Every finding on record at Grangeville Health & Rehabilitation of Cascadia

Based on observation, Food Drug Administration (FDA) Food Code review, record review, and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained, cleaned, and sanitized. These deficiencies had the potential to affect the 42 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include:The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented, surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned. Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.The FDA Code Section 4-602.12 Cooking and Baking Equipment documented, food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use.The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. On 8/7/25 at 7:30 AM, the following was observed:Baking sheets had a black layer of encrusted residue.Ceiling vent over the food preparation area had a layer of grey particles accumulated.Large ceiling vent over the reach in refrigerator had a thick layer of dark grey particles accumulated over the majority of the vent.Ceiling over food preparation area had a dark residue in various circular sizes.Wall/door frame entering dry goods area attached to food preparation area had food/grime particles on wall.On 8/7/25 at 7:45 AM, the Dietary manager stated, the baking sheets are just stained, and we use baking sheet covers, then used her fingernail to scrape off the black residue. She then confirmed they were dirty and should be cleaned better. The Dietary Manager stated the vents in the kitchen are scheduled to be cleaned weekly. When asked about the state of the air vents in the ceiling she confirmed they looked dirty and the large vent over the reach in refrigerator looked like that one had not been cleaned in a while. The Dietary Manager confirmed the wall/ door frame entering the dry goods area and the ceiling needed to be cleaned. The Dietary Manager confirmed the kitchen cleaning and sanitation should be done at least weekly and had not been.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure infection prevention standards of practice were maintained during insulin administration. This was true for RN #1 when she was observed administering an insulin injection. This failure created the potential for harm to all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The [NAME] Pharmaceuticals, Semglee Prefilled Insulin Pen- Instructions for Use, approved 7/2021, documented to always wipe the rubber seal on the insulin pen with alcohol before attaching a new pen needle on to the insulin pen.The Centers for Disease Control (CDC) Infection Control, Standard Precautions for All Patient Care, web page, dated 4/3/24, accessed on 8/14/24, documented Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. The web page instructs to perform hand hygiene after contact with a contaminated surface and use personal protective equipment (PPE) whenever there is an expectation of possible exposure to an infectious material.The facility's Insulin Pen Demonstration of Skill checklist documented staff would perform hand hygiene and put on gloves, wipe the rubber seal of the insulin pen with alcohol before attaching a new pen needle, and wipe the insulin pen off with a 10% bleach disposable cloth before returning the pen to the medication cart.On 8/7/25 at 7:20 AM, RN #1 was observed preparing an insulin injection. She was observed performing hand hygiene, taking the cap off the insulin pen, attaching a new pen needle onto the insulin pen, verifying the appropriate information on the MAR, and using the dose knob to set the dose. RN #1 was not observed to wipe the rubber seal of the insulin pen with alcohol before attaching a new pen needle. RN #1 then walked to the resident room, greeted him, informed him she was going to administer his insulin injection, used an alcohol swab to clean the injection site on his abdomen, and inserted the needle into his skin. RN #1 was not observed performing hand hygiene or putting on gloves before administering the injection. The dose knob was observed clicking while the dose was delivered. After the clicking had completed, RN #1 was observed to wait approximately 2-3 seconds before removing the needle from his skin. RN #1 then disposed of the used pen needle in the sharps disposal and performed hand hygiene, put the cap back on the insulin pen, returned it to the medication cart, and documented the insulin administration in the MAR. RN #1 was not observed wiping the insulin pen with a disinfecting wipe before returning it to the medication cart.On 8/7/25 at 7:30 AM, RN #1 stated she did not perform hand hygiene and put on gloves because she did not touch the residents' skin with her bare skin. She stated she was in a hurry and forgot to wipe the rubber seal with alcohol before attaching a new pen needle and forgot to wipe the pen off with a disinfecting wipe before putting it away.On 8/7/25 at 9:38 AM, the Infection Prevention Nurse stated, the nurse should be performing hand hygiene and wearing gloves when administering an insulin injection.On 8/8/25 at 11:07 AM, the DON stated, the Insulin Pen Demonstration of Skill checklist is the procedure all nurses should be following when administering insulin with an insulin pen. The DON stated she could not provide documentation RN #1 had satisfactorily returned demonstration of skill for administering insulin using an insulin pen.

Based on record review, CDC guidance, policy review and staff interviews, it was determined the facility failed to ensure residents were offered and/or administered the appropriate pneumococcal vaccine as indicated. This was true for 2 of 5 residents (#5 and #13) reviewed for pneumococcal immunizations. This deficient practice placed residents at risk of developing pneumococcal pneumonia, a potentially life-threatening condition. Findings include:The facility's Pneumococcal Program policy for residents revised 2/22/22, documented the following:Adults 65 years or older who have not previously received PCV (a form of pneumococcal pneumonia vaccine) or whose previous vaccination history is unknown, should receive 1 dose of either PCV20 or PCV15. a. If PCV20 is used, no additional dosing recommended. b. If PCV15 is used, it should be followed by a dose of PPSV23 (another form of pneumococcal pneumonia vaccine) one year later.Adults aged 19-64 years with certain underlying medical conditions or other risk factors who have not previously received PCV or whose previous vaccination history is unknown should receive 1 dose of PCV20 or PCV15.1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood. Resident #5 was over the age of 50 at the time of admission.Resident #5's immunization history on his EMR did not document he had received the pneumococcal vaccine.Resident #5's Informed Consent for Vaccines form, dated 11/13/24, documented he was offered the Influenza, Covid-19, and RSV vaccines. The informed consent form documented Resident #5 was not offered the pneumococcal vaccine.On 8/7/25 at 10:00 AM, the online CDC Pneumovax Adviser web page recommended Resident #5 should have been offered one dose of PCV15, PCV20, or PCV21. On 8/7/25 at 10:09 AM, the IP nurse reviewed resident #5's record and confirmed, he should have been offered the pneumococcal vaccine, and he was not. 2. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, high blood pressure, and dementia. Resident #13 was over [AGE] years old on admission.Resident #13's immunization history on her EMR documented she had received PPSV23 on 9/24/20.Resident #13's Informed Consent for Pneumococcal Vaccine form dated 11/14/24, documented she was not offered a pneumococcal vaccine.On 8/7/25 at 10:20 AM, the online CDC Pneumovax Adviser web page documented Resident #13 should have been offered one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23.On 8/7/25 at 10:25 AM, the IP nurse reviewed Resident #13's record and confirmed, she should have been offered the pneumococcal vaccine PCV15, PCV20, or PCV21 at least one year after her last dose of PPSV23, and she was not.

Based on record review, CDC guidance, and staff interview, it was determined the facility failed to ensure COVID-19 vaccinations were offered and administered to the residents. This was true for 1 of 5 residents (Resident #17) whose COVID-19 vaccinations were reviewed. This deficient practice placed residents at risk of severe illness, hospitalization, and death due to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus - the virus that causes the COVID-19 illness) and had the potential to affect all residents in the facility. Findings include:The CDC website article titled: Staying Up to Date with COVID-19 Vaccines dated 6/6/25 and accessed on 8/15/25 documented:Protection from COVID-19 vaccine decreases over time.Immunity after COVID-19 infection decreases with time.The 2024-2025 vaccine is especially important if you: a. Never received a COVID-19 vaccine, b. Are ages 65 years and older c. Are at high risk for severe COVID-19 d. Are living in a long-term care facility.1. Resident #17 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD), heart disease and acute respiratory failure. Resident #17 was over the age of 65 at the time of admission.Resident #17's COVID-19 Vaccination consent form dated 3/28/25, documented he signed an informed consent to receive the COVID-19 vaccine.Resident #17's record did not include documentation the COVID-19 vaccine was administered to him after he consented on 3/28/25.On 8/7/25 at 9:50 AM, the IP Nurse reviewed Resident #17's record and stated she did not find documentation the COVID-19 vaccine was administered. The IP Nurse stated she did not know why Resident #17 did not receive the COVID-19 vaccine after he signed the informed consent on 3/28/25.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 1 of 2 residents (#5 and #26) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include:The RAI Manual, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood. Resident #5's Annual MDS Assessment, dated 8/8/24, documented under A1500 in Section A, no for the question, Is the resident currently considered by the State Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II observed in his electronic medical record, dated 8/8/23. 2. Resident #26 was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, depression, anxiety, and psychotic disorder with delusions. Resident #26's Admissions MDS Assessment, dated 1/20/25, documented under A1500, no, for the question, Is the resident currently considered by the State Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Although, Resident #26's EHR documented a PASRR Level II dated 2/10/25. On 8/6/25 at 9:45 AM, the MDS Coordinator stated Resident #5 and #26's MDS assessments were coded in error at question A1500 and did not accurately reflect their mental health diagnoses.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure a licensed nurse had the specific skill set necessary to appropriately administer an insulin injection. This was true for RN #1, when she was observed administering an insulin injection. This failure created the potential for adverse effects if the resident did not receive the complete dose of their insulin. Findings include:The [NAME] Pharmaceuticals, Semglee Prefilled Insulin Pen- Instructions For Use, approved 7/2021, documented the following instructions:- Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles. The safety test instructions direct the person preparing the injection, after attaching a new pen needle, to select a dose of 2 units of insulin, to hold the pen needle pointing upwards, tap the cartridge so that any air bubbles rise up to the needle, then press the injection button all the way down, ensuring insulin comes out of the needle.- For dose injection, insert the needle into the skin, deliver the dose by pressing the injection button all the way, the number in the dose window will return to 0 [zero] as you inject, the dose knob will turn and you will hear clicks as you press down, keep the injection button pressed all the way in, slowly count to 10 before you withdraw the needle from the skin, this ensures that the full dose will be delivered. The facility's Insulin Pen Demonstration of Skill checklist documented staff would perform a safety test of the insulin pen and pen needle to remove air bubbles and validate they were functioning correctly before delivering the dose, and while delivering the dose, the staff should slowly count to 10 to ensure the full dose was delivered before withdrawing the needle from the skin.On 8/7/25 at 7:20 AM, RN #1 was observed preparing an insulin injection. She was observed performing hand hygiene, taking the cap off the insulin pen, attaching a new pen needle onto the insulin pen, verifying the appropriate information on the MAR, and using the dose knob to set the dose. RN #1 then walked to the resident room, greeted him, informed him she was going to administer his insulin injection, used an alcohol swab to clean the injection site on his abdomen, and inserted the needle into his skin. RN #1 was not observed performing the safety test before the injection. The dose knob was observed clicking while the dose was delivered. After the clicking had completed, RN #1 was observed to wait approximately 2-3 seconds before removing the needle from his skin. RN #1 was not observed to slowly count to 10 before withdrawing the needle to ensure the full dose was delivered. RN #1 then disposed of the used needle in the sharps disposal and performed hand hygiene, put the cap back on the pen, returned it to the medication cart, and documented the insulin administration in the MAR.On 8/7/25 at 7:30 AM, RN #1 stated she did not realize she should perform a safety test before each injection and stated she was in a hurry and did not realize she had rushed the administration of the insulin injection.On 8/8/25 at 11:07 AM, the DON stated, the Insulin Pen Demonstration of Skill checklist is the procedure all nurses should be following when administering insulin with an insulin pen. The DON stated she could not provide documentation RN #1 had satisfactorily returned demonstration of skill for administering insulin using an insulin pen.

Based on review of the Payroll Based Journal (PBJ) Staffing Data Report, record review, and staff interview, it was determined the facility failed to ensure an RN was on-site for 8 consecutive hours, 7 days a week. This failure created the potential for harm if routine and/or emergency nursing needs were unmet and had the potential to affect the 46 residents living at the facility. Findings include: The facility's PBJ Staffing Data Report for Fiscal Year, Quarter 3, 2024 (April 1 - June 30), documented the facility reported an RN was not on-site on the following 7 dates: -Sunday 4/7/24 -Saturday 4/20/24 -Sunday 4/21/24 -Saturday 5/4/24 -Sunday 5/5/24 -Saturday 6/1/24 -Saturday 6/15/24 The facility's Three-Week Nursing Hours worksheet, completed by the Administrator, documented there fewer than 8 consecutive hours of RN on-site coverage for the following 6 dates: -Sunday 9/29/24 documented 1.50 RN hours -Saturday 10/5/24 documented 2.25 RN hours -Sunday 10/6/24 documented 1.38 RN hours -Saturday 10/12/24 documented 0.00 RN hours -Sunday 10/13/24 documented 4.22 RN hours -Saturday 10/19/24 documented 0.00 RN hours In addition to the above dates, the facility's labor report for April 1 - October 19, 2024, documented there were fewer than 8 consecutive hours of RN on-site coverage for the following 10 dates: -Thursday 7/4/24 documented 0.00 RN hours -Saturday 7/27/24 documented 1.35 RN hours -Sunday 7/28/24 documented 0.00 RN hours -Saturday 8/10/24 documented 2.50 RN hours -Sunday 8/11/24 documented 4.12 RN hours -Saturday 8/24/24 documented 1.50 RN hours -Sunday 8/25/24 documented 0.00 RN hours -Saturday 9/14/24 documented 0.75 RN hours -Sunday 9/15/24 documented 3.17 RN hours -Saturday 9/28/24 documented 0.00 RN hours On 10/24/24 at 4:39 PM, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were interviewed together. The DON stated the facility did not have enough RNs to staff the weekends and they have an RN on-call who would come into the facility in case of emergency. The DON added, if an RN on-call were to come into the facility on the weekend, it was unlikely they would work 8 consecutive hours. On 10/24/24 at 4:49 PM, the Administrator stated the facility has not been able to hire any RNs and he understood the facility did not meet the regulatory requirement to have an RN on-site for 8 consecutive hours, 7 days a week.

Based on record review and staff interview, it was determined the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR), was completed within the required timeframe for 1 of 5 residents (Resident #40) reviewed for PASARR screenings. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: Appendix PP of the State Operation Manual, revised 8/8/24, documented all applicants to Medicaid-certified nursing facilities are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level 1 and should be completed prior to admission to a nursing facility. Resident #40 was admitted to the facility on [DATE], with multiple diagnoses including traumatic brain injury and alcohol-induced dementia. Resident #40's care plan, created on 9/4/24, documented Resident #40 was prescribed an antidepressant medication related to his depression and dementia. Resident #40's medical record included a completed Level 1 PASSAR for Washington State. His record did not include a completed Level 1 PASARR for the State of Idaho. On 10/24/24 at 6:07 PM, the facility's Administrator and the Social Services Director (SSD) were interviewed and Resident #40's record was reviewed in their presence. The SSD stated she was responsible for ensuring PASSARs were completed and entered into a resident's record when they were admitted to the facility. She confirmed Resident #40 was transferred to the facility from another facility in Washington State and was not provided with an Idaho Level 1 PASSAR before his admission. The Administrator confirmed the Idaho PASSAR should have been completed before Resident #40 was admitted to the facility.

