacral wound. The dressing change was performed by the hospice nurse, with RN #8 and a hospice CNA present to assist. Upon entering Resident #20's room, he was observed again to be in bed with his legs in a "butterfly" position, with a pillow behind his head, with bare feet and legs. He was on the same type of scoop mattress as observed the day before. No heel protectors were in place, his heels were not floated, and there were no pillows being used for positioning besides the pillow behind his head. The hospice nurse asked Resident #20 if she could take his vital signs before beginning. Resident #20 declined. With the hospice nurse and CNA on Resident #20's left, and RN #8 on his right, the three rolled him onto his right side to begin the dressing change. They did not tell Resident #20 they were going to roll him over. As they rolled him over, the surveyor noted a bed sheet, a draw sheet, an incontinence pad, and an incontinence brief were all between Resident #1 and the mattress. Upon exposing the wound to Resident #20's buttocks, the surveyor asked if this wound was considered Wound #1 for this resident. The hospice RN stated, "It was Wound #1 and #2, then it merged as one wound. I'm not sure if we're calling it Wound 1 or Wound 2 now." The surveyor observed a large wound encompassing the entirety of Resident #20's buttocks. It was only when Resident #20 began to have a bowel movement that the surveyor was able to discern the location of Resident #20's anus. The inner portion of the wound was red and dry with a dark area inside his left buttock wound. Using her gloved hand, the hospice nurse inserted her hand into Resident #20's wound and began to press on the darkened area. The hospice nurse identified this area as a "bladder fistula." There was an odor of stale urine and sweat in the room prior to the dressing change, with the added odor of stool when Resident #20 began to have a bowel movement. Scant serous drainage was noted on the soiled dressing removed from the wound. As the hospice nurse began to clean the wound, the wound began to bleed. There was an exposed softball-sized mass located on the lateral side of his right hip area. The hospice nurse stated she had measured the wound the day before, and was not prepared to measure the wound again at this time. As Resident #20 was laying on his right side, supported by RN #1 and the hospice CNA, he began to call out, "Ow. Sh** (expletive). My shoulder. It hurts." RN #8 stated, "We'll be done soon." No further assessment was made of Resident #20's discomfort and no correction was offered (pain meds, repositioning, etc) to correct his discomfort. The surveyor asked about the type of mattress being used for Resident #20. The hospice nurse identified it as a, "scoop mattress because we don't want him to fall." The surveyor asked if an air mattress had been considered for Resident #20. At that time, Resident #20 stated, "It's uncomfortable", referring to the bed. Resident #20 stated, "The only reason I have this one (sore) on my hip is because of this mattress." At that point, the blanket covering the upper portion of Resident #20's body slipped off to the side of his body (the blanket remained on the bed). Resident #20 stated, "What are you doing?" RN #8 then picked up the corner of the blanket and tossed it over Resident #20, so that the blanket was covering Resident #20's chest, as well as his head. RN #8 then looked at the surveyor and stated, "He likes to hide." Meanwhile, Resident #20 was using his arms and attempting to twist his torso so as to remove the blanket from his head. The hospice CNA then began to use a wipe to clean Resident #20's stomach and chest. She did not tell Resident #20 she was going to clean him. Resident #20 became upset and stated, "Don't clean me up with that. Use a warm washcloth." The CNA then went to the bathroom to get a warm washcloth to use to clean Resident #20. On 7/10/13 at 12:30 PM, the ADON, and RN #8 were asked about Resident #20's care plan, which called for an air mattress for his wounds. RN #8 stated, "No. He has a scoop mattress." RN #8 was asked why, with such a substantial wound to his buttocks and sacrum, as well as at least 6 other pressure ulcers, Resident #20 would not have an air mattress, RN #8, who was identified as the facility wound nurse, stated, "I'm not sure." RN #8 was asked who in the facility made the determination as to which mattress should be used for Resident #20. RN #8 stated, "The MDS nurse and the interdisciplinary team." RN #8 was asked if she had input on this process as the facility wound nurse. RN #8 stated, "No. I just do the dressing changes." On 7/10/13 at 12:35 PM, the Administrator, ADON, and the corporate CR person were again interviewed by the surveyors. RN #15 was also present. The corporate CR person handed the surveyor a yellow paper which was consistent in appearance with the facility's MAR indicated July 2013". The document had an area for, "Cleanse buttocks wound with wound wash, pat dry, pack with ABD pads, place carbon pad in wound bed, cover with ABD pads and tape in place. Order Date: 6/13/13. NOCS every day." This form contained spaces for a time and nurse's initials to be documented every day. These spaces were filled out for 7/1/13 through 7/9/13. Aside from this dressing change, there was no indication of anything else to be documented on that form. The corporate CR person stated the facility could not locate the page from Resident #20's July 2013 MAR indicated [REDACTED]. The corporate CR person stated, "We had (the ADON) drive all over town, to the homes of the nurses who changed those dressings, and we re-created the MAR. We are not representing this as the original, but we have re-created the MAR." The corporate CR person identified RN #15 as one of the nurses who would have been responsible to change Resident #20's dressing to his sacrum and buttocks. RN #15 stated he had worked on the evening shift for 7/2/13 and 7/6/13, and would have changed Resident #20's dressings on those shifts and documented it on the MAR. RN #15 was uncertain as to where this document from Resident #20's MAR indicated [REDACTED]. On 7/10/13 at 3:45 PM, The Administrator, DNS, and corporate CR person met again with the survey team. The surveyors asked if the facility had further information as to why Resident #20 did not have preventive/protective skin measures in place per his care plan, i.e., air mattress, heel protectors, positioning with pillows. The Administrator stated the facility had opted for the scoop mattress as Resident #20 had fallen out of bed twice right after his admission to the facility in March 2013. The surveyor asked if the facility had considered fall prevention measures which would also address Resident #20's skin needs. The Administrator stated the facility wanted to protect Resident #20 from potential injuries from a fall. The surveyors then asked if the facility had re-evaluated this plan in light of the severity and deterioration of Resident #20's wounds, and the development of at least 6 new pressure ulcers since admission. The corporate CR person stated they felt the potential for

