Every finding on record at Idaho State Veterans Home - Pocatello

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 10 of 54 residents (#1, #2, #4, #9, #19, #26, #27, #29, #46, and #55) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. Findings include:The facility’s Residents Rights Regarding Treatment and Advance Directives policy dated March 2025, documented It is the policy of this facility to support and facilitate a resident’s right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives. a. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including coronary artery disease, GERD (a chronic digestive disorder where stomach acid frequently flows back into the esophagus), and anemia (when the body doesn't have enough healthy red blood cells to carry oxygen to the body's tissues). Resident #1’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. b. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including Afib (irregular heartbeat), hypertension (high blood pressure), and malnutrition. Resident #4’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. c. Resident #27 was admitted to the facility on [DATE], with multiple diagnosis including non-traumatic brain dysfunction (brain damage not caused by external force), hyperlipidemia (elevated fats in the blood), and thyroid disorder (when the thyroid gland doesn't produce the right amount of hormones). Resident #27’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. d. Resident #46 was admitted to the facility on [DATE], with multiple diagnosis including hypertension, diabetes, and PTSD. Resident #46’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. On 8/5/25 at 12:41 PM, the Administrator stated he could not find advanced directives for residents #1, #2, #4, #9, #19, #26, #27, #29, #46, or #55 and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. e. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and heart failure. Resident #9's medical record contained a POST document but no advance directives document and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. f. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease and post-traumatic stress disorder (PTSD). Resident #26's medical record contained a POST document but no advance directives document and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. g. Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures) and aphasia (a language disorder that affects a person's ability to communicate). Resident #55's medical record had a POA for healthcare dated 10/19/14, but she revoked the POA on 12/19/23. Resident #55's medical record contained a POST document but no advance directives document and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. h. Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including coronary artery disease, hemiparesis (partial paralysis), and dementia. Resident #2’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. i. Resident #19 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including heart failure and diabetes. Resident #19’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive. j. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including dementia and muscle weakness. Resident #29’s medical record contained a POST but did not document an advance directive and no documentation the facility informed or provided written information concerning the right to formulate an advance directive.

Based on the facility Bowel Management Protocol, record review and staff interview, it was determined the facility failed to follow the facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 5 of 16 Residents (#5, #9, #11, #26, and #35) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The facility Bowel Management Protocol dated 4/2018, documented a resident's bowel movement(s) will be documented in Point of Care every shift. The licensed nurse will write and implement standing orders for progressive bowel elimination intervention as follows:- Step 1 - Bisacodyl tab give 10 mg by mouth as needed for constipation if no BM X 48-72 hours.- Step 2 - Bisacodyl suppository, insert 1 suppository rectally as needed for constipation if no BM X 12-24 hours following Bisacodyl tabs administration.- Step 3 - Fleet Naturals cleansing enema, insert one dose rectally as needed for constipation if no BM X 12-24 hours after Bisacodyl suppository. May repeat X1 if no results in 12-24 hours. a. Resident #5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fracture of left femur and depression. Resident #5’s medical record documented in the CNA Task Bowel Activity, he had a bowel movement on 7/17/25 documented at 20:09, and not again until 7/22/25 documented at 20:43, 120 hours later. Resident #5’s MAR for July 2025, documented bowel management protocol had not been initiated between 7/17/25 and 7/22/25. b. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including Huntington’s disease (inherited condition that affects brain cells) and anxiety. Resident #11’s medical record documented the following in the CNA Task Bowel Activity: - he had a bowel movement on 7/9/25 documented at 11:17, and not again until 7/23/25 documented at 21:29. Resident #11’s MAR for July 2025, documented the following bowel management protocol: - Step 1 had been initiated on 7/9/25 which did not result in documented BM. - Step 2 had been initiated on 7/14/25 which did not result in documented BM. - Step 3 had been initiated on 7/15/25, 7/16/25, 7/17/25, 7/18/25, 7/19/25, 7/20/25, 7/21/25, 7/22/25, which did not result in documented BM. c. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease and post-traumatic stress disorder. Resident #26’s medical record documented in the CNA Task Bowel Activity, he had a bowel movement on 7/23/25 documented at 13:59, and not again until 7/28/25 documented at 14:00, 120 hours later. Resident #26’s MAR for July 2025 documented the bowel management protocol was initiated for Resident #26 on 7/28/25. d. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including dementia and PTSD. Resident #35’s medical record documented the following in the CNA Task Bowel Activity: - he had a bowel movement on 7/6/25 documented at 21:47, and not again until 7/12/25 documented at 21:44, 144 hours later. - he had a bowel movement on 7/15/25 at 13:39 and not again until 7/20/25 at 15:41, 120 hours later. Resident #35’s MAR for July 2025 documented the following bowel management protocol: - Step 1 had been initiated on 7/10/25 which did not result in documented BM. On 8/6/25 at 2:38 PM, the DON stated the nursing staff should have documented they followed the bowel protocol step 1, 2, and 3 and had not.

Based on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 1 of 4 residents (Residents #19) observed for covered urinary drainage bag. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: Resident #19 was admitted on [DATE] with readmit on 6/17/24, with multiple diagnoses including heart failure, diabetes, and obstructive uropathy (condition when urine cannot drain through the urinary tract). On 8/4/25 at 2:31 PM, Resident #19's urinary drainage bag was uncovered and visible from the open doorway of his room. On 8/4/25 at 3:26 PM, the DON stated the urinary drainage bag should have been covered and was not.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's rights to be free from abuse were protected. This was true for 1 of 1 resident (Resident #61) whose record was reviewed for resident-to-resident abuse. This failure placed residents at risk for potential abuse and potential physical and psychosocial harm. Findings include:The facility Freedom from Resident Abuse, Neglect, Mistreatment, and Exploitation policy dated 2024, documented each resident.has the right to be free from verbal, sexual, physical, and mental abuse.Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including dementia and history of falling. Resident #29’s care plan dated 9/19/24, documented as a focus, I can be intrusive into others space while interventions are listed as intervene, redirect and remove environment as needed and observe and report signs and symptoms of me posing danger to self and others and intervene as needed. Resident #61 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and anxiety disorder. On 9/17/24 at 9:15 AM, Resident #29 approached and yelled to stop tapping on the fish tank, at Resident #61 who was cleaning the outside glass of the day room lounge fish tank. Both residents exchanged words loudly when Resident #29 struck Resident #61 across his face leaving 3 open scratches which drew blood. According to the facility investigation report of the incident 2 nurses and 2 CNAs were present when the incident began and observed Resident #29 hit Resident #61 leaving scratches on his face. Following the facility investigation of the 9/17/24 incident, the facility conducted additional education for all staff related to resident-to-resident abuse prevention. Resident #29 was reassigned to a different dining room table to allow for greater geographical separation between both residents. Staff were advised to continue to monitor both residents with no further issues occurring. Both residents continue to have positive interactions with each other, and both are comfortable with the plan to limit interactions with each other. Based on the corrective action taken by the facility and no other incidences of abuse, neglect, misappropriation of property, or exploitation to residents after 9/19/24, the facility was cited for past non-compliance.

Based on review of the Resident Assessment Instrument (RAI), record review, and staff interview, the facility failed to ensure residents Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 16 residents (Resident #46) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments. Findings include:Chapter 3 of The Resident Assessment Instrument (RAI), revised 10/1/2024, documented if a resident is currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have a serious mental illness, then section A1500 of the MDS should be marked yes.Chapter 5 of the RAI documented if an MDS assessment is found to have errors that incorrectly reflect the resident's status, that assessment must be corrected.Resident #46 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, diabetes, and PTSD (a serious mental illness).Resident #46's MDS assessment dated [DATE], documented in A1500, he did not have a serious mental illness.Residents #46's level II PASRR dated 2/19/25, documented he had a diagnosis of PTSD.Resident #46's medical record did not document a correction was completed for section A1500 to his MDS dated [DATE].On 8/6/25 at 11:30 AM, the DON stated section A1500 of Resident #46's MDS should have been corrected after receiving the level II PASRR on 2/19/25.

Based on record review and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 16 residents (Resident #35) reviewed for Pre-admission Screening and Resident Review (PASARR) Level II evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include:Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including dementia and PTSD.Resident #35 Level I PASRR dated 6/6/25, was generated in Arizona and had not documented PTSD, which was documented in his medical record diagnoses. A Level II PASRR for Resident #35 had not been requested or completed as required in Idaho. On 8/6/25 at 2:35 PM, the DON stated they should have created an updated Level I PASRR documenting PTSD and requested a Level II PASRR and did not.

Based on observation, interview, and record review, the facility failed to follow the resident's comprehensive person-centered care plan. This was true for 2 of 16 residents (#9 and #35) whose care plans were reviewed. This deficient practice of not following care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include:a. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and heart failure.On 8/4/25 at 8:30 AM, observed CNA #1 transfer Resident #9 from his wheelchair to his bed using a sit to stand device.Resident #9's physician orders related to assistive devices documented transfer stability for inability to bear weight related to CVA and left side hemiplegia and weakness.Resident #9's care plan documented that resident is a two person assist when transferred using a sit to stand device.b. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including dementia and PTSD.Resident #35's PTSD diagnosis had not been addressed with interventions in his care plan.On 8/6/25 at 2:37 PM, the DON stated Resident #9 should have been transferred with two persons per the care plan and had not been and Resident #35's PTSD diagnosis should have been care planned and was not.