Based on observation, interview, and record review the facility failed to implement accepted infection control standards related to donning (putting on) and doffing (taking off) PPE (personal protective equipment) for residents on droplet precautions due to 14-day quarantine for residents newly admitted to the facility. This failure potentially placed residents in the facility at risk for exposure to the [MEDICAL CONDITION] and potential for facility transmission of COVID-19. Findings include: During the entrance interview on 7/22/20 at 8:45 AM, the administrator and the DNS reported the facility was COVID-free with no residents or staff tested positive for COVID-19. The administrator reported the surrounding community had no COVID spread. The facility had four residents on droplet precautions for new admission 14-day quarantine status. During observations conducted 7/22/20 at 10:45 AM on the 100 Hall resident room [ROOM NUMBER] had signage that indicated droplet + precautions. Observation revealed no PPE or supplies for droplet precautions outside the room. Nursing assistant CNA1 explained the process for room [ROOM NUMBER]. room [ROOM NUMBER] was empty and had an adjoining bathroom with room [ROOM NUMBER] so room [ROOM NUMBER] was the clean side where staff donned PPE. PPE and other supplies were in room [ROOM NUMBER]. CNA1 said staff washed hands and donned PPE in room [ROOM NUMBER] then entered room [ROOM NUMBER] through the bathroom. PPE was doffed in the room and staff exited 104 directly into the corridor. On 7/22/20 at 11:10 AM housekeeper (HK1) correctly donned PPE in room [ROOM NUMBER] and entered room [ROOM NUMBER] through the bathroom. HK1 completed the cleaning of room [ROOM NUMBER] then doffed PPE at the door and exited directly into the corridor still wearing the goggles. When HK1 reached the housekeeping cart in the corridor HK1 realized HK1 still had the goggles on. HK1 removed the goggles, took them into room [ROOM NUMBER], and placed the soiled, potentially contaminated goggles on a paper towel on the sink counter. HK1 sanitized the goggles with bleach wipes but then placed the goggles back down on the same paper towel which was contaminated when the soiled goggles were placed on it. When asked: If the goggles were not considered clean when placed on the paper towel; was the paper towel still considered clean now? HK1 replied; Oh no it's not, I will redo it. HK1 sanitized her hands and again sanitized the goggles then placed them on a clean paper towel which served as a barrier between the goggles and the sink surface. On 7/22/20 at 11:45 AM the clinical nurse manager (CNM1) was present during observation as therapy staff (TS1) donned PPE to enter resident room [ROOM NUMBER] to deliver a recliner chair. Signage indicated droplet precautions and PPE supplies were located in a movable cart in the corridor next to the door to room [ROOM NUMBER]. TS1 wore a mask and donned gown then gloves and finally a face shield. At 11:47 AM TS1 removed gloves and placed them in the trash bin in the room and immediately donned new gloves. TS1 did not wash hands or use alcohol based hand gel with glove change. TS1 wiped down the hand truck with bleach wipes then removed gloves and performed hand hygiene when exiting the room. In an interview immediately following the observation, CNM1 confirmed TS1 donned PPE in incorrect order. CNM1 said the face shield should be donned before gloves. Gloves should be donned last. Additionally CNM1 confirmed TS1 failed to perform hand hygiene with glove change. CNM1 said she provided weekly education on donning and doffing PPE. CNM1 said the education included the order to don and doff PPE and the proper use of barriers. CNM1 said TS1 and HK1 had training regarding PPE. Signage posted in the facility indicated the order to don and doff PPE. Order to don; 1. Gown 2. Mask and eye protection 3 gloves and order to doff 1. Gloves 2. Gown 3. Mask and eye protection. The posted signage was consistent with the CDC (Centers for Disease Control and Prevention) guidelines for PPE use.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food was prepared and served under sanitary conditions when staff members' hair was observed not properly restrained in a hairnet. This failure created the potential for each of the 38 residents residing at the facility to be exposed to food contamination and potential disease-causing pathogens. Findings include: The facility's policy and procedure for Food Handling, dated 6/13/18, directed food handlers to wear hairnets or caps to effectively keep hair from contacting exposed food, clean equipment, utensils and linens. The (YEAR) Food and Drug Administration Food Code, Chapter 2, regarding hygienic practices and hair restraints, documented Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens and unwrapped single-service and single-use articles. On 2/3/20 at 11:35 AM, Dietary Staff (DS) #2 and the Dietary Manager (DM) were observed in the kitchen as they prepared food for the lunch meal. DS #2 wore her hair up in a pony tail on the top of her head with a large flower attached to the pony tail, and loose hair flowed down the back of her head and neck. DS #2 wore a hairnet over her pony tail. DS #2's hairnet did not cover the hair that flowed down the back of her head and neck, and her hair was exposed from root to tip. The DM wore a scarf which was tied to her head. The DM's scarf did not cover her bangs which flowed freely from root to tip. The DM and DS #2 wore their hair in this manner throughout the preparations and delivery of food for the lunch meal. On 2/4/20 at 8:10 AM, DS #2 and the DM were observed in the kitchen as they prepared food for the breakfast meal. DS #2 had her hair up in a pony tail with a large flower attached to the pony tail. DS #2 wore a hairnet around her pony tail and flower and down slightly on the back of her head but above the level of her ears. There was a significant amount of loose hair that was not contained in the pony tail or the hairnet. The DM wore a scarf which was tied to her head in alignment with her ears. The DM's bangs were not covered and flowed freely. On 2/4/20 at 12:06 PM, the DM said she was not positive about the facility's policy requirement for restraining hair while working in the kitchen. The DM said she believed all of the hair needed to be covered.

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure staff performed proper hand hygiene and appropriate peri-care during resident cares. This was true for 1 of 4 residents (Resident #3) who was observed during resident cares. The deficient practice placed residents at risk of infection from cross-contamination. Findings include: The facility's policy and procedure for Handwashing, dated 6/13/18, directed staff to wash their hands before applying and removing gloves, before handling clean supplies or equipment, and before and after contact with non-intact skin, mucous membranes, blood, or any moist body fluid, even if gloves were worn during contact. The facility's policy and procedure for Incontinent Care While in Bed, dated 2/27/18, documented staff were to: * Remove the incontinent brief from the patient by rolling the brief/pad toward the inside soiled area, and remove the brief from front to back containing the fecal matter as much as possible * Cleanse the skin of patient from front to back and clean to dirty using incontinent wipes * Replace the soiled brief with a fresh brief or pad * Remove their gloves and discard them into a designated container * Wash and dry hands thoroughly On 2/4/20 at 8:34 AM, CNA #1 and CNA #2 were observed providing pericare to Resident #3. CNA #1 and CNA #2 repositioned Resident #3 to her left side, rolled the soiled incontinent brief and placed a clean incontinence brief under Resident #3's left hip. CNA #2 then wiped the feces from Resident #3's buttocks. CNA #1 and CNA #2 then rolled Resident #3 onto her back slightly to her right side to remove the soiled incontinence brief and then unrolled the clean incontinence brief. Resident #3 was repositioned on her back with the clean incontinence brief placed under her buttocks. CNA #2 continued providing pericare to Resident #3 using the same soiled gloves she used to wipe Resident #3's feces from her rectal area. CNA #2 then proceeded to clean Resident #3's genitalia using the same soiled gloves. CNA #2 then pulled the front side of the clean incontinence brief and fastened the tape. CNA #2 did not change her gloves or sanitize her hands between dirty and clean tasks during pericare. CNA #2 also did not fully clean Resident #3's peri area prior to placing her on the clean incontinence brief. On 2/4/20 at 8:47 AM, CNA #1 said Normally we would not have continued to clean her after she was on the clean pad. CNA #1 said they were trying not to roll Resident #3 more than they had to roll her because she was in pain. On 2/6/20 at 9:12 AM, the DON said her expectation was for staff to clean both sides of a resident's periarea prior to applying new incontinence brief. The DON said the way the staff provided pericare to a resident may vary slightly depending on the resident's needs. The DON also said she did not think it was necessary for the staff to remove their gloves or sanitize their hands between dirty and clean tasks. On 2/6/20 at 2:10 PM, during the follow-up interview, the DON said the CNAs were to wash their hands every time they removed their gloves. The DON said the CNAs should have wiped Resident #3's front side and then cleansed her back side. The DON also stated it was okay for the CNA to apply the clean incontinence brief before they removed the soiled gloves or sanitized their hands.

Based on staff interview and record review, it was determined the facility failed to ensure residents receiving [MEDICAL CONDITION] medications had clear indications for use of the medications and clinical rationale supporting the continued use of the medications. This was true for 1 of 5 residents (Resident #12) whose records were reviewed for unnecessary medications. This deficient practice had the potential for harm if residents received [MEDICAL CONDITION] medications that were unwarranted and used for excessive duration. Findings include: Resident #12 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #12's quarterly MDS assessment, dated 11/25/19, documented she was cognitively intact and received anti-psychotic and anti-depressant medications in the past 7 days. Resident #12's physician order [REDACTED]. * [MEDICATION NAME] (anti-depressant medication) 50 mg tablet once a day for depression. * [MEDICATION NAME] (anti-psychotic medication) 1 mg twice a day for acute psychotic episodes. * [MEDICATION NAME][MEDICATION NAME] (anti-[MEDICATION NAME] medication also used to treat [MEDICAL CONDITION]) 50 mg at bedtime for [MEDICAL CONDITION]. a. Three pharmacy reviews addressed to Resident #12's physician, dated 5/29/19, 9/30/19, and 12/31/19, documented the [MEDICATION NAME] and [MEDICATION NAME] medications were reviewed and the following concerns were identified: * A GDR was indicated for [MEDICATION NAME]. The pharmacy reviews stated if there was no change to the [MEDICATION NAME] dose, the physician was to write a brief risk versus benefit statement for the continued need of the medication. Resident #12's physician's responses to the pharmacy reviews of [MEDICATION NAME], documented Stable no change. * [MEDICATION NAME] was not indicated for geriatric use and a GDR was indicated. The pharmacy reviews stated if there was no change to the [MEDICATION NAME] dose, the physician was to write a brief risk versus benefit statement for the continued need of the medication. Resident #12's physician's responses to the pharmacy reviews of [MEDICATION NAME] documented Stable no change. b. A pharmacy review addressed to Resident #12's physician, dated 5/29/19, documented the daily dosage of [MEDICATION NAME][MEDICATION NAME] and duration of usage was greater than recommended guidelines, and a GDR was recommended. The pharmacy review stated if there was no change to the [MEDICATION NAME][MEDICATION NAME] dose, the physician was to write a brief risk versus benefit statement for the continued need of the medication. Resident #12's pharmacy reviews to the physician, dated 8/29/19 and 12/31/19, documented Resident #12 was receiving [MEDICATION NAME][MEDICATION NAME] routinely. The pharmacist recommended the physician consider changing the order to as needed for [MEDICAL CONDITION], and if long term management for [MEDICAL CONDITION] was needed to consider using Trazadone or [MEDICATION NAME] (medications used to treat [MEDICAL CONDITION]) as potential alternatives to hypnotic agents. The pharmacist also stated the use of hypnotics should generally be limited to 7-10 days. Resident #12's physician's responses to the pharmacy reviews of [MEDICATION NAME][MEDICATION NAME] documented Stable no change. Resident #12's physician responses to the pharmacy reviews of [MEDICATION NAME], and [MEDICATION NAME][MEDICATION NAME] did not include clinical rationales of risks versus benefits for the continued use of the medications or for continued use at the current doses. On 2/6/20 at 10:35 AM, the DON reviewed Resident #12's record and said she would look for the physician's risk versus benefits statements for Resident #12's medications. On 2/6/20 at 10:46 AM, Administrator #1 said they did not find the physician's statement of risk versus benefits for Resident #12's medications. The Administrator said they only had the physician's statement the resident was stable.

Based on record review, policy review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed when a) blood pressure medications were held when a resident's pulse was outside of ordered parameters for 1 of 5 residents (Resident #12) reviewed for unnecessary medications; and b) staff failed to dispose controlled medications consistent with the facility's policy to prevent drug diversion for 2 of 2 licensed nurses (LPN #1 and LPN #2) who were interviewed during medication cart inspection. These failed practices placed Resident #12 at risk of dangerously low blood pressure, and created the potential for harm for each of the 38 residents residing in the facility if controlled medications were diverted and residents did not receive medications as ordered. Findings include: 1. Resident #12 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #12's physician orders [REDACTED]. * [MEDICATION NAME] (medication to lower blood pressure) 12.5 mg twice a day. Hold the medication if Resident #12's systolic blood pressure (a measurement of the amount of blood pressure in arteries during the contraction of the heart muscle) was less than 90 or if her pulse rate was less than 60. This order was not followed. Resident #12's MAR documented her pulse rate was less than 60 and [MEDICATION NAME] was administered on: * 1/8/20 (pulse was 56) * 1/13/20 (pulse was 56) * 1/14/20 (pulse was 58) On 2/5/20 at 2:27 PM, the DON reviewed Resident #12's MAR and said [MEDICATION NAME] was administered to Resident #12 and it should have been withheld when her pulse rate was less than 60. 2. The facility's policy and procedure for Destruction of Medications, dated 2/7/18, documented the following: * Two licensed nurses or one licensed nurse and one registered pharmacist destroyed controlled medications. * If prompt destruction of controlled medications was not feasible, the medications were retained in a securely locked location with restricted access until destroyed by the DON and one licensed nurse or registered pharmacist. * Staff were not to flush medicines down the sink or toilet unless specific labeling information instructed them to do so. * The controlled medication was removed from the original container and mixed with an undesirable substance such as used coffee grounds, charcoal, or kitty litter. Staff were to place the mixture in an impermeable nondescript container and put it in the facility dumpster for regular trash removal. * If the above destruction was not immediately feasible, it was permissible to flush controlled medications unless the specific labeling information indicated flushing was contraindicated. This policy was not followed: On 2/5/20 at 5:10 PM, during the inspection of 100 Hall Medication Cart, LPN #1 said controlled medications were destroyed or wasted in the presence of two licensed nurses. LPN #1 said both nurses signed and dated the narcotic log book for the controlled medications to be destroyed or wasted. LPN #1 said if there was only one tablet of controlled medication, he placed it in the sharps container attached to the medication cart. LPN #1 said if there were multiple tablets of controlled medication to be destroyed, he put them in a plastic container, added hot water, and let them dissolve. He said after the controlled substances dissolved, he put them down the sink in the presence of another licensed nurse. On 2/5/20 at 5:15 PM, LPN #2 said controlled medications were wasted or destroyed in the presence of two licensed nurses. LPN #2 said both nurses signed and dated the narcotic log book. LPN #2 said she put the wasted controlled medications in the sharps container. On 2/5/20 at 5:19 PM, the DON said controlled medications were dissolved in water and the mixture was flushed in the toilet. The DON said controlled medications were not to be placed in sharps containers.

Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 2 of 5 residents (#5 and #32) who were reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the risks and benefits associated with the medications and the right to refuse the medications. Findings include: a. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5's physician's orders [REDACTED]. Resident #5's record did not include documentation he consented to the Donezepil, or was informed about beneficial effects and possible side effects of the medication. b. Resident #32 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #32's physician's orders [REDACTED]. Resident 32's record did not include documentation she consented to the Donezepil, or was informed about beneficial effects and possible side effects of the medication. On 2/5/20 at 4:17 PM, Administrator #2 said the facility did not obtain consents for Donezepil.