Based on staff interview, observation and record review, the facility failed to document information on a resident's right heel pressure sore. This was true for 1 of 4 (#23) sampled residents. This practice created a potential for harm if the facility does not document or track pressure sore status to determine if treatment is effective. Further, the facility failed to develop a care plan addressing the right heel pressure sore. Findings include: Resident #23 was admitted to the facility, on 7/18/13 with [DIAGNOSES REDACTED]. The most recent admission MDS, dated [DATE], documented the resident: * had short and long term memory problems, * required extensive assist with bed mobility, transfers, dressing, toileting and personal hygiene, * had one unstageable pressure sore. The interpretive guidance at F 314 specifies the facility should document on each pressure sore at a minimum the following information: "ULCER CHARACTERISTICS It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. When a pressure ulcer is present, daily monitoring, (with accompanying documentation, when a complication or change is identified), should include: ?An evaluation of the ulcer, if no dressing is present; ?An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); ?The status of the area surrounding the ulcer (that can be observed without removing the dressing); ?The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and ?Whether pain, if present, is being adequately controlled. With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and: ?Location and staging; ?Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; ?Exudate, if present: type (such as purulent/serous), color, odor and approximate amount; ?Pain, if present: nature and frequency (e.g., whether episodic or continuous); ?Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and ?Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate." The resident's comprehensive care plan dated 7/23/13 documented a Focus of: "Has actual impairment to skin integrity related to history of pressure ulcer to coccyx and sacrum and current SDTI (suspected deep tissue injury) site to left heel related to limited mobility." There was no care plan for the sore on the right heel SDTI in the medical record. The resident's medical record was reviewed on 10/9/13. It contained information indicating that the resident had two pressure sores. There was one on the right heel and one on the left heel. The record lacked clear information about the right heel pressure sore. The electronic medical record had three different types of documentation on pressure sores. The "LN -Admission Assessment Comprehensive" had a section on skin integrity. There was an assessment titled "LN-Skin Assessment Evaluation - PRN Weekly," one titled, "LN - Skin Pressure Ulcer Weekly," and one titled, "LN-Interdisciplinary Team Skin Review - Weekly Update." There was extensive documentation on the pressure sore on the left heel but only rare documentation of the right heel. The only documentation found for in the record for the the right heel was as follows: The "LN-Admission Assessment Comprehensive" form, dated 7/18/13, did not have any information about the pressure sores on the heels. The form only addressed there were "2 pressure areas on (the) buttocks" and "cracks on bilateral heals (sic)." The "LN - Skin Pressure Ulcer Weekly" first documentation was 7/18/13 but lacked anything about the right heel. Subsequent documentation was completed weekly about the left heel. There was nothing about the right heel. This form had a place for the information that is recommended by the interpretive guidance for F 314. This form was completed by the ADON who was the wound nurse. The "LN -Skin Assessment / Evaluation - PRN Weekly" only documented the "Site, Type, Length, Width, Depth, and Stage" information with a box for additional comments. The forms documented: The 8/14/13 documentation for the right heel was: "Site Right heel, Type Pressure, Length 1.5, Width 1.5, Depth blank, Stage Suspected Deep Tissue Injury (SDTI)." The additional comments were: "Bilateral heels to have skin prep daily and monitored for change. Both heel beds are black at current time. Wound beds are hard and deep tissue is unable to stage at current time." The 8/17/13 documentation was: "1) Bilateral heels are black and hard to touch." The 8/31/13 documentation was: "1) Bilateral heels are black and hard." The "LN -interdisciplinary Team Skin Review - Weekly Update" documented only one note about the right heel; the rest were about the left heel only. This documentation was: On 8/16/13 at Section II "Wound Management/Pressure ulcer Review" was documented, "SDTI's to bilat(eral)heels..." At Section V "Response to Treatment Plan was documented, "Bilateral heels to have skin prep daily and monitored for change. wound to left heel measures in cm 2.5 x 2.5 x 0. wound to right heel measures in cm 1.5 x 1.5 x 0. Both wound beds are black at current time. Wound beds are hard and deep tissue is unable to stage at current time...." There was no other documentation describing the right heel wound in the record. On 10/8/13 at 9:10 a.m. Resident #23's heels were observed. The resident had a sore on the right heel which was about 1 cm in diameter covered with an eschar and was unstageable. The Administrator, DON and assistant director of nursing (ADON) were interviewed on 10/8/13 at 10:30 a.m. They indicated that they were monitoring the sore on the right heel but acknowledged the medical record was lacking descriptive documentation of that wound. They indicated descriptive information outlined in the interpretive guidance was on a spreadsheet that was located on a thumb drive, and was not associated with the electronic medical record, nor was there a copy in the paper medical record for review. The information on the thumb drive was not available in the record, either electronically or hard copy, for surveyors or practitioners to review. They indicated the ADON updated the information during the skin meetings. A paper copy of the spreadsheet from the thumb drive was provided to the surveyors. The thumb drive, according to the ADON interview on 10/8/13 at 12:10 p.m., was kept in the ADON's office and the information was updated when the skin team met each week. See F 164 also for more information on the thumb drive. The facility failed to monitor the pressure sore on the right heel, failed to document if the treatment ordered was effective for the resident and failed to have a care plan for the right heel pressure sore.

Based on a complaint from the general public received by the BFS on 2/27/12, staff and family interview, record review, and review of ER records, it was determined the facility failed to thoroughly assess a resident's rash and monitor the rash after the initial assessment. This failure to assess and monitor the resident's rash resulted in harm to the resident when the resident experienced increased pain and delay in treatment for [REDACTED]. This was true for 1 of 1 residents (#1) reviewed for rashes. Findings included: The complainant stated an identified resident complained of pain around the belly and developed a rash while in the facility. The resident complained of pain on 2/25/12. The resident fell on [DATE] and the family was concerned the pain was caused by a possible [MEDICAL CONDITION], back or pelvis. The family told the nurse the resident needed to be examined. The nurse said all the resident needed was a pain pill. The resident was transferred to the hospital on [DATE]. The rash was diagnosed as [MEDICAL CONDITION]. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 2/21/12, coded: * BIMS score of 9 indicating moderately impaired cognitive skills for daily decision making * No pain in the last 5 days Resident #1's Pain Assessment Form, dated 2/14/12, documented the resident did not have any persistent or frequent pain during the past 2 weeks and did not exhibit any nonverbal signs that could indicate pain. The "comments" section of the form documented, "States no pain." Resident #1's February 2012 MAR indicated [REDACTED]. The resident's last dose of [MEDICATION NAME] was documented as given on 2/18/12 at 9:15 pm for complaints of pain in his feet. Resident #1's Comprehensive Resident Admission Assessment, dated 2/14/12, documented, the general skin condition as "normal, cool/cold, Capillary Refill greater than 3 seconds." The Skin Integrity diagram in the Comprehensive Resident Admission Assessment, dated 2/15/12, documented, "red blanches" with a line drawn to a circle located on the coccyx area of the diagram. Various other bruises, scabs and flaky skin were identified on the diagram which were located on a hand and both feet. The Weekly Skin Evaluation form documented Resident #1's skin condition as follows: * 2/15/12 Skin Diagram: "Slightly red coccyx" with a line to the coccyx area, "bruise" with lines to the right arm, "bruises (and) discolored brown" three lines to the right arm, "scab" with a line to the right heel, "bruises" with lines to the left arm and hand, "scratches" with a line to the right knee area, and "scab" with a line to the right foot area. * 2/22/12 Skin Diagram: "red" written on the coccyx area, "bruise" written on the right arm, and "bruises" with lines to the left arm. * 2/23/12 Skin Diagram: "bruising" with a line to the left arm, "ST (skin tear)" with a line to the left elbow area, and "Rash" with a line to the right posterior flank area. NOTE: The Weekly Skin Evaluation form did not document the time when each skin evaluation was completed. Resident #1's nursing PNs contained a single nursing note regarding the rash, dated 2/24/12 at 2:30 am, "...Noted rash to R(ight) flank area this shift will report to Day nurse." NOTE: Neither the Skin Diagram of 2/23/12 nor the nursing progress note from 2/24/12 documented a thorough assessment of the rash. Perry & Potter in Fundamentals of Nursing, 7th Edition, p. 569, under the section "[MEDICAL CONDITION]" states, "When you detect a lesion, inspect it for color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). Observe any exudate for color, odor, amount, and consistency. Measure the size of the lesion... Palpation determines the lesion's mobility, contour (flat, raised, or depressed), and consistency (soft or indurated). Certain types of [MEDICAL CONDITION] have a characteristic pattern. ...After you identify a lesion, closely inspect it in good lighting. ...Note if the client complains of tenderness during palpation." Resident #1's nursing PNs also documented, in part: - 2/24/12 at 3:00 pm: "Res(ident)was found on floor between bed and chair. ST 3 cm (centimeters) to Rt (right) forearm noted. Called MD (physician) about incident N.O. (new order) [MEDICATION NAME] 25 mg po (by mouth) daily." The Telephone Orders form documented on 2/24/12 at 3:15 pm: "[MEDICATION NAME] 25 mg po Q day ([MEDICATION NAME] 25 milligrams by mouth every day) " for "anxiousness." The February 2012 MAR indicated [REDACTED]. NOTE: There was no documentation in the resident's nursing PN's regarding anxiousness. - 2/24/12 at 4:20 pm: "Res is alert (with) episodes of being confused..." - 2/25/12 at 3:00 am: "...Resident is able to answer questions correctly... Resident continues to try et (and) self transfer Alarms sounds to Alert staff. Resident is on 15 min(ute) (checks) for safety..." - 2/25/12 at 8:05 am: "late entry family notified of fall on 2/24/12" - 2/25/12 at 6:00 pm: "Stomach was hurting. Called (physician's name) for [MEDICATION NAME]/[MEDICATION NAME] administering [MEDICATION NAME] patient says his stomach feels better." NOTE: There was no documentation on the MAR indicated [MEDICATION NAME] or [MEDICATION NAME] 30 cc (cubic centimeters) po AC prn (before meals as needed)." - 2/25/12 at 7:30 pm: "pt c/o (patient complains of) stomach pain. pt family here and want pt sent to ER, charge nurse called (physician name) and got order to send pt to ER via non-emergent transport. Pt (family members listed) in room and notified of MD orders." NOTE: This was the last entry on the resident's nursing PN before he was transported to the ER. A nursing PN note at 11:30 pm documented the LN "called the ER. pt admitted to (hospital name)." NOTE: The ER Admission Form documented the resident was admitted to the ER at 8:19 pm. On 3/29/12 at 2:20 pm, RN #10 was interviewed regarding Resident #1. - RN #10 was the charge nurse for the day shift on 2/25/12. RN #10 stated she had not worked with the resident prior to this shift. She stated, "This was my first observation of the resident." - RN #10 said she looked at the 24 hour report at the beginning of her shift and spoke to LPN #11 regarding Resident #1. According to RN #10, LPN #11 stated they were waiting for results of a blood test on Resident #1. RN #10 stated, "Nothing else was reported (on Resident #1). - RN #10 stated that Resident #1 went to lunch in the assisted dining room. The resident had some [MEDICAL CONDITION] pain. The family was called and suggested "sodium [MEDICATION NAME]." RN #10 stated the physician was called and said, "OK for [MEDICATION NAME] or [MEDICATION NAME]." NOTE: There was no documentation on the MAR indicated [REDACTED]. NOTE: LPN #11 stated in her interview below, that she gave the medication around 5:00 pm. - RN #10 stated that Resident #1 went to the dining room for about 45 minutes for the evening meal and then went back to his room. - RN #10 stated that LPN #11 informed her that, "A (family member) was very upset, wants the resident to go to the hospital." RN #10 went into Resident #1's room, introduced herself to the (family member) and asked, "How can I help you?" The (family member) said he (Resident #1) was "having terrible lower abdominal pain, groin pain." RN #10 stated, "The (family member) pulled down the resident's sheet and rubbed the resident's right lower quadrant and said, 'Doesn't that hurt (Resident #1)?' " RN #10 stated Resident #1 "sort of said 'yes.' (The family member) was upset regarding his (Resident #1's) pain." RN #10 "asked (Resident #1), 'How long has it been hurting?' He didn't say. (The family member) said, 'all day.' (The family member) said, 'I want you to get him to the ER right now.' " - RN #10 stated to the family member that she would call the physician. RN #10 called the doctor and told the physician that Resident #1 had not been complaining of pain and had not shown physical signs of pain. RN #10 stated, "The doctor said, 'Not a clear idea of what's going on.' So (the doctor) okayed for non-emergent (transfer) to ER." NOTE: This was the same physician that had ordered the [MEDICATION NAME] or [MEDICATION NAME]. - RN #10 was asked if she performed a physical assessment of the resident's abdomen. She stated, "I did not. The (family member) just wanted to get him to the hospital. I don't know if (LPN #11) had done that (assessment) earlier." NOTE: Resident #1's nursing PN's does not contain any documentation of RN #10's interactions with the resident or family. On 3/29/12 at 3:00 pm, LPN #11 was interviewed regarding Resident #1. - She stated she cared for the resident on 2 different occasions on the day shift. The second time she cared for the resident was on 2/25/12. She stated, "The resident was pleasant the first time, the second time he was more irritable." She said that the resident's "demeanor went from pleasant to irritable, anxious." -She stated when she came onto her shift she was given report from the previous shift and "did not remember anything particular from report." - She stated the resident denied pain until the night of his discharge. LPN #11 was asked if she did a pain assessment. She stated, "I did. His stomach was hurting. I felt his stomach, he said it was tender. His (family member) said '[MEDICATION NAME].' The resident refused Tylenol. I gave him 2 tablespoons [MEDICATION NAME]. It helped a little. The pain was still there. I felt his stomach area or abdomen. It was his upper abdomen, no side in particular." LPN #11 stated she gave the [MEDICATION NAME] "around 5:00 pm at the end of my shift." - When asked if she performed a skin assessment, LPN #11 stated, "I don't believe so." - When asked if the family