Based on record review and staff interview, it was determined the facility failed to ensure accurate use of over the counter (OTC) medication left at bedside, and controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 16 residents (Resident #55) and the facility. This failure created the potential for undetected misuse of medications and/or diversion of controlled medications and had the potential to affect all residents who received medication in the facility. Findings include: a. Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including epilepsy and aphasia (a neurological condition that affects a person's ability to communicate). On 8/4/25 at 8:15 AM, observed in Resident #55’s room on the bedside table a bottle of Tylenol and Nyquil. There was a physician's order for the Tylenol but not the Nyquil. 8/6/25 at 2:41 PM, the DON stated residents often bring in OTC medicines and don’t tell nursing staff of the recent purchase. When nursing staff see the medicines at the bedside, they should get a physician’s order and had not. b. On 8/5/25 at 9:42 AM, during [NAME] Hall medication cart audit, observed the narcotic accountability record, dated 8/1/25 to 8/5/25, with 1 licensed nurse signature not documented. On 8/5/25 at 9:44 AM, LPN #7 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 8/5/25 at 3:12 PM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observations, and staff interviews it was determined the facility failed to ensure medications were stored and kept secure, and biologicals were labeled when opened. This was true for 1 of 16 Residents (Resident #46) and the facility. These deficient practices created the potential for theft or misuse of medication and the use of expired biologicals. Findings include: 1. The following was observed for biologicals. On [DATE] at 10:25 AM, one set of glucose test solutions were not dated with the open date or the expiration date. On [DATE] at 10:27 AM, LPN #2 stated the glucose test solutions were not dated and should have been. On [DATE] at 10:50 AM, RN #9 stated glucose test solution bottles should be dated when opened and were not. 2. Resident #46 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, diabetes, and PTSD. On [DATE] at 9:40 AM, Resident #46’s morning medications was observed sitting in a medication cup on his bedside table in his room with no licensed nurse present. On [DATE] at 9:45 AM, RN #2, stated she had no idea if Resident #46 had a self-medication administration assessment because this was her first day working with him. On [DATE] at 3:19 PM, RN #9 stated RN #2 is an agency nurse, and this was her first day working with Resident #46. He stated RN #2 should not have left Resident #46’s medications at the bedside and left the room. On [DATE] at 11:33 AM, the DON stated Resident #46 was not approved to self-administer medications and RN #2 should not have left his medications at the bedside.

Based on observation, staff interview, and record review it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 4 of 16 residents (#9, #21, #22, and #36) and the facility observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include: 1.Resident #9 was initially admitted to the facility on [DATE], with readmission on [DATE], with multiple diagnoses including coronary artery disease and diabetes. Resident #9’s medication orders included administer Novolog 100u/ml per sliding scale and Glargine 19u every AM. On 8/6/25 at 8:35 AM, observed RN #2 place a syringe containing Novolog insulin and a syringe containing Glargine insulin on Resident #9’s bed next to him as she cleaned the injection site. RN #2 then picked up each syringe off the bed and administered the insulin to Resident #9. On 8/6/25 at 8:38 AM, RN #2 stated she should have placed the insulin syringes on a protective barrier on Resident # 9’s bedside table, not in his bed. On 8/7/25 at 9:38 AM, the IP stated RN #2 should have placed her resident medications on a protective cover on top of Resident #9’s bedside table, not in his bed. 2. The facility's Equipment/Supplies Cleaning/Disposal Schedule policy, revised 4/20, stated shared equipment such as but not limited to: vital carts…etc. will be disinfected between each use with disinfectant wipes. On 8/6/25 at 8:30 AM, observed Resident #36 in East hallway at RN #2’s medication cart when RN #2 removed the blood pressure cuff from the vital cart and placed the blood pressure cuff on him, then removed the cuff and placed the blood pressure cuff back into the vital cart basket. On 8/6/25 at 8:42 AM, observed Resident #21 in East hallway at RN 2’s medication cart. RN #2 removed the blood pressure cuff from the vital cart and placed on Resident # 21’s arm then removed the cuff and placed the blood pressure cuff back into the vital cart basket. On 8/6/25 at 9:07 AM, RN #2 stated she should had cleaned the blood pressure cuff between resident uses and had not. On 8/7/25 at 9:38 AM, the IP stated blood pressure cuffs should be cleaned between resident uses and RN #2 had not followed the policy. 3. On 8/4/25 at 8:30 AM, observed CNA #1 clean a sit to stand device after a resident transfer but she did not clean the strap used during the transfer. CNA #1 stated she was not sure when the straps get washed. After CNA #1 cleaned the sit to stand device she draped the dirty straps over the cleaned device. On 8/6/25 at 2:36 PM, the DON stated the lift straps should have been cleaned and not just draped over the cleaned lift.

Based on a facility reported investigation, policy review, and staff interview, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency within two hours. This was true for 1 of 18 residents (Resident #149) reviewed for abuse. This failure resulted in Resident #149's allegation of sexual abuse not being acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation, which placed all residents in the facility at risk of abuse. Findings include: The facility's policy, Abuse Prevention Notification and Reporting Guidelines, states the facility does not condone resident abuse or neglect by anyone. All personnel will promptly report any incident or suspected incident of resident abuse. The first person to suspect abuse, is responsible for notifying the Home Administrator by telephone per the facility's Policy. - Resident #149 was admitted to the facility on [DATE], with multiple diagnoses including post hospitalization care for fracture of her right tibia and fibula (shin bones) Type 2 Diabetes, major depressive disorder, and anxiety disorder. -Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease and dementia. A facility investigation report, signed by the facility Administrator on 1/22/24, documented Resident #149 was interviewed by the SW. The SW stated Resident #22 walked in on Resident #149 while she was bathing. The following day Resident #22 approached Resident #149 at the nurse's cart in the hallway, rubbed her shoulder, and said inappropriate things to her. When Resident #19 was asked if she felt threatened, Resident #149 stated she felt very threatened and unsafe in the facility. Review of the facility's investigative documents documented that the SA was notified of the allegation of sexual abuse on 1/16/24. During an interview on 7/15/24 at 5:02 PM with the Administrator and DON, the Administrator stated that he received a call on 1/15/24 from Resident#149 who reported an incident between her and Resident #22. The Administrator stated Resident#149 stated Resident #22 came into the shower room while she was in the shower. Resident #149 yelled at Resident #22 to get out and he looked around the curtain at her. The Administrator said this happened on 1/14/24 and then on 1/15/24, Resident #22 cornered Resident #149 at the nursing station and said that he liked what he saw, and if she needed help next time, he would help her. The Administrator stated he advised staff they had 24 hours to report the incident, and he would handle it upon coming to the facility on [DATE]. The Administrator stated the allegation of sexual abuse was reported to the State Agency on 1/16/24. The Administrator stated he did not know about the two hour requirement for reporting abuse to the State Agency.

Based on record review, facility investigation report, and resident and staff interview, it was determined the facility failed to ensure physician orders were followed for pain medication administration and a respiratory treatment. This was true for 1 of 18 residents (Resident #18) reviewed for quality of care. These failures created the potential to adversely affect Resident #18 whose care and services were not delivered according to physician orders. Finding include: Resident #18 was admitted to the facility on [DATE] with multiple diagnosis including Chronic Obstructive Sleep Apnea (when a blockage in the airway keeps air from moving through the windpipe while asleep). A quarterly MDS assessment, dated 5/31/24, documented Resident #18 received oxygen therapy. A physician order, dated 6/29/24 documented Resident #18 was to receive a Norco Oral tablet (narcotic pain medication) 5-325 milligrams (mg), 1 tablet as needed. The order also documented Resident #18 was to receive continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while sleeping) with two liters oxygen via mask at bedtime for Obstructive Sleep Apnea. Resident #18's MAR, dated 5/11/24, did not include documentation Resident #18 received the prescribed Norco pain medication on the evening shift. Resident 18's TAR, dated 5/11/24, did not include documentation Resident #18 received the ordered CPAP with two liters oxygen via mask at bedtime. A facility investigation report, dated 5/16/24, included a statement from RN #2 who documented she did not administer Resident #18's pain medication nor his CPAP treatment. RN #2 documented that she assumed another staff member addressed Resident #18's needs/requests. During an interview on 7/17/24 at 9:30 AM, Resident #18 stated there was a problem with RN #2, who was the evening nurse on 5/11/24, not giving him the pain medication and CPAP treatment that the physician ordered for him. Resident #18 stated he had a nightly routine starting at 8:00 PM in which he received pain medication and his CPAP. Resident #18 stated he made several requests for RN #2 to start his treatment. Resident #18 stated he received messages RN #2 was busy with another resident. He stated RN #2 never came to address his needs. Resident #18 stated he felt this nurse intentionally did not respond to his requests. During an interview on 7/19/24 at 10:06 PM, the DON stated on the evening of 5/11/24, RN #2 sent word to Resident #18 that she would be with him as soon as possible. The DON further stated RN #2 assumed another staff member addressed Resident #18's needs so she did not enter his room. The DON stated RN #2 admitted she did not administer Resident #18's pain medication, nor his CPAP treatment. The DON also stated that RN #3, the night nurse, administered Resident #18's pain medication but did not administer his CPAP treatment.

Based on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure alternatives to bed rails were attempted or were assessed for use of bed rails prior to placing bed rails on the residents' bed. This was true for 2 of 2 residents (#33 and #34) reviewed for bed rails. This failure created the potential for harm due to the risk of entrapment and injury. Findings include: The facility's policy titled, Proper Use of Bed Rails, dated 10/2023, stated it is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. The policy further stated the facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms, or behavioral patterns for which a bed rail was considered. The following residents did not have complete assessments that included why alternatives to bed rails failed or why a resident had continued use of bed rails after an assessment documented the resident no longer needed bed rails. a. Resident #34's was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cervical fractures, hypertension, insomnia, cardiac arrythmia, heart failure, and history of falling. Resident #34's care plan for assistive devices, initiated 2/11/22, documented the goal was to improve independence, promote comfort, assist with positioning, skin integrity, increase ADL [Activities of Daily Living] independence, improve mobility, safety decreased fall risk. Interventions included Resident #34 had transfer rails on both sides of the bed to help improve bed mobility and transfer stability. During an observation and interview on 7/16/24 at 2:49 PM, and on 7/18/24 at 3:48 PM, Resident #34 was observed in his room in bed with raised bilateral upper side rails and an air mattress. Resident #34 stated he used the side rails. A Side Rail assessment dated [DATE], documented alternative interventions attempted for Resident #34 included reminders to use the call light, regular toileting, and use of a urinal/bed pan. The summary of findings documented side rails were indicated for Resident #34 and served as an enabler to promote independence. The assessment documented based on the summary of findings 1/4 bed rails were recommended for Resident #34 on the left and right side of the bed. The assessment did not include how the alternatives attempted failed to work for Resident #34. b. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses including heart disease, hypertension, obstructive sleep apnea, and vertigo. Resident #33's care plan for assistive devices documented he used assistive devices and the goal was to improve independence, promote comfort, assist with positioning, skin integrity, to increase ADL independence, improve mobility, and for safety/decreased fall risk (initiated 5/11/22). The care plan also documented Resident #33 had 1/4 rails bilaterally for bed mobility, ADL assistance, transfer stability, and had padded side rails for skin integrity and comfort (initiated 2/16/22). Side Rail Assessments, dated 2/1/22 through 4/27/23, stated Resident #33 should have bilateral upper quarter rails. Side Rail Assessments dated 7/27/23, 1/16/24, and 7/27/24 documented Resident #33 did not need bed rails. During an observation on 7/16/24 at 3:10 PM and on 7/19/24 at 12:17 PM, Resident #33 was in his room with raised bilateral upper side rails covered in a sheepskin-like material on his bed. During an interview on 7/19/24 at 4:58 PM, regarding attempted alternatives to side rails and how they failed, the Administrator stated an expectation was to try everything we can before placing side rails and if they are assessed to not need side rails that they do not have them.