Based on record review, staff interview, and policy review, the facility failed to initiate or conduct a thorough investigation of neglect for 1 of 3 residents (#40) whose closed clinical records were reviewed for death in the facility; and, potential abuse for 1 of 16 residents (#16) whose records were reviewed. Resident #40, whose clinical record included a POST form documenting his wishes for resuscitation/full code status, did not receive CPR during an emergency situation and subsequently died . Resident #16 was at risk for potential ongoing abuse when a bruise and small bump of unknown origin found on her chin was not investigated as potential abuse. The failure to conduct a thorough investigation of neglect to provide CPR for Resident #40 and to immediately put effective measures in place to ensure further neglect did not occur placed the health and safety of the other 3 residents (#37, #140, and #141) in the facility who chose resuscitation/full code in the event their heart stopped or they stopped breathing, in immediate jeopardy. Findings include: The facility's Abuse Policy, dated [DATE], documented, The following types of incidents must be reported to the State Survey agency: .c. Resident injuries of unknown origin. These injuries whose source was not observed by any person or the source of the injury could not be explained by the resident; and, the injury includes bruising on the head, neck, or trunk, fingerprint bruises anywhere on the body, lacerations, sprains, or fractured bones. Minor bruising and/or skin tears on the extremities need not be reported, injuries found immediately after a fall need not be reported as unknown origin. And, that injuries of unknown origin need to be investigated . The above policy was not followed. Examples include: 1. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His POST located in his paper chart under the Advance Directives tab, documented he checked Full Code (cardiopulmonary resuscitation is to be performed by staff in the event the resident is absent of pulse and respiration) on [DATE] and his physician signed it on [DATE]. Resident #40's Physician Orders, dated [DATE], documented his code status was Full Code. A Nurses Note, dated [DATE] at 10:50 PM, documented, .resident was talking to CNA, he was on the floor and she had called for help at 2251 (10:51 PM). She was in room when he started to have petite mal [MEDICAL CONDITION] while on the floor. I was called to room and we couldn't get him to respond. 911 (emergency response) called we started O2 (oxygen) and started hitting him on the back and chest compressions. No pulse or respirations noted. Attempted to call wife at 2315 (11:15 PM) but had no good number the one we had was res. (residents) cell phone. At about 2320 (11:20 PM) called (name of) Hospital to notify MD (physician). I asked if they had a number for his wife. They gave me the number. I attempted to call it but it just continued to ring. Wife called back about 2330 (11:30 PM). She was notified about what had happened. DNS and ADM (Administrator) called due to no funeral home in chart. Sheriffs (sic) office called here and asked if we had done everything we could have. I told them we had. They told me to call (name) funeral home. I called them and they stated they would be there shortly. They got here about 0010 (12:10 AM). Wife got here about 0015 (12:15 AM) and talked to ADM. and (name) Funeral Home representative. She then went to see resident and left. Funeral home took resident and left about 0030 (12:30 AM). Resident #40's Record of Death, dated [DATE], documented, .Resident was found on floor next to bed, had petite mal [MEDICAL CONDITION] and then had no resp (respiration) & no heart rate . On [DATE] at 5:45 PM, the DNS stated she was called to the facility by the Administrator on [DATE] because Resident #40 had died and CPR was not initiated. The DNS said when she arrived at the facility, LPN #2, who was the charge nurse on [DATE], was at the nurses' station charting. The DNS said she asked LPN #2 why CPR was not initiated when Resident #40 did not have a pulse or respiration and the LPN said because she thought his code status was DNR (do not resuscitate). The DNS said LPN #2 had checked the resident information sheet in Resident 40's closet, rather than his medical record, to find his code status. The DNS stated that on [DATE], the facility's practice was to maintain residents' code status on a resident information sheet located inside their closet door, and in the the paper chart under the Advance Directives tab. The DNS said after the [DATE] incident they removed residents' code status from the resident information sheets. The DNS said she spoke to LPN #2 about where to look in the chart to identify a resident's code status but that she did not document the conversation. The DNS stated she expected staff to look for a resident's code status in their paper chart (clinical record). The DNS stated the facility was aware LPN #2 failed to obtain Resident #40's code status information from his paper chart and that CPR was not initiated per his POST form directions in his paper chart. The DNS said RN #4 had incorrectly documented Resident #40's code status as DNR on the resident information sheet inside his closet. The DNS said the facility did not initiate a formal investigation into the [DATE] incident and they did not provide education/retraining of facility staff, other than to LPN #2 and RN #4. The DNS stated the facility did not have a policy that directed staff where to check a resident's advance directive information in a medical emergency and that she had not developed such a policy to educate staff. On [DATE] at 9:20 AM, the Administrator said he was aware Resident #40 did not receive CPR on [DATE] because his code status was incorrectly checked as DNR instead of Full Code on the resident information sheet in his closet. He said the DNS addressed the incident with LPN #2 and he provided personnel action with RN #4, who had made the code status error on Resident #40's resident information sheet. The Administrator stated that a thorough investigation was not conducted into the neglect of CPR for Resident #40 and action was not taken and measures were not implemented to ensure other residents were not affected. On [DATE] at 7:30 PM, LPN #2 stated that she did not perform CPR when Resident #40 stopped breathing and he did not have a pulse because she thought his code status was DNR. LPN #2 said the resident information sheet on the inside of the Resident #40's closet door, rather than his medical record, was checked for his code status. The facility did not conduct a thorough investigation or ensure preventive measures were in place after Resident #40 died on [DATE] when LPN #2 neglected to accurately verify his code status and provide CPR when he did not have a pulse or respirations. 2. Resident #16 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident #16's quarterly MDS assessment, dated [DATE], documented her cognition was severely impaired and she never/rarely made decisions. Resident #16's Care Plan, dated [DATE], documented cognitive loss and dementia with a goal that she would not sustain serious injury. Interventions included behavior monitoring. A [DATE] at 9:57 PM Nurses Note documented, Bluish-Purple skin discoloration on resident's right jawline noted this shift. Unknown etiology. No recent falls known. Small pea-sized bump noted underneath upon assessment of area. Also noted to have brief episode during evening meal of non-responsiveness. Staff reported resident being less active this shift. Placing resident on alert charting status for this issue. Will continue to monitor bruising until resolved, and provide ongoing support as needed. On [DATE] at 2:03 PM, the DNS stated she was not aware of an injury of unknown origin for Resident #16 on [DATE]. She said there was not an incident/accident report regarding the injury and that an investigation was not initiated. On [DATE] at 8:30 AM, RN #2 stated she did not initiate an investigation when the new bruise and lump was noted on Resident #16's chin on [DATE]. The RN stated she reported the new bruise/lump to the nurse who relieved her on [DATE]. RN #2 said she received training on the company's abuse policy during orientation in (MONTH) (YEAR) and she was responsible to start an investigation and notify the administrator when an injury of unknown origin was found. The RN said she just forgot to do it. REMOVAL OF IMMEDIATE JEOPARDY PRIOR TO EXIT CONFERENCE: The IJ was identified on [DATE] and determined to first exist on [DATE], when Resident #40 was without pulse and respiration and CPR was not initiated by the facility. On [DATE] at 9:30 PM, the facility's Administrator, DNS, and Corporate Nurse were informed verbally and in writing of the IJ. On [DATE] at 1:50 PM, the Corporate Nurse and Administrator provided an acceptable plan to remove the immediacy of the IJ. The facility's plan to remove the IJ immediacy was: 1. Revision of the Cardiopulmonary Resuscitation P&P on [DATE] to include, CPR is to continue to be performed by staff until EMS (emergency medical service personnel) arrives. 2. Creation of a P&P on [DATE] regarding where the staff are to locate a resident's code status in the EHR (electronic health record) and paper chart. 3. In-service education for all employees (not just licensed staff), which began on [DATE], regarding: a. Abuse and neglect P&P (identification and reporting - whom to report to and time frames). b. Where to locate a resident's code status (new P&P), and informed the staff to always use the resident's paper chart for identification of code. c. CPR policy for Full Code patients with emphasis on continuing CPR until EMS arrives. This is to be completed by each employee from all departments prior to starting their next scheduled shift. Each in-serviced staff member is given a copy of the P&P (policy and procedure) pertaining to the afore mentioned items in 1, 2, 3, and signs in-service log upon completion). 4. Initiated an investigation of the neglect that resulted in a death in the facility with Idaho Department of Health and Welfare abuse portal, Incident (number) on [DATE] 5. Notified Medical Director of Immediate Jeopardy, steps taken so far, and suggestions for future actions to be taken to prevent further incidents of this nature. He agreed with the current steps and to assist with a plan of correction. 6. Required the nurse identified in the IJ to watch CPR & [MEDICATION NAME] video by American Heart Association and return demonstrate to the DNS for accuracy and understanding prior to working any further shifts.

Based on record review, staff interviews, and policy review, it was determined the facility failed to ensure 1 of 3 residents (Resident #40) reviewed for death in the facility was provided CPR per his documented instructions in his POST. The licensed staff neglected to verify Resident #40's code status when he did not have a pulse or respirations and neglected to provide CPR per his documented wishes. The neglect resulted in Resident #40's death, and placed the health and safety of the 3 other residents #37, #140, and #141) in the facility with a code status of Full Code (resuscitate/initiate CPR) in immediate jeopardy. Findings include: Resident #40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #40's POST form, located in the front of his paper chart, documented he checked Resuscitate (Full Code) for cardiopulmonary resuscitation in the event he did not have a pulse and/or was not breathing. He signed the POST form on [DATE] and the physician signed it on [DATE]. Physician Orders, dated [DATE], documented Resident #40's code status was Full Code. A Nurses Note, dated [DATE] at 10:50 PM, documented Resident #40 was talking to CNA, he was on the floor and she had called for help at 2251 (10:51 PM). She was in room when he started to have petite mal [MEDICAL CONDITION] while on the floor. I was called to room and we couldn't get him to respond. 911 (emergency response) called we started O2 (oxygen)and started hitting him on the back and chest compressions. No pulse or respirations noted. Attempted to call wife at 2315 (11:15 PM) but had no good number the one we had was res. (resident's) cell phone. At about 2320 (11:20 PM) called (name of) Hospital to notify MD (physician). I asked if they had a number for his wife. They gave me the number. I attempted to call it but it just continued to ring. Wife called back about 2330 (11:30 PM). She was notified about what had happened. DNS (Director of Nursing) and ADM (Administrator) called due to no funeral home in chart. Sheriffs (sic) office called here and asked if we had done everything we could have. I told them we had. They told me to call (name of) funeral home. I called them, and they stated they would be there shortly. They got here about 0010 (12:10 AM). Wife got here about 0015 (12:15 AM) and talked to ADM. and (name of) Funeral Home representative. She then went to see resident and left. Funeral home took resident and left about 0030 (12:30 AM). The Record of Death identified on [DATE] Resident was found on floor next to bed, had petite mal [MEDICAL CONDITION] and then had no resp (respiration) & no heart rate . On [DATE] at 5:45 PM, the DNS stated the Administrator called her to come to the facility on [DATE] because Resident #40 had died when CPR was not provided. The DNS stated when she arrived, LPN # 2, who was the charge nurse on [DATE], was at the nurses' station charting. The DNS stated she asked why CPR was not initiated when Resident #40 did not have a pulse or respiration and LPN #2 said she thought his code status was DNR because DNR was on the staff instruction sheet inside his closet door. The DNS said LPN #2 did not check Resident #40's medical record for his code status. The DNS stated the facility's practice at the time of the incident on [DATE] was residents' code status was on a resident information sheet located on the inside of their closet doors as well as under the Advance Directive tab in the front of their paper chart. She stated that after the incident, the code status was removed from the resident information sheets and she talked to LPN #2 about where to look for the code status in the paper chart. The DNS stated she did not document the conversation with LPN #2 and the facility did not have a policy about where to locate a resident's code status in an emergency situation. On [DATE] at 5:45 PM, the Administrator stated he was informed on [DATE] that Resident #40 did not receive CPR, and had died . He said LPN #2 did not perform CPR for Resident #40 because the resident information sheet in his closet incorrectly documented DNR as his code status. The Administrator said another nurse, RN #4, had put the wrong code status, DNR rather than Full Code, on Resident #40's resident information sheet. On [DATE] at 7:30 PM, LPN #2 said she was called to Resident #40's room by staff who found him on the floor and thought he was having a [MEDICAL CONDITION]. LPN #2 said when she got to the room, NA #1 and Staff B were there and Resident #40 was on the floor. LPN #2 said she thought he might have choked, so she provided oxygen and one of the staff hit him on the his back. LPN #2 stated Staff B called 911 (emergency medical system) because we didn't know what to do and thought he needed to go to the hospital. She said while Staff B was on the phone with the 911 dispatcher, Resident #40 stopped breathing and did not have a pulse. She said one of the staff gave him a few compressions to see if he was just choking or something but nothing happened. LPN #2 said they were not sure if he was a code or not so one of the staff checked the paper in his closet which documented DNR. LPN #2 said she heard Staff B tell the 911 dispatcher the ambulance was not needed because he had passed away. LPN #2 said she returned to the Nurses' Station and attempted but was unable to contact his wife, she called the hospital and asked a nurse to notify Resident #40's physician that he had passed away, and she obtained Resident #40's wife's correct phone number. LPN #2 said she called and left a message for Resident #40's wife. LPN #2 said the wife returned the call later and the LPN told her what had happened. After that, LPN #2 tried unsuccessfully to contact the DNS so she called the Administrator. LPN #2 said she was confused and didn't know what to do because a funeral home was not listed for Resident #40. LPN #2 said the Administrator arrived within a few minutes and provided the name of a funeral home to call. LPN #2 said the 911 dispatcher called back later and asked if they had done everything they could for Resident #40 and at that time she said they had. When Resident #40's wife arrived, she asked LPN #2 why Resident #40 had not gone to the hospital and said that he should have gone to the hospital. LPN #2 stated that was when she checked Resident #40's chart and saw that his code status was Full Code. She said the Administrator who was still in the facility and she notified him of the situation. LPN #2 stated, At that time how you identified code status was a paper in the closet and it said no code. The LPN also stated, I believe it's (code status information) on the face sheet and that she should have looked at the chart right away. A [DATE] Personnel Action documented, .(RN #4's name) created a resident information form that incorrectly identified a resident as DNR when they were in fact full code . An undated Write Up Information sheet documented, (DNS' name) asked (LPN #2's name) where DNR information was obtained for patient and initial information was pulled from the resident information sheet on the resident's door. (LPN #2's name) was educated that night verbally about her responsibilities of where to find information in the patient chart and about continuation of CPR until EMS arrival. Upon investigation of the information sheet it was noted that the sheet was incorrectly filled out by (RN #4's name) .After speaking to legal counsel, it was determined that (RN #4) should have official corrective action for her mistake. Corrective action has since occurred The facility's undated policy regarding the POST form documented, .The licensed nurse places the completed and signed .POST form in the front of the individuals clinical record and under Advanced Directives . REMOVAL OF IMMEDIATE JEOPARDY PRIOR TO EXIT CONFERENCE: The IJ was identified on [DATE] and determined to first exist on [DATE], when Resident #40 was without pulse and respiration and CPR was not initiated by the facility. On [DATE] at 9:30 PM, the facility's Administrator, DNS, and Corporate Nurse were informed verbally and in writing of the IJ. On [DATE] at 1:50 PM, the Corporate Nurse and Administrator provided an acceptable plan to remove the immediacy of the IJ. The facility's plan to remove the IJ immediacy was: 1. Revision of the Cardiopulmonary Resuscitation P&P on [DATE] to include, CPR is to continue to be performed by staff until EMS (emergency medical service personnel) arrives. 2. Creation of a P&P on [DATE] regarding where the staff are to locate a resident's code status in the EHR (electronic health record) and paper chart. 3. In-service education for all employees (not just licensed staff), which began on [DATE], regarding: a. Abuse and neglect P&P (identification and reporting - whom to report to and time frames). b. Where to locate a resident's code status (new P&P), and informed the staff to always use the resident's paper chart for identification of code. c. CPR policy for Full Code patients with emphasis on continuing CPR until EMS arrives. This is to be completed by each employee from all departments prior to starting their next scheduled shift. Each in-serviced staff member is given a copy of the P&P (policy and procedure) pertaining to the afore mentioned items in 1, 2, 3, and signs in-service log upon completion). 4. Initiated an investigation of the neglect that resulted in a death in the facility with Idaho Department of Health and Welfare abuse portal, Incident (number) on [DATE] 5. Notified Medical Director of Immediate Jeopardy, steps taken so far, and suggestions for future actions to be taken to prevent further incidents of this nature. He agreed with the current steps and to assist with a plan of correction. 6. Required the nurse identified in the IJ to watch CPR & [MEDICATION NAME] video by American Heart Association and return demonstrate to the DNS for accuracy and understanding prior to working any further shifts.

Based on observation, staff interview, and policy review, it was determined the facility failed to provide services that met professional standards of quality for blood glucose (BG) testing. This was true for 1 of 2 residents (#28) whose BG testing was observed. The failure to allow the alcohol on Resident #28's finger to dry before testing her BG created the potential for an inaccurate BG reading and harm if she received an inappropriate dose of insulin based on an erroneous BG result. Findings include: The facility's 12/15/17 policy for Capillary Blood Sampling instructed the staff to wipe the area to be lanced with an alcohol wipe, use a lancet to obtain a blood sample, place the blood sample on the test strip per the manufacturer's recommendations, wipe any visible blood with a cotton ball, gauze or tissue, and ample pressure until the bleeding subsided. On 10/24/18 at 4:45 PM, LPN #1 was observed as he prepared to check Resident #28's BG. LPN #1 cleaned Resident #28's left middle finger with an alcohol wipe, waited 4 seconds, punctured the side of her fingertip with a lancet, wiped off the first drop of blood with the same wet alcohol wipe, then, without waiting for the alcohol to dry, immediately used the second drop of blood to test her BG level. Her BG reading was 303, for which the LPN administered 10 units of Humolog insulin by subcutaneous injection per the physician's orders [REDACTED]. An Evencare glucometer by Medline was used to test the BG level. Immediately after LPN #1 administered the insulin to Resident #28, he said he had cleaned her finger with an alcohol wipe to prepare to test her BG and he used the same alcohol wipe to wipe off the first drop of blood. He said the alcohol was not dry when he tested the second drop of her blood. The Evencare glucometer Healthcare Professional Operator's Manual instructions for BG testing included, Step 3. Wash the patient's hand thoroughly, and dry well . The Lippincott Manual of Nursing Practice, Ninth edition, 2010, documented the Blood Glucose Monitoring Technique included, Prepare the finger to be lanced by having the patient wash hands in warm water and soap. Dry Thoroughly. For convenience, an alcohol wipe may be used to cleanse the finger. Alcohol must dry thoroughly before finger is lanced.