mentioned any other concerns, LPN #11 stated, "No, just that he hurt in his stomach. I think his abdomen." On 3/29/12 at 2:10 pm, LPN #9 was interviewed regarding Resident #1. - LPN #9 stated he cared for Resident #1 on 2/25/12 from 6:00 pm until the resident was transferred to the ER. - LPN #9 stated that the previous shift had reported that, "The resident was in the assist dining room getting assistance with eating by a CNA, due to the resident was not eating very well." He was told the family suggested an over-the-counter medication for heartburn and that, "He (Resident #1) was doing OK. His pain was under control, not complaining, much less stomach upset." - LPN #9 stated the charge nurse said, "they were trying an antacid and it was working for him." - LPN #9 stated, "A family member said the resident needed to go to the ER." LPN #9 stated another nurse talked to the family and the charge nurse took care of the non-emergent transport. - LPN #9 was asked if he performed any assessments on Resident #1. LPN #9 stated, "I did a pain assessment, touched and listened to his belly, heard bowel sounds. The resident did not want to go to the ER, that we could take care of it here." -LPN #9 was asked if he performed any skin assessments. LPN #9 stated, "No-except just areas exposed. My first time assigned to this resident. The resident was out (of the facility) in around one hour of me showing up (for work). The resident said he had no pain and no indigestion." The ER physician report from a local hospital, dated 2/25/12, documented, "HISTORY: ...Today he (Resident #1) was complaining of abdominal pain in his right mid abdomen. ...PHYSICAL EXAM: Abdomen: ...He does, however, have a rash extending from the midline in the back around the right flank into the right midabdomen (sic). This rash is consistent with a [MEDICAL CONDITION] rash. ...EMERGENCY DEPARTMENT COURSE: ...I think the patient's abdominal pain was coming from his [MEDICATION NAME]" A history and physical report from the local hospital, dated 2/26/12, documented, "HISTORY OF THE PRESENT ILLNESS: ...He (Resident #1) has complained of some right lower quadrant abdominal pain, but apparently this had been fairly constant also... On evaluation in the Emergency Department, (physician name) discovered an area of a blistered-type [MEDICAL CONDITION] with the appearance of shingles, which were located on the lateral portion of the right lower quadrant of the abdomen. Workup showed no other likely etiologies for the abdominal pain complained of... PHYSICAL EXAMINATION: ...ABDOMEN: ...He has a large, at least 4 x 4 or little larger patch in the right lower quadrant. Lateral to that patch, though there are some what appeared to be healing and some very fine blistery-type [MEDICAL CONDITION] in a linear rate of approximately 2-3 inches long with the appearance of what could be shingles... ASSESSMENT AND PLAN: 1. Probable shingles, right lower quadrant of the abdomen. The patient has been started on [MEDICATION NAME]" NOTE: [MEDICATION NAME] or famciclovir was an [MEDICAL CONDITION] medication that "does not cure [MEDICAL CONDITION]" but "used to decrease pain and itching by allowing sores to heal and by preventing new ones from forming (McGraw-Hill in Nurse's Drug Hnadbook, 6th edition, 2011, page 446-447)." According to Lippencott Manual of Nursing Practice, 8th Edition, p. 1105, [MEDICAL CONDITION] is "usually diagnosed by clinical presentation." The CDC websites (http://www.cdc.gov/shingles/about/symptoms.html, http://www.cdc.gov/shingles/about/prevention-treatment.html) provided the following information regarding the rash associated with [MEDICAL CONDITION] (shingles): - "Shingles usually starts as a painful rash on one side of the face or body. The rash forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks. - Most commonly, the rash occurs in a single stripe around either the left or the right side of the body. In other cases, the rash occurs on one side of the face. ... - Other symptoms of shingles can include fever, headache, chills, upset stomach. - Several [MEDICAL CONDITION] medicines-[MEDICATION NAME], and famciclovir-are available to treat shingles. These medicines will help shorten the length and severity of the illness. But to be effective, they must be started as soon as possible after the rash appears. Thus, people who have or think they might have shingles should call their healthcare provider as soon as possible to discuss treatment options." On 3/30/12 at 9:30 am, DON #s 6, 7, & 8 and Administrator #s 3, 4, and 5 were informed that Resident #1's rash was diagnosed as [MEDICAL CONDITION] in the ER as documented above. DON #7 stated that information regarding the rash discovered on 2/23/12 according to the Skin Evaluation form, was passed on to the day shift LPN #12 who worked on 2/24/12 and that LPN #12 examined Resident #1's skin and did not find a rash. NOTE: There was no documentation in Resident #1's record that this assessment was performed. DON #7 stated that the rash from [MEDICAL CONDITION] "is transient during stress and could have diminished" so that LPN #12 did not see a rash when she examined Resident #1's skin. The survey team was provided with a hand written statement signed by LPN #12 and dated 3/30/12. The statement documented, in part, "On the day of February 24th 2012 this nurse got report from noc (night) nurse on (Resident #1). Nurse report possible rash to upper Rt (right) flank area. Asked this nurse to f/u (follow-up). This nurse took in AM meds (morning medications) to res(ident). (Family member named) in room with Res. This nurse went to res bed-side to assess res reguarding (sic) rash reported by noc nurse. Assessed Resident by sitting res up in bed look (at) resident back no skin issues/problems noted by this nurse looked (at) front of res also nothing found on Res trunk/Abd (abdomen) area. Spoke (with) (family member named) as I was doing assessment and told (family member) I was looking for a possible rash As I was doing an assessment. I believe PT (physical therapy) entered the room to work (with) (Resident #1." On 4/2/12 at 12:26 pm, the family member referenced in LPN #12's written statement was interviewed by the survey team on speaker phone. The family member stated that on the Friday morning before Resident #1 went to the ER, (which would be 2/24/12), he/she brought Resident #1 breakfast. An LPN entered the room and told the family member that an aide said he (Resident #1) had a rash on his back. The family member stated that during the LPN's check of the skin, he/she helped to pull Resident #1 forward so the LPN could check the resident's back. The family member stated, "He was too weak for me to look (at Resident #1's skin). The LPN said it was [MEDICAL CONDITION]." The family member was asked if the LPN described the rash. The family member stated the LPN said, "It looks like [MEDICAL CONDITION] to me." The family member was present in the ER when Resident #1 was transferred to theER on [DATE]. The family member was asked if Resident #1 was in pain. The family member stated, "Yes. My (Resident #1) is not very vocal, but he was grimacing and saying 'it's like knives stabbing me in the back and abdomen.' " Resident #1's ER nursing notes, dated 2/25/12, documented the "Complaint" as "Abdominal pain" and described Resident #1's abdominal pain, in part, as: - 8:21 pm: "Patient complains of pain described as, deep, on a scale 0-10 rates pain as 4. Pain is intermittent..." - 8:25 pm: "...c/o abdominal pain. ...Pt states he has had off/on pain. ...dull pain, periumbilical, to the suprapubic region. Onset of pain 5 hours ago, intermittent...Nothing has been tried to alleviate the pain." In summary: * Resident #1 was harmed when the facility failed to perform and