Every finding on record at Lewiston Transitional Care of Cascadia

Based on observation, review of the Food, Drug, Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure staff food and physical therapy ice packs were stored separately from resident food in a freezer, resident food was not dated correctly, and pest control measures were not followed. This was true for the 66 residents who consumed food stored and prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 6-403.11 documented areas designated for employees to eat, drink, and use tobacco products shall be located so that food, equipment, and linens, single-service and single use articles are protected from contamination. On 8/21/25 at 9:27 AM, it was observed in the A-Wing Resident Snack freezer, therapy ice packs were stored with two packages of raw beef burgers labeled for employee use. On 8/21/25 at 9:35 AM, in the El Bistro Resident refrigerator, an open and incorrectly dated orange juice (dated use by 11/25) was observed. In the freezer, therapy ice packs were stored with 3 open and undated ice cream containers. On 8/21/25 at 9:40 AM, the Culinary Director stated, staff food, like the beef burgers and physical therapy ice packs should not be stored with resident's food items. She stated all food should be labeled with the resident's name, open date, and use by date. The Culinary Director stated the orange juice was not correctly dated, the ice cream should have been dated, and staff needed more education on how to properly label and date resident foods.2. The FDA Food Code Section 6-501.111 Controlling Pests documented the premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control., and (D) Eliminating harborage (a hiding place for pests) conditions.On 8/21/25 at 10:04 AM, two kitchen dumpsters were observed with their lids left open. Dumpster #1 was immediately outside the kitchen door and had multiple flies surrounding the trash inside it. Dumpster #2 located in an enclosed area on the property was observed with garbage and leaves piled around it on the ground. On 8/21/25 at 10:25 AM, the Maintenance Director stated the leaves and trash surrounding dumpster #2 was normally cleaned every Monday when the garbage was collected, but had not been cleaned on 8/18/25. He stated the [Pest Control Company] came to the facility every two weeks. The Maintenance Director stated all facility staff are instructed to close the dumpster lids after use and the lids should not have been left open.

Based on record review and staff interview it was determined the facility failed to update a resident's care plan for 1 of 17 residents (Resident #54) reviewed for care plan accuracy. This deficient practice created the potential for harm if resident's care plan was not current for health care interventions. Findings include:Resident #54 was admitted to the facility on [DATE] with multiple diagnoses including COPD (Chronic Obstructive Pulmonary Disease: an irreversible lung disease that progressively makes breathing difficult), dependence on supplemental oxygen, diabetes, dementia, depression, and cognitive communication deficit.A physician's order, dated 5/31/23, documented Resident #54 was to receive oxygen at 2 liters/minute via nasal cannula continuously. This order was discontinued on 6/21/23. Resident #54's care plan, dated 6/5/25, documented Resident #54 had COPD with oxygen dependence; however, it did not address Resident #54 was no longer using oxygen. On 8/19/25 at 4:15 PM, the CNO stated Resident #54 no longer had an oxygen machine and added we should have updated her care plan when the order was discontinued on 6/21/23.

Based on record review and staff interview it was determined the facility failed to follow a dietary restriction related to a food allergy. This was true for 1 of 1 resident (Resident #14) whose medical record was reviewed for food allergies. This deficient practice had the potential to cause harm or death related to anaphylaxis (a severe, potentially life-threatening allergic reaction) when staff failed to follow dietary restrictions related to food allergies. Findings include: Resident #14 was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes, high blood pressure, depression, and anxiety. Resident #14's admission MDS assessment, dated 6/18/25, documented Resident #14 was not cognitively intact. A review of Resident #14's care plan documented the resident had an allergy to aspirin, peanuts, and pollen. A nursing progress note, dated 8/19/25 at 3:16 PM, documented Resident #14 mistakenly ate a peanut butter sandwich. On 8/20/25 at 5:30 PM, the CNO stated a facility staff gave Resident #14 a peanut butter sandwich on 8/19/25 when she asked for something to eat. The CNO reported the facility staff did not check Resident #14's medical record prior to giving the peanut butter sandwich. She added, when the facility nurse was informed Resident #14 had eaten a peanut butter sandwich, the nurse immediately notified the physician, the facility administration, and the resident's representative. The facility nurse was directed by the doctor to monitor the resident for signs and symptoms of allergic reaction. As of 8/20/25 at 5:30 PM, the CNO reported Resident #14 had not experienced any signs or symptoms of an allergic reaction. The CNO stated the snack room had a binder to record all resident food allergies to keep staff educated on resident needs. The CNO added the allergen binder had not been updated and was not where it belonged in the snack room on 8/19/25.

Based on record review, and resident and staff interviews, it was determined the facility failed to ensure resident's pain was effectively managed and treated. This was true for 1 of 3 residents (Resident #31) reviewed for pain management. This deficient practice created the potential for harm should residents not receive effective pain management. Findings include:Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including lymphedema (accumulation of fluid due to disruption of lymphatic flow for a variety of reasons) and congestive heart failure (when the heart is unable to pump enough blood to meet the body's needs, leading to a buildup of fluid in the body).A physician's order, dated 8/13/25 documented Resident #31 was to receive the following medications:- hydrocodone -acetaminophen (narcotic pain medication) oral tablet 10-325 mg, one tablet every four hours as needed for pain level of 1-5.- hydrocodone -acetaminophen oral tablet 10-325 mg, two tablets every four hours as needed for pain level of 6-10.Resident #31's August 2025 MAR, documented the physician's order was not followed. Resident #31 received the hydrocodone -acetaminophen oral tablet 10-325 mg incorrectly on the following instances:- 8/14/25 at 1:17 PM, one tablet of hydrocodone -acetaminophen 10-325 mg for a pain level of 0- 8/14/25 at 7:33 PM, one tablet of hydrocodone -acetaminophen 10-325 mg for a pain level of 6- 8/16/25 at 7:03 PM, two tablets of hydrocodone -acetaminophen 10-325 mg for a pain level of 4- 8/17/25 at 3:44 AM, two tablets of hydrocodone -acetaminophen oral tablet 10-325 mg for a pain level of 4- 8/17/25 at 7:52 PM, two tablets of hydrocodone -acetaminophen oral tablet 10-325 mg for a pain level of 5- 8/18/25 at 3:59 PM, two tablets of hydrocodone -acetaminophen oral tablet 10-325 mg for a pain level of 5On 8/21/25 at 9:476 AM, the CNO with the Clinical Resource Nurse present, stated Resident #31's physician's orders were not followed and the nurse should have reviewed the physician's orders after assessing Resident #31's pain level.