Based on staff interview and review of annual competency evaluations, it was determined the facility failed to ensure every CNA/NA's performance was evaluated at least once every 12 months and annual evaluations were performed. This was true for 9 of 15 CNAs/NAs #2, #3, #4, #5, #6, #11, #12, #13, & #14) and 1 of 3 staff working as an NA who did not meet NA eligibility criteria (Staff B), who worked in the facility for a year or longer. This failure created the potential for incompetent CNAs/NAs providing care and increased the risk for harm for 41 of 41 residents living in the facility, including 16 of 16 sample residents (#1, #4, #6, #13, #16, #17, #19, #25, #27, #28, #35, #36, #37, #38, #140, and #141). Findings include: On 10/26/18 at 2:30 PM, the Corporate Nurse provided CNA Skills/Knowledge Orientation records and Competency Checklists for NAs and said, This is all we could find. The records did not include annual evaluations for Staff B and CNAs/NAs #2, #3, #4, #5, #6, #11, #12, #13, and #14, each who worked in the facility for a year or longer.

Based on staff interview and review of staffing schedules, reports, and personnel files, it was determined the facility failed to ensure full-time employees working as NAs were either in a State approved training and competency evaluation program or had recently successfully completed such a program. This was true for 3 of 4 staff (Staff A, Staff B, and Staff C) included on the facility's list of full time CNAs/NAs, whose personnel files were reviewed. The failure had the potential to result in negative outcomes for the 41 residents living in the facility at the time of the survey, including 16 of 16 sample residents (#1, #4, #6, #13, #16, #17, #19, #25, #27, #28, #35, #36, #37, #38, #140, and #141). Findings include: On [DATE] at 2:30 PM, the Administrator provided a list of full time CNA/NAs. The list documented upcoming in handwriting by the name of Staff A, Staff B, and Staff C. The Administrator said Staff A, Staff B, and Staff C were NAs and upcoming meant they were waiting to take the next CNA class. He said that Staff B and Staff C had started a CNA class but both of them dropped out of the class for personal reasons. On [DATE], the (MONTH) (YEAR) CNA/NA staffing schedule was reviewed. The schedule documented Staff A, Staff B, and Staff C were 3 of 5 full-time CNA/NA staff regularly scheduled to work the night shift (10:00 PM to 6:00 AM). It documented Staff A was scheduled to work on [DATE], [DATE], and [DATE] - [DATE]; Staff B was crossed off the schedule as of [DATE]; and Staff C was scheduled to work on [DATE] - [DATE]. The personnel files for Staff A, Staff B, and Staff C included the following: * Staff A was hired on [DATE] in the nursing department. The Idaho State Nurse Aide Registry Verification Report, checked [DATE], documented her certification status had Lapsed and her certification expired on [DATE]. * Staff B was hired on [DATE] in the nursing department and as of [DATE] she was on maternity leave. The Idaho State Nurse Aide Registry Verification Report, checked [DATE], documented no record of certification was found. * Staff C was hired on [DATE] in the nursing department. Her file did not contain an Idaho State Nurse Aide Registry Verification Report. [DATE] at 8:00 PM, the DNS said Staff A and Staff C were taken off the schedule effective that day and Staff B was on maternity leave and not scheduled to work. On [DATE] at 2:00 PM, the Administrator said he had misunderstood the regulation regarding NAs eligibility to work.

Based on medical record review, staff interview, and policy review, it was determined the facility failed to ensure residents, and/or their representatives, were provided written information about their right to formulate advance directives. This was true for 41 of 41 residents living in the facility, including 16 of 16 residents (#1, #4, #6, #13, #16, #17, #19, #25, #27, #28, #35, #36, #37, #38, #140, and #141) reviewed for advanced directives. The deficient practice increased the risk of residents not having their advance directive decisions documented, honored, and respected when they were unable to make or communicate their health care preferences. Findings include: The facility's Admission Packet identified Advance Directives - The Patient and/or Legal Representative has been given written materials about the Patient's right to accept or refuse medical treatments as provided by state law and has been informed of the Patient's right to formulate Advance Directives . This policy was not followed. Examples include: a. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The medical record did not contain documented evidence the facility had discussed or provided Resident #1 or her representative with advance directive information, other than a POST. b. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #6's medical record did not contain documented evidence the facility had discussed or provided him or his representative with advance directive information, other than a POST. c. Resident #16 was admitted to the facility in (YEAR), with [DIAGNOSES REDACTED]. The medical record did not contain documented evidence the facility had discussed or provided Resident #16 or her representative with advance directive information other, than a POST. d. Resident #19 was admitted to the facility in (YEAR), with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence that the facility had discussed or provided her or her resident representative with advance directive information, other than a POST. e. Resident #35 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. His medical record did not include documented evidence the facility had discussed or provided him or his representative with advance directive information, other a POST. f. Resident #36 was admitted to the facility on (YEAR), with [DIAGNOSES REDACTED]. The medical record did not include documented evidence the facility had discussed or provided Resident #36 or her representative with advance directive information, other than a POST. g. Resident #37 was admitted to the facility in (YEAR), with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided her or her representative with advance directive information, other than a POST. h. Resident #38 was admitted to the facility in (YEAR), with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided her or her representative with advance directive information, other than a POST. i. Resident #140 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The medical record did not contain documented evidence the facility had discussed or provided Resident #140 or her representative with advance directive information, other than a POST. j. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided Resident #140 or her representative with advance directive information, other than a POST. k. Resident #13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided Resident #140 or her representative with advance directive information, other than a POST. l. Resident #17 was readmitted to the facility in 2014, with [DIAGNOSES REDACTED]. His medical record did not contain documented evidence the facility had discussed or provided him or his representative with advance directive information, other than a POST. m. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The medical record did not contain documented evidence the facility had discussed or provided him or his representative with advance directive information, other than a POST. n. Resident #27 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided her or her representative with advance directive information, other than a POST. o. Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided her or her representative with advance directive information, other than a POST. p. Resident #141 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her medical record did not contain documented evidence the facility had discussed or provided her or her representative with advance directive information, other than a POST. On 10/24/18 at 9:00 AM, the DNS and SSD were interviewed about advance directives. The DNS stated that advance directive information was discussed when a resident was admitted to the facility and reviewed during quarterly care conferences. The DNS stated the POST was the tool they used to discuss advance directives and that other advance directive written materials were not provided. Further, the DNS stated that discussions about advance directives with residents or their representatives were not documented or maintained in their medical records.

Based on observation, record review, and staff interview, it was determined the facility failed to provide adequate supervision and to revise a resident's care plan to prevent falls. This was true for 1 of 8 sample residents (#1). Resident #1 was harmed when the resident fell and sustained a left hip fracture that required surgical intervention; and, Resident #1 had numerous falls after the left hip surgery. In addition, 2 sections of handrails were found broken and splintered which had the potential to affect all ambulatory residents moving about the 100 and 300 hallways. Findings included: 1. Resident #1 was initially admitted to the facility on [DATE], was discharged from the facility on 1/30/11 after a fall that resulted in a left hip fracture, readmitted on [DATE] after surgical repair of the hip fracture, discharged again on 4/28/11 related to an infected pressure ulcer, and readmitted on [DATE]. The resident's primary [DIAGNOSES REDACTED]. Resident #1's admission MDS assessment, dated 1/17/11, coded inattention, disorganized thinking, poor recall, wandering 4-6 days out of 7, limited assistance of one person for transferring, walking, and toileting, and supervision and set up assistance for showering. The 1/17/11 MDS coded no falls since the resident's admission. Resident #1's admission physician orders, dated 1/11/11, included: * Aricept 5 mg (milligrams) daily; * Seroquel 100 mg at bedtime; * Diltiazem 60 mg twice per day; * Sinemet 25/100 1/2 hours before meals; * Lasix 20 mg daily; * Potassium 10 mg daily; * Ativan .5 mg - 1 mg by mouth every 6 hours as needed for agitation; and * ASA (aspirin) 81 mg daily. Resident #1's admission Fall Risk Assessment (FRA), dated 1/11/11, documented the resident was disoriented, ambulatory and incontinent, required the use of assistive devices, had no noted drop in blood pressure between lying and standing, took 3-4 medications that could increase the resident's risk for falls, and had 1 to 2 predisposing conditions that placed him at greater risk for falls. The total fall risk score was 13. The FRA instructions documented, "If the total score is 12 or greater the patient should be considered at RISK for falls. A prevention protocol should be initiated immediately and documented on the care plan." The associated Fall Risk Protocol and Care Plan summarized that Resident #1 was at moderate risk for falls due to: mental status, ambulation, elimination, gait balance, medications, and diagnosis. The interventions included an OT/PT (Occupational Therapy/Physical Therapy) consult and "Safety alarms to Bed and Wheelchair." A Resident Review for Inclusion in the Falling Star Program, dated 1/11/11, documented the resident did not meet the criteria for the Falling Star Program (FSP). No rationale was given for why Resident #1 did not meet the criteria for the FSP. The form documented Resident #1 did not score 10 or above with mental status change (Note: The assessment only allowed for a score of 2 for disoriented or a 4 for intermittent confusion. There was no coding of 10 in the scoring options). The form documented the resident did not have two or more falls in the past 30 days, did not have a history of multiple falls, and did not regularly move about the facility. However, the form did document, "Decrease cognitive/safety awareness, resident unable to make safe choice or follow safety precautions - such as not getting up unassisted." Resident #1's admission Interim Care Plan, undated, but stamped "admitted [DATE]," documented the resident had self-care deficits and required assistance with all ADLs. The Interim Care Plan indicated a bed and wheel chair (w/c) alarm was in place, the resident could bear weight, and needed assistance with transfers. The use of a w/c was not marked and the care plan documented the resident would use a walker with assistance for mobility, "In room only." Problem Oriented Progress Notes (POPNs), dated 1/11/11 at 11:35 a.m., documented, Resident #1 was ambulatory with a front wheel walker and assistance, was very confused, and a Wander Guard Bracelet had been placed on him. An 8:45 p.m. entry documented, "(Resident) attempted to stand making chair alarm go off. Assisted out to lobby and sofa there. ... Later went across hall into another woman res (resident's) room and thought she was his wife. ... Requires one person assist (with) ADLs." POPN's dated 1/12/11 through 1/22/11 frequently documented the resident was confused, unsteady on his feet, and attempted to stand independently from a chair and walk or wander. Resident#1's Interim Care Plan for that period of time did not clearly identify the resident's unsteadiness on his feet, attempts to stand and walk on his own, his attempts to wander, or the use of the Wander Guard. In addition, based on the 2011 Nursing Drug Handbook, 5 of the resident's medications; Diltiazem, Lasix, Aricept, Sinemet, and Seroquel, had known side effects of hypotension and/or orthostatic hypotension with related dizziness and vertigo. Resident #1's blood pressure normally ranged from 118/76 to 132/72. However, between 1/11/11 and 1/22/11, the resident's blood pressure was frequently documented as low (hypotension). There was no documentation in Resident #1's clinical record that the resident's physician was notified of the low blood pressures. Note: Refer to F157, regarding the lack of physician notification related to the resident's hypotension. On 1/20/11, Resident #1 was seen by the physician. However, there was no indication the physician evaluated the resident's hypotension in relationship to his unsteadiness. Patient Incident Reports (PIR) for January 2011 indicated the resident fell twice between 1/23 and 1/30/11. The 1/30 fall resulted in a fractured left hip that required hospitalization and surgical intervention on 1/31/11. The PIR report, dated 1/23/11 at 3:55 p.m., documented the resident was, "... in chair (in room), stood up to get something that wasn't there and fell to floor. (No complaint) of pain, (no) bruising... vital signs taken and put to bed." The PIR documented the resident's blood pressure was 101/61 after the fall, pulse 87, and oxygen level 94%. The report documented the resident was confused at the time he was found, the actual fall was not witnessed, but the resident was last seen 30 minutes before the fall. The results of the Interdisciplinary Team (IDT) review documented, "Resident to be near nurses station in chair when not in bed. He needs close supervision and to rest can be at nurses station." A Care Plan Update form, dated 1/23/11 at 3:55, documented, "Will continue to assist res...continue to observe for safety, personal alarm in place, make sure shoes fit properly." An entry on the Interim Care Plan, dated 1/24/11, documented, "... needs to be in Lobby to sit and rest." Note: Resident #1's Plan of Care was not revised to reflect the resident's need for increased supervision related to his attempts to stand, increased confusion, and unsteadiness on his feet. POPNs between 1/22 and 1/30/11 documented the following, in part: * 1/25 untimed - "...has poor safety awareness. ... Loses track of what he is doing. unable to stay focused on dressing etc (etcetera)..." * 1/26 noted only as a.m. - "...(BP) 80/60...WCTM (will continue to monitor) for weakness." * 1/26 at 8:30 p.m. - "...anxious, agitated (and) combative (after) dinner, CNAs spend a lot of 1:1 (one to one) time (with) pt., but he is difficult to redirect...continues to self-transfer." * 1/29 at 9:10 p.m. - "... Up and about per usual. Continues to attempt to get up without assistance. Requires one person assistance with ADLS. ... was anxious (and) would not calm down. Xanax given... calmed down after Xanax. WCTM." Note: Xanax was a new order received for agitation. * 1/30/11 at 6:45 p.m., "... stood up from straight chair he was sitting in, he took a couple of steps (and) fell . ...landed on his (left) side. ROM (range of motion) done to all extremities (and) he grabbed (left) leg...(physician's name)...called (at 7:30 p.m.) (and) told me to give a pain pill (and) place ice on affected area...if it doesn't feel any better by morning bring him in then... (Wife's name) decided to wait until morning to have Res. see Dr (doctor) if not any better. Tylenol...given (and) Res. is asleep now." * 1/30/11 t 9:20 p.m., "...Keeps trying to get up (without) assist... Requires one person assist for ADL's..." * 1/30/11 at 10:30 p.m., "Aide alerted me that pt is c/o (complains of)...left hip pain...(left) leg approx(imately) 1 1/2 (inches) shorter than (right)...Called (name of area hospital) for further instructions..." * 1/30/11 at 11:00 p.m., "...Dr. has ordered pt to be transported...for x-rays (and) eval(uation)..." * 1/30/11 at 11:40 p.m., "...ambulance here to transp(ort) pt to hosp(ital)..." The PIR, dated 1/30/11 at 6:45 p.m., documented the resident was alert and confused "per usual," sitting in a straight back chair in a hallway when he fell . His B/P was 102/68 and pulse was 78 after the fall, "Alarm was in place (and) functioning (and) alerted staff. CNA couldn't get to him quick enough to prevent fall..." Other findings/comments on page 2 documented, "Res has poor safety awareness. Stands up all the time, but is very unsteady on feet." Note: The Interim Care Plan, last updated 1/24/11, did not document that the resident had poor safety awareness, frequently attempted to stand, and was unsteady on his feet. Note: The 1/30/11 PIR did not indicate in which hallway the resident was when he fell . Upon re-admission to the facility on [DATE], a FRA dated 2/7/11, documented the resident continued to be disoriented, had 3 or more falls in the past 3 months, required Restraints/Assist with Elimination, had a balance problem, unstable gait, and required the use of assistive devices, had no noted drop in blood pressure between lying and standing, took 3-4 medications that could increase the resident's risk for falls, and had 1 to 2 predisposing conditions that placed a resident at greater risk for falls. The total fall risk score was 15. The Resident Review for Inclusion in the Falling Star Program form documented the resident met the criteria for the Falling Star Program (FSP). The form documented Resident #1 scored 10 or above with mental status change (Note: The assessment still only allowed for a score of 2 for disoriented or a 4 for intermittent confusion. There was no coding of 10 in the scoring options). The form documented the resident had two or more falls in the past 30 days, a history of multiple falls, and decreased cognitive/safety awareness, the resident was unable to make safe choice or follow safety precautions - such as not getting up unassisted. The facility's Falling Star Policy and Procedure, undated, documented that inclusion in the Falling Star program included, "It will be care planned and added to the flow sheets to visualize the resident at least every 30 minutes... inclusion will also be noted on the CNA day sheets." The associated Fall Risk Protocol and Care Plan, dated 2/7/11, stated the resident was at moderate risk for falls due to history of falls, mentation, ambulatory status, balance/gate, medications, and diagnosis. The interventions included, "Refer to Falling Star program, OT/PT (Occupational Therapy/Physical Therapy) Consult, Safety alarms to Bed (and) Wheelchair, Bed in Lowest Position." No additional interventions were listed. Resident #1's re-admission Interim Care Plan, undated, but stamped "admitted [DATE]," documented the following falls/fall prevention approaches, "Bed alarm...w/c alarm...bears weight but is unreliable, Transfers: x 2 (2 person) assistance...PT evaluation, Mobility: Assist wheelchair...low bed (with) fall matts 2-10-11." The care plan also documented, "If res is restless please offer food, fluids, toilet or amb(ulate) as he is able. 02-illegible-11." PIR reports for February 2011 through March 2011 documented Resident #1 fell six times between 2/7/11 and 3/22/11. PIR reports for that time frame documented in part: * 2/10/11 at 9:00 p.m. -"...found on his knees at his bedside. (and) He stated he needed to use the bathroom - given urinal." No injuries were reported. The IDT did not review the fall until 2/14/11. The results of the review were documented as, "Alarms in place (and) functioning, put in lo bed with fall matts to prevent injuries. Interventions successful." Based on the Fall Risk Care Plan dated 2/7/11, and the readmission interim care plan, all of these interventions were already in place. No new interventions were added Note: The resident's BP continued to run low at intervals between 2/9/11 and 2/11/11. Again, see F157. A POPN, dated 2/12/11, indicated the resident continued to be anxious and agitated. It documented, "(Resident) was a 1-1 for a few hours during this shift. He tried to stand and ambulate about every 2 - 3 minutes. we offered him food/fluid, bathroom, ambulated him, gave him magazines. he was unable to be consoled." Note: The Plan of Care did not address increasing the resident's supervision to 1:1. A POPN, dated 2/13/11, indicated the resident continued to attempt to ambulate on his own. One entry, timed as "PMS", documented, "Is wide eyed and still largely a 1:1 but did relax on the couch before hand. We did some sit-to-be-fit exercises...Before we started exercising together he would lift himself off his w/c (wheelchair) like whe was going to stand (and) he looked like he was going to tumble out of his w/c..." Another POPN entry on 2/13/11, documented, "...Still requires 1:1 assist..." A PIR, dated 2/14/11 at 6:30 p.m., documented the resident was observed to slide off the couch onto his buttocks. The report identified that the resident had last been visualized 10 minutes before slipping from the couch. The IDT review, dated 2/15/11, documented that alarms were in place and functioning and, "...very poor safety awareness, he moves and fidgets constantly...wife states resident did this at home. resident working with PT for strength and balance. Will continue current plan. When resident gets restless take him for a walk and offer drink, food, toilet." This intervention was added to the Interim Care Plan on 2/15/11. However, the care plan did not list the resident's "constant" fidgeting identified in this PIR and in the POPNs. Neither did the care plan clearly identify the resident's "severe dementia, or address when/why 1:1 supervision should be used. A PIR, dated 2/17/11 at 3:45 a.m., documented the resident's alarm was sounding and the resident was found in a semi-kneeling position beside his bed. The fall mat was in place. Although the resident was on the Falling Start Program which required visualization of the resident every 30 minutes, the PIR documented the last contact with the resident was at 2:15 a.m., 1 1/2 hours before the resident was found on the floor. The IDT review of the incident, dated 2/17/11, documented, "Resident continues to have poor safety awareness, bed alarm in place.. bed in low position with fall mat in place. Interventions keep him from injuring self. will continue with current plan of care." No new interventions to assess why the resident was attempting to get out of bed, or ideas for preventing falls were documented. A PIR, dated 2/21/11 at 4:00 a.m., documented that a CNA heard the bed alarm, entered the room and found Resident #1 kneeling on the floor. The CNA returned the resident to bed, gave him a urinal, got him dressed for the day, and placed him in a lounge chair at the nurses station. The report documented the CNA was checking on the resident every 30 minutes prior to the fall. The IDT review, dated 2/21/11, documented, "All interventions in place to prevent injury, will continue with current plan as has been effective in preventing injury." No new interventions to assess and/or prevent falls were added. A PIR, dated 3/15/11 at 5:40 a.m., documented, "Resident found on all fours off of the fall mat. Bed alarm working properly, gown with pull tab attached on bed." Staff offered him the toilet following the fall and helped him get up for the day. The resident was last visualized at 5:30 am. The IDT review, dated 3/16/11 documented, "Bed in low position. Fall mattress in place, resident able to get OOB (out of bed) (without) injury, family pleased, they want him to remain as mobile as possible (without) injury. Will continue (with) current plan." A PIR, dated 3/21/11 at 5:50 p.m., documented the resident was sitting in his wheelchair in the hall way, "He got out of it and sat on the floor." The IDT review, dated 3/22/11, documented, "Will use Velcro Alarm Lap Belt with alarm." An assessment of Need For Physical Restraint was completed on 3/22/11 and a consent was signed by the family the same day. The Care Plan was updated on 3/22/11 to include the Velcro alarm lap belt and to check/reposition/toilet every 2 hours. Intermittent low blood pressures continued to be recorded for the resident without evidence of assessment for orthostatic hypotension as a potential contributor to the resident's unsteadiness on his feet and continued falls. Systolic blood pressure (SBP) readings below 100 were recorded on 2/9, 2/21, 2/17, 2/19, 2/20, twice on 2/21, 2/27, 3/2, 3/3, 3/15, 3/16, 3/19, 3/20, etc. Please refer to F157 as it related to Resident #1's hypotension and lack of physician notification. Note: On 4/28/11, the resident was transferred to an area hospital related to an infected pressure ulcer. He was readmitted to the facility on [DATE]. Resident #1's 5/20/11 Care Plan continued to list the same Fall Risk/Injury Prevention interventions as the previous care plan dated 2/20/11. The interventions were: Low bed with fall mats, bed/chair alarms on and functioning, call bell within reach at all times, encourage to call for assist and not attempt self-transfer, Falling Star Program, family aware of all interventions in place and is involved with CP (care plan), non skid rug, Velcro alarm lap belt. A PIR, dated 5/13/11 at 4:50 p.m., documented, "CNA walked into rsdt (resident's) bedroom (and) seen him try to stand (and) he fell on to knee hitting fall mat." The IDT review, dated 5/14/11, documented, "Resident (with) low bed, fall matts, bed alarms. He does have very significant dementia (and) does not make safe choices. All interventions in place. Will cont(inue) (with) current plan, family does not want him restrained any further. Interventions have kept him from being injured (and) allow him to get OOB as he chooses." A PIR, dated 5/24/11 at 7:40 p.m., documented, "We were standing in doorway...(to enter) and we heard a thump (and) then we found him on the floor. No injury apparent. On floor next to bed on fall matt." The IDT review, dated 5/25/11, documented, "Fall mat in place (and) cont(inue) (with) current alarms for safety. Family does not wish for any further intervention or restraints (at) this (time). Current interventions effective to prevent (and) lessen injury." A PIR, dated 5/26/11 at 4:20 p.m., documented, "Rsdt found walking on knees pushing w/c when staff walked in." The IDT review, dated 5/27/11, documented, "Cont (with) current interventions (with) fall mat, alarms (and) frequent monitoring, Family does not wish for any further interventions (at) this (time)." On 6/1/11, a tag alarm was hand written onto the 5/20/11 care plan. This alarm was actually implemented on/around 3/15/11, but was not added to the 2/20/11 CP. A PIR, dated 7/5/11 at 9:45 a.m., documented, "Resident was sitting in chair in front lobby staff member walked by resident in chair another resident pointing at resident when staff turned around resident sitting on floor in front of w/c. (N)o alarm sounding found to be turned off. Skin tears (times) 2 on (left) wrist..." The IDT review, dated 7/6/11, documented, "O.T. to evaluate w/c (and) cushions for comfort to help (decrease) restlessness." Based on May, June, and July 2011 POPNs and PIR, Resident #1 continued to attempt to get out of bed and out of his chair. He experienced falls on 5/13, 5/24, 5/26, and 7/5/11 with no significant changes to the resident's care plan or implementation of new interventions other than an order to have OT evaluate his w/c cushion for positioning and comfort. In addition, no documentation was found in the clinical record regarding conversations that the family not did not want any further interventions. On 7/14/11 at approximately 10:00 a.m., the DON was interviewed regarding Resident #1's falls. The DON stated that she would have to review the resident's clinical record and the PIRs. On 7/15/11 at approximately 11:30 a.m., the DON provided a hand written list of the PIR reports, but no other information. On 7/20/11 at 9:40 a.m., a facsimile (fax) was received from the DON. The fax included a typed note regarding Resident #1's falls which stated, "... Just note that because he has A & I's (Accident and Incidents) does not mean they were all 'falls'. The reg(ulation) states change to next lower surface. Because the resident is free to crawl in/out of his bed to fall matt next to bed it is a change of level. So we do accident reports. These interventions have kept this resident from receiving injury and have allowed him freedom to move in/out of bed. Family insistent that we add no further 'restraint'..." Resident #1 was harmed when the facility failed to recognize and respond to the residents serious fall risk. The resident fell on [DATE], and then continued to attempt to self-transfer, experienced confusion, attempted to wander and experienced very low blood pressure readings. The resident received several medications that could have contributed to hypotension as well as dizziness and vertigo. The physician was not notified of the resident's episodes of hypotension and the facility failed to reassess the resident after his first fall. The resident fell again on 1/30/11 which resulted in a fractured hip and required hospitalization and surgical repair of the fracture. In addition, after the resident was readmitted to the facility, the IDT continually assessed that the interventions put into place were effective at preventing the resident from injuring himself during falls. The resident experienced a total of 11 falls in the 5 months following his fractured hip. 2. On 7/12/11 at 9:30 a.m. a check of the handrails in the facility was conducted. A 1 1/2 foot long section at the bottom of the wooden handrail to the right side of the door to room 103 was broken and splintered. A 3 foot long section on the bottom of the handrail on the left side of the door to room 309 was also broken and splintered. The Administrator was immediately informed of the findings, and maintenance personnel were observed sanding the areas within 30 minutes of it being reported.