Based on review of Incident and Accident reports, record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as care needs changed. This was true for 2 of 6 residents (#1 and #5) reviewed for care plan revision. This deficient practice placed residents at risk of and had the potential for harm if care and/or services were not provided due to inaccurate information in the care plan. Findings include: The facility's resident care plan policy, revised 9/2019, documented each resident would have a current, individualized resident care plan. It documented the licensed nurse would update resident care plans when problems were identified or new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] This policy was not followed: 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses, including chronic [CONDITION(S)] of the left ankle and foot (an infection in the bone caused by bacteria or fungi) and [CONDITION(S)] (a skin infection caused by bacteria) of the left toe. Resident #1's care plan for skin impairment, initiated on 9/16/19, documented the following interventions: * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. * Encourage good nutrition and hydration to promote healthier skin. a. A nursing progress note, dated 6/8/21 documented Resident #1 had a change in his skin condition. It noted Resident #1 had calluses on the bottom of both feet, and his left outer foot callous fell out when cleaned by the nurse. He had a second callous on his left 5th metatarsal (long bones of the foot) area with maceration (softening and break down of skin related to moisture) and drainage. A nursing progress note, dated 6/8/21, documented Resident #1 was seen by the wound clinic provider to evaluate his chronic callous with ulceration to the left 5th metatarsal and an evaluation of the right and left lower outer foot calluses. A nursing progress note, dated 6/12/21, documented the physician was notified of a wound on Resident #1's left foot that had an odor. The physician ordered a wound culture (a test that detects and identifies bacteria that causes infections) to be collected. A nursing progress note, dated 6/13/21, documented Resident #1's legal representative was notified about the change of the wound condition. The legal representative agreed to send Resident #1 to the hospital for further evaluation and treatment. A hospital admission note, dated 6/14/21, documented Resident #1 was admitted to the hospital on 6/13/21 for [CONDITION(S)] and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 returned to the facility from the hospital on 6/17/21. There was no information or interventions about Resident #1's wounds on his care plan. b. A wound progress note, dated 6/18/21 at 6:09 AM, documented Resident #1's left and right foot calluses were venous ulcer wounds (a sore on the leg or foot that is very slow to heal due to poor blood circulation). His left outer foot had a 1.3 x 1.5 x 0.1 cm venous ulcer, and his right foot had a 1.7 x 1.4 x 0.1 cm venous ulcer. Resident #1's TAR for June and July 2021 documented he received wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no information or interventions about Resident #1's venous ulcer wounds or specific skin condition changes on his care plan On 8/17/21 at 1:10 PM, the DON stated Resident #1 had a care plan for skin impairment, and it should have been updated to include care related to venous ulcer treatment. 2. The facility policy for fall prevention, dated 5/2007, documented an incident investigation report was completed if a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy was not followed: Resident #5 was admitted to the facility on [DATE], readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 6/4/21, documented Resident #5 had short-term and long-term memory impairment. It documented he required limited assistance for bed mobility, transfer, and extensive assistance for locomotion, dressing, toilet use, and personal hygiene. The facility's Incident and Accident Reports documented Resident #5 had one witnessed and six unwitnessed falls between 5/11/21 and 6/19/21. He fell on the following dates: 5/11/21 (2 falls), 5/17/21, 6/4/21, 6/18/21, and 6/19/21, a total of 7 falls in 6 weeks. Resident #5's care plan for assistive device use documented the following interventions for assistive devices to increase independence: * Quarter length side rails for bed mobility and transfer stability, initiated 7/2/18. * Ensure non-skid mat is under wheelchair cushion, initiated 7/2/18. * Anti-rollback device to wheelchair to promote safety, initiated 12/18/19. * Non-skid floor mat to the door side of the bed for independence and stability with transfers, initiated 8/7/20. * Long-handled reacher to assist with daily living independence, initiated 3/24/21. * Bathroom alarm to alert staff to Resident #5's need for assistance secondary to weakness, impulsivity, decreased safety awareness, and decreased visual acuity, initiated 5/21/21. Resident #5's care plan for falls documented the following interventions: * Be sure call light is within reach and encourage him to use it as needed, initiated on 4/3/18. * Ensure Resident #5 wore appropriate footwear, shoes, slippers, non-skid socks when sitting up at bedside, transferring, ambulating, or mobilizing wheelchair, initiated 4/3/18. * Encourage Resident #5 to place his coat or jacket in the bag behind his wheelchair when using a wheelchair, initiated 5/8/18. * To promote safety and proper body ergonomics with transfers, the bed would be placed at the correct height, initiated 1/9/19. * Staff would encourage Resident #5 to ask for assistance, initiated 10/11/19. * Alarm in place due to decreased safety awareness, impulsiveness, weakness, initiated on 5/21/21. Resident # 5's care plan did not include updated interventions related to his most recent falls on 5/11/21, 6/4/21, 6/18/21, and 6/19/21. On 8/17/21 at 1:00 PM, the DON stated care plans should have been updated and interventions adjusted after each fall.

Based on observation, interview, and record review, the facility failed to follow standard infection precautions when 1 of 3 housekeepers (HK) failed to complete hand hygiene after removing gloves. This failure placed all residents at risk for preventable exposure to infection and the development of disease and infection. Findings include: The facility's policy for Using gloves with a revised date of 4/2020 indicated that the purpose was To provide guidelines for the use of gloves for resident and employee protections .1. Clean glove procedure .g. Perform hand hygiene after removing gloves. Gloves do not replace hand washing .2. Gloves should be used .c. When providing housekeeping for resident areas that may expose staff to potentially infectious materials, such as but not limited to: changing linens, cleaning resident sink areas, bedside tables, wheelchairs, ect .c. Removing gloves .iv. Always remember to perform hand hygiene after removing gloves. The facility's policy for Hand Hygiene with a revision date of 5/2020 indicated that Hand hygiene is a general term that applies to either handwashing (mechanical cleansing using soap and water) or the use of an antiseptic (alcohol-based) hand rub. Hand hygiene is a simple and effective method for preventing the spread of pathogens, such as bacteria [MEDICAL CONDITION] which cause infections. Pathogens can contaminate the hands of staff through direct contact with residents or contact with contaminated equipment and environmental surfaces within close proximity to residents, staff and environmental surfaces .All staff, contractors .are expected to follow the hand hygiene policy . HK1 was observed on 6/24/20 at approximately 10:10 AM on the East Hallway. HK1 was observed putting on gloves, getting a clean rag and spray bottle of bleach out of the housekeeping cart. HK1 took these items into resident room [ROOM NUMBER]. HK1 was observed wiping high-touch areas; picking up trash; and cleaning around the sink area in the resident room. HK1 then brought out the trash emptying it in the housekeeping cart's trash bag, placed the used rag in a plastic bag attached to the cart, and placed the spray bottle back into the cart. HK1 than took a broom-like device and entered the resident room to sweep the floor. HK1 swept the debris to the room entrance and swept the material into a dustpan. HK1 then mopped the floor. HK1 did not change gloves during this observation. After mopping the room, HK1 removed his gloves and walked to another resident room and looked in; HK1 then went back to the housekeeping cart and put on another pair of gloves. HK1 did not wash or use hand sanitizer between glove changes. HK1 then got a clean rag and a spray bottle of bleach and walked to room [ROOM NUMBER]. When HK1 reached room [ROOM NUMBER], a certified nursing assistant stated that the resident needed care; HK1 walked back to the housekeeping cart and returned the rag and spray bottle to the cart. HK1 removed his gloves but again did not complete hand hygiene before leaving the area. HK1 returned to the housekeeping cart at approximately 10:25 AM with a can of window/glass cleaner. HK1 walked down the hall looking into resident rooms. HK1 returned to the cart and put on a pair of gloves, got a rag and a bottle of bleach spray; he then went to room [ROOM NUMBER]. HK1 was observed cleaning room [ROOM NUMBER] much like he had room [ROOM NUMBER] (wiping high-touch areas, emptying trash, cleaning the sink and bathroom area). After mopping room [ROOM NUMBER], HK1 returned the mop to the cart and removed his gloves. No hand hygiene was observed by HK1. HK1 then moved the cart down the hall and looked in other resident rooms. HK1 then left the East hallway and walked to the West hallway. HK1 came back to the East hallway at approximately 10:40 AM with a container of soap, which he took to a resident room. HK1 then returned to the cart where HK1 picked up a soiled rag with his bare hand and placed the rag in a plastic bag attached to the cart. HK1 did not complete hand hygiene after touching the soiled rag. HK1 then left the area. HK1 was observed to be vacuuming on the West hall at approximately 10:55 AM. On 6/24/20 at 2:35 PM, an interview was conducted with the housekeeping supervisor (HKS). The HKS was asked about hand hygiene and glove use. The HKS acknowledged that staff should wash hands after removing gloves or use hand sanitizer. On 6/24/20 at 4:10 PM an interview was conducted with administrative staff. The observations of HK1 were discussed all administrative staff acknowledged that all staff should do hand hygiene after removing gloves.