Based on record review and staff interview it was determined the facility failed to ensure significant medication errors were prevented. This was true for 1 of 6 residents (Resident #14) reviewed for significant medication errors. This failed practice had the potential for harm if medications were not administered according to physicians orders. Findings include: Resident #14 was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes, high blood pressure, depression, and anxiety. Resident #14's Admissions MDS assessment, dated 6/18/25, documented Resident #14 was not cognitively intact. A physician's order, dated 6/18/25, documented Resident #14 was to receive the following medications: -Namenda (a dementia medication), give 5 mg by mouth once per day [AM/morning.] -Carvedilol (a blood pressure medication), give 6.25 mg by mouth two times per day [8:00 AM; 5:00 PM.] A physician's order, dated 6/19/25, documented Resident #14 was to receive the following medications: -Amlodipine Besylate oral tablet (a blood pressure medication), give 10 mg by mouth one time per day [AM.] -Hydrochlorothiazide (a blood pressure medication), give 12.5 mg by mouth one time per day [AM.]-Losartan Potassium (a blood pressure medication), give 100 mg by mouth one time a day [AM.] -Sertraline HCl Oral Tablet (an antidepressant), give 150 mg by mouth one time per day [AM.] -Budesonide Inhalation Suspension (for COPD), 1 mg/ 2 ml, 1 dose inhaled orally two times a day [AM; PM.] A physician's order, dated 7/23/25, documented Resident #14 was to receive the following medications: -Fluticasone-Salmeterol Inhalation Aerosol Powder 250-50 mcg (for COPD), 1 puff inhaled orally two times per day [AM; PM.] Resident #14's MAR was reviewed from June - August 2025, with the following AM medications documented as not received: Resident Sleeping: - 6/25; 6/29; 6/30- 7/2; 7/4; 7/8; 7/9; 7/11; 7/15; 7/18; 7/20; 7/23; 7/24; 7/28 - 8/1; 8/11; 8/12; 8/17; 8/20 Resident Refused: -7/1 Resident #14's care plan, initiated on 6/18/25, documented the use of antipsychotic medication related to unspecified psychosis and dementia. The care plan directed staff to give medications as ordered by the physician, and to monitor and document the effectiveness and potential side effects including over-sedation and lethargy, and to notify the physician as indicated. Nursing progress notes, dated 6/18/25 through 8/19/25, documented the following: -On 8/15/25, an SBAR was submitted with the statement: Resident [#14] prefers to sleep in until 11:00 AM most days per direct care staff. [The facility staff] are having issues waking her up early to give her [morning medications.] -No further documentation regarding the effects of medication, missed medications, or notification to the physician was found. On 8/20/25 at 5:27 PM, the CNO stated there was no documentation in Resident #14's medical record regarding her 'sleeping' and missing medication until 8/15/25. She verified there were no staff to physician notifications in Resident #14's medical record regarding the multiple days of missed medication as documented in the MAR due to Resident #14 sleeping. On 8/21/25 at 11:14 AM, the CNO stated the facility does not have a policy relating to when the doctor should be notified, but best practice would be to notify the doctor within 24-48 hours, depending upon the medication. The physician should have been notified in June 2025 of Resident #14's missed medications.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure infection prevention standards were followed. This was true for 1 of 1 resident (Resident #40) whose intravenous (IV) medication administration was observed. This failure created the potential for harm if infectious pathogens (any organism that causes disease) were introduced to his peripherally inserted central catheter (PICC- a thin tube placed in a vein in the arm passed through to the large vessels near the heart). Findings include: The National Library of Medicine web page, World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care, article dated 2009, accessed 8/25/25, documented indications for hand hygiene included to perform hand hygiene before handling an invasive device for patient care and after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient. The CDC Infection Control, Standard Precautions for All Patient Care, web page, dated 4/3/24, accessed on 8/25/25, documented Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. The web page instructs to perform hand hygiene after contact with a contaminated surface and use personal protective equipment (PPE) when needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment).The facility's IV Fluid Administration checklist, undated, documented directions for infection control as Perform hand hygiene. Apply gloves. Use infection control measures and standard precautions during the entire procedure with the rationale, Prevents the transmission of microorganisms.Resident #40 was admitted to the facility on [DATE] with multiple diagnoses, including sepsis (a life-threatening, extreme response to an infection that causes the immune system to damage the body's organs and tissues), pneumonia, and diabetes.On 7/3/25, Resident #40 was diagnosed with osteomyelitis (a bone infection) and had a PICC line placed in his inner right upper arm for IV antibiotic administration. Resident #40's physician orders documented an order, dated 8/14/25, for an antibiotic, vancomycin hcl intravenous solution 1250 mg/ 250 ml, administer 1250 mg once a day, intravenously, over 1 hour, for osteomyelitis. On 8/21/25 at 9:20 AM, LPN #1 was observed preparing Resident #40's IV vancomycin. LPN #1 walked into Resident #40's room while introducing herself, she then hung the bag of vancomycin on the IV pole with pump near his bed while explaining she was there to administer his IV antibiotic. LPN #1 was observed washing her hands with soap and water, then dried them, she put on a clean reusable PPE gown, and put on gloves. LPN #1 was observed closing the resident's divider curtain with her gloved right hand when the resident asked her to. She was then observed gathering an alcohol wipe and sterile 10 ML saline solution syringe from a plastic bag hanging on the IV pole, feeding the IV tubing through the pump, pressing the IV pump buttons to set the rate of delivery, then primed the medication tubing using the prime button on the IV pump with her right hand, while holding the open end of the IV tubing over the garbage can with her left hand. The open end of the IV tubing stayed in LPN #1's left hand while she opened a sterile 10 ML saline solution syringe and alcohol wipe. LPN #1 accessed one of the two ports on Resident #40's PICC line by removing the cap, she then scrubbed the opening of the port with the alcohol swab, then attached the saline syringe, and verified the PICC line was functioning appropriately. LPN #1 then attached the open end of the IV tubing and began delivery of the IV vancomycin by pressing start on the IV pump. LPN #1 was not observed to change her gloves or perform hand hygiene after touching the divider curtain and IV pump in Resident #40's room before accessing his PICC port. On 8/21/25 at 10:24 AM, LPN #1 stated she should have performed hand hygiene and changed her gloves after touching things in Resident #40's room before accessing his PICC port. On 8/21/25 at 10:26 AM, the CNO stated nurses should always perform hand hygiene and put on clean gloves before accessing an IV site.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure food was not expired and the stove hood was cleaned in 1 of 1 kitchen. These deficiencies had the potential to affect 69 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The facility's Food and Supply Storage policy, dated [DATE], documented All food .shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption. During an observation on [DATE] at 6:28 AM, the walk-in refrigerator contained four (32-ounce) containers of low-fat yogurt, dated [DATE], from the manufacturer. There was one (five-pound) container of sour cream dated with a use-by-date of [DATE]. During an interview on [DATE] at 6:31 AM, [NAME] #1 confirmed the food was expired. 