document a thorough initial assessment of a right flank rash discovered on 2/23/12 and failed to perform ongoing assessments of the rash after it was discovered. The lack of thorough initial and ongoing assessments of the rash resulted in no clear clinical presentation of the rash, which according to Lippincott, was essential for the [DIAGNOSES REDACTED]. * Resident #1 experienced abdominal pain which was attributed to the [MEDICAL CONDITION] by the ER physician. Resident #1 did not receive [MEDICAL CONDITION] medications until 2/25/12, 2 days after the rash was discovered on 2/23/12. According to the CDC, [MEDICAL CONDITION] medications "will help shorten the length and severity of the illness" and "must be started as soon as possible after the rash appears. Thus, people who have or think they might have shingles should call their healthcare provider as soon as possible to discuss treatment options." In addition, [MEDICAL CONDITION] medications "are used to decrease pain and itching by allowing sores to heal and by preventing new ones from forming" according to McGraw-Hill. * Resident #1's rash was not reported to the physician (Please refer to F157) making it difficult for the physician to interpret the resident's increasing anxiousness and [MEDICAL CONDITION] and abdominal pain. According to RN #10, when called about the resident's abdominal pain, the physician stated, " 'Not a clear idea of what's going on.' So (the doctor) okayed for non-emergent (transfer) to ER." On 3/30/12 at 11:00 am, during the exit conference, Administrator #s 3, 4, and 5, and DON #s 6, 7, and 8 were informed of the deficient practice. The facility provided no other information or documentation that resolved the concern.

Based on record review, interview and observation, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This applied specifically to: 1) Monitoring Resident #3's acute on-set of swelling in the right knee. The resident's NPNs documented swelling, mild heat and redness to the resident's right knee on 10/25/10. The resident's NPNs did not provide evidence that nursing staff continued to perform thorough assessments of the resident's right knee from 10/27/10 through 11/2/10. On 11/2/10, a specialized out-patient treatment center contacted the facility. The treatment center notified the facility that Resident #3's right knee was inflamed, swollen, and Resident #3 was "moaning and grimacing." Resident #3 was harmed when the failure to monitor the resident's right knee resulted in a delay in treatment for [REDACTED]. 2) Resident #4's physician ordered and the resident was care planned for wheelchair and bed alarms, however the alarms were not in place for the resident. 3) In addition, based on a complaint from the public, it was determined the facility failed to perform thorough pain, skin, and urinary assessments on random Resident #15. Specifically; a) No thorough initial pain assessment to include the resident's use of a [MEDICATION NAME] pump for pain management, and no evaluation prior to and after receiving an oral pain medication; b) No thorough initial urinary assessment to identify the resident's brand and size of condom catheter, no evaluation prior to obtaining a urine culture, and no follow-up to the physician after the laboratory report was received; c) No thorough assessment to determine the cause or extent of the resident's "red" elbow, which was discovered just prior to the resident's discharge from the facility. This affected 3 of (#s 3, 4, and 15) sampled residents. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to The Mosby Medical Dictionary, revised edition, [DIAGNOSES REDACTED] is defined as, "a spasm of the muscle or a group of muscles." The resident's 10/21/10 quarterly MDS assessment coded severely impaired cognitive skills, unclear speech, sometimes able to make self understood, sometimes understood others, did not walk in room or corridor, totally dependent on two people for transfers and bed mobility, totally dependent on one person for locomotion on and off unit and for eating, toileting, bathing, and ROM impairment of both upper and lower extremities. The resident's medical record was observed with a pink colored paper on the outside of the record next to the resident's name. On the pink paper were the words, "chart daily q (every) shift." On 11/19/10 at 12:30 p.m., the ADON stated, "The chart daily q shift means that the medical doctor wants charting every shift on the resident." The resident's NPNs, Physician Notes, Physician/Prescriber Please Sign and Return forms (physician orders), and Diagnostic Imaging Report form documented the following: - NPN 10/25/10 at 6:30 a.m., "CNA noted pt (patient) guarding (right) knee, this LN assessed pt noted swelling, mild heat and redness in (right) knee, limited ROM (with right) knee (left) knee ROM WNL. Info(information) passed to day LN in report." Note: The NPN did not document the size of the swollen knee or measurement of the reddened area, firmness of the area, or level of pain. There was no Incident/Accident report initiated. - Local hospital Diagnostic Imaging report form, dated 10/25/10 at 5:43 p.m., verified that the resident was in the hospital x-ray department. Note: The observation of the resident's right knee was passed to the day LN in report on 10/25/10 at 6:30 a.m. However, the resident was not in the local hospital x-ray department until 10/25/10 at 5:43 p.m. for the x-ray. This constituted a delay in treatment of [REDACTED]. - Telephone order form 10/25/10, time not documented, "...x-ray (right) knee dx: (diagnosis) swelling of knee..." - NPN 10/25/10 at 6:00 p.m., "Call to (resident's doctor) about (right) knee wants pt sent to radiology for x-ray. Pt does guard the leg & has limited ROM. Med (with) 500 mg Tylenol at 1300 (medicated with 500 milligrams Tylenol at 1:00 p.m.)." Note: It is unclear when the physician was actually notified, as the NPN documented, "6:00 p.m.," however, the resident was in the x-ray department at 5:43 p.m. In addition, the LN did not document the size of the knee or measurement of redness, warmth, firmness of the area, or level of pain. - Physician Note 10/26/10, "...noted by her (Resident #3's) nurse yesterday to have a swollen right knee. No trauma per nursing. No fever. She holds her knee flexed...right knee swelling ? (question) cause with x-ray all WNL and no suggestion of effusion...follow for fever and worsening..." Note: The facility did not ensure an investigation was conducted, therefore, it was unclear how staff determined there was "no trauma" to the resident's knee. - NPN 10/26/10 at 3:40 a.m., "...x-ray to (right) knee still pending..." - NPN 10/26/10 at 11:00 a.m., "Pt oof @ (out of facility at specialized out-patient treatment center). Received x-ray of (right) knee back. Faxed to (resident's doctor's name)." Note: The nursing NPNs did not document the size of the knee or measurement of redness, warmth, firmness of the area, or level of pain on either shift. - NPN 10/27/10 at 5:00 a.m., "0 s/s (No signs or symptoms) of pain this shift. Pt does guard (right) knee does not appear tender to touch..." Note: The NPN did not document the size of the knee or measurement of redness, warmth, or firmness of the area. NOTE: The subsequent NPNs, dated 10/27/10 from 2:30 p.m. through 11/2/10 1:00 a.m., also did not contain documented evidence that the LNs assessed the resident's right knee for continued redness, warmth, firmness, or level of pain. - NPN 11/2/10 at 12:40 p.m., "(specialized out-patient treatment center) called about pt @ 1100. Stated her (right) knee was swollen & inflamed. They applied ice. (Resident's doctor's name) notified @ 1230 about pt's knee. Pt moaning and grimacing. Guarding knee & flexed towards torso." - Physician Note 11/2/10, no