Based on observation, record review, facility policy review, and resident and staff interview, it was determined the facility failed to ensure the required information was conveyed to the receiving facility or other health care provider when residents were transferred to the hospital and/or discharged home. This was true for 5 of 5 residents (Resident #37, #38, #44, #47, and #61) reviewed for transfer/discharge. This failure created the potential for harm if residents were not treated appropriately or in a timely manner due to a lack of information. Findings include: The facility's policy for Resident Transportation/Transfer, revised (MONTH) 2006, was reviewed. The policy did not address the need to convey the required information to the receiving facility and document what information was sent. 1. Resident #44 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A progress note, dated 7/9/19 at 8:43 PM, documented Resident #44's daughter was notified Resident #44 had a fall resulting in a bump to her left temporal lobe (left side of head). A progress note, dated 7/9/19 at 8:44 PM, documented the physician was notified of Resident #44's fall. A progress note, dated 7/9/19 at 8:55 PM, documented Resident #44's daughter was informed Resident #44 had a second fall of the evening which resulted in a deep skin tear to her left hand, and her daughter agreed to send Resident #44 to the ER for treatment. A progress note, dated 7/9/19 at 9:05 PM, documented direction from the physician to send Resident #44 to the ER for evaluation and treatment of [REDACTED]. Resident #44's record did not include documentation the required information was provided to the hospital ER to ensure a safe and effective transition of care. A progress note, dated 7/10/19 at 1:10 AM, documented Resident #44 returned to facility at 1:05 AM. There was no evidence the hospital was made aware of the bump to Resident #44's head which she sustained during her first fall the evening of 7/9/19 and whether it was assessed at the hospital. On 8/8/19 at 8:50 AM, the DNS said Resident #44's record did not include documentation the facility conveyed the required information to the hospitalER on [DATE]. 2. Resident #37 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On 8/7/19 at 10:18 AM, Resident #37 was in his room with oxygen in place at 4 liters per minute by nasal cannula (tubing that administers oxygen through the nose). Resident #37 had an oximeter on his finger, and it read his oxygen saturation level was 84%. Resident #37 said his breathing was not feeling very good. A physician's orders [REDACTED].#37 to a hospital emergency room (ER) for evaluation for shortness of breath with [MEDICAL CONDITION]. A Nursing Note, dated 8/7/19 at 10:33 AM, documented the RN Manager assessed Resident #37 for concerns that he was unable to catch his breath. Resident #37's oxygen saturation level was low, the physician was notified, and an order was received to have him evaluated in the ER. A Nursing Note, dated 8/7/19 at 4:30 PM, documented Resident #37 was admitted to the hospital with [REDACTED]. There was no documentation that the required information was provided to the receiving hospital when Resident #37 was transferred. On 8/8/19 at 10:05 AM, the RN Manager said when a resident was transferred to the hospital, the charge nurse documented the assessment and details of the transfer in the Progress Notes. On 8/8/19 at 2:00 PM, the DNS said when a resident was transferred to the hospital, facility staff contacted the family, obtained an order from the physician, copied the resident's face sheet, advanced directive, and Medication Administration Record [REDACTED]. The DNS said no other documentation was completed upon resident transfers, and he did not think documentation would be found in a Progress Note about what information was sent with Resident #37 to the hospital. 3. Resident #47 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Nursing Note, dated 8/6/19 at 9:15 AM, documented Resident #47 had a nosebleed upon returning from breakfast and the bleeding continued. He verbalized feeling like he was going to pass out, and was subsequently sent to the ER for treatment. A Notice of Resident Transfer form, dated 8/6/19, documented Resident #47 was being transferred to a hospital ER. On 8/6/19 at 11:19 AM, Charge Nurse #1 stated Resident #47 went to the hospital that morning due to a nosebleed. There was no documentation in Resident #47's record the required information was provided to the receiving hospital when he was transferred to the hospital. On 8/8/19 at 10:05 AM, the RN Manager said when a resident was transferred to the hospital, the charge nurse documented the assessment and details of the transfer in the Progress Notes. There was no documentation in Resident #47's record the required information was provided to the receiving hospital when he was transferred to the hospital. On 8/8/19 at 2:00 PM, the DNS said he did not think documentation would be found in a Progress Note about what information was sent with Resident #47 to the hospital. 4. Resident #38 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A progress note, dated 8/6/19 at 12:30 PM, documented verbal communication from the physician to send Resident #38 to the hospital via emergent transport for evaluation and treatment. A progress note, dated 8/6/19 at 1:30 PM, documented Resident #38 was sent to the hospital ER for unresponsiveness, inability to follow commands, weakness, and bradypnea (abnormally slow breathing), after consulting with Resident #38's Durable Power of Attorney. Resident #38's record did not include documentation the required information was provided to the hospital to ensure a safe and effective transition of care. On 8/8/19 at 9:30 AM, the DNS stated Resident #38's record did not include documentation the facility conveyed the required information to the hospitalER on [DATE]. 5. Resident #61 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Fax Transmittal Sheet, dated 5/8/19, documented information was faxed to a named home health agency. The faxed information included the face sheet, orders, physician note, and physical therapy note. The Fax Transmittal Sheet did not document advance directive information was sent. A physician's orders [REDACTED].#61 may discharge to home today 5/9/19 with home health (and) PT (physical therapy). Resident #61's Physician Discharge Summary note, dated 5/9/19 at 3:50 PM, did not include his advance directive information. A Recapitulation of Resident's Stay, dated 5/9/19, did not document his advance directive information. On 8/9/19 at 10:10 AM, LSW #2 provided Resident #61's Recapitulation of Resident's Stay and Discharge Checklist. LSW #2 said there was no further documentation regarding Resident #61's discharge, and his discharge was abrupt and sudden. On 8/9/19 at 10:27 AM, LSW #2 said the documentation did not indicate his advance directive information was sent to the home health agency.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure the physician was notified when a resident's oxygen saturation (percentage of oxygen in the blood) was below prescribed parameters. This was true for 1 of 5 residents (Resident #37) reviewed for oxygen therapy, and created the potential for harm should the resident experience adverse consequences from lack of physician notification and intervention. Findings include: The facility's policy for Notification of Changes, undated, documented the physician was notified immediately in the event a resident experienced changes, including but not limited to a significant change in the resident's physical, mental, or psychosocial status, or when there was a need to alter treatment. Resident #37 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #37's annual MDS assessment, dated 6/14/19, documented he had shortness of breath with exertion, when sitting at rest, and when lying flat. The MDS documented he received oxygen therapy. Resident #37's physician orders [REDACTED]. Use oximeter (a device to measure the percentage of oxygen in the blood) during oxygen administration to check oxygen saturation levels. Resident #37's care plan documented the following: * Oxygen at zero to four liters per minute to keep oxygen saturation level above 89%, initiated on 6/7/18 and revised on 1/2/19. * Monitor for any indication of decline in health status. Notify physician of any significant changes, initiated on 6/7/18. Resident #37's Treatment Administration Record (TAR) for (MONTH) 2019 documented his oxygen saturation level was below 89% as follows: * On day shift 8/2/19 = 88%. * On evening shift 8/4/19 = 87%. * On day shift 8/5/19 = 88%. * On evening shift 8/6/19 = 83%. Resident #37's Weights and Vitals Summary documented his oxygen saturation level was below 89% as follows: * On 7/2/19 at 9:46 PM = 80%. * On 7/3/19 at 9:43 PM = 80%. * On 7/4/19 at 5:38 AM = 88%. * On 7/4/19 at 10:35 PM = 86%. * On 7/5/19 at 1:06 AM = 66% (on room air). * On 7/5/19 at 10:05 PM = 80%. * On 7/6/19 at 1:32 AM = 88%. * On 7/8/19 at 6:07 PM = 86%. * On 7/10/19 at 10:03 PM = 87%. * On 7/15/19 at 1:59 PM = 88%. * On 7/17/19 at 10:51 AM = 88%. * On 7/17/19 at 1:30 PM = 88%. * On 7/18/19 at 2:45 PM = 88%. * On 7/21/19 at 3:17 PM = 88%. * On 7/30/19 at 9:18 PM = 87%. * On 7/31/19 at 9:57 AM = 88%. There was no documentation in Resident #37's record prior to 8/7/19, the physician was notified when his oxygen saturation level was less than 89%. On 8/7/19 at 10:18 AM, Resident #37 was in his room with oxygen in place at 4 liters per minute by nasal cannula (tubing that administers oxygen through the nose). Resident #37 had an oximeter on his finger, and it read his oxygen saturation level as 84%. Resident #37 said his breathing was not feeling very good, and he said the hospital previously told him his oxygen saturation level should be 88% to 90%. On 8/7/19 at 10:23 AM, LPN #3 said Resident #37 had hard time maintaining his oxygen saturation level at greater than 89%, and she just administered an inhaler to him. LPN #3 said she did not know why Resident #37 had a hard time maintaining his oxygen saturation level, and it was 86% that morning. LPN #3 said the physician's orders [REDACTED].#37's oxygen saturation level above 89%, and he was on four liters of oxygen. LPN #3 said if Resident #37's oxygen saturation level was less than 89%, the nurse should notify the physician and charge nurse, and she had not done that. A Nursing Note, dated 8/7/19 at 10:48 AM, documented there was difficulty keeping Resident #37's oxygen saturation above 86%, and his oxygen saturation dropped into the 70's. When the oxygen tubing was placed in Resident #37's mouth the oxygen saturation increased, but when the tubing was placed into his nose the oxygen saturation dropped back into the low 80's and high 70's. Resident #37 asked to be evaluated in the emergency room , and the charge nurse assessed him. A Nursing Note, dated 8/7/19 at 10:33 AM, documented a physician's orders [REDACTED].