2. The 2022 Food and Drug Administration (FDA) Food Code, page 452, dated [DATE], documented The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard. During an observation on [DATE] at 6:29 AM, the stove hood was greasy with lint throughout. During an additional observation on [DATE] at 10:35 AM, the hood remained greasy with lint buildup. The Culinary Assistant stated it was cleaned last week. She confirmed the hood was dirty and stated it was supposed to have been cleaned last week. During an interview on [DATE] at 12:44 PM, the CM stated she was in the process of making a new cleaning checklist. She stated the stove hood was supposed to be cleaned every week. She stated it was not cleaned yet this week. She confirmed there was no other documentation of the stove hood being cleaned before last week. She stated she was not aware of how the staff cleaned the hood last week. She stated she was not the one who cleaned it. During an interview on [DATE] at 4:01 PM with the RD, CM, the Administrator, and the Director of Maintenance, the RD stated the stove hood was cleaned last week but was not scrubbed.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was updated to include a diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for 1 of 1 resident (Resident #29) whose PASARR record was reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated screening. Findings include: The facility's Pre-Admission Screening and Resident Review (PASARR) policy, dated 11/28/17, documented Any resident with newly evident or possible serious mental disorder, ID [Intellectual Disability], or related condition is to be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including PTSD and other anxiety disorders. A quarterly MDS assessment, dated 6/7/24, documented Resident #29 was cognitively intact. Resident #29's Care Plan, revised 1/5/24, documented Resident #29 had a mood disorder related to diagnosis of other anxiety, and PTSD. A PASARR, dated 9/6/23, documented No for Resident #29 under the question: Does the individual have any of the following Major Mental Health Illnesses (MMI)? The list included PTSD and anxiety disorders. A PASARR, dated 9/8/22, documented No for Resident #29 under the question: Does the individual have any of the following Major Mental Health Illnesses (MMI)? The list included PTSD and anxiety disorders. During an interview on 6/11/24 at 10:31 AM, the Social Services (SS) staff stated she oversaw the PASARR reviews. She stated she reviewed the documentation on admission to make sure the mental health diagnoses and substance abuse were captured. She stated if any of the sections were marked Yes, then she would send it to the state for them to determine A level II PASARR or if any recommendations were needed. She verified Resident #29 had a diagnosis of PTSD and she needed to update the PASARR to include that information.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were provided with bathing consistent with their needs. This was true for 1 of 3 residents (Resident #6) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and skin impairment due to a lack of personal hygiene. Findings include: The facility's ADLs policy, revised 11/14/17, documented staff were to provide a shower, tub bath, or bed bath as scheduled and document resident refusals of care. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness and difficulty walking. A quarterly MDS Assessment, dated 5/6/24, documented Resident #6 was cognitively intact. Resident #6's Care Plan, revised 11/16/21, documented Resident #6 had an ADL self-care performance deficit and required substantial/maximal assistance for bathing with the assistance of one staff member (revised 5/10/24). During an interview on 6/10/24 at 7:48 AM, Resident #6 stated her shower schedule was Tuesdays and Fridays. She stated some showers were missed and she was supposed to receive them at least twice a week. Resident #6's bathing/shower record for May 2024 through June 2024, documented Resident #6 missed her scheduled bathing/shower on 5/7/24, 5/10/24, 5/24/24, 5/28/24, and 6/4/24. During an interview on 6/11/24 at 1:05 PM, CNA #2 stated she completed resident showers during the week Monday-Friday from 6:00 AM- 4:00 PM. She stated if a shower was missed a refusal sheet was completed and signed and they would make up the shower the next day. She stated Resident #6 would sometimes decline showers. During an interview on 6/11/24 at 1:53 PM, the Administrator stated missed showers would have had a refusal completed. At 2:52 PM, she stated there was a lack of documentation of refusals/ missed showers, so it did not flag in the system for them to follow up.

Based on observation, policy review, review of facility in-service, and staff interview, it was determined the facility failed to ensure staff followed infection prevention practices for environmental cleaning and hand hygiene. This had the potential to result in exposing residents to infection and cross-contamination including COVID-19. Findings include: 1. The CDC guidance titled Preparing for COVID-19 in Nursing Homes, updated 6/24/20 and accessed on 11/4/20, included a section on Environmental Cleaning and Disinfection, Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. The CDC states high-touch surfaces include bed rails, bed frames, moveable lamps, tray table, bedside table, handles, phones, and call lights. The facility's policy Managing Epidemic/Outbreak of Infection and Reporting, revised 5/21/20, included a section on Environmental Measures which stated staff will clean and disinfect resident-care areas to include frequently touched surfaces such as bedrails, bedside tables, and equipment in close proximity to the resident using an appropriate disinfectant following manufacturer directions at a designated frequency. This policy and guidance were not followed. On 11/3/20 at 11:23 AM, Housekeeper #1 had on an N95 mask and face shield and donned a gown and gloves. Housekeeper #1 then entered room [ROOM NUMBER] with a bleach solution in a spray bottle and a cloth. Housekeeper #1 sprayed the resident dresser tops, doorknobs, light switches, and bathroom area with the bleach solution. She then returned to the doorway, where her housekeeping cart was located, and waited for the appropriate 1-minute dry time. Housekeeper #1 then went back into room [ROOM NUMBER] and wiped down the items she had sprayed and mopped the floor. Housekeeper #1 said she did not wipe down the call lights and the cords of the call lights. On 11/3/20 at 3:40 PM, the Housekeeping Manager said resident rooms were cleaned daily, and the expectation was the daily cleaning included the call lights and the cords of the call lights. On 11/4/20 at 10:52 AM, the Housekeeping Manager said she had a 5-Step Daily Room Cleaning in-service sheet which she gave to her housekeepers to read and sign. The Housekeeping Manager said she did not provide interactive teaching or use the teach-back process with the housekeepers before or after they signed the in-service sheet. The Housekeeping Manager said she sometimes completed an inspection of the daily cleaning. The Housekeeping Manager said the in-service sheet did not include cleaning the call lights and cords, and she assumed the housekeepers would clean the call lights and the call light cords. Housekeeping staff did not disinfect high-touch surfaces in resident rooms. 2. The facility's policy Personal Protective Equipment (PPE) Donning & Doffing, revised 7/21/20, instructed staff to perform hand hygiene prior to putting on PPE and after removing gloves. On 11/3/20 at 11:40 AM, the OT entered room [ROOM NUMBER] which had a sign on the door stating the resident was under quarantine. The OT put on an N95 respirator, face shield, gown, and gloves without first performing hand hygiene. A short time later the OT removed the gown and gloves and exited room [ROOM NUMBER]. The OT did not perform hand hygiene after removing his gloves. The OT said before entering the quarantine room he was to don a gown and gloves. He said he did not use hand hygiene before or after donning and doffing gloves. On 11/3/20 at 12:51 PM, the Rehabilitation Manager entered room [ROOM NUMBER] while wearing an N95 respirator, face shield, gown, and gloves. After the Rehabilitation Manager had provided therapy services she removed the gloves and put on a new pair of gloves without performing hand hygiene. The Rehabilitation Manager said she did not perform hand hygiene after removing her gloves and before putting on a new pair of gloves. On 11/3/20 at 3:24 PM, the Rehabilitation Manager said the expectation was therapy staff performed hand hygiene before they entered and exited a room. She said staff should also perform hand hygiene after they removed their gown and gloves. Staff did not perform hand hygiene as directed in facility policy.