time recorded, "...Her (Resident #3's) nurse thought the knee seemed a little better yesterday (11/1/10)...Infection right knee suspect pre-patellar bursitis..." NOTE: Although the physician noted that the LN "thought the knee seemed a little better yesterday," there was no evidence that the LN documented any knee assessment on 11/1/10. The facility was notified by the outpatient treatment center of the worsening of the resident's knee. - NPN 11/3/10 at 1:00 a.m. There was no documented assessment of the resident's right knee despite the [DIAGNOSES REDACTED]. The following NPNs from 11/3/10 at 3:50 p.m., through 11/11/10 did not contain documented evidence that the resident's right swollen knee was thoroughly assessed for further signs/symptoms of infection or worsening of her condition. There were no measurements taken of the knee or redness to the area, or assessment for warmth or firmness. Her pain level was not adequately assessed. - NPN 11/3/10 at 3:50 p.m., "...Phys(ician) feels that (right) knee is [MEDICAL CONDITION]" - NPN 11/4/10 at 1:00 a.m., "...0 problems noted..." - NPN 11/4/10 at 9:30 a.m., "...0 s/sx (signs or symptoms) of pain or discomfort..." - NPN 11/5/10 at 5:00 a.m., "...swelling and redness of (right) knee (decreased) but pt still guarding & showing s/s (signs and symptoms) of pain..." - NPN 11/5/10 at 3:30 p.m., "...0 s/sx of pain or discomfort...(right) knee (with decreased) redness but still guarding & won't fully extend leg..." - NPN 11/6/10 at 2:35 a.m., "...0 s/s of pain this shift..." - NPN 11/6/10 at 9:30 a.m., "...knee still lightly red pt has knee drawn close to body..." - NPN 11/7/10 at 5:00 a.m., There was no documented assessment of the resident's right knee - NPN 11/7/10 at 9:40 a.m., "Pt keeps (right) knee flexed towards body. It is hard to let pt extend (right) leg...0 s/s (of) pain at this time..." - NPN 11/8/10 at 1:00 a.m., "...0 c/o (no complaints of) pain or discomfort noted..." - NPN 11/8/10 at 3:05 p.m., "...still keeps knee flexed towards body. 0 s/s (of) pain at this time..." - NPN 11/8/10 at 2:00 a.m., "...0 current c/o pain/discomfort..." - NPN 11/9/10 at 7:10 p.m., "Res(ident) continues to work (with) therapy for (right) knee 0 problems noted..." - NPN 11/10/10 at 5:00 a.m., "...0 s/s of pain. Pt moving (right) leg and redness/swelling appear to be resolving..." - NPN 11/10/10 at 3:00 p.m., "...(right) knee..looks better - 0 redness & swelling decreased..." - NPN 11/11/10 at 12:15 a.m., "...0 crying & moaning. 0 s/s of pain. Pt not guarding (right) knee as much as day before..." - NPN 11/11/10 at 3:00 p.m., "...knee looks better - 0 redness & swelling decreased...0 s/sx of pain or discomfort..." - NPN 11/12/10 at 1:10 p.m., "...0 redness or swelling to (right) knee..." - NPN 11/13/10 at 1:05 a.m., "...temp(erature) 100.1(degrees Fahrenheit (*F))..." NOTE: The resident's Vital Sign Flowsheet documented a temperature of 100.1 *F. There was no documented evidence that staff rechecked temperature to verify the elevated temperature or notified the physician despite the [DIAGNOSES REDACTED]." - NPN 11/13/10 at 3:30 p.m., "...0 redness in knee but pt keeps it contracted..." - NPN 11/14/10 at 1:30 a.m., "...redness better. sl (slight) red center of knee..." - NPN 11/15/10 at 1:35 a.m., "...0 redness or swelling to (right) knee..." - NPN 11/15/10 at 3:00 p.m., "...(decreased) redness of (right) knee will cont(inue) to assess..." - Physician Note 11/16/10, "...Still uncertain what caused or contributed to knee problem...Right knee [MEDICAL CONDITION] - better but not resolved..." On 11/18/10 at 11:30 a.m., the surveyor informed the interim DON that the resident's NPNs did not provide evidence that nursing staff monitored the right knee from 10/27/10 through 11/2/10. The DON stated, "When the resident's right knee was first observed, the resident's physician was notified. The resident's physician ordered an x-ray. The x-ray was within normal limits for age." The DON also stated, "I have no answer as to what or why (there is a lack of documentation) but it is evident there is no documentation (regarding the swollen knee) in the NPNs from 10/27/10 through 11/2/10 by nursing staff." On 11/18/10 at 2:00 p.m., the interim DON was again interviewed regarding the lack of documented evidence of an on-going assessment. The DON acknowledged that the medical record did not contain assessments of the right knee between 10/27/10 and 11/2/10. On 11/19/10 at 1:00 p.m., during the exit interview, the Administrator, the interim DON, and the ADON were informed that there was a delay in treatment for [REDACTED].#3's right knee was swollen and inflamed. On 11/22/10 at 11:52 a.m., the facility provided the Bureau of Facility Standards with additional documentation for consideration that included: 1) a cover letter signed by the Administrator, 2) a statement from the resident's physician, 3) 2 physician telephone orders, one dated 11/3/10 and one dated 11/4/10 (no time recorded on either form), both related to ordering an antibiotic for the resident, 4) 1 physician telephone order, dated 10/25/10, for x-ray of the right knee, 5) 1 physician telephone order, dated 10/26/10, for laboratory analysis, 6) 1 physician telephone order, dated 11/2/10, for another laboratory analysis and an appointment with another medical doctor for the swollen knee, 7) Vital Signs Flowsheet form, dated 10/22/10 thorough 11/18/10, that documented in part the resident's elevated temperatures on 10/29/10, 10/29/10, 10/30/10, and 11/5/10. 8) Physician Notes dated 10/26/10, 11/2/10, and 11/16/10, 9) Skin Observation - Shower forms, dated 10/25/10 through 11/4/10, 10) Daily Audit Forms dated 10/25/10 through 11/3/10. The Skin Observation - Shower forms contained a body diagram and a section next to the diagram to document the condition of the resident's skin. The form also contained 2 sections, one titled "CNA Comments" and another titled, "Licensed Nurse Comments (LNC)" and 5 different preprinted areas with a blank box next to the areas for staff to document yes or no. The 5 different areas were; bruises, skin tear, red areas, open areas, and rashes. NOTE: None of the following handwritten entries located near the body diagrams contained staff's names or initials. The following was documented on the forms. - 10/25/10, no handwritten documentation near the body diagram. The word "No" was marked next to "red areas." The form was signed by a CNA and a LN. The LNC section was left blank. - 10/26/10, circle marked around the right knee body diagram and a handwritten entry, "red & swollen." The word "Yes" was marked next to "red areas." The form was signed by a CNA and a LN. The LNC section was left blank. - 10/27/10, circle marked around the right knee body diagram and a handwritten entry, "looks better." The word "No" was marked next to "red areas." The form was signed by a CNA and a LN. The LNC section was left blank. - 10/28/10, circle marked around the right knee body diagram and a handwritten entry, "not much swelling." The word "No" was marked next to "red areas." CNA signed the form. The LNC section was left blank and there was no LN signature. Note: The handwritten entry, "not much swelling," appeared to be in different handwriting than that of the CNA who signed the form. It could not be determined which staff wrote the word, "not much swelling" near the right knee diagram. - 10/29/10, no handwritten right knee documentation. The word "No" was marked next to "red areas." The form was signed by a CNA and a LN. The CNA Comments and LNC sections were left blank. - 10/30/10, no handwritten right knee documentation near the body diagram. The word "No" was marked next to "red areas." The form was signed by a CNA and a LN. The LNC section was left blank. - 10/31/10, no handwritten