#37 to the ER for evaluation. There was no documentation in Resident #37's record prior to 8/7/19, the physician was notified when his oxygen saturation level was less than 89%. On 8/7/19 at 11:28 AM, the RN Manager said he was not aware of Resident #37's decreased oxygen saturation levels until LPN #3 told him that morning. The RN Manager said when a resident had a decreased oxygen saturation level, he would expect the nurse to administer nebulizer treatments (medications in an inhaled mist form), and to notify the charge nurse, who would notify the physician. The RN Manager said Resident #37's physician order [REDACTED]. On 8/7/19 at 3:52 PM, the DNS said Resident #37 had an oximeter to monitor his oxygen saturation, and he wore it all day. The DNS said if the oxygen saturation level was low, he expected the nurse to have Resident #37 take deep breaths, check the oxygen tank to make sure there was oxygen in the tank, and check the position of the oxygen tubing. The DNS said if Resident #37's oxygen saturation level did not come back up, he would expect the nurse to get in touch with the physician.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure bruises of unknown origin in suspicious areas of a resident's body were reported to the Administrator and State Survey Agency within 2 hours of when the bruises were identified by facility staff. This was true for 1 of 1 resident (Resident #31) reviewed for injuries of unknown origin. This failure created the potential harm if the injuries of unknown origin on Resident #31's thigh and breast were a result of abuse. Findings include: The facility's policy titled Freedom from Abuse, Neglect, and Exploitation, last revised 12/2017, documented all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The policy also documented all violations involving injuries of unknown source were to be reported immediately and an Incident Report completed. Resident #31 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #31's admission MDS assessment, dated 6/8/19, documented she was severely cognitively impaired, totally dependent on two staff members for transfers, and required extensive assistance of two persons for bed mobility. Resident #31's admission skin assessment, dated 5/31/19, documented there was scattered scabbing to the entire body and face with multicolor yellow bruising in various stages of healing. The skin assessment not include documentation of a bruise on Resident #31's left thigh or breast. Resident #31's Progress Note, dated 6/28/19 at 10:35 PM, documented a skin assessment was completed by Charge Nurse #1, and Resident #31 had various areas of bruising that included a bruise on the left thigh. Charge Nurse #1 documented there were no new concerns. On a skin assessment, dated 7/5/19 at 10:17 PM, LPN #5 documented Resident #31 had a bruise on her left breast. LPN #5 documented there were no new concerns. On 8/8/19 at 3:15 PM, Charge Nurse #1 stated he did not remember the skin assessment he completed for Resident #31 on 6/28/19. He stated he did not remember anything about the bruise on her left thigh, such as where the bruise was located on the thigh, the size, and the color. Charge Nurse #1 stated when a new bruise was noted, staff were to write up an Incident Report. Charge Nurse #1 stated he did not follow the procedure. On 8/9/19 at 10:14 AM, LSW #2 stated she did not recall anyone reporting the bruise on the thigh of Resident #31. LSW #2 stated she expected an Incident Report to be filled out, and it should contain a description of the bruise, its location and size, and staff monitoring of it. On 8/8/19 at 2:30 PM, the DNS confirmed there was no Incident Report completed for Resident #31 regarding the bruise of unknown origin on her thigh on 6/28/19 and for the bruise of unknown origin on her breast on 7/5/19. On 8/8/19 at 2:45 PM, the Administrator stated he was not aware of any bruises on Resident #31's thigh because an Incident Report was not completed. The Administrator stated the bruise of unknown origin would trigger more investigating because of its location. On 8/8/19 at 2:55 PM, the Administrator stated, depending on the initial investigation, he would have reported the incident to the State Survey Agency's reporting portal and then completed a five day follow up with the results of the investigation.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure bruises of unknown origin in suspicious areas of a resident's body were investigated. This was true for 1 of 1 resident (Resident #31) reviewed for injuries of unknown origin. This failure created the potential for Resident #31 to experience undetected abuse. Findings include: The facility's policy titled Freedom from Abuse, Neglect, and Exploitation, undated, documented injuries of unknown origin included injuries that were not observed by any person, or the source of the injury could not be explained. The injuries included severe bruising on the head, neck, or trunk, fingerprint bruises anywhere on the body, lacerations, sprains, or fractures, and were considered a crime. Minor bruising was not considered a crime and did not have to be reported. The policy documented all violations involving injuries of unknown source were reported immediately. The policy documented an incident was an unexpected, unintended event that could cause a resident injury, and an Incident/Accident report was initiated for skin tears and bruises. Any individual aware of an incident/accident that involved a resident should report the incident to the licensed nurse on that unit. The Incident Report was initiated and completed by the attending nurse by the end of the shift. The policy directed staff to initiate immediate interventions, and alert charting would be done, as needed. The DNS or designee reported the incident to the clinical team for multidisciplinary evaluation. Resident #31 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #31's admission MDS assessment, dated 6/8/19, documented she was severely cognitively impaired, totally dependent on two staff members for transfers, and required extensive assistance of two persons for bed mobility. Resident #31's admission skin assessment, dated 5/31/19, documented there was scattered scabbing to the entire body and face with multicolor yellow bruising in various stages of healing. The skin assessment not include documentation of a bruise on Resident #31's left thigh or breast. Resident #31's skin assessment, dated 6/21/19, did not document any issues with her skin. Resident #31's Progress Note, dated 6/28/19 at 10:35 PM, documented a skin assessment was completed by Charge Nurse #1, and Resident #31 had various areas of bruising that included a bruise on the left thigh. Charge Nurse #1 documented there were no new concerns. On a skin assessment, dated 7/5/19 at 10:17 PM, LPN #5 documented Resident #31 had a bruise on her left breast, and there was no documentation of a bruise on her left thigh. LPN #5 documented there were no new concerns. On 8/8/19 at 2:20 PM, the Wound Nurse stated an investigation should have been initiated for the bruises that were found on Resident #31's thigh and breast, and it was unknown how the bruises occurred. The Wound Nurse said the bruises should have been documented in the Progress Notes, and an Incident Report should have been initiated. The Wound Nurse stated the charge nurse should have been informed and the facility should have called Resident #31's family. The Wound Nurse stated Resident #31 did not have any falls that could have caused the bruising since she was admitted to the facility. On 8/8/19 at 3:15 PM, Charge Nurse #1 stated he did not remember the skin assessment he completed for Resident #31 on 6/28/19. After reviewing the skin assessment, Charge Nurse #1 stated he did not remember anything about the bruise on Resident #31's left thigh, such as where the bruise was located on the thigh, the size, and the color. Charge Nurse #1 stated in hindsight he should have written up an Incident Report. Charge Nurse #1 stated he had been employed at the facility for less than six months and was still learning the policies and procedures. Charge Nurse #1 stated when a new bruise was noted, staff were to write up an Incident Report, obtain witness statements, measure the bruise and document the location, document any person who had contact with the resident, and notify the family, healthcare team, and the physician. Charge Nurse #1 stated he did not follow the procedure. On 8/9/19 at 10:14 AM, LSW #2 stated she did not recall anyone reporting the bruise on the thigh of Resident #31. LSW #2 stated she expected an Incident Report to be filled out, and it should contain a description of the bruise, its location and size, and staff monitoring of it. On 8/8/19 at 2:30 PM, the DNS confirmed there was no investigation or Incident Report completed for Resident #31 regarding the bruise of unknown origin on her thigh on 6/28/19 and for the bruise of unknown origin on her breast on 7/5/19. The DNS stated when the bruise was noted on Resident #31's thigh and breast, an Incident Report should have been initiated and an investigation should have followed. The DNS stated the Interdisciplinary Team reviewed the Incident Reports each day, and there was no evidence an Incident Report was completed for Resident #31. On 8/9/19 at 8:21 AM, the DNS stated an LPN discovered the bruise on Resident #31's breast during a skin assessment on 7/5/19. The DNS stated he talked to the LPN previously, and she thought documenting the bruise was all that was necessary. The DNS stated the LPN was a new nurse, and she was hired at the end of (MONTH) 2019. On 8/8/19 at 2:45 PM, the Administrator stated he was not aware of any bruises on Resident #31's thigh because an Incident Report was not completed. The Administrator stated the bruise would trigger more investigating because of its location. The Administrator said an Incident Report should have been initiated, the DNS should have been notified, and an investigation should have been completed.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were updated to accurately reflect their code status. This was true for 1 of 15 residents (Resident #37) whose care plans were reviewed. This failure created the potential for life sustaining treatment to be administer or withheld, contrary to residents wishes should they become incapacitated. Findings include: The facility's policy for Resident Care Planning, undated, documented the folllowing: * Each resident had a care plan that was current, individualized, and consistent with the medical regimen. * The interdisciplinary team reviewed and updated the care plan as necessary. * The licensed nurse updated the care plan as new physician orders [REDACTED]. Resident #37 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #37's annual MDS assessment, dated 6/14/19, documented he was moderately cognitively impaired. Resident #37's care plan documented Full Code (resuscitate), initiated on 6/11/18. Resident #37's Physician order [REDACTED]. On 8/7/19 at 9:57 AM, LSW #2 said she was involved with advance directive planning. LSW #2 said Resident #37 had a care conference, and his guardian wanted to continue with his wishes regarding his code status. LSW #2 said there was a discrepancy on Resident #37's care plan regarding his code status. On 8/7/19 at 11:25 AM, the RN Manager said there was a discrepancy on Resident #37's care plan regarding his code status, and the MDS Nurse was the one who made sure the care plan matched. On 8/7/19 at 11:39 AM, the MDS Nurse said Social Services was involved with advance directive planning and followed the information on the care plan. The MDS Nurse said Resident #37 may have updated his POST information, and she was not involved with updating the POST information.