Based on observation, and interview the facility failed to ensure standard infection control practices were implemented during resident room cleaning on the 200 and 300 halls. These failures could potentially contaminate surfaces in the resident environment placing residents at risk for exposure to infectious organisms and at risk for facility-transmitted infection. Findings include: During the entrance interview on 6/16/20 at 9:00 AM the facility administrator reported the facility had no COVID positive residents. The 300 hall had two new residents on 14-day quarantine. The facility was in phase four of the re-opening plan. During observation of the 300 hall on 6/16/20 at 11:10 AM, environmental services staff HK1 damp-mopped the floor in room [ROOM NUMBER]. HK1 returned to the housekeeping cart in the corridor and removed the mop pad, then removed gloves. HK1 did not perform hand hygiene (no use of hand sanitizer and no hand washing). The administrator, while passing by, cued HK1 to wash or sanitize hands between rooms. HK1 did not wash or sanitize his/her hands and moved the housekeeping cart to room [ROOM NUMBER]. Signage posted on room [ROOM NUMBER] read; STOP Neutropenic Precautions *perform hand hygiene when entering and before leaving room *put on gloves before entering and remove before leaving room *put on gown before entering and remove before leaving the room *Put on mask before entering room if you have a respiratory infection. HK1 placed a hand-carry caddy which contained cleaning supplies on the floor just inside room [ROOM NUMBER]. One spray bottle with clear solution fell out of the caddy onto the floor. HK1 picked up the bottle and returned it to the caddy. HK1 did not sanitize the spray bottle. HK1 did not sanitize or wash hands after handling the spray bottle which was considered contaminated when on the floor. HK1 wore a face mask and proceeded to don a gown and gloves and entered room [ROOM NUMBER]. HK1 used the spray bottle to wet a cleaning cloth and used the cloth to wipe down surfaces in the room. HK1 did not touch the bottle with the cloth. While wiping the fixtures under the sink, the cloth fell to the floor. HK1 retrieved the cloth from the floor and placed the cloth on the edge of the sink. HK1 did not change gloves after handling the cloth that was on the floor. HK1 later without first rinsing or sanitizing it, used the cloth, to wipe down the sink. HK1 then sprayed the sink with disinfectant and let it air dry. HK1 carried the caddy to the bathroom and placed it on the bathroom floor while cleaning the bathroom. HK1 did not place a barrier to protect the caddy from floor contaminates. HK1 returned the caddy to the bottom shelf of the housekeeping cart. HK1 did not sanitize the caddy and did not place a barrier in the housekeeping cart to protect the cart from the contaminated caddy. The CDC (Centers for Disease Control and Prevention) official web site indicated neutropenic precautions are used when a patient has a low number of [DIAGNOSES REDACTED]s (white blood cells, main defense against infection) in their immune system, making them immunocompromised. The administrator and the Infection Preventionist (IP) were immediately informed of the observations. IP said Resident (R1) was on [MEDICAL CONDITION] and was at higher risk for infection. IP said her blood counts were good but she (IP) felt better keeping R1 on precautions. The administrator and IP went directly to the 300 hall and observed HK1 exited room [ROOM NUMBER] and placed the cleaning supply caddy directly on the corridor floor while unlocking the housekeeping cart. The administrator directed HK1 to not place supplies or equipment directly on the floor and directed staff to clean the rooms again with supervision. On 6/16/20 at 11:50 AM HK2 cleaned room [ROOM NUMBER]. HK2 said the room did not require transmission-based precautions. HK2 sanitized hands and donned gloves. HK2 took a cleaning supply hand-carry caddy from the housekeeping cart and placed it directly on the bathroom floor with no barrier to protect the caddy from contamination. The caddy held a toilet brush. HK2 used the brush to clean the toilet then immediately returned the brush to the caddy. HK1 used a cloth wetted with disinfectant solution to wipe the outside of the toilet, the rim, and toilet seat. HK2 held the now soiled cloth in a gloved hand and carried the caddy to the housekeeping cart. HK2 while still wearing the soiled gloves, unlocked the housekeeping cart and placed the caddy on the bottom shelf next to multiple spray bottles of cleaning solutions. HK2 did not place a barrier to protect the cart from contamination by the caddy. HK2 still held the soiled cleaning cloth which was finally placed in a plastic bag. In an interview immediately following the observation, HK2 said she was employed by a company contracted to provide environmental services to the facility. HK2 said the company provided training and education about infection control and housekeeping procedures. HK2 sated the housekeeping cart contained one supply caddy and one toilet brush which she carried from bathroom to bathroom. IP approached during the interview and the observations were described. IP observed inside the housekeeping cart and directed HK2 to not place supplies on the floor without a barrier. IP acknowledged the caddy was contaminated now and so were all the items in the same housekeeping cart compartment. IP directed HK2 to remove the contents of the housekeeping and sanitize the outside and inside of the housekeeping cart then discard or sanitize the contents before returning them to the cart. When asked about facility surveillance for infection control with housekeeping procedures, IP said housekeeping surveillance was not something the facility had been doing. IP stated the facility provided contracted employees education regarding hand washing and use of hand sanitizer. IP said the facility utilized surveillance tools for linen handling with respect to the nursing staff and patient care but not for housekeeping processes. During the exit interview on 6/16/20 the administrator reported the facility contracted environmental services which included housekeeping and laundry. IP reported the facility had two housekeeping carts, two housekeepers and one supervising environmental services staff.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure resident records included an advanced directive, or documentation of an advanced directive being offered. This was true for 3 of 7 residents (#2, #50, and #52) whose records were reviewed for advanced directives. This failed practice created the potential for harm if residents' wishes regarding end of life or emergent care were not honored if they became incapacitated. Findings include: The State Operations Manual, Appendix PP, defines an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician order [REDACTED]. medical condition into consideration. A POST [MEDICATION NAME] form is not an advance directive. The facility's policy for Advance Directives/Health Care Decisions, dated 10/1/17, documented the following: * Upon a resident's admission to the facility, the facility determined whether the resident executed an advance directive or gave other instructions to indicate their wishes in case they became incapacitated. * If the resident or their representative had executed an advance directive, a copy was obtained and maintained in the resident's record. * If the resident did not execute an advance directive, the facility advised the resident and their family of their right to establish an advance directive. * The facility documented the discussions regarding advance directives in the resident's medical record. * The facility identified, clarified, and periodically reviewed at least quarterly, after a life altering event (e.g. [DIAGNOSES REDACTED].) and after return from hospitalization , as part of the comprehensive care planning process, the existing care instructions and whether the resident wished to change or continue those instructions. * If a resident changed their advance directive, the facility documented in a progress note the update and current care decisions. This policy was not followed. 1. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's physician orders [REDACTED]. Resident #2's care plan documented she had a DNR POST (Physician order [REDACTED]. Resident #2's quarterly MDS assessment, dated 10/4/19, documented she was cognitively intact. Resident #2's record did not include documentation of an advance directive, or that it was offered or discussed with her. On 1/9/20 at 4:13 PM, the Resident Support Services assistant said there was only a POST in Resident #2's record. The facility had no documentation an advance directive was offered or discussed with Resident #2. 2. Resident #50 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #50's General Power of Attorney, signed on 10/25/12, did not address the power to make decisions for health care. Resident #50's MDS assessment, dated 12/19/19, documented he was severely cognitively impaired. Resident #50's physician orders [REDACTED]. Resident #50's care plan documented his wishes were DNR, he had a POST in place, initiated on 2/20/19. Resident #50's record did not include documentation of an advance directive, or that it was offered or discussed with him or his representative. On 1/9/20 at 4:18 PM, the Licensed Medical Social Worker (LMSW) said Resident #50 only had a General Power Of Attorney. The facility had no documentation that an advance directive was offered or discussed with Resident #50 or his representative. 3. Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #52's MDS assessment, dated 12/20/19, documented she was cognitively intact. Resident #52's physician orders [REDACTED]. Resident #52's care plan documented her status was DNR, and it was outlined in her POST. The focus area was initiated on 1/20/18 and updated on 2/7/18. Resident #52's record did not include documentation of an advance directive, or that it was offered or discussed with her. On 1/9/20 at 4:45 PM, the LMSW said she did not see any other documentation regarding advance directives in Resident #52's record. The facility did not provide documentation of an advance directive being offered or discussed with Resident #52 or her representative.