right knee documentation near the body diagram. The word "Yes" was marked next to "red areas." CNA Comments, "area around anus...cream applied." The form was signed by a CNA and a LN. The LNC section was left blank. - 11/1/10, circle marked around the right knee body diagram and a handwritten entry, "still a little swollen." The word "Yes" was marked next to "red areas." The form was signed by a CNA and a LN. The LNC section documented, "Pt. has red irritated area on buttocks." The LN did not document any right knee findings in the comments sections. Note: The handwritten entry of "still a little swollen" appeared to be in different handwriting than that of the CNA or the LN who signed the form. It could not be determined which staff wrote the word, "still a little swollen" near the right knee diagram. - 11/2/10, circle marked around the right knee body diagram and a handwritten entry, "knee still swollen & red." The word "Yes" was marked next to "red areas." In CNA Comments section, "...right knee still swollen and red and appears painfull (sic)." LNC section, "Tx nurse aware - documented (treatment nurse aware and documented)." The form was signed by a CNA and a LN. Review of the treatment sheet revealed the treatment started was for the buttocks irritation. Also, there was no documented evidence that the LN assessed the knee after the CNA documented, "knee still swollen and red and painfull (sic)." - 11/3/10, no Skin Observation- Shower form provided. - 11/4/10, circle marked around the right knee body diagram and a handwritten entry, "better." The word "No" was marked next to "red areas." The form was signed by a CNA and a LN. The LN section was left blank. Note: The handwritten entry of "better" appeared to be in different handwriting than that of the CNA or the LN who signed the form. It could not be determined which staff wrote the word,"better" near the right knee diagram. Note: The above Skin Observation - Shower forms were not provided to the survey team during the survey process nor were the forms available in the resident's medical record. The LNs who signed the forms did not document a thorough assessment of the size of the knee or measurement of redness, warmth, firmness of the area, or level of pain. The documentation provided by the facility on 11/22/10 at 11:52 a.m. also contained a cover letter that documented in part, "...The records for the following days noted: (a) no fever present as her baseline temperature appears to be about 98.5 degrees and the recorded temperatures for the days following the physician visit do not differ from that approximate baseline by more than 1 degree... (b) in the days following the visit, the redness and swelling are noted to decrease on 10/27/2010 and 10/28/2010 with the notes being "looks better" and "not much swelling" on those respective days. Then 10/29/2010, 10/30/2010, and 10/31/2010 there is no evidence of redness and swelling of the knee. This information is pulled from the shower sheets filled out by the aides and licensed nurses when the patient receives a shower..." NOTE: The resident's 10/26/10 Physician Note documented in part, "...right knee swelling ? (question) cause with x-ray all WNL and no suggestion of effusion...follow for fever and worsening..." The resident's 11/2/10 Physician Note documented in part, "...Over the weekend she has had a low grade temp(erature) of up to 99.4 (degrees Fahrenheit (*F)) - but I was not called. Her nurse thought the knee seemed a little better yesterday (11/1/10)...she has ongoing swelling right knee but now purplish discoloration over superior and pre-patellar aspect of right knee. Some (increased) warmth. She holds it in flexion to 60* now...infection right knee suspect prep-patellar bursitis...schedule appt (appointment) with (specialist physician) tomorrow...lab(oratory) today..." IN ADDITION: The NPNs and Skin Observation - Shower forms did not contain any assessment that Resident #3's swollen right knee had, "purplish discoloration over superior and pre-patellar aspect of right knee" as noted by Resident #3's physician on 11/2/10. Resident #3 was a resident who was severely cognitively impaired. The resident had unclear speech and was sometimes understood and sometimes understood others. The resident was found with a swollen right knee on 10/25/10 and licensed nursing staff did not thoroughly assess the resident's right knee. The medical record contained limited documentation regarding the swollen right knee from 10/25/10 through 10/27/10. There was no documentation of the swollen right knee from 10/27/10 through 11/2/10. The facility was notified by a specialized out-patient treatment facility that Resident #3's right knee was swollen and inflamed and the resident was "moaning and grimacing." Although the facility was made aware of the swollen right knee, the licensed nursing staff did not thoroughly assess Resident #3's swollen right knee for signs and symptoms of worsening or improvement after 11/2/10. 2. Resident #4 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 11/10 physician's orders [REDACTED]. 1) 6/18/10 order date, "Tab alarm when in bed to alert staff of unsafe transfers." 2) 6/18/10 order date, "Tab alarm when up in w/c (wheelchair) to alert staff of unsafe transfers. The resident's undated "Falls-Risk for Injury" care plan documented a 6/18/10 problem/need of risk for falls with potential for injury. The problem/need date column contained a handwritten entry that documented, "reviewed 9/17/10." One of the problem/need approach plans was, "Tab alarm wib, wiwc (Tab alarm when in bed and when in wheelchair)." On 11/17/10 at 11:00 a.m., the surveyor observed that there were no tab alarms on the resident's wheelchair or bed. The resident stated, "There are no alarms on the wheelchair or the bed. There were (alarms) when I first came in." - At 11:05 a.m., the MDS Coordinator stated, "We aren't ready to take the alarms off the care plan yet as we are not confident that they are not needed." On 11/18/10 at 1:50 p.m., LN #11 stated, "I am not sure about the alarms. When he was first admitted , he was on the other unit. " - At 2:25 p.m., LN #1 stated, "When he was on our unit, he kept removing the alarms. I am not sure about if or when the alarms were discontinued." On 11/19/10 at 1:00 p.m., the Administrator, the interim DON, and the ADON were informed of the findings. No further information was provided. 3. The complainant alleged an identified resident did not receive proper respite care while in the facility and developed skin breakdown, and a urinary tract infection. Resident #15 was admitted to the facility on [DATE] for respite care and discharged on [DATE]. He had [DIAGNOSES REDACTED]. The resident currently had an implanted [MEDICATION NAME] pump for pain management, had a history of [REDACTED]. a) The resident's record contained a Comprehensive Resident Admission Assessment form, signed by an LN and dated 10/22/10, which identified on the Skin Integrity body diagram that the resident had a "pain pump" located on his right mid-abdomen. The Pain Assessment Form, also signed by the LN and dated 10/22/10, contained instructions which directed the LN to complete the entire form if the resident's answer to the first three pain questions was "Yes." The form documented the resident had responded "Yes" to each question. The form directed, "List current pain management measures in use..." This section was left blank. The "Comments" section was also left blank. The Pain Risk Assessment form, signed and dated by the same LN on 10/22/10, documented the resident's pain risk score was "14" or high risk. The October 2010 MAR indicated [REDACTED]. The resident's NPNs were reviewed from the time of admission through discharge. There was no mention of the resident's use of the [MEDICATION NAME] pump. The entries on 10/24/10 at 1:30 pm, and 10/26/10 at 10:30 am, contained the only mention of the resident's pain level and the resident had no complaints of pain. The Pain Assessment & Intervention form contained documentation on 10/22, 23, 24, and 26, 2010, that the resident had no signs/symptoms of pain. There was no documentation for 10/25/10. The resident's record contained a physician order, dated 10/25/10 at 1:40 pm, which directed in part, "[MEDICATION NAME] 10/325 (one by mouth) one time dose...