Based on observation, staff interview, record review, and review of the facility Pressure Ulcer Prevention policy and procedure, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers (PU). This was true for 3 of 4 residents (#s 1, 5, and 8) sampled for PU and resulted in harm to Resident #s 1 and 5: Resident #1 was harmed when he developed multiple Stage II PU to the coccyx/buttock area, one of which progressed to Stage III and became infected, as well as 2 left heel PUs, one of which was documented as a healed Stage IV. Resident #5 was harmed when she developed recurring and multiple Stage II PU to her buttocks and bilateral ischial tuberosities. The resident was admitted to the facility with two Stage II pressure ulcers, yet was assessed as only a "moderate" rather than "high" risk for pressure ulcers. Additionally, the facility failed to provide Resident #5 with consistent preventative skin assessments. Resident #8 developed a PU to the left hand when the facility failed to provide adequate [MEDICATION NAME] medication coverage for a pressure relief device that was painful to the resident This lack of adequate pain relief contributed to the resident's refusal to keep the device in place (Please refer to Federal Citation F309). Findings include: 1. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. NOTE: A Nurse's Note, dated 4/4/11, documented that the resident's buttocks and peri-area were "excoriated" due to "liquid stools." A Nurse's Note, dated 4/6/11, documented the resident was scheduled for discharge from the facility on 4/6/11 for a [MEDICAL CONDITION] surgery at a nearby hospital. The resident was observed during the facility's annual re-certification and state licensure survey with the surgical stoma and [MEDICAL CONDITION] pouch in place. Resident #5's most recent admission MDS assessment, dated 5/9/11, documented the following: * Cognitively intact for daily decision making skills * Total dependence on at least two staff members for bed mobility, transfers, and bathing * Total dependence on one staff member for toileting * Two Stage II pressure ulcers present upon admission to the facility The resident's Pressure Ulcer CAA, dated 5/2/11, documented, "Triggered d/t (due to) bed mobility, 2-stage II pressure ulcers, and is at risk for skin issues. Resident admitted with 2 areas on her coccyx and surgical wound. Both are healing adequately. Other risk factors include DM (diabetes mellitus), new ostomy placement with excoriation, limited mobility, and urinary catheter. PO (Oral) intake of food fair and fluid adequate. On air mattress, protective device in w/c (wheelchair), TX (treatment) per MD (physician) order, turning and repositioning program, and cath(eter) care Q (every) shift." An Admission Assessment, dated 4/26/11, documented that Resident #5 was admitted to the facility with two Stage II pressure ulcers. The assessment did not name the anatomical location of the two pressure ulcers, however a diagram indicated an ulcer to the left buttock area measuring "1 cm (centimeter) X (by) 1 cm," and an ulcer to the right buttock area measuring "1.3 cm X 0.8 cm." A Pressure Ulcer Risk Assessment for Resident #5, dated 4/26/11, documented a score of "6," indicating the resident was at "moderate" risk of developing pressure ulcers. Recapitulated physician orders, dated 7/1/11, documented the following medications/treatments: * "Skin at Risk: Monitor skin weekly on bath day." Start date: 4/26/11. * "Z.O. (Zinc oxide) to St(age) II pressure ulcers to bilateral ischial tuberosity QD (daily) (and) PRN (as needed) (for) X1 Wk (week) then re-eval(uate)." Start date: 6/20/11. Resident #5's Pressure Ulcer Care Plan in effect for July 2011 documented the following: * "Problem(s): Stage 2 pressure sore is present on admit." * "Goal(s): Problematic or affected area will be healed." * "Approach(s): Adequate fluid and food intake (5/13/11); Keep linens dry and wrinkle free (5/13/11); Encourage and assist to turn/reposition Q 2 hrs (every two hours) and PRN (no date provided); Maintain good body alignment (with) weight distributed evenly (5/13/11); Protective device/Roho cushion in w/c (wheelchair) (5/13/11); On rotating air mattress (5/13/11); Followed weekly by NRR (Nutritional Risk Review) (5/13/11); Tx per MD order." A second Pressure Ulcer Care Plan also in effect for July 2011, documented the following: * "Problem(s): Risk for skin breakdown due to FC (Foley catheter) and decreased bed mobility."* "Goal(s): Will be free from skin breakdown with good skin integrity." * "Approach(s): Bilateral half SR (siderails) to assist with bed mobility (5/13/11); Assist resident out of bed several times daily (5/13/11); Assist/teach resident to reposition self (5/13/11); Body/skin audit at least weekly (5/13/11). A Care Plan Update, dated 6/20/11, documented: * "Problem: St(age) II pressure ulcers." * "Goal: Resolve in 14 days or less." * "Approaches: Z.O. as ordered; T&R (Turn and reposition) (hourly and) PRN; Keep skin clean; Cont(inue) (with) air mattress (and) Roho cushion; (First) up last down for meals; Keep on side to relieve pressure." Weekly Skin Reports for Resident #5 documented the following: * 4/27/11 - "Stage II - 1 cm X 1 cm - Lt (left) buttock." * 4/27/11 - "Stage II - 1.3 (cm) X 0.8 cm - Rt (right) buttocks." * 5/4/11 - "Stage II - 0.8 (cm) X 0.4 cm - Lt buttocks." * 5/4/11 - "Stage II - 0.8 (cm) X 0.2 cm - Rt cheek - Nearly healed." * 5/11/11 - "Stage II - 0.3 (cm) X 0.2 cm - Lt buttock." * 5/11/11 - "Stage II - 0.2 (cm) X 0.1 cm - Macerated periwound white Rt superficial. Healed." * 5/19/11 - No wound documentation. * 5/25/11 - No wound documentation. * 6/1/11 - No wound documentation. * 6/2/11 - "Stage II - 1.2 cm diam(eter) 1.2 (cm) X 1 cm - (left) IT (ischial tuberosity)." * 6/2/11 - "Stage II - 1 (cm) X 0.5 cm, 1 cm diam(eter) - (right) IT." * 6/9/11 - No wound documentation. * 6/29/11 - "Stage II - Small shearing 2 on ischtube (ischial tuberosity) (less than) 0.5 cm. 2 on upper buttocks. Healed." Nurse's Notes for Resident #5 documented the following: * 4/2/11 - "Buttocks very excoriated (secondary to) loose stools. Ointment applied (and) res(ident) given routine Questran for loose stools." * 4/3/11 - "Bottom cont(inues) to be excoriated." * 4/6/11 - "Res(ident) D/C (discharged ) to (area hospital) for ([MEDICAL CONDITION]) surgery..." * 4/26/11 - "Res(ident) readm(itted) from (area hospital). Has open pressure sores on both buttock cheeks (hand drawn diagram) 0.3 (cm) (left), 1.3 (cm) X 0.5 (cm) (right)." * 4/27/11 - "P.U. (Pressure ulcers) remain to buttocks, covered (with) drsg (dressing) (at) this X (time). Call in to MD for wound care orders." * 4/27/11 - "Has new Dr's (physician) orders for [MEDICATION NAME] to buttocks." * 4/28/11 - "Had shower (and) dressing to bottom (change). Continues very excoriated on both cheeks (with no) improvement. At present (with) thin [MEDICATION NAME]." * 4/30/11 - "Res(ident) had rolled [MEDICATION NAME] on coccyx. Dressing (changed) (and) areas improved. Drier area on Lt cheek 1 cm X 0.5 cm. Area on Rt cheek 0.8 (cm) X 0.5 cm." * 5/5/11 - "Areas on bilateral ischial tuberosity. Rt side improved 0.8 (cm) X 0.4 cm. Granulation noted. Wound bed dark pink. (No) odor, (no) drainage on old dressing. Rt side nearly healed 0.8 (cm) X 0.2 cm. Superficial. Wound bed pink edges. Flush. (No) depth - (No) c/o pain, periwound intact 100% granulation. (No) slough. Present Tx of [MEDICATION NAME] effect(ive)." * 5/8/11 - "Drsg on bottom old PUs (pressure ulcers) CDI (clean, dry, and intact)..." * 5/9/11 - "Zinc cream applied to red chaffed peri-area ..." * 5/12/11 - "[MEDICATION NAME] still on bottom of buttock where PUs are." *5/21/11 - "Resident periarea less red than in past." * 6/17/11 - "Two open areas found on rsdt's (resident's) ishial (sic) tuberosity area. Treated (with) zinc oxide (and) placed on alert charting." * 6/19/11 - "Open areas on coccyx covered (with) ZO (and) repositioned (every two hours)." * 6/20/11 - "Reddened areas on lateral hips remain the same. Turned Q2 hours." * 6/20/11 - "Res(ident) noted (with) reopening of old wound sites to ischial tuberosities. (Left) side approx(imately) 2 cm diam(eter) (and) (right) side approx(imately) 1 cm diam(eter) (secondary to) St(age) II pressure ulcers. Res(ident) has alternating air mattress (and) Roho cushion in w/c. Z.O. to areas QS (every shift) and PRN X 1 wk then re-eval(uate). Res(ident) refused to be compliant (with) lying down over the last several days d/t behavioral issues. Res(ident) to be last up first down for meals (and) res(ident) to be repositioned (every hour). Alert LN to any (changes with) skin. Res(ident) ref(used) to turn or stay on side for side/side reposition. Will turn self to back. Res(ident) aware of need to (change) position (and) is non-compliant." NOTE: Please refer to F250 as it relates to the facility's failure to address the psychosocial impact of Resident #5's medical condition and its effect on the resident's "non-complaince" with position changes. * 6/25/11 - "Res(ident) turned (and) repositioned (every two hours)." * 6/26/11 - "Reposition (every two hours) but resident returned to laying on her back." * 6/26/11 - "Was turned (and) repositioned (every two hours)." * 6/27/11 - "Repositioned (every two hours)." * 6/29/11 - "Turned (every two hours)." * 6/29/11 - "Areas on buttocks appear to be shearring (sic). Has 4 areas (less than) 0.5 cm circular - 2 on Ischial tuberosity (and) 2 on buttocks. Wound beds dark pink to red. Res(ident) has been on self-imposed bedrest since 6/23/11, causing (increased) skin issues." * 6/30/11 - "Zinc oxide applied to buttocks." * 7/1/11 - "Repositioned (every two hours)." * 7/6/11 - "Repositioned (every two hours)." * 7/6/11 - "Areas on buttocks completely healed. Will continue (with) protective barrier." * 7/7/11 - "Periarea remains red (and) tender, ointment applied." On 7/14/11, at 8:05 a.m., the facility's Infection Control/Wound Care Nurse (IC/WCN) was interviewed. When asked whether the two wounds first documented in the Nurse's Note of 6/17/11 were new pressure ulcers to the resident's ischial tuberosities, as reported, or a re-opening of the earlier "buttock" wounds, the IC/WCN stated, "Those are new ones because the areas she had when she got back from (area hospital) were definitely on her butt cheeks." When questioned about the two pressure areas to the resident's buttocks documented in the 6/29/11 Nurse's Note and attributed to "shearing," the IC/WCN stated, "I can't say if the buttock sores re-opened or were new." Resident #5 was readmitted to the facility with two Stage II pressure ulcers that were documented as "healed" on 5/11/11. The resident developed two Stage II pressure ulcers on 6/2/11, and an additional two Stage II pressure ulcers on 6/17/11. No mention of "non-compliance" with position changes by the resident was documented until 6/20/11 - more than a month after the original two pressure ulcers were documented "healed," 18 days after the two ulcers were discovered on 6/2/11, and three days after the appearance of the two ulcers on 6/17/11. The facility failed to prevent Resident #5 from developing new pressure ulcers or ensure that pressure ulcers present at the time of admission did not develop into recurrent pressure sores. 2. Resident #1 was admitted to the facility initially on 1/11/11, discharged on [DATE] after a fall that resulted in surgical repair of a left [MEDICAL CONDITION], readmitted on [DATE], discharged again on 4/27/11 related to an infected pressure ulcer, and readmitted on [DATE]. The resident's primary [DIAGNOSES REDACTED]. Resident #1's admission MDS assessment, dated 1/17/11, documented, in part: * Severe cognitive impairment; * Sometimes understood others/understood by others; * Limited assistance of 1 person for bed mobility/transfers/ambulation in room/hall/dressing/personal hygiene/bathing; * No PUs; * Pressure relieving mattress on bed; and * Ointments/medications applied to skin, other than the feet. Resident #1's re-admission MDS assessment, dated 2/14/11, documented, in part: * Severe cognitive impairment; * Usually understood others/understood by others; * Extensive assistance of 1 person for bed mobility/transfers/ambulation in room/hall/dressing/personal hygiene/bathing; * One stage 2 PU; * Pressure relieving mattress to the bed/chair; * Turning/repositioning program; and * Ointments/medications applied to skin, other than the feet. Resident #1's admission MDS assessment, dated 5/10/11, documented, in part: * Severe cognitive impairment; * Usually understood others; * Usually understood by others; * Extensive assistance of 2 or more persons for bed mobility/transfers/toileting; * Extensive assistance of 1 person for dressing/hygiene/bathing; * One stage 2 and one stage 3 PU, both present on admission; * Pressure relieving mattress to the bed/chair; * Turning/repositioning program; * Nutrition and hydration interventions; * Ulcer Care; and * Ointments/medications applied to resident's skin, other than the feet. An Admission Assessment, undated other than the date stamp "admitted [DATE]," contained a section entitled Skin Conditions. The Skin Conditions section documented 1 stage II PU and 1 stage III PU. The most severe tissue type for any PU was documented as "Granulation tissue" and "Slough." The amount of slough was written as a percentage; however, the number had been written over and was illegible. Healed PU were documented as zero. The aforementioned Admission Assessment also contained a section entitled "Identify Areas of Concern" which included an anterior (front) body diagram and a posterior (back) body diagram. The posterior body diagram contained a small circle drawn to the right of the coccyx and labeled "1.8 x (by) 1.5 x 1.5 (with) tunneling (at) 3 o'clock stage III. Also, a small dot was drawn lower down on the buttock area, below the first mentioned PU, and labeled "0.5 x 0.3 stage II. The 2 PU were not numbered, for example as #1 and #2, nor were they identified as, for example A and B. In addition, the anatomical location of the two PU was not named on this assessment. Resident #1's PU CAA , dated 2/14/11, documented: "...has 1 stage II pressure ulcer to the coccyx. Ointments and (illegible) being applied... Healing adequate. Other risk factors include: requires assist (with) bed mobility, occ (occasional) inc (incontinence) of urine, and decreased mobility (secondary) to (left) hip repair. ...on pressure relief mattress, protective device in w/c (wheelchair), turning/repositioning program, and toileting schedule in place." Resident #1's July 2011 recapitulation of physician orders, included the following treatments: * "Skin At Risk: Monitor Skin Weekly On Bath Day (-) = No Problems (+) = Skin Problem Found. Document On Back Of Treatment Sheet." The order was dated 5/4/11. * "Cleanse Open Area On Coccyx With Vashe Wash (and) Leave Soaked Gauze In Place x (times) 20 Mins (minutes), Apply Silvisorb And Light Packing With Idoiform (sic) Gauze, Cover W (with)/[MEDICATION NAME] (sic) (and) Secure W/transparent Dressing." The order was dated 6/27/11. Resident #1's Care Plan, identified the problem, "Stage 2 & (and) 3 pressure sore is present on coccyx on 5/4/11." Approaches for this problem included, "Adequate fluid and food intake. 5/20/11(,) Treatments as ordered. See MAR. 5/20/11(,) Keep linens dry and wrinkle free. 5/20/11(.) Encourage and assist to turn/reposition (every) 2 hrs (hours) and PRN (as needed)(.) Maintain good body alignment w/ weight distributed evenly. 5/20/11(.)...Roho cushion in w/c (wheelchair). 5/20/11(.) Report any red or open areas. 5/20/11(.)...Followed weekly with NRR (nutrition at risk). 5/20/11(.) SAR (skin at risk) program. 5/20/11(.) On rotating air mattress. 5/20/11(.)..." On 7/13/11 at 9:45 a.m., the IC/WN was observed as she performed the first part of the wound care (see the physician orders [REDACTED].