Based on observation, staff interview, manufacturer's instructions, and policy review, it was determined the facility failed to ensure a vial of [MEDICATION NAME] Purified Protein Derivative (PPD- a solution that is injected under the skin and used to help diagnose [MEDICAL CONDITION]) was discarded 30 days after the open date. This was true for 1 of 2 medication storage rooms reviewed for outdated medications. This failed practice had the potential to result in decreased potency of the PPD, resulting in a false [MEDICAL CONDITION] (TB) test readings, and had the potential to affect all residents who resided on the A wing and received the PPD. Findings include: The facility's policy for Medication Management, revised on 2/28/18, documented medications are discarded by the expiration date unless indicated by the manufacturer's instructions to discard sooner. The undated manufacturer's instructions for the PPD documented vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 1/9/20 at 12:57 PM, the medication refrigerator on A wing was inspected, and an opened vial of PPD was found. The vial had the date 10/28/19 hand written on it. On 1/9/20 at 1:01 PM, LPN #1 verified the date written on the vial of PPD indicated when it was first opened and used. On 1/9/20 at 1:58 PM, RN #1 confirmed the manufacturer's printed instructions for the PPD instructed staff to discard the vial 30 days after opening. On 1/9/20 at 2:20 PM, LPN #1 confirmed the vial of PPD, dated 10/28/19, should have been thrown away. On 1/9/20 at 2:24 PM, the RCM confirmed the vial of PPD should have been discarded 30 days after opening.

Based on observation, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' room temperatures were maintained at a comfortable level. This was true for 2 of 17 residents (#41 and #46) whose environment was observed. This deficient practice created the potential for harm if residents became too cold or hot and it compromised their health status. Findings include: The facility's Resident's Environment policy, dated 11/28/19, directed staff to keep ambient temperatures above 71 degrees F (Fahrenheit). This policy was not followed. On 1/7/20 at 9:33 AM, Resident #46 said his room, which he shared with Resident #41, was cold because the thermostat did not work. Resident #46 said he told facility staff about it and the room was still cold. The wall thermostat control unit was set at 76 degrees F, and the thermostat documented the room temperature was 68 degrees F. The ceiling air register above the room sink was blowing cool air. On 1/8/20 at 9:45 AM, the Maintenance Director said he was not aware the room was cool and said the control unit in Resident #41's and Resident #46's room was set at 76 degrees F. He tested the ambient air with a laser temperature gauge and said it read 66.8 degrees F. The Maintenance Director said the temperature should have been higher and said he would find out why the room was cool. On 1/8/20 at 10:02 AM, the Health Information Director (HID) said she found the window in Resident #41's and Resident #46's room was opened a crack, and she closed it. The window was observed, and it had a small gap near the top of the window. The HID then attempted to re-close the window, and on the third attempt it closed completely. The HID said she would report the window condition to the Maintenance Director. On 1/9/20 at 8:53 AM, in Residents' #41's and Resident #46's room, the wall thermostat control unit was set at 90 degrees F, and the thermostat documented the room temperature was 71 degrees F.

Based on record review, policy review, and resident representative and staff interview, it was determined the facility failed to ensure transfer notices were provided in writing to residents and their representatives. This was true for 1 of 2 residents (Resident #50) reviewed for transfers. This created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: * The facility provided sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility. * The written notice included: the reason for the discharge, effective date of transfer/discharge, location where the resident was being transferred/discharged , a statement of the resident's right to appeal the action of transfer/discharge, the contact information for the state long term care ombudsman, and the mailing address and phone number of the agency responsible for protection and advocacy of developmentally disabled or mentally ill individuals. This policy was not followed. Resident #50 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #50's Discharge MDS assessment, dated 12/8/19, documented he had an unplanned discharge to the hospital. A Progress Note, dated 12/8/19 at 6:46 PM, documented Resident #50 was sent to the emergency room by ambulance. The note documented Resident #50's physician order [REDACTED]. There was no documentation in Resident #50's record the facility provided written notification of the transfer to Resident #50 and his representative when he was transferred to the hospital on [DATE]. On 1/9/20 at 3:28 PM, the DON said Resident #50's family lived in another state, and they were notified verbally of his transfer to the hospital. The DON said the documentation in Resident #50's record was the only documentation regarding the transfer. On 1/9/20 at 3:41 PM, Resident #50's daughter said she did not receive written notification of Resident #50's transfer to the hospital on [DATE].