(increased) pain." The verbal order was written by an LN for the treating physician. The order was signed but not dated by a nurse practitioner. The MAR indicated [REDACTED]. Neither the MAR, the Pain Assessment & Intervention form, nor the nurses notes contained any documentation of the location or intensity of the resident's pain. There was also no documentation of the pain medication's effectiveness. On 11/17/10 at 3:10 pm, during an interview with the DON and the ADON, the ADON stated that on Monday, 10/25/10, she was called into the resident's room by a visitor. "The resident seemed in pain. (Physician's name) was notified and he came in and visited with the resident...he ordered a one time dose of [MEDICATION NAME]. After the medication he (Resident #15) was happy as a lark." The DON and ADON were informed that the surveyor did not find documentation in the record of the resident's pain level or of the physician's visit to the resident. At the time of the survey exit, no further documentation was received. b) Resident #15's physician history and physical report, dated 10/13/10, identified: "...Recurrent urinary tract infection, possibly secondary to a [MEDICAL CONDITION] bladder, kidney stones, possibly contributing to his recurrent infections...Keflex 500 milligram caps one daily to prevent recurrent UTI..." The Comprehensive Resident Admission Assessment form, signed by an LN and dated 10/22/10, documented the resident had urinary incontinence and wore, "condom cath(eter) and breifs (sic.)" The Bladder Incontinence Evaluation form, also signed by the LN and dated 10/22/10, documented under Contributing Factors/Conditions, "[MEDICAL CONDITION]." Urinary tract infection was not marked on the form. The section, Bladder Status, documented: Catheter: "Yes." If yes, specify type and size: "Condom Cath." NOTE: The form did not identify which brand or size condom catheter the resident wore. The form also did not identify any additional products that might have been needed to keep the condom catheter in place. The physician's admission orders [REDACTED]." The resident's NPNs were reviewed from the time of admission through discharge. The entries did not identify any signs/symptoms of a possible urinary tract infection. The entries on 10/23/10 at 5:00 am, and 1:30 pm, 10/24 at 4:45 am, and 1:30 pm, identified the resident's condom catheter was intact and to dependent drainage. The entries on 10/25 at 2:30 am, and 10/26 at 10:30 am, documented, "Foley (catheter) to DD (dependent drainage.) NOTE: A Foley catheter is an indwelling urinary catheter, not an external condom catheter. The resident's record contained a physician order, dated 10/25/10 at 1:40 pm, which directed in part, "UA (urinalysis) and culture...UTI? (question if a urinary tract infection was present.)" The verbal order was written by an LN for the treating physician. The order was signed but not dated by a nurse practitioner. On 11/17/10 at 3:10 pm, during an interview with the DON and the ADON, the ADON stated that on Monday, 10/25/10, she was called into the resident's room by a visitor. "The resident seemed in pain. (Physician's name) was notified and he came in and visited with the resident...he ordered a UA." The DON and ADON were informed that the surveyor did not find documentation in the record that the resident had any signs/symptoms of a urinary tract infection or of physician's visit to the resident. The laboratory report documented: "Collection date, 10/25/10 at 5:17 pm, Result date, 10/26/10 at 8:53 am...Urine Culture: Culture Observations, Greater than 100,000 cfu/ml (colony-forming units per milliliter of specimen) Gram Negative Rods." NOTE: Other than the laboratory report, there was no documentation in the resident's record that the urinalysis was obtained. There was no documented evidence that after the report was received by the facility, that the physician was notified in order for him to determine the need for further studies or if antibiotic medication was indicated. NOTE: The resident was admitted to the facility on Friday, 10/22/10 at approximately 4:30 pm. The urine specimen was obtained on Monday at approximately 5:00 pm. Based on this timeframe, it could not be determined if the resident, who had a history of [REDACTED]. c) The physician's history and physical report, dated 10/13/10, identified: "...HX (History) of decubitus ulcer (pressure ulcer) status [REDACTED]. The Comprehensive Resident Admission Assessment form, signed by an LN and dated 10/22/10, identified on the Skin Integrity body diagram that the resident had a vertical scar along his spinal region and a scar on the sacrococcygeal region, "Scar (with) pink blanch (blanchable) area." There were no other pressure point areas marked on the body diagram. The Braden Scale form, also signed by an LN and dated 10/22/10, identified the resident was at high risk for the development of pressure ulcers. The resident's NPNs were reviewed from the time of admission through discharge. The only entry documenting a skin assessment was at the time of discharge on 10/26/10 at 10:30 am, "...Skin (check) done prior to departure - (No) open areas observed..." The Discharge Skin Assessment form, not signed or dated by any LN, documented on the body diagram that the right elbow site was "Red." There was no size recorded or description if the red area blanched or not. The form contained the pressure ulcer staging definitions. "Stage I: Nonblanchable [DIAGNOSES REDACTED] of intact skin, the heralding lesion of skin ulceration..." The form also contained a section for staff to document any pressure point assessment findings. NOTE: This section was left blank. The form also contained a section which directed: "Document...including scars over bony prominences." NOTE: The sentence was underlined for its importance in the skin assessment process. The section was left blank despite the documentation in the Comprehensive Resident Admission Assessment and physician H & P that the resident had a history of [REDACTED]. The LN failed to thoroughly assess the "Red" area on the right elbow to determine if the area blanched or if the red area was a Stage I pressure injury. On 11/17/10 at 9:15 am, the LN who wrote the discharge nurses note was interviewed. LN #1 acknowledged she had not assessed the resident's skin prior to discharge. The LN identified a second LN, LN #2, who had actually performed the skin assessment. On 11/17/10 at approximately 9:55 am, the surveyor contacted LN #2 by telephone. The DON and the payroll supervisor were present in the room during the interview. The LN stated that the nurse who was assigned to Resident #15 was on lunch break, so she performed the skin assessment on the resident. She stated she performed a full head-to-toe assessment and noted no redness or skin breakdown, to the sacrum, coccyx, buttock region, or heels. She verified that she filled in the documentation on the form, including writing the word, "Red" at the right elbow site. At this time she and the DON were informed that there was no LN signature or date on the form. At the time of the survey exit, no further documentation was received from the facility regarding the resident's pain, urinary, or skin assessments.