Based on observation, record review, facility smoking policy, and resident and staff interview, it was determined the facility did not ensure 1 of 3 residents (#1) sampled for falls was provided adequate supervision. Resident #1 was harmed when he was left unattended in the tub room following a bath, attempted to stand without assistance and fell which caused a left hip fracture and required surgical intervention. In addition, the facility failed to identify safety hazards and ensure staff and residents who smoked, used the designated smoking areas. This failed practice had the potential to affect 1 of 11 (#3) sampled residents and any other resident who would have to pass by smokers in order to use the outside courtyard which could harm the resident if a fire broke out and there were no safety measures in place. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 11/8/13 quarterly MDS assessment, documented the following: * Required extensive assistance with two staff to transfer in/out of tub; * Required extensive assistance with two staff to dress; and, * Was moderately cognitively impaired, BIMS =11. The resident's 2/7/14 quarterly MDS assessment documented the resident was cognitively intact, BIMS =14. The resident's Fall Risk Evaluation, dated 6/29/13, documented the resident was a high risk for falls. The resident's Falls care plan, dated 11/19/13, documented a focus of: "HX (history) of falls. Unable to maintain balance, Does not recognize own physical limitations, CVA (cerebrovascular accident) with [DIAGNOSES REDACTED], delusional disorder, dementia, weakness, poor eyesight...", With a goal of, "safety measures will be utilized this quarter." The resident's ADL care plan, dated 11/19/13, documented a focus of: "Extensive assistance for self care ADL's...Post CVA; depression, Paranoia; [DIAGNOSES REDACTED], Slow to process information, Unable to maintain balance, Weakness, Poor eye sight...", With Interventions dated 8/27/13, "Use 2 person assistance to transfer into tub. Prefers tub bath in the evenings." and "Requires 2 person assistance with dressing related to weakness..." A facility "Fall Scene Investigation" dated 12/20/13 indicated the resident fell on [DATE] at 4:30 PM. The investigation documented the following: The "Recreation..." section documented, "Staff was waiting for assist(ance) and stepped away from res(ident) to check door/hallway. Resident impatient and tried to stand. Aide turned around and resident was laying on floor on left side." Note: The tub is approximately 13 feet from the door. There is a call light cord 2 feet from the tub and another call light cord in the shower stall approximately 11 feet from the tub. The "Fall Huddle" section documented, "Staff not prepared and stepped away from resident. Educated aides to work as team and check on each other during shift." The "Root Cause of This Fall" section documented, "Resident states 'I was in a hurry to get up and get dressed.' Resident tends to forget he is not wt. (weight) bearing..." The "Conclusion" section documented, "The aide used poor judgement (and) did not prepare properly for the bath." A facility investigation titled "Fall with Fracture" dated 12/21/13 documented: "The Veteran had just finished his bathing and was sitting at the edge of the tub to be transferred to the bathing chair and taken to his room. The staff member who was assisting went to the door to look down the hall for help for having a second person transfer per the Veterans care plan. The staff member did not pull the call light prior to leaving the side of the Veteran. The staff member turned and noticed the Veteran on the floor next to the tub; he immediately pulled the call light in the shower stall next to him and went to get help." NOTE: The tub contained a hinged water tight door which closed vertically allowing the tub to fill up with water and secure the resident's safety. The tub was then tilted backwards while the resident sat reclined in the tub. After the bath, the water was drained, the tub was tilted back leaving the resident in a sitting position in the tub. Once the door was opened, the resident could swing their feet out to the left and step away from the tub. The resident's Progress Note documented the resident did not complain of pain to his left hip until 6:35 PM on 12/20/13 and was given pain medication, "...which helped." On 12/21/14 a note at 1:54 AM documented, "...left hip increase pain when staff turned him...decision to sent (sic) to ER (emergency room ) for eval(uation)...left at 1:38 (AM) via ambulance." A local hospital record dated 12/21/14 documented, "He was brought into the emergency room and found to have a left hip fracture..." Note: Hospital records documented the hip fracture required surgical repair. On 4/22/14 at 1:38 PM Resident #1 was interviewed regarding the fall. He said he remembered the incident. He said during his bath, CNA #7 was the only staff member in the room and after his bath he was left alone by the CNA with his legs draped over the tub and became cold. At this point the resident stated to the CNA, "I'm done." The resident said he did not receive a verbal response from the CNA and could not see him in the tub room, so the resident stood up unassisted and fell . On 4/24/14 at 1:35 PM, the DNS was interviewed regarding the incident. She reviewed the "Fall Scene Investigation" and was asked what her conclusion was, she stated, "He (CNA #7) knew better...I think he made a bad decision." Note: CNA #7 no longer worked at the facility at the time of the interview. When asked why CNA #7 opened the tub door prior to having a second CNA to help dress and transfer the resident as indicated in the care plan, she said this was her question to CNA #7 and he did not give her an answer. The facility did not ensure they kept the resident safe, even though he was a high fall risk, was unable to maintain balance, and did not recognize his own physical limitations, when he was left unattended on the edge of a tub prior to his fall. 2. The facility's Nursing Procedure Manual titled Smoking documented the following: "Smoking procedures for this facility are necessary for ensuring the safety of each resident, staff, and visitor. The Administrator has the ultimate responsibility for enforcing the facility smoking procedure... A. Resident smoking is allowed only in designated areas around the facility. No other area is available for smoking by anyone. B. The only smoking area within the facility is the smoking room across from the nurses' station. This room is available for use by residents at scheduled times which are posted on the door. The room will be kept locked at all other times... E. Individuals who wear oxygen and smoke tobacco products must remove oxygen prior to smoking. If smoking outdoors, individuals who do not wear oxygen and smoke tobacco products will not smoke by a resident who is wearing oxygen." On 4/23/14 at 10:00 AM, during the Environmental tour, the outdoor smoking area was observed. When the Maintenance Director was asked if residents smoke outside he stated that residents do smoke outside in the courtyard, especially in the summertime. When asked about resident safety he said, "I don't know much about that. (CNA #1) would know about that." The Maintenance Director stated the courtyard had two exits from the facility; the locked chapel entrance at the end of the hallway, and the sliding door/puzzle room entrance, which is unlocked. Note: Any resident, staff member or visitor may exit through the sliding door/puzzle room entrance door to get to the court yard at any time. The chapel entrance was locked and required a code to enter and exit. The labeled smoking area for was located outside the locked door near the chapel entrance. There was a smoking sign, an ash tray and tables with chairs in this area. On 4/23/14 at 10:40 AM, approximately 26 cigarettes butts were observed to be on the ground outside in the courtyard; the majority of the cigarette butts were between 12 and 18 feet from the sliding glass door entrance off the puzzle room. In this area no smoking sign or ash tray was visible and no aprons or fire extinguishers were observed near the entrance. On 4/23/14 at 10:45 AM, CNA #1 was asked about residents smoking outside. He reported residents occasionally go outside to smoke. CNA #1 said that the only resident who smokes and wears oxygen, leaves his oxygen tank at the nurses station before going outside to smoke. On 4/23/14 at 10:50 AM, the Administrator was shown the courtyard immediately outside the sliding glass doors off the puzzle room and asked about resident safety and smoking outside. The Administrator said, "You are right the sign is down." When asked how the Administrator ensures the area is safe for residents he replied, "We have independent smokers. Everyone has an individual assessment to determine whether or not they can come outdoors to smoke. It is determined by the assessment. I need to look at the policy." He also said, "The smoking area is only 12 feet away from the nurses station... If they have to be observed, they don't come outside." Note: The courtyard is 25 feet from the nurses station and is not visible from the nurses station because the puzzle room wall obstructs the view. On 4/23/14 at 11:00 AM, The administrator provided the facility's smoking policy, the Smoking Assessment form used to assess individual residents for smoking safety, Social Services Procedure for Smoking, and Title 39 Health and Safety Chapter 55 titled Clean Indoor Air. When asked how many residents in the facility smoke, the Administrator held up his hand and said, "I have something much more urgent to take care of right now." On 4/23/14 at 3:55 PM, the DNS was interviewed and asked how many residents smoked. The DNS stated there were five residents who smoked. Three residents were assessed to be independent smokers and two residents were assessed to need supervision with smoking. The residents who were assessed to require supervision have their cigarettes and lighters stored at the nurses station. On 4/23/14 at 5:30 PM, the Administrator stated he believed the cigarette butts found outside the double doors and throughout the courtyard were cigarettes staff members smoked and they were blown over to the area outside the sliding glass door entrance by the wind and the area had been cleaned up. Note: The smoking area outside of the locked entrance near the chapel is approximately 100 feet away and around a corner from the sliding glass door puzzle room entrance. Additionally, the only outside ash tray was located in the smoking area and was designed so wind could not blow cigarette butts out of the ash tray. Note: The facility's policy designates one indoor smoking area for residents and documented "No other area is available for smoking by anyone" to include staff members. Because the sliding glass door entrance is located off the puzzle room, it is not within line of sight of the nurses station. Additionally, all residents have access to the courtyard. Residents who wear oxygen who can locomote themselves, or visitors who take residents who wear oxygen out to this area have the potential to be in close proximity to staff members and/or residents who are smoking. This creates a hazard for fire as residents would have to pass by anyone smoking in the area in order to access the courtyard.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents' care plans included the supervision/staff required when assisting residents with toileting activites, and failed to ensure that the appropriate staff supervision was provided. This was true for 2 of 7 residents (#1 and #6) sampled for falls. Resident #1 was harmed when a CNA rolled her to her side in her bed and she fell to the floor. Resident #1 experienced bilateral fractures to her left and right femurs when she fell . Resident #6 was harmed when she fell and fractured her wrist when staff did not assist her in toileting after a meal. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS assessment dated [DATE] and the 1/17/11 quarterly MDS assessment, documented the following: * Cognitively intact * Extensive assistance of two staff for bed mobility, dressing, and personal hygiene (grooming) *Total Dependence of 2 staff for transfers * Delusions and behaviors *The 10/25/10 assessment documented she required extensive assistance of 2 staff for toilet use, however the 1/17/11 assessment documented she was totally dependent on 2 staff for toilet use. The Care Area Assessment (CAA) completed with the annual assessment on 10/25/11 included Resident #1 required extensive to total assistance with ADLs (Activities of Daily Living ) and mobility due to past CVA (stroke). A 1/25/11 Fall Risk Assessment score of 18 placed Resident #1 at a high risk for falls. The assessment documented intermittent confusion and increased risk due to the use of antihypertensive, diuretic, and psychotropic medication. A 3/30/11 Resident Incident Report documented at 8:45 a.m. two CNAs transferred Resident #1 to her bed. One of the CNAs left and the other continued to provide peri-care. The report documented the resident was rolled to her side, "Her legs flinched" and she fell to the floor. The CNA pulled the call light but when no one responded to the call light she went to get help. The Summary/Results of Investigation on the report documented Resident #1's physician was notified of, "Hysterics/agitation" related to the fall. The nurse was unable to assess for injuries due to the resident's behaviors. At 3:30 p.m. the Resident's left knee was noted to be more painful and edematous. The physician was notified and the resident was taken to the hospital for x-rays. The x-ray report, dated 3/30/11, documented fractures to the right and left femur. The Investigative Report attached to the Incident Report documented Resident #1's Care Plan identified two staff were required for transfers with a mechanical lift. The Investigative Report (IR) documented the resident's Care Plan (dated 1/25/11) did not indicate if the resident required two staff for activities of daily living. The (IR) included the residents weight of 205 pounds. The IR documented 4 of 6 direct care (CNAs, Therapy Assistants and Restorative aides) preferred to have 2 staff if the resident was hallucinating, confused, or needed cleaned after a bowel movement. One staff stated they preferred 2 due to back problems. The last CNA stated sometimes the resident attempted to kick them and they preferred to use 2 staff. The IR documented while at the hospital Resident #1 stated she had fallen while trying to get away from the, "Snakes and ants." The IR documented, "She had these types of hallucinations in the past...I was also not sure whether these were a result of the sedation medication she'd had earlier or if she was having hallucinations earlier when she fell ." The IR documented the family reported the physician stated surgery would not be done and the right leg was in good alignment but the, "Left artificial knee had been jammed into the femur." On 11/30/11 at 2:45 p.m. the DON stated Resident #1 did not require assistance of 2 people for peri-care. The DON stated during the assessment period, staff used 2 staff as that was their preference. The DON stated after the fall the Care Plan was revised to 4 person for ADLS (due to injuries) and later 2 person assist. On 12/6/11 the facility faxed data collected from 1/12/11 -1/18/11 and 3/24/11 - 3/30/11. The following was documented: Bed Mobility - 2 staff Toilet use - 2 staff 1/12/11 - 1/18/11 - 17 of 21 times 10 of 11 times 3/24/11 - 3/30/11 - 20 of 22 8 of 10 times The data collected documented Resident #1 was assisted by 2 staff the majority of the time. The facility failed to ensure Resident #1's CP included she required extensive assistance of 2 people to assist her in bed mobility and toileting as determined by the 10/25/11 and 1/17/11 MDS assessments. While being assisted by only one staff, Resident #1 fell to the floor experienced harm requiring medical evaluation and treatment at the hospital. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 7/28/11, documented the following: * Intact cognitive skills for daily decision making * Limited assistance of one staff member required for bed mobility and transfers * Extensive assistance of one staff member required for locomotion within the facility, dressing, personal hygiene, and bathing * No range-of-motion limitations * Supervision only of one staff member required for toileting * Continent of both bowel and bladder * "Occasional" pain rated at "2" on a "1-10" pain rating scale ("0" = no pain, "10" = most excruciating pain imaginable) * No falls at the facility Resident #6's most recent annual MDS assessment, dated 10/31/11, documented the following: * Intact cognitive skills for daily decision making * Extensive assistance of at least two staff members required for bed mobility, transfers, dressing, personal hygiene, and toileting * Extensive assistance of one staff member required for locomotion within the facility, eating, and personal bathing * Incontinent of bladder * "Almost constant" pain rated at "8" on a "1-10" pain rating scale * Bilateral range-of-motion limitation of the upper extremities * Fall at the facility Care Area Assessment (CAA) Narratives for Resident #6, dated 11/9/10, documented the following: * "Falls - (Resident #6) needs staff assistance at times with transfers. This puts her at risk for falling. Her Fall Assessment (11/3/10) indicates she is a high risk due (to) medications and orthostatic hypotension. In addition, she takes an antidepressant that can cause drowsiness. (The resident) is able to use her call light without problems and will wait for staff assistance if she feels that she needs it. Plan to proceed with Falls Care Plan to maintain safety." * "Urinary Incontinence - (Resident #6) has an occasional episode of urinary incontinence. Her B&B (bowel and bladder) Assessment (11/3/10) indicates she has urge incontinence. She has been placed in a bed nearest the bathroom door for quicker access. Plan to proceed with Elimination Care Plan to assist (the resident) with managing her incontinence." Fall Risk Assessments for Resident #6 documented the following factors and scores: * 11/3/10 - One-to-two falls in the preceding three months, chairbound and/or assistance required with elimination, systolic blood pressure drop of less than 20 mm Hg (millimeters of hemoglobin), one-to-two medications that place resident at risk for falls, one-to-two predisposing diseases present (hypotension, vertigo, cardiovascular accident, Parkinson's disease, loss of limb(s), seizures, arthritis, osteoporosis, or fractures). Total score was documented as 12. NOTE: Scores of "10" or greater indicated the resident was at "high risk" for falls. * 2/7/11 - One-to-two falls in the preceding three months, no orthostatic blood pressure taken, three-to-four medications that place resident at risk for falls, no predisposing diseases. Total score was documented as "9." * 5/2/11 - No falls in the preceding three months, no orthostatic blood pressure taken, three-to-four medications that place resident at risk for falls, no predisposing disease. Total score was documented as "7." * 7/18/11 - No falls in the preceding three months, no orthostatic blood pressure taken, three-to-four medications that place resident at risk for falls, no predisposing disease. Total score was documented as "7." * 9/26/11 - Intermittent confusion, one-to-two falls within the preceding three months, chairbound, no noted drop in blood pressure between lying and standing, three-to-four medications that place resident at risk for falls, one-to-two predisposing diseases present. Total score was documented as "17." Care Area Assessment (CAA) Narratives for Resident #6, dated 11/4/11, documented the following: * "Falls - (Resident #6) fell on [DATE] resulting in a fractured arm. Because of the fall and the limited ROM (range-of-motion) in affected arm, she needs staff to help steady her when transferring. The need for staff assistance to maintain balance, increases her risk of falling even more." * "ADL Functional/Rehab(ilitation) Potential - (Resident #6) has declined over the past quarter due to a fractured arm. Because of this, she now needs extensive assistance with all aspects of ADL's (sic)." * "Urinary Incontinence - (Resident #6) continues to have an occasional episode of urinary incontinence. Her B&B Assessment (11/3/10) indicates she has urge incontinence. In addition, she now also needs extensive assistance for toileting due to broken arm." * "Pain - (Resident #6) has had an increase in pain since last assessment due to fractured arm. She currently rates her pain as '8.'" A Resident Incident Report documented that Resident #6 was discovered on the floor of her bathroom on 9/19/11 at 1:30 p.m. It was reported that the resident, who was physician ordered to have oxygen up to four liters per minute via nasal cannula, was not wearing the nasal cannula at the time of her discovery on the bathroom floor. A section of the form entitled Licensed Staff Assessment documented the resident sustained [REDACTED]." The resident was sent to the emergency room of a nearby hospital, where she was diagnosed and treated for [REDACTED]. O2 (Oxygen) tubing was long enough to allow toileting - she took it off so it wouldn't be in the way. Refuses to ask for assist - very stubborn about routine (and) we have tried to accommodate her choices as much as possible. Has been able to do own transfers (and) ambulate short distances in the room since admission. Did not put call light on for assistance." Resident #6's Bladder Incontinence Care Plan in effect at the time of the September 2011 fall, included the following: * "Problem - Episodes of bladder incontinence r/t (related to) urgency. AEB (as evidenced by): inability to hold urine. Potential for constipation r/t decreased mobility." Start date: 11/3/10 * "Approaches - (Resident #6) will let you know when she needs assistance with toileting. If incontinence episodes occur, provide thorough peri-care." Start date: 11/17/10. NOTE: The resident's MDS assessment of 7/28/11 documented that Resident #6 required the limited assistance of one staff member for bed mobility and transfers, such as from her wheelchair to the toilet. The 7/28/11 MDS also documented that the resident required the supervision of one staff member for toileting. No transfer assistance or toileting supervision was provided to Resident #6 at the time of the 9/19/11 incident that resulted in the resident fracturing her left wrist. * A handwritten note, dated 10/19/11, documented, "(Resident #6) will still tell you when she needs toileting. Offer toileting after meals - this has been her history of toilet use." The resident's current Bladder Incontinence Care Plan in effect at the time of the facility's annual re-certification and licensure survey, dated 11/24/11, documented the following: * "Problem - Episodes of bladder incontinence r/t urgency. AEB: inability to hold urine. Potential for constipation r/t decreased mobility. Has limited use of (right) arm and leg r/t CVA (cardiovascular accident), limited use of (left) arm r/t fx (fracture). Dependent of (sic) staff. Denies problem with incontience (sic)." Start date: 11/3/10. * "Approaches - (The resident) will still tell staff when she need (sic) to toilet, offer toileting after meals as this is her usual routine." Start date: 10/19/11. Resident #6's current Falls Care Plan, dated 11/24/11, documented the following: * "Problem - Potential for falls r/t right sided weakness, poor standing and transfer balance. Increased confusion at times, attempts to self transfer." Start date: 11/3/10. * "Approaches - Remind resident to ask for assist with transfers, ensure nasal cannula is in place." Start date: 9/19/11. On 12/1/11, at 12:35 p.m., the DON was interviewed. When asked to explain why the resident's Fall Risk Assessments of 2/7/11, 5/2/11, and 7/18/11 did not include orthostatic blood pressure measurements, which according to the 11/3/10 Fall Risk Assessment placed the resident at higher risk for falls, and whether that failure resulted in lower scores that led the facility to underestimate the resident's risk for falls, the DON stated, "I don't think so. We could have done orthostatic blood pressures every day, but the only way we could have stopped her from doing her own transfers would have been to restrain her and we certainly weren't going to do that." The DON noted that Resident #6 customarily self-toileted and self-transferred, and stated, "She rarely turned on her call light for any any reason. When she fell I did try to think of what we could have done short of tying her to a chair; I just don't know what we could have done without taking away some of her independence." On 12/1/11, at 2:00 p.m., Resident #6 was interviewed. When the surveyor asked, "Is there anything the facility could have done to prevent your fall back in September?" the resident stated, "There's nothing that anyone could have done. Nothing. I haven't had good balance for years." When asked whether staff offered to toilet her following the noon meal that day, Resident #6 stated, "Not that I remember." On 12/2/11, the BFS received a FAX from the facility that documented Resident #6's vital signs, including blood pressures, from 8/28/11 through 9/21/11. The most hypotensive of the blood pressures documented was 100 mg hm systolic, 58 mg hm diastolic. Resident #6 was assessed as a "high fall risk" upon admission to the facility on [DATE]. The resident's subsequent fall risk assessments recorded lower risk scores than documented on the initial assessment when the facility failed to continue measuring the resident's orthostatic blood pressures or continue to factor in the resident's "predisposing diseases." In addition, the resident's MDS assessment of 7/28/11 documented that Resident #6 required the limited assistance of one staff member for bed mobility and transfers, such as from her wheelchair to the toilet, and that the resident required the supervision of one staff member for toileting. No transfer assistance or toileting supervision was provided to Resident #6 at the time of the 9/19/11 fall that resulted in the resident fracturing her left wrist. Lastly, the resident's Care Plan directed staff to toilet the resident following meals as that was the resident's "history" and "routine." The lunch meal at the facility was scheduled for service at 12:30 p.m.; the resident fell at the facility while self-toileting at 1:30 p.m. and did not, when questioned, have any recollection of staff offering assistance prior to that fall which resulted in a fractured wrist and a subsequent decline in her ability to perform ADL at her previous level. Resident #6 was harmed as a result of the facility's failure to accurately assess her risk for falls, adequately provide for the resident's needs on her Urinary Incontinence and Falls Care Plans as determined by the resident's MDS admission assessment, or provide those interventions (assistance with transfers, toileting after meals) per the facility's awareness of the resident's "history" and "routine."