#1's coccyx. Upon completion of the first step, the IC/WN removed her gloves but she did not perform hand hygiene before she left the resident's room. (Refer to F441, Infection Control, as it related to this failed practice.) At 10:10 a.m., the IC/WN was observed as she resumed the wound care treatment to Resident #1's right of coccyx PU. The IC/WN measured the PU and stated that it was improved and the tunnel had decreased to 0.5 cm depth. The IC/WN cut a piece of [MEDICATION NAME] gauze, approximately 3 1/2 to 4 inch in length, and packed it accordion style into the tunnel using a sterile cotton tipped applicator, then she completed the treatment. Upon completion of the second step, the IC/WN removed her gloves but she did not perform hand hygiene before she left the resident's room. (Refer to F441, Infection Control, as it related to this failed practice.) Resident #1's clinical record was reviewed. The wound care documentation was found in the Problem Oriented Progress Notes (POPN). POPN, dated 2/7/11 at 3:30 p.m. through 4/28/11 at 12:50 p.m. documented, in part: * 2/12 a.m., "...Red area (right) inner buttox (sic)..." * 2/13 p.m., "...(Water) blister on coccyx..." * 2/13 p.m., "The red area on his buttocks just barely below his coccyx, now has a clear fluid filled blister that's about 1 cm (by) 3 cm long..." * 2/16 a.m., "...Red area to buttocks (with) small blister (at) top. Red area blanchable (and) blister is clear (and) fluid filled, appears to be (secondary) to plastic or attends type skin reaction (versus) pressure related..." * 2/17 a.m., "...L (left) heel was mushy. Upon examination...two blisters on his (left) heel. One on L side (and) bottom approx(imately) 6 cm (by) 6 cm (and) one on Rt (right) side of L heel approx 3 cm (by) 3 cm..." * 2/18 4:00 a.m., "...left heel has large blister, resident moves his legs constantly rubbing feet on sheets, have heel protectors in place (and) have floated but he continues to move so much all interventions need replace (every) hour. Will cont(inue) to observe." * 2/20 a.m., "...(L) heel blister non-fluid filled, dark color, and non tender appears to be resolving..." * 2/20 p.m., "...Buttocks slightly red healing well." * 2/21 2:45 p.m., "...Lt heel blister all disolved (sic)..." * 2/22 8:30 p.m., "Skin Assessment...(L) heel (with) blister re-absorbed, has bark brown firm skin were (sic) blister had been..." * 2/23 2:55 a.m., "Skin assessment...find area were blister on bottom had been, area superficial open blister gone. Center pink. Area healed." * 2/23 2:00 p.m., "...Tinc of [MEDICATION NAME] to both heels. Area (illegible) little over 1 cm dia(meter) each...Coccyx (illegible) red area (illegible) and (illegible) on Rt cheek crusty, rough but not open." * 2/24 untimed, "Lt heel Fluids have reabsorbed (and) now has Lt (light) brows (sic) firm pink (no) [DIAGNOSES REDACTED]..." * 2/24 p.m., "Rsdt (resident's) coccyx (and) buttocks tx'd (treated with) zinc oxide. Tinctur (sic) of [MEDICATION NAME] to (L) heel..." * 2/25 a.m., "...Tx done to (L) heel, absorbing well, Z.O. (zinc oxide) also applied because res c/o (complained of) pain to heels (after) tx...area to buttocks still red, blister reabsorbed..." * 2/25 8:00 p.m., "...applied [MEDICATION NAME] to bilat heels. Heels appear to be tuffing up...Cream applied to buttocks area red difficult to see open area (at) this time but is very bright red." * 2/28 a.m., "...Buttox (sic) cont to have reddened area (R) of coccyx and is closed...(L) heel is absorbing well, hardened..." * 2/28 untimed, "Skin integrity: Res cont (with) brown stable scab (and) dark pink blanchable area on buttocks..." * 3/1 a.m., "...has brown scab to heels...Buttox (sic)- Dk (dark) pink (blanchable) area..." * 3/2 a.m., "...Buttox (sic) (with) dk pink area that blanches...Heels continue to resolve, brown area remains intact..." * 3/3 2:00 p.m., "...Heels resolving (with) brown areas on both heels..." * 3/4 2:00 p.m., "...Lt heel area dark 1 (inch) dia(meter)..." * 3/5 a.m., "...Skin cont to resolve on buttox (sic)...Heels cont to resolve..." * 3/6 a.m., "...Skin cont to improve slowly..." * 3/7 2:00 p.m., "...Bottom (no) prob(lem) Heels tinc of [MEDICATION NAME] applied." * 3/9 untimed, "Skin Integrity area on heel where res had a blister has sloughed (and) has light pink intact skin..." * 3/11 a.m., "...heels looking good...buttocks good. WCTM (will continue to monitor)." * 3/13 untimed, "Shift assessment: ...Blister on Lt heel resolved." * 3/22 a.m., "...Red area to (L) buttocks reported to (wound care nurse)..." * 3/23 11:30 p.m., "...Slight redness bottom area (not) open...No blisters noted on heels..." * 4/5 10:35 a.m., "...1 cm open area to top of coccyx. (No) depth...Staff state he was scratching his bottom...Will make sure...nails trimmed. Will put Roho cushion in w/c..." * 4/5 5:25 p.m., "...order to clean pressure sore (with) 1) scrub brush/soap (and) (water). 2) [MEDICATION NAME] (and) [MEDICATION NAME] to be applied daily. Use sheepskin/eggcrate mattress while in bed." * 4/6 8:50 p.m., "Old drsg (dressing) on coccyx had red drainage on it. Area 1 cm in diameter. Cleansed area (with) soap (and) (water) (with) 2 (by) 2 scrubbing (no brush) [MEDICATION NAME] applied (and) covered (with) Mepelex drsg." * 4/7 9:00 p.m., "No change in area. Some sm(all) amt. (amount) redish (sic) drainage on old drsg." * 4/8 p.m., "Coccyx red, (no) drainage noted. N/O (new order) to clean area (with) normal saline (no scrubbing)..." * 4/11 9:00 p.m., "Dressing (changed) to coccyx. Red area 1 (inch) dia(meter) clean and redressed. WCTM..." * 4/12 2:00 p.m., "Dressing (change) to bottom...3/4 (inch) (with) wrinkles groves in area, but appears intact..." * 4/13 untimed, "Skin Integrity area on coccyx 1 cm (by) 1.5 cm yellow wound bed wound edges dark red-some blood drainage on old dressing- periwound red (and) Fragile (sic) - area has (increase) in size...Due to high risk for Falls is not on a rotating air (at) this time. Will continue to monitor condition remains superficial (with) slight wound edges noted...Error-Due to increased in size as of 4-8-11- new wound care orders were received." * 4/13 p.m., "Drsg changed...(no) difference from the description above..." * 4/14 p.m., "(No) (change) in circumfrance (sic) of area on coccyx. Scant drainage on drsg when removed. (Illegible) brownish in color..." * 4/15 p.m., "Rsdt coccyx (no) better (and) no worse than yesterday. Well approx(imated) 1 cm (by) 1.5 cm..." * 4/17 p.m., "Coccyx red (with) small black area (at) bottom of coccyx..." * 4/18 untimed, "Wound Care Area on coccyx improved but has small 0.2 cm (by) 0.2 cm open area just below original site...A- measures 1 cm (by) 0.3 cm superfical (and) site (B) 0.2 (by) 0.2 (10 mm (millimeters) deep peri wound intact. Wound edges red wound bed pink scant drainage on old dressing..." * 4/19 9:05 p.m., "Dressing on coccyx (changed). Area looks like yesterdays report. Scant drainage on old drsg..." * 4/20 a.m., "Drsg to coccyx wound (changed) prn (as needed) today areas to coccyx look good, some yellow slough, (no) s/s (signs or symptoms) of infx (infection), areas small (and) superficial...WCTM." * 4/21 8:30 a.m., "...Rotating air mattress not an option due to his high risk for falls. wound on coccyx is improving..." * 4/21 a.m., "Res. has acne type rash breaking out around wound. (Wound nurse's name) aware of new findings. WCTM." * 4/22 11:00 a.m., "After shower observed 3 areas on bottom 1/4 (inch) oval area (with) red area 1 (inch) dia on Rt cheek by coccyx white base - some improvement. One 1/8 (inch) area 1 1/4 (inch) under other sore on (Rt) cheek (illegible) small area starting on (Lt) cheek 1/8 (inch) not open but blistered..." * 4/22 p.m., "Called (an area hospital) (and) left message r/t (related to) coccyx (and) buttock area for on call MD (physician). No new orders...Bottom (coccyx area) appears to have several areas of irritation almost vesicle like. They are red, swollen (and) hot (with) scant drainage. WCTM." * 4/23 a.m., "Dressing intact on bottom-kept off bottom to help (with) healing." * 4/24 8:45 p.m., "Dressing changed (and) area on coccyx still 1 cm (with) area around it about 3 cm (by) 1.5 cm. Then on Rt buttock has sm pustual (sic) about 1 cm (and) two smaller areas on L buttock..." * 4/25 untimed, "Wound Care Condition-Area on coccyx (increased) in size (and) depth-large amt of blood on old dressing. Has 1 cm circular area below originial (sic) that is open (and) raised-Res self limiting of diet (and) hydration coughing temp(erature) 101.5...(with) cough...(phone call) to (name of clinic) to speak (with name of physician). Not in. Spoke (with) wife who is very concerned about res. condition..." * 4/25 12:30 p.m., "...(physician's name) returned called (and) discussed res condition...wants to treat Res in facility (and) if (no) improvement in 24-48 (hours) or if condition deteriates (sic) will adm(it) to (name of hospital). Res on [MEDICATION NAME] 500 mg I/m (intramuscular injection) (times) 5 days which should help (with) wound healing..." * 4/25 8:30 p.m., "...Drsg changed to coccyx (and) buttocks. Coccyx area (with) 1 cm open area (with) larger area around it about 3 cm (by) 2 1/2 cm surface depth. On right buttock has area 1.5 cm in diameter raised slightly in middle (and) open about .75 cm..." * 4/26 a.m., "Called to shower room to assess Res. wounds. Res. has large wound on coccyx approx. 3 (by) 3 cm (with) 100% of wound bed covered in yellow slough, peri wound has significant [DIAGNOSES REDACTED] (and) is indurated approx. 2-3 cm surrounding wound. Wound #2 on buttocks is also larger (and) wound bed covered (with) 100% yellow slough, wound approx. 2 (by) 2 cm (and) induration is approx the size of a large egg (and) very firm. Drsg placed on area (and) updated wound care nurse (hand drawn arrow) MD (hand drawn arrow) DON aware. Physician notified of condition change. WCTM." Note: A Problem Condition/Nurses Note, dated 4/26/11 but untimed, documented, "Call returned from MD re(garding) wound status. Res to go to clinic on Thursday 4/28/11 for appt (appointment) for infected wounds to buttocks. New order for [MEDICATION NAME] (and) sterile (water) for cleansing (and) cont(inue) (with) same wound drsg as currently ordered." * 4/26 8:50 p.m., "...Drsg (changed) (with) mod(erate) amt Sero sanguinous drainage on old drsg. The open area on Rt buttock is approx 1 cm in diameter (and) also is very hard around it. No [MEDICATION NAME] here so did drsg as before until it comes in." * 4/27 a.m., "...Difficult to keep resident off of back side. Drsg in place (with) serosango drainage noted. Resident (illegible) alertness (decreased) as morning progress. Wife in to see resident decision to send resident to (name of hospital) for direct admit per (physician's name)..." * 4/28 untimed, "Skin intergirty (sic) res prior to discharge has wound care. Area on coccyx measures 2.5 cm (by) 1.2 cm irregular shape (with) blood drainage peri (illegible) macerated from blood drainage area below original area is 1 cm (by) 0.8 cm an increase in size - suspect area infected r/t - (increased) pain, large amt of blood drainage (and) deteriation (sic) of wound sites - res is self limiting (and) difficult to keep in a position off of coccxy (sic) - area the bottom started as pinpoint pustule (with) sm. blister (and) a lump under site. on 2/11/11 was noted to have a red 6 x 0.8 cm red spot that did blanch (sic) (and) did not improve." A hospital Admission History & Physical Examination report, dated 4/27/11, documented in part, "... Chief Complaint: 'He has been running a fever and he has an ulcer on his sacral area. ... History of Present Illness: ...has developed an ulcer kind of on the right sacral area. The patient has had some [DIAGNOSES REDACTED] in this area for a while. Now, he has finally developed skin breakdown in two different areas. ... The skin is now fairly [DIAGNOSES REDACTED]tous. The patient also has been running some fever. Reportedly, he had a temperature to 101 last night...He has complained of some pain in the buttock area... Skin: ...area of [DIAGNOSES REDACTED] in the right sacral and coccyx area. The patient does have two different areas where he has skin breakdown. Associated with this, there is kind of a yellowish eschar. The patient does have a small pimple associated with the most superior of the ulcers. No particular drainage. They seem to be a little bit tender to touch...no significant fluctuance of the areas. ... Assessment: 1. Decubitus ulcers of the right sacral area. 2. Secondary [MEDICAL CONDITION] associated with the ulcers... Plan: ... He does have pretty significant ulcers which appear to be infected..." An Acute Discharge/Swing Admission report, dated 4/30/11, documented in part, "Hospital Course: He was sent to swing bed to continue antibiotics (he [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant Staph aureus))... They will not accept him back to (name of facility) until he has two consecutive negative cultures..." A Swing Discharge Summary, dated 5/4/11, documented in part, "Hospital Course: ... His biggest problem here in our hospital was his sacral pressure ulcers. They grew [MEDICAL CONDITION] ..." On 7/14/11 at 8:25 a.m., the Infection Control/Wound Nurse (IC/WN) was interviewed and asked about Resident #1's PUs. The IC/WN provided Weekly Skin Reports (WSR), dated 1/5/11 to 6/21/11. The WSR contained documentation for multiple residents. The IC/WN stated the WSR documentation was not kept in individual residents' clinical records. She stated the only other documentation of skin/wound care/PU was in nurses notes (POPN). The IC/WN stated that performed wound assessments on all residents every Wednesday. She indicated she was the only staff who conducted the weekly skin checks. When asked about 14 days between a WSR dated 2/16 and one dated 3/2/11, 14 days between a WSR dated 3/9 and one dated 3/23/11, and 12 days between a WSR dated 6/9 and one dated 6/21/11, the IC/WN stated, "I'm the only one who does this. If I have to cover the floor, it (WSR) would be put on the back burner." The WSR contained 2 sections: one titled Dressing Changes and Other, the other titled Pressure Ulcers. The PU section contained 9 areas to document: resident name; room; stage; measurement/description/location; admitted with date; in-house date; preventive devices/treatment; improving yes/no; and [MEDICAL CONDITION]. The WSR, dated 2/16 to 6/21/11 documented the following for Resident #1: * 2/16/11 - "Stage II Blister intact just (right) of coccyx," in-house date "2/12/11," treatment "Skin prep to keep skin (illegible) nearly reabsorbed," improving yes/no "yes reabsorby (sic)." * 3/2/11 - "Stage II Lt (left) heel blister intact stable brown scab," in-house date "2/12/11," treatment "Pressure off tinc ([MEDICATION NAME]) of [MEDICATION NAME] let top layer slough," improving yes/no "yes reabsorbed," no [MEDICAL CONDITION]; * 3/9/11 - "Stage IV Lt heel blister intack (sic) Lt (light) brown scab," a slash mark was in each of the following areas: admitted with date/in-house date/preventive devices and treatment; improving yes/no "healed 3/9/11." * 4/7/11 - "Stage II 1 cm (centimeter) coccyx superfical (sic)," in-house date "4/4/11," treatment "Silvsob (sic) (with) dressing," improving yes/no "New." * 4/13/11 - "Stage II 1 cm x 1.5 cm superfical (sic) yellow wound bed," in-house date "4/4/11," treatment "Silasorb (sic) dressing," improving yes/no "(increased) size," no [MEDICAL CONDITION]. * 4/20/11 - "Stage II 1 cm x 0.5 cm," in-house date "4/4/11," treatment "Silvisorb (and) mepipx (sic) dressing," Improving yes/no "Yes (decreased) size," no [MEDICAL CONDITION]. * 4/20/11 - "Stage II 0.2 x 0.2 cm Rt buttock cheek," in-house date "4/18/11," treatment "Silvasorvb (and) Mepiplex dress," improving yes/no was blank, no [MEDI