Based on staff interview, record review, and policy review, it was determined the facility failed to ensure resident MDS assessments were accurate regarding falls and anticoagulant use. This was true for 2 of 16 residents (#36 and #57) whose MDS assessments were reviewed. This deficient practice created the potential for harm if residents received inappropriate care related to inaccurate MDS assessments. Findings include: The facility's policy for Resident Assessment, dated 11/28/17, documented a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity and needs is conducted using the Resident Assessment Instrument (RAI), which directs the care of the resident based on his or her individual needs. This policy was not followed. 1. Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #57's physician's orders [REDACTED]. Resident #57's MAR for (MONTH) 2019 documented Apixaban tablet 5 mg two times a day related to [MEDICAL CONDITION] with a start date of 10/23/19. The Apixaban was administered two times a day for the month of (MONTH) 2019. Resident #57's quarterly MDS assessment, dated 12/20/19, documented he did not receive anticoagulant medication during the past 7 days. On 1/8/20 at 1:31 PM, the MDS Coordinator verified Resident #57 was receiving an anticoagulant, and said the MDS assessment dated [DATE] should have documented Resident #57 received anticoagulant medication on 7 out of the past 7 days. 2. Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #36's quarterly MDS assessment, dated 11/29/19, documented she had no falls since admission. Incident and Accident reports, dated 10/12/19 and 11/12/19, documented Resident #36 fell while in the facility. A Progress Note, dated 10/12/19 at 10:47 AM, documented a nurse found Resident #36 on the floor in her room. A CNA was in Resident #36's room with her, and Resident #36 fell backwards and landed on the floor as the CNA turned to pick up a blanket from the floor. A Progress Note, dated 11/12/19 at 4:40 PM, documented Resident #36 was found sitting on the floor on her bottom. The note documented Resident #36 attempted to sit on a coffee table and it moved away from her, resulting in her falling to the floor. On 1/7/20 at 11:03 AM, Resident #36's son said she slipped out of bed a couple times since she was admitted to the facility. On 1/8/20 at 11:41 AM, the DON said Resident #36 had fallen in the facility since her admission. On 1/8/20 at 2:15 PM, the MDS Coordinator said Resident #36's fall status needed to be updated on her MDS assessment.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure care conferences were held after each assessment, including the comprehensive and quarterly assessments. This was true for 1 of 16 residents (Resident #2) whose care plans were reviewed. These failures created the potential for harm if residents and/or their representative were not included in making decisions regarding residents' care, and if care was not provided or care decisions were made based on inaccurate information. Findings include: The facility's policy for Care Plans, dated 11/28/19, documented the following: * Care conference meetings were scheduled upon admission, quarterly, and with change of condition. * The care plan included directives for revising and updating the plan of care as needed to reflect the resident's current status. * The facility developed and implemented a comprehensive person-centered care plan for each resident, and it included measurable objectives and time frames to meet the resident's needs as identified in the comprehensive assessment. * The team of qualified persons monitored the resident's condition and effectiveness of the care plan interventions and revised the care plan quarterly, annually, with a significant change assessment or more frequently as needed with input from the resident and/or the representative. This policy was not followed. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's record documented the most recent care conference was held on 7/18/19. On 1/7/20 at 9:20 AM, Resident #2 said she had not attended care conference meeting recently. On 1/8/20 at 10:17 AM, the Social Services Director said Resident #2's last care conference was held on 7/18/19, and it should be held quarterly.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure medication was not left unattended at a resident's bedside. This was true for 1 of 6 residents (Resident #21) who were observed during medication pass. This failure created the potential for harm if residents did not ingest the medication as ordered by the physician resulting in a decrease or change in their health status. Findings include: The facility's Medication Pass Guide, dated 1/1/18, directed staff to Observe resident ingest medication, do NOT leave at bedside. This policy was not followed. On 1/8/20 at 7:03 AM, LPN #1 was observed administering medications to Resident #21. LPN #1 presented a medicine cup that contained 7 pills and a plastic cup containing Clearlax (a laxative) in water to Resident #21. Resident #21 swallowed the pills from the medicine cup, and then said he did not want to take the Clearlax until he received breakfast. LPN #1 said okay and placed the cup of Clearlax on Resident #21's overbed table, which was over his lap. LPN #1 then exited the room and left the Clearlax with Resident #21. On 1/8/20 at 7:29 AM, LPN #1 said she knew Resident #21 was not going to take the Clearlax until he received breakfast, and she should have watched him take it. On 1/8/20 at 8:23 AM, the Clinical Resource Nurse said medication should not be left at the bedside unless the resident was assessed for self-administration of medication. The Clinical Resource Nurse said Resident #21 was not assessed for self-administration of medication, and the nurse should have removed the medication from the room when he said he did not want to take it at that time.

Based on record review, policy review, and staff interview, it was determined the facility failed to consistently implement a restorative nursing program (RNP). This was true for 1 of 3 residents (#36) reviewed for restorative nursing services. The failure created the potential for harm if residents experienced a decline in Range of Motion (ROM). Findings include: The facility's policy for Restorative Nursing, dated 2/28/18, documented the following: * Restorative nursing is a program established to help residents progress to a higher level of function and/or rehabilitate function, augment progress made in therapy or during recovery, and assists the resident to live as independently and safely as possible. * Restorative nursing is initiated when a resident has been discharged from therapy, when a resident has been admitted to the facility with restorative needs, when a resident is not eligible for rehabilitation therapy, and when restorative needs arise during the resident's stay in the facility. * Integrated restorative nursing services occurred 24 hours a day, 7 days a week. During the course of the day and during all routine care activities, residents should be encouraged to perform at their optimal functional level . * Areas of function may include urinary and/or bowel toileting program, passive and/or active range of motion, splint or brace assistance, bed mobility and/or walking, transfer training, dressing and/or grooming training, eating and/or swallowing training, amputation/prosthesis care, and communication training. This policy was not followed. Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #36's quarterly MDS assessment, dated 11/29/19, documented she required physical assistance of 1 person for locomotion, extensive assistance of 1 person for dressing, personal hygiene, and toileting, and physical assistance of 1 person for bathing. Resident #36's care plan documented she required RNP for ambulation and active ROM, initiated on 4/15/19. The care plan documented Resident #36 was to ambulate outdoors with supervision for 15 minutes, 7 days a week, and she was to perform bilateral upper extremity exercises with supervision for 15 minutes, 7 days a week, initiated on 4/15/19. Resident #36's ADL flowsheet documented she received RNP services 9 times out of 29 opportunities from 12/10/19 through 1/7/20. The flowsheet documented the RNP services were provided for less than 15 minutes on 12/15/19, 12/28/19, 12/31/19, 1/1/20, and 1/7/20. On 1/8/20 at 1:39 PM, CNA #1 said Resident #36 did not receive RNP services on 1/7/20 because the Restorative Aide was pulled to work on the floor. On 1/8/20 at 2:46 PM, the DON said there were 2 aides to provide the RNP, and the facility hit a bad spot with staffing so we did the programs as best as we could for maintenance. The DON said there were times when the Restorative Aide helped out on the floor, and she would have to talk to the CNAs to find out why Resident #36 did not receive Restorative Nursing services consistently.

Based on staff interview, record review, and policy review, it was determined the facility failed to ensure an as needed [MEDICAL CONDITION] medication had a physician evaluation or documented rationale when the medication order extended beyond 14 days . This was true for 1 of 5 residents (Resident #32) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents experienced adverse effects from unnecessary [MEDICAL CONDITION] medications. Findings include: The facility's policy for Unnecessary Medications and [MEDICAL CONDITION]/Antipsychotic Medication, dated 11/28/17, documented the following: * The residents' medication regimen was free of any medication used in excessive dose, excessive duration, without adequate monitoring, and without adequate indication for its use. * PRN [MEDICAL CONDITION] medications, which were not antipsychotic medications, were limited to 14 days, unless a longer timeframe was deemed appropriate by the attending physician or prescribing practitioner. * PRN orders for [MEDICAL CONDITION] and antipsychotic medications were used only when necessary to treat a diagnosed specific condition, and PRN use was limited to 14 days. * The PRN order could be extended beyond 14 days if the attending physician or prescribing practitioner believed it was appropriate to extend the order. The attending physician or prescribing practitioner documented the rationale in the resident's record and indicated the specific duration. This policy was not followed. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #32's physician's orders [REDACTED]. A pharmacy note to the attending physician/prescriber, signed by the Nurse Practitioner (NP) on 10/8/19, documented the pharmacist recommended to include a stop date for Resident #32's [MEDICATION NAME], and to document the rationale in the resident's record if the stop date was more than 14 days. The NP documented Stop date 6 months from start date. The pharmacy note did not include a rationale from the NP for the extended stop date for Resident #32's [MEDICATION NAME]. On 1/9/20 at 3:55 PM, the RCM confirmed she was unable to find a rationale for Resident #32's [MEDICATION NAME] documented in his record. The RCM said she spoke to the NP, who thought signing the 6-month order was the justification and she did not write an additional note addressing the reason for the extended stop date for the [MEDICATION NAME].