Based on staff interview and record review it was determined the facility failed to ensure that resident care plans, MDS assessments, and CNA flow sheets each included current, accurate, and relevant information for accident and injury prevention; and failed to adapt interventions as appropriate to reduce the risk of falls. This was true for 3 of 6 residents (#s 3, 4, and 9) sampled for falls during an on site follow up visit to the facility. Resident #3 fell out of bed 5 times in approximately 4 months, but no interventions were added or changed after the fifth fall on [DATE]. Resident #9 was assisted to the floor when he fell on [DATE], but the fall was not documented in his care plan. Resident #4's fall interventions included a condom catheter at night and assistance by 2 staff for Hoyer transfers, but his care plan and CNA flow sheet were not accurate. Findings included: NOTE: Refer to the [DATE] Summary Statement of Deficiencies and the facility's Plan of Correction with an alleged completion date of [DATE]; which documented: "The MDS assessment will be used to identify the level of care and assistance required... The care plans will be updated... as indicated by the MDS assessment. The Interdisciplinary Team (IDT) will... review the care plans and MDS assessments... the MDS Coordinator will monitor the additions or changes made to the care plans and assure that the CNA flow sheets are also updated to reflect the current care plans." 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired at the facility on [DATE]. The resident's [DATE] Admission and [DATE] Quarterly MDS assessments coded: * Severely impaired cognition, with no signs or symptoms of delirium or behaviors * Extensive assistance of at least two staff members required for bed mobility, and total dependence on at least two staff members required for transfers * Not steady, only able to stabilize with human assistance; no functional limitation for range of motion; wheelchair required for mobility * Falls prior to admission to the facility; resident believed he was capable of increased independence, but staff did not * The [DATE] assessment coded that the resident had 2 or more falls at the facility without injury, and 2 or more falls at the facility with minor injury, since the [DATE] assessment The [DATE] Resident Plan of Care included the following interventions started on the dates indicated: * [DATE]-[DATE] - Body pillows in bed for positioning. Padded SR for skin maintenance. Low bed as assistive device for safety secondary to history of falls and impaired judgement for safety. Watch for increased restlessness or fidgiting (sic) that may indicate the need for toileting. Hoyer lift for transfers due to increased weakness and safety with transfers. Non-skid mats to both sides of bed to assist resident with safe transfers. Molded mattress to bed as assistive device to define bed parameters. * [DATE] - ,[DATE] SR x4 (four quarter-length SR) NOTE: This was changed to ,[DATE] SR x4 (four half-length SR) on [DATE] per other documentation. Refer to F272 for further information about SR implementation. * [DATE] - Dress while in bed related to inability to bear weight. * [DATE] - Use 2 person assistance to "scoot" up in bed related to weakness. Use 2 staff assistance to dress while in bed and with Hoyer lift for transfers. The resident's medical record documented that he had fallen out of bed on [DATE], [DATE], [DATE], and [DATE]. Then on [DATE], the resident crawled over the SR and fell to the floor. The Resident Incident Report documented, "Resident crawled over side rails and was kneeling at the (head of bed). Blood on floor from toes being scraped open... Continues (with) attempts to self transfer despite his physical disabilities. (History) of falls here (and at) home for same reasons - cognitive deficits (and) memory loss." Minutes from the (undated) [DATE] "Falls (December and January)" IDT meeting documented that they discussed the resident's falls: "Continues with attempts to self-transfer despite his physical disabilities. He has a (history) of (falls) here and at assisted living prior to admission. He has memory loss and cognitive deficits with impaired ability to make safe choices." NOTE: The facility's decision to use 4 side rails added a hazard for the resident and contributed to the seriousness of the fall on [DATE]. There were no documented changes to the care plan, to provide increased supervision and prevent falls out of bed at night after the [DATE] fall - the resident's 5th fall out of bed since admission to the facility. Minutes from the [DATE] Physical Restraint Meeting documented: "(Resident #3) has had another fall on ([DATE]) from his bed and this after applying (half) SR x2 on each side of the bed. It was suggested that the falls could possible (sic) be (related to) pain and/or continued restlessness with RLS. It was determined that nursing would monitor his behaviors at (night) that might be suggestive of pain and medicate accordingly. A suggestion was also made to move his bed up against the wall to give him only one side of the bed to slip out of. A suggestion was also made to consider an antianxiolytic at (night) only to decrease his restlessness. We have moved him to a different room which might make a difference. We will monitor for appropriateness of changing or adding a medication to aid in a more restful sleep." NOTE: There was no indication that the facility followed through with any of the suggested interventions before the resident expired on [DATE]. On [DATE] at 10:00 AM the DON was interviewed about fall interventions for Resident #3. She was unable to describe any additional interventions which had been attempted after the resident's fifth fall out of bed on [DATE]. The DON and Administrator were informed of the findings on [DATE] at 12:15 PM. No further information was received from the facility. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's [DATE] Admission and [DATE] Quarterly MDS assessments coded: * Assistance required for walking in the room and corridor, on and off the unit * Wheelchair and walker used for mobility * Unsteady, only able to stabilize with human assistance while turning around and walking * Decreased range of motion in 1 upper extremity The [DATE] Resident's Plan of Care included that he was to ambulate with front wheeled walker and contact guard assistance. The resident's Fall Prevention Intervention Guideline (part of the care plan) documented falls on [DATE], [DATE], and [DATE]. It did not include a fall in which he was "assisted to the floor" on [DATE]. A [DATE] Resident Incident Report documented, "While walking resident back from supper, his (left) leg buckled and resident started to fall. I was holding the gait belt attached on resident and was able to lower him to the floor." The Administrative Follow-Up section documented, "He is easily distracted (secondary to) cognitive loss." Nurse's Progress Notes from [DATE]-[DATE] documented multiple times when the resident was frustrated or angry with staff related to impatience, "being babysat", and wanting to be more independent with transfers and ambulation. In addition: * [DATE] - "Resident telling staff he doesn't need any help and going to do everything on his own regardless of what we say... Gait unsteady at times with ambulation." * [DATE] - "lowered to floor" * [DATE] - "Still bothered about his (left) knee 'giving out' a few days ago. States 'I thought I was getting better, but I am not!" * [DATE] - "Feeling 'shakey (sic) (and) weak' (and) refused to ambulate." * [DATE] - "Up (and) about (with) walker (and wheelchair)". * [DATE] - "Angry because he wanted to transfer his (sic) self (and) not get help." On [DATE] at 9:52 AM the DON was interviewed about the resident's [DATE] fall and why it was not documented on the Fall Prevention Intervention Guideline part of the care plan. She stated, "If he looks away, he has difficulty walking. He'd looked away. It wasn't really a fall. We already had him supervised, we know what happened. What would we do differently? That's why we did an incident report. I'll add it (to the care plan). He's going to continue to ambulate and we will try not to let him get distracted." She agreed that it would be important for staff to be aware of the fall via the care plan, for further fall prevention. The DON and Administrator were informed of the findings on [DATE] at 12:15 PM. No further information was received from the facility. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated [DATE], coded: * BIMS score of 15 indicating cognitively intact. * Frequently incontinent of bladder. A [DATE] Resident Incident Report (IR) documented at 2:50 p.m. Resident #4 was lying on the bathroom floor. Three staff used the Hoyer lift to assist the Resident back to bed. Resident #4's Care Plan (CP) for elimination, dated [DATE], had a hand written statement dated [DATE] that indicated a Hoyer lift would be used for transfers. Another hand written entry dated [DATE] documented, "Condom cath (catheter) on 12 hours days off 12 hours noc. (nights) Per res (resident) request and to decrease fall risk." The South Wing CNA flow sheet, dated [DATE], documented the use of a condom catheter at night time and 2 person assist for the Hoyer lift. On [DATE] at 9:52 a.m. the DON stated Resident #4 used the condom catheter in the daytime. The DON was informed the information on the CNA flow sheet was incorrect and did not match the CP. The DON was also informed the CP did not include 2 staff were to be used (with the Hoyer lift) as documented on the CNA flow sheet. The DON stated the CP was scheduled to be updated "today."