Based on observation, staff interview, and record review, it was determined a resident experienced harm as a result of the facility's failure to provide adequate pain relief during medical treatments. This was true for 1 of 7 residents sampled for pain control (Resident #8). Findings include: Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent annual MDS assessment, dated 5/27/11, documented the following: * Severely impaired cognitive skills for daily decision making * Usually understood, usually able to understand others * Unilateral limitation in range of motion for both the upper- and lower extremity * Almost constant moderate pain Resident #8's Pain CAA, dated 5/20/11, documented, "Arthritis primary cause of mild to moderate daily pain. Also has cervical disk disease with nerve root compression. Routine and PRN (as needed) meds (medications) available and effective according to resident. Resident stated her pain is constant, but it doesn't hinder her sleep or function during the day. Has contracture to the Lt (left) fingers, and decreased mobility." A physician's progress note, dated 1/12/11, documented, "(Resident #8) complains of inability to open her left hand ... she was complaining of (pain) in the left side of her neck prior to her developing a contracture of her left hand." A physician's progress note, dated 5/12/11, documented, "She does complain of the contractures in her left hand which have been a problem now for some time, although she does not have any evidence of acute arthritis. The contractures have developed felt to be due to cervical disk disease. Contracture left hand from probably cervical disk disease with persistent nerve root compression." Physician orders [REDACTED]. 3/25/11 * "APAP (Tylenol) 650 (milligrams three times daily) for chronic pain in joints." 4/14/11 * "D/C (Discontinue) routine Tylenol. Tylenol 650 mg (by mouth daily) 5 a.m. - pain upon AM (morning) cares." 4/25/11 * "D/C all Tylenol orders. Tylenol/Arthritis 650 mg (two tablets by mouth) at 5 a.m., 11 a.m., and (5 p.m. daily) for arthritis pain (won't ask for PRN (as needed) pain relief)." 6/29/11 * "(Change) Tylenol to Arthritis Tylenol 650 mg PO (at) 11 a.m. (and 5 p.m.). [MEDICATION NAME] 5 mg PO (at 5:00 a.m.) Resident #8's recapitulated physician orders, dated 7/1/11, documented the following: * "[MEDICATION NAME] ([MEDICATION NAME]) 100 mg PO TID (by mouth three times daily for) pain." Start date: 2/23/11. * "Tylenol 650 mg 2 tabs PO (at) 5 a.m., 11 a.m. (and 5 p.m. for) arthritis pain." Start date: 4/25/11. NOTE: Nursing 2012 Drug Handbook, by Lippincott, Williams, and Wilkins, documented the following information pertaining to Resident #8's physician ordered pain medications and times of administration: * Tylenol 650 mg - Peak effectiveness = 30 minutes to 2 hours; Duration of effectiveness = 3-4 hours. * [MEDICATION NAME] 5 mg - Peak effectiveness = 1-1.5 hours; Duration of effectiveness = 3.5-4 hours (Source: www.drugs.com/pro/[MEDICATION NAME].html). * [MEDICATION NAME] 100 mg - Peak effectiveness = "unknown;" Duration of effectiveness = "unknown." Care Plan updates for Resident #8 documented the following: 3/25/11 * "Problem: Arthritis pain." * "Goal: Manage pain (with) medication." * "Approaches: Give meds (medications) as ordered (by a physician). Monitor for breakthrough pain. Update MD (physician) as needed. Monitor for AR/SE (adverse reactions and/or side effects)." 4/25/11 * "Problem: Pain in hands due to arthritis. Res(ident) won't ask for pain med." * "Goal: Will be pain free." * "Approaches: Tylenol arthritis 650 (milligrams, two tablets by mouth at) 5 a.m., 11a.m., (and) 5:00 p.m. 7/11/11 * "Problem: Arthritic joints (with) [MEDICAL CONDITION]." * "Goal: Resolve [MEDICAL CONDITION] (and decrease) pain." * "Approaches: Give meds as ordered. Monitor [MEDICAL CONDITION]/pain. Monitor for AR/SE. Update MD (with) any (changes)." Resident #8's Care Plan in effect for July 2011 did not contain a specific area for pain management, however the section of the Care Plan for the "risk for skin breakdown due to decreased bed mobility" documented the following: "Lt (Left) hand with padding between 3rd (and) 4th fingers on at all times." A handwritten note next to the Care Plan approach documented, "Wound between 3rd (and) 4th digit outter (sic) aspect 3rd digit. 5/13/11. Meds (Medications) (and) Tx (treatment) per MD (physician) order. Update MD if Tx not effective. 5/13/11." NOTE: Please refer to Federal Citation F314. Nurse's Notes for Resident #8 documented the following: * 3/25/11 - "Res(ident) c/o (complains of) severe hand pain. Not relieved (with) routine (or) PRN medication. Alerted MD (and) N/O (new order) rec'd (received) to re-start APAP Arthritis Strength (two tabs) TID." * 3/25/11 - "Rsdt (Resident) having some relief in (left) hand but still c/o some pain." * 5/25/11 - "Silvasob (sic) (and) [MEDICATION NAME] foam applied. Res(ident) c/o severe pain (with) stretching fingers apart ..." * 6/10/11 - "Area on 3rd digit remains open. Res(ident) continues to be uncooperative (and) resistant to treatment." * 6/14/11 - "Res(ident's) wound better today but res(ident) still c/o severe pain to affected hand." * 6/15/11 - "Wound better today. Almost resolved. (Dressing changed). Contractures to that hand very painful." * 6/17/11 - "(Left) hand (with) contractures very painful for resident when doing (dressing changes)." NOTE: A Therapy Progress Note, dated 6/17/11, documented, "This therapist observed res's (resident's) (left) hand repeatedly in last year beginning when res(ident) was participating in physical therapy... Subsequently a fleece palm protector was trialed because res(ident) complained of discomfort and repeatedly removed the cotton/lamb's wool material. Her family was concerned about res' (resident's) complaints of pain and palm protector was discontinued... Since these approaches in addition to hand care and wound care by nursing have only reduced the frequency of skin breakdown and res(ident) has been noncompliant with using recommended interventions, it is recommended res(ident) begin on RNA (Restorative Nursing Aide) program (three time weekly) to supplement her nursing care." * 6/21/11 - "Res(ident) has not used [MEDICATION NAME] since 4/12/11 so both [MEDICATION NAME] 5 mg IV (intravenous)(and) [MEDICATION NAME] 10 mg (subcutaneous every hour as needed) D/C'd for non-use." * 6/28/11 - (Dressing change) completed ... difficult to get dressing (change) completed - resident resistant to (dressing change) hand (with) contractures c/o discomfort (with) movement." * 6/28/11 - "Sent request to (physician's name) for medication for breakthrough pain for resident. She has been requesting pain med more frequently. Will await for return call." * 6/29/11 - "Res(ident) cont(inues) to have a ... superficial pressure area on her (left) hand, which is severely contracted, causing pressure on 3rd finger first nuckle (sic). Area is improved but this re-occurs frequently due to res(ident) removes pressure reduction devices between fingers ..." 6/29/11 - "Rec'd (Received) return call (from physician). New orders rec'd. Arthritic Tylenol 650 mg (by mouth) (11:00 a.m. and 5:00 p.m.). Give [MEDICATION NAME] 5 mg PO (at 5:00 a.m.)." * 7/1/11 - "(Continues) to ask for more pain meds (at bedtime). No adverse reaction to [MEDICATION NAME] noted." * 7/3/11 - "(Continues) to ask for something for pain (at bedtime). No adverse reaction from [MEDICATION NAME] in AM (morning)." * 7/5/11 - "Even (with) recent pain med (changes) resident continues to c/o pain in her hands. Family here to visit (and) concerned. Phoned (physician) this AM. Awaiting return call." 7/5/11 - "Received order for: May have [MEDICATION NAME] 5 (mg) BID (twice daily) for pain. Also give [MEDICATION NAME] 10 (mg) PO QID (four times daily) X 2 days." * 7/5/11 - "Started [MEDICATION NAME] (at bedtime) last (night) but not [MEDICATION NAME] (at 5:00 p.m.) because she had APAP already. Not complaining of as much pain this evening." * 7/6/11 - "Is noted that res(ident) (and) family continues to remove devices to reduce pressure (and) dressings between. Very arthritic (and) contracted finger. Prior [MEDICAL CONDITION](cardiovascular accident) res(ident) had severe arthritis (with) joint deformity (after)[MEDICAL CONDITION] (sic) occurred (sic) (and) is very painful for res(ident) to spread her fingers apart or allow staff to place a roll under fingers. Family is very concerned r/t (related to) res(ident's) pain. DR (Physician) has (increased) pain medications (and) started on [MEDICATION NAME] to (decrease) inflammation. Res(ident) frequently removes interventions to (decrease) pressure. Family has also removed devices (at) res(ident's) request when she c/o pain." * 7/10/11 "(Wound care provided, nails clipped, pressure relief devices put into place). Pain med given (at) time for c/o pain symptoms." * 7/11/11 - "Call placed to (physician's name) (and) updated on current condition of swelling to hand (and) current pain tolerance (and) wound status. Res(ident) voices c/o pain when ROM (range-of-motion) performed on affected digits." * 7/11/11 "(Physician's staff member's name) stated (Resident #8's physician) unaware of res(ident) having pressure ulcer on (left) middle digit, but Dr. ordered [MEDICATION NAME] - signed order dated 5/13/11." 7/11/11 - "Res(ident) refused to allow tx (treatment) of hand today - stated it was too painful even (with) APAP attempt X2. Passed along to PM (evening) nurse to attempt (after) routine pain pill this afternoon." * 7/11/11 - "Updated MD on [MEDICAL CONDITION] (and) pain to hand. N/O received for [MEDICATION NAME] taper X 6 days for arthritis (and) [MEDICAL CONDITION]." * 7/11/11 - "Res(ident) has very little use of her (left) hand due to s/[MEDICAL CONDITION](status [REDACTED]. (At) present has an open area on 3rd digit first knuckle. This area tends (to) to open up (and) breakdown frequently. Has healed (and) open(ed) several X's (times). Res(ident) removes devices that relieve pressure due to she states, 'It hurts to (sic) bad.' Dr. has adjusted her pain (medications) (and) placed on [MEDICATION NAME] (sic) to (decrease) arthritic inflammation." On 7/12/11, at 9:35 a.m., the facility's Infection Control/Wound Care Nurse (IC/WCN) and CNA transported Resident #8 into the 100-hall shower room, where surveyors observed the IC/WCN and CNA #2 apply the [MEDICATION NAME] foam to the resident's tightly contracted left hand. Upon initiating the procedure, the IC/WCN informed surveyors that the resident had been "medicated" prior to the [MEDICATION NAME] foam application. However, throughout the procedure Resident #8 cried out in pain, flinched, and attempted to pull her hand away from the IC/WCN and CNA #2. NOTE: A narcotic check-out sheet for Resident #8 documented that on 7/12/11 the resident was given [MEDICATION NAME] 5 mg on 7/12/11 at 5:00 a.m. and at 4:30 p.m. The resident's MAR indicated [REDACTED] On 7/12/11, at 11:35 a.m., Resident #8 was observed in a wheelchair in the facility's main dining room with a blue sock covering her left hand, which she was cradling and rubbing with her right hand. When asked whether her pain medication was effective in helping control the pain associated with cares to her left hand, the resident stated the procedure left her in pain "every day." On 7/14/11, at 8:50 a.m., Resident #8 was observed in a wheelchair and rubbing her left hand, encased in a blue sock, near the nurses desk. When greeted by the surveyor, the resident stated she was waiting for pain relief medication because her left hand "hurt." LN #3, who was standing at a medication cart a few feet away from the resident, stated she was just then procuring the resident's scheduled [MEDICATION NAME] and that the resident would receive Tylenol per schedule at 11:00 a.m. The resident was observed in obvious pain during cares to her severely contracted left hand and expressed to surveyors that she endured pain daily with those and other associated cares to her left hand; the resident's record consistently documented that the cares provided to the resident caused her severe pain; and [MEDICATION NAME] medications administered to the resident prior to dressing changes had surpassed their peak and duration periods by the time the resident was provided with painful dressing changes to her affected left hand. The facility's consistent failure to adequately provide interventions for pain management in situations that repeatedly caused the resident pain and in which the facility could be reasonably expected to anticipate the resident's pain caused harm to Resident #8.

Based on observation, record review, and staff interview, it was determined the facility failed to provide medically-related social services for a resident whose behaviors escalated following medical procedures that result in alterations in body image, resulting in harm to the resident. This was true for 1 of 5 residents (#5) sampled for social services. Resident #5 did not receive psychosocial interventions after a colostomy surgery despite an increase in behaviors that resulted in decreased food and fluid consumption, emotionally distraught, non-responsiveness to staff, self isolation, and repeated refusals to accept medications or complete self-care tasks. Findings include: Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #5's most recent admission MDS assessment, dated 5/9/11, documented the resident was younger than [AGE] years of age, cognitively intact for daily decision making skills, had mild depression, understood others, was understood by others, and listed a former relative by marriage as her durable power of attorney (DPOA). The resident's Incontinence and Indwelling Catheter CAA, dated 5/2/11, documented, "Triggered as resident has chronic Foley catheter. Recently hosp(italized) for ostomy placement to stop soiling the catheter that was contributing to chronic UTIs (urinary tract infections). PO (Oral) intake of fluids adequate..." Resident #5's Psychotropic Medication Use CAA, dated 5/2/11, documented, "Receives Remeron 15 mg (milligrams) QHS (daily at bedtime) for depression, Fluoxitine 20 mg PO QAM (each morning) for depression, and Ativan 1-2 mg PO Q 4hrs (every four hours) PRN (as needed) for anxiety. These meds (medications) are not new to resident. Mood appears stable." A Social Services Admission assessment, dated 5/4/11, documented the following: * Feelings of hopelessness and helplessness * Difficulty sleeping * No behaviors of physical or verbal abuse, or resisting cares * No indication of need for psychiatric or counseling services Recapitulated physician orders [REDACTED]. * "Concerta 18 mg PO QD (daily) (for) poor appetite." Start date: 4/26/11. * "Fluoxetine 20 mg PO Q AM (every morning) (for) depression." Start date: 4/26/11. * "Ativan 1-2 mg PO Q 4hrs PRN (for) anxiety." Start date: 4/26/11. * "Comfort care measures." Start date: 6/24/11. The resident's Mood Care Plan for July 2011 documented the following: * "Problem(s): Derpression (sic) managed with psychoactive medications." * "Goal(s): Prescribed medications will remain effective to treat indicated symptoms with no adverse s/e (side effects)." * "Approach(s): Observe for s/s (signs and/or symptoms) that may indicate increase in depression, i.e.; change sleep pattern, mood, appetite." A Care Plan Update, dated 6/25/11, documented the following: * "Problem: Yelling out r/t (related to) pain/discomfort." * "Goal: Maintain comfortable." * "Approaches: Pain meds (medications) as ordered along with positioning." A Care Plan Update, dated 6/27/11, documented the following: * "Problem: Does not want to participate in RNA (Restorative Nursing Aide) therapies exercise of UE (upper extremities)." * "Goal: Will be comfortable." * "Approaches: D/C'd (discharged ) from RNA UE therapeutic exercise." Nurse's Notes for Resident #5 documented the following: * 3/25/11 - "Res(ident) up (and) out for both a.m. meals, good/fair appetite. Res(ident) wakeful for a.m. shift - maybe 1 (hour) of naps today. Res(ident) with good safety awareness. Works well (with) therapies. Res(ident) pleasant (and) coop (cooperative) (with) staff." * 3/27/11 - "Res(ident) up (and) out to MDR for both a.m. meals, good appetite. Res(ident) wakeful for a.m. (with) exception of small 'cat naps.' Res(ident) (with) good safety awareness. Res(ident) pleasant (and) coop (with) staff for ADLs." 3/29/11 - "Res(ident) up (and) out to breakfast, good appetite ... pleasant (and) cooperative (with) cares." * 3/30/11 - "Was (up) in w/c (wheelchair) for dinner, ate 100%." * 4/1/11 - "Rsdt (Resident) visiting (with) others." * 4/5/11 - "Resident will be leaving (at) 6 a.m. on 4/6/11 for admit to outpatient for colostomy surgery." * 4/5/11 - "Doing well eating today. Ate BKfast (breakfast) in MDR (main dining room)." NOTE: A Nurse's Note, dated 4/6/11, documented that the resident was scheduled for discharge from the facility on 4/6/11 for a colostomy surgery at a nearby hospital. The resident was readmitted to the facility on [DATE] and was observed during the facility's annual re-certification and state licensure survey with the surgical stoma and colostomy pouch in place. * 4/27/11 - Spoke to resident's POA regarding plan for future. He states it's time for nature to take its course. He thinks its getting ridiculous all these trips to the hospital. I told him we will continue to keep him posted as any condition (changes and) he can decide each time if he wants facility to ship her to the hospital or keep her here (at the facility and) keep her comfortable." * 4/27/11 - "Res(ident) voices (no) c/o (complaints) (at) this X (time). Res(ident very weepy this a.m. Wants attention freq(uently) (and) cries a lot. Res(ident) was taking her medication this a.m. (and) started out crying (and) moaning, but when this nurse did not respond to negative behavior res(ident) quit crying (and) took meds. Res(ident) refused Questran but took all other meds. Ativan given for obvious anxiety - med effective. Colostomy intact (at) this X. Res(ident) noted to pull (at colostomy) bag." * 4/29/11 - "Phone given to patient to call her (DPOA) per her request at beginning of shift. Continues to have ileostomy bags found breaking when checked on rounds. Appears possibly patient may be removing them herself to get more time (and) attention from staff." 5/8/11 - "Patient may be pulling at the (ileostomy) bag causing it to come loose, previous shifts found stool (illegible) from appliance under her nails." * 5/14/11 - "Res(ident pulling off appliance from stoma site, less than 30 min(utes) (after) appliance put on securely (and) was holding it was off (sic) upon inspection site was pulled loose (at) top of wafer area." * 5/15/11 - "Res(ident) very weepy (and) needy." * 5/19/11 - "Resident crying (and) very upset this a.m. Ostomy bag in place. Resident calmer after cares." * 5/20/11 - "Resident not as weepy today, more rational when discussing attempting to (illegible) resident becoming more independent in cares. Resident agrees to start helping (with) ostomy bag (changes)." * 5/21/11 - "Attempting to have resident learn (to change) ostomy bag herself. Resident reluctant to learn. Attempting to have resident come out to dining room for meals. Resident declined to out for lunch." * 5/22/11 - "Res(ident) not providing own ostomy care. Res(ident) set up but refuses to do it herself. Res(ident) has reusable bag (and) given instructions on how to clean it (and) re(fuses) to do it. Res(ident) freq(uently) undoes her ostomy appliance herself in an attempt (at) attention." * 5/24/11 - "(Resident #5) did (change) own ostomy (with) little assist." * 5/24/11 - "Res(ident) doing all stoma care." * 6/22/11 - "Resident does not wish to go to hospital for eval(uation) (and) tx (treatment) due to Hx (history of) urosepsis. Awake but lethargic, oriented X3 (person, place, and time). Slowly took a.m. meds PO (with) sips of (water). Informed DON of pt (patient's) wish to refuse transport to hospital." * 6/22/11 - "Not very responsive, but will awaken to voice (and) touch. When asked if she wanted to go to the hospital, she stated no. When asked if she was in pain, she said no." * 6/23/11 - "Afirmed (sic) that she did not want to go to the hospital." * 6/23/11 - "Didn't eat this a.m. nor take meds." * 6/23/11 - "Rsdt sleeping most of shift. She would moan (and) holler in between. She will not talk or answer anyone. She will not even make eye contact, but she will (at) times stop moaning when being talked to as though she is listening. She spit out all of her medications. She will (at) times takes (sic) sips of (water) but (at) other times she refuses or even spits it out after holding it in her mouth." * 6/24/11 - "Resident in small dining room next to nurses station for safety. Resident crying out on and off through the night unable to comfort. Refused to answer questions, make eye contact, or help with any cares. Asked if she was in pain and if she would take a pain pill with (no) response. Offered fluids and food with (no) response." * 6/24/11 - "I called the responsible party and his spouse would not take my name or number of our facility so I could notify him of the comfort care orders. She would not give me her name either (and) stated it was 'irrelevant.' She also informed me the rsdt 'is passing away right now and will no longer need rehab.'" * 6/24/11 - "Rsdt has slept most of shift. Refused supper (and) medications. She also (refused) snacks. Occasionally she calls out in a moan, but much more quietly from last PM (evening). (DPOA) returned call at (7:18 p.m.). He's aware of the comfort care orders and will be here in the a.m. to visit." * 6/25/11 - "Resident moved to small dining room next to nurse's station for safety and privacy. (DPOA) in to visit most of the night. Resident crying out most of the night - unable to comfort. Would answer questions part of the time, makes eye contact and requested a pain pill at (5:45 a.m.) then refused it." * 6/25/11 - "Resident was yelling out earlier at beginning of shift. Not able to keep comfortable and refusing care from nurses and aides d/t (due to) yelling out we moved her into an empty room and encouraged her not to yell out. Refusing oral meds." * 6/26/11 - "Refused to eat and take oral meds." * 6/26/11 - "Mouth cares given when she would allow. Much of the time she would not open her mouth at all." * 6/27/11 - "Was talking 'yes' (and) 'no' answers." * 6/27/11 - Refuses PO meds (at) this time. (DPOA) (at) bedside. Resident refusing to open mouth for oral intake. * 6/27/11 - "D/C from RNA UE Therapeutic Exercise Program. Res(ident) does not desire to participate." * 6/29/11 - "(Resident) refused most of her meds." On 7/14/11, at 9:40 a.m., the facility's Social Services designee (SSD) was interviewed. When asked what Social Service assessments or interventions were considered or implemented following Resident #5's return to the facility after the colostomy surgery, the SSD stated she visited with the resident privately. When asked to provide documentation of the one-to-one visits with Resident #5, the SSD stated, "I guess I didn't document it because it's not in the (resident's) chart." When asked what social services were provided to the resident to address alterations in body image secondary to the colostomy surgery, the SSD stated she did not discuss body image alteration difficulties the resident may have been having as evidenced by the increase in documented behaviors following the surgery. The SSD stated, "I agree with you, but it never occurred to me - body image is important." The SSD stated she was not aware of any difficulties involving the the resident's DPOA arrangement and denied knowing about the exchange between the facility and the DPOA's "spouse" as documented in the Nurse's Note of 6/24/11. The State Operations Manual, Appendix P, documented under the Psychosocial Outcome Severity Guide, that examples of "negative psychosocial outcomes as a result of the facility's noncompliance" may include a persistent depressed mood, social withdrawal, irritability, anxiety, hopelessness, tearfulness, crying, a loss of interest in every day activities, verbal agitation, apathy, social disengagement, sustained distress, anger or aggression that leads to self-injury or agressive behaviors towards others. The facility failed to provide medically-related social services to Resident #5 to address an increase in behaviors that affected the resident's food and fluid intake, social interaction with others, medication administration, and self-care following a colostomy surgery that immediately preceded the resident's wish to be placed on "comfort care" measures.