Based on observation, staff interview, policy review, record review, and review of Incident and Accident Reports, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 4 (#30 and #106) residents reviewed for pressure ulcers. Resident #106 was harmed when daily assessments were not completed, physician orders [REDACTED]. The pressure ulcers were related to a brace placed on Resident #106's right lower leg following a fracture. Resident #30 harmed when the facility failed to ensure the catheter tubing positioned to his leg was properly placed and free of kinks and he developed a stage II pressure ulcer. Findings include: The facility's Prevention and treatment of [REDACTED]. condition demonstrates they are unavoidable . Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. 1. Resident #106 was admitted to the facility on [DATE] with multiple diagnoses, including osteo[DIAGNOSES REDACTED] (bone infection), history of pressure ulcers, and diabetes mellitus. Resident #106's annual MDS assessment, dated 9/20/17, documented Resident #106 was moderately cognitively impaired and required two person assistance with ADL's and transfers. The MDS assessment documented Resident #106 was at risk for pressure ulcers and had no unhealed pressure ulcers. An Incident and Accident Report, dated 11/2/17 at 4:30 PM, documented Resident #106 fell from the salon chair to the floor, landed on her left side, sustained a small abrasion to her nose, had range of motion to all extremities, and denied pain. After Resident #106 was assessed, two staff members transferred Resident #106 with a Hoyer lift to the wheelchair. A Weekly Skin Alteration Report, dated 11/2/17 at 9:30 PM, documented Resident #106 had an [MEDICAL CONDITION] (swollen) area with bruising to the right ankle and it extended in a proximal direction. The [MEDICAL CONDITION] area measured 11.5 x 6.5 cm and the bruised area measured 6.5 x 5.0 cm. The color was described as light purple and light green. Resident #106 had periodic pain that was relieved by pain medication. A Nurse's Progress Note, dated 11/3/17 at 3:02 PM, documented Resident #106 complained of severe right leg pain with increased swelling and bruising to the right leg up to the right knee. Resident #106 was sent to the ER for further evaluation per physician's orders [REDACTED].>An X-ray Report from the hospital, dated 11/3/17 at 5:54 PM, documented the impression of the right ankle for Resident #106 as follows: * Mild comminuted (break or splinter of the bone into more than two fragments) spiral [MEDICAL CONDITION] tibial metadiaphysis (lower part of the shin bone) with mild displacement * Spiral [MEDICAL CONDITION] fibula diaphysis (broken ankle) with minimal displacement * Severe [MEDICAL CONDITION] A Nurse's Progress Note, dated 11/3/17 at 9:14 PM, documented Resident #106 returned from the ER. An ER physician's orders [REDACTED]. The care plan area addressing Resident #106's skin integrity bruise on the right medial lower leg, dated 11/3/17, documented, monitor daily, until resolved .Notify physician, for any adverse changes to affected area. A Nurse's Progress Note, dated 11/4/17 at 10:22 PM, documented, Resident with slight increase in pain with movement to right LL (lower leg). Walking boot in place along with wrap. Toes are warm and blanchable. Resident with no sensation to bottom of foot. The (MONTH) (YEAR) TAR, dated 11/4/17 and discontinued on 11/30/17, documented for licensed staff to monitor bruise to the right medial lower leg, every day, until resolved. Update physician, for any adverse changes. The TAR was left blank from 11/4/17 to 11/26/17 and 11/29/17, indicating the monitoring did not occur. A physician's orders [REDACTED].#106 had a Tib/Fib Fx (fracture) treat with Tall Walking Boot; (MONTH) open Front of boot and adjust air bladders 1 and 2 as needed; (MONTH) remove ACE Bandage prn (as needed). There was no documentation from 11/7/17 to 11/11/17 the facility requested clarification from the Orthopedic physician regarding when or why to remove the ACE bandage and how often the licensed staff should assess under the walking boot and ACE bandage on Resident #106's right lower leg. Resident #106's (MONTH) (YEAR) TAR included the above orders by the Orthopedic physician and all the spaces for documentation were blank. Resident #106's (MONTH) (YEAR) TAR and Nurse's Progress Notes from 11/7/17 to 11/11/17 did not contain documentation of the removal of the ACE bandage or opening the front of the walking boot to adjust the air bladders. A primary Physician's Progress Note, dated 11/10/17, documented, Resident #106 did not like wearing the boot, but will wear it and an Orthopedic physician was following her for her fractured right ankle. A Nurse's Progress Note, dated 11/12/17 at 8:14 PM, documented RN #2 removed the walking boot, ACE wrap, and webril (cotton pad) from Resident #106. RN #2 documented Resident #106 had 6 SDTI's (Suspected Deep Tissue Injuries) on RLE. Heel was 3.1 x 4 x 0 cm; lateral ankle was 1.6 x 3.4 x 0 cm; posterior foot and nearbase of 5th toe was 3 x 4 x 0 cm; anterior leg was 7.6 x 3.6 x 0 cm; anterior foot was 2.8 x 1.8 x 0 cm, and near 1st metatarsal head was 0.8 x 1.2 x 0 cm. All areas are dark purple, not open. The care plan area addressing Resident #2's skin integrity, pressure ulcer, use of boot to RLE, dated 11/12/17, documented staff were to, encourage/assist with frequent position changes; follow physician orders [REDACTED]. On 11/12/17 at 8:20 PM, RN #2 requested clarification orders from Resident #106's primary physician to check skin periodically. A physician' order by the primary physician, dated 11/13/17 at 4:03 PM, documented, please call (Orthopedic physician's name) as she (Resident #106) may need a second x-ray to be sure the fx remains in place. Resident #106 was seen by the Orthopedic physician on 11/14/17. No new orders were received. An Orthopedic physician's orders [REDACTED].#106's boot on her right lower leg every day, apply a border foam dressing to the SDTIs, and to wrap her leg with an ACE wrap and then reapply the boot to her right lower leg. Resident #106's (MONTH) (YEAR) TAR, dated 11/16/17, documented the above orders by the Orthopedic physician. The TAR was left blank on 11/17/17 and 11/18/17. The TAR was documented as refused on 11/16/17 and 11/19/17 with no explanation on the back of the TAR or in the Nurse's Progress Notes as to why Resident #106 refused the dressing changes. The Nurses' Progress Notes did not contain documentation of removing Resident #106's boot and ACE wrap to assess the SDTIs to her RLE from 11/13/17 to 11/19/17. A Weekly Pressure Ulcer Report, dated 11/20/17, documented, this right heel wound has deteriorated from SDTI to an unstable wound. The right heel wound is now unstageable d/t (due to) necrotic (dead) tissue at site. The right heel measurement was 4.6 x 5.2 x 0 cm. A Weekly Pressure Ulcer Report, dated 11/20/17, documented the right ankle SDTI and the right anterior SDTI had merged to create one large wound. Currently presents as a dark, fluid filled blister, bordered foam has a tacky covering, which could cause blister to open. A Skin/Wound Progress Note, dated 11/20/17 at 5:11 PM, documented, SDTI's to right lower extremity are deteriorating. Right heel wound is now unstageable d/t necrotic tissue at site. Anterior leg wound is a blister, with very fragile skin covering blister. Current tx is bordered foam over SDTI's. Bordered foam has sticky convening (sic), putting fragile skin over blisters at risk of tearing Resident #2's care plan area addressing her skin integrity, pressure ulcer, use of boot to RLE, updated 11/20/17, documented, TX/order. A physician's orders [REDACTED]. Apply nonadherent dressings to SDTI's. Wrap with ace wrap and reapply boot. Use two people for tx, one to support leg. Santyl (debridement treatment) to right heel qd. Apply nonadherent dressing. Resident #106's (MONTH) (YEAR) TAR, dated 11/21/17, documented the above orders by the primary physician. The TAR was documented as refused on 11/21/17 and 11/26/17 with no explanation on the back of the TAR or in the nurses' progress notes on why Resident #106 refused the dressing treatment. A Nurse's Progress Note, dated 11/23/17 at 10:28 PM, documented Resident #106 dressings were changed on her RLE. The progress note documented, Slight drainage noted to middle of shin area with skin peeling. Areas remain very dark brown. There was no documentation the physician was notified of the change. A Weekly Pressure Ulcer Report, dated 11/27/17, documented Resident #106's right unstageable heel ulcer measurement was 7 x 18 x 0 cm. RN #2 documented, Heel wound has merged with other wounds, creating larger wound. Necrotic tissue remains on heel portion of wound. Will continue current tx, continue to monitor. A Weekly Pressure Ulcer Report, dated 11/27/17, documented Resident #106's right anterior foot ulcer measured 4.6 x 3.4 x 0 cm and had slightly decreased in size. The right lateral leg ulcer measured 2.5 x 2.2 x 0 cm. RN #2 documented, This SDTI to right lateral leg is open, with dark covering to wound. Covering appears to be dried drainage rather than eschar (dark, leathery or hard dead tissue). Periwound area is without redness or [MEDICAL CONDITION]. Will notify MD with request for tx change. The right posterior foot ulcer measured 4 x 6 x 0 cm, was stable, and the wound appeared to be fading. The right great toe ulcer measured 1.6 x 2.2 x 0 cm and was stable. The physician was not notified of the change of measurements to the right heel ulcer and that the right lateral leg was an open wound. A Nurse's Progress Note, dated 11/29/17 at 9:22 AM, documented Resident #106 was sent to the ER, due to change in mental status, post tib-fib fx and resulting pressure related injuries to the Rt lower leg. An ER physician's orders [REDACTED]. A Nurse's Progress Note, dated 11/29/17 at 3:40 PM, Resident #106 returned from the ER with new orders to change hard boot for soft heel protectors and dressing changes to a [MEDICATION NAME] dressing every other day to right lower leg. Resident #106's (MONTH) (YEAR) TAR, dated 11/30/17, documented, [MEDICATION NAME] dressing change every other day for pressure ulcer treatment until resolved. The TAR was left blank on 12/2/17 and 12/4/17, indicating the dressing changes did not occur on those dates. A Weekly Pressure Ulcer Report, dated 12/4/17, documented Resident #106's unstageable pressure ulcer to right heel, measured 10 x 10 x 0 cm with black eschar in place. The right lateral leg measured 2.5 x 2.2 x 0 cm unstageable pressure ulcer with black eschar in place. The right ankle measured 8.2 x 11 x 0.1 cm unstageable pressure ulcer. RN #2 documented, This right lateral ankle/anterior leg wound has deteriorated. Wound bed is irregularly shaped and is a mix of eschar and skin exposed by open blister. The physician was notified. A physician's orders [REDACTED]. Resident #106's (MONTH) (YEAR) TAR, dated 12/8/17, documented the above orders for the [MEDICATION NAME]. The TAR was left blank for 12/8/17 and 12/9/17, indicating the orders were not carried out on those dates. A Nurse's Progress Note, dated 12/9/17 at 10:45 AM, documented Resident #106 was sent to the ER for evaluation due to complaints of generalized unwell feeling and increased confusion. A Nurse's Progress Note, dated 12/9/17 at 5:32 PM, documented Resident #106 was admitted to the hospital for treatment and cardiac observation. A hospital discharge summary, dated 12/11/17, documented Resident #106's X-rays show the fractures were not healing. The summary documented, She has severe necrotic wounds, lower extremity, and it is clear she probably has some vascular compromise with superficial vessels from the fractures . The patient was seen by (Physician's name) who reiterates that patient needs more than just a debridement, that it likely needs amputation, but the patient would not tolerate that, and it was for the patient to go back to the facility with hospice. A Nurse's Progress Note, dated 12/11/17 at 9:51 PM, Resident #106 was readmitted to the facility and to continue with palliative care. Resident #106 passed away 12/12/17. On 7/27/18 at 9:00 AM, the DNS was unable to provide additional information that Resident #106's RLE was assessed daily from 11/4/17 to 11/12/17. The DNS stated the nurses should have documented daily assessments and notified the physician of changes to Resident #106's RLE. The DNS stated if the TAR was left blank that meant the treatment was not done. On 7/27/17 at 12:15 PM, RN #2 stated Resident #106's physician's orders [REDACTED]. RN #2 stated the Orthopedic physician would not respond when the facility faxed and called with clarification of orders. RN #2 stated Resident #106's primary physician kept referring clarification orders to the Orthopedic physician. RN #2 stated the brace to Resident #106's RLE caused pressure to her RLE. On 7/27/17 at 12:20 PM, the DNS and RN #2 stated the facility called the Orthopedic physician's office frequently to receive the dictation from the office visits on 11/7/17 and 11/14/17. The DNS stated the facility's Medical Director had several calls to the Orthopedic physician to receive dictation for the office visits. The facility received the dictation on 12/7/17. 2. Resident #30 was originally admitted to the facility in (YEAR) and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. A 7/11/18 significant change MDS assessment documented Resident #30 had moderately impaired cognition; required extensive assistance for transfers, dressing, and toileting; used an external (condom) urinary catheter; and, a stage II pressure ulcer developed on 7/9/18. A 7/9/18 Skin Alteration Investigation for Resident #30 documented a blister to the left upper leg was found when his condom catheter tubing was in improper position. The investigation included a statement by a CNA which documented, Resident found on rounds with condom cath(eter) with penis positioned upward with kink in catheter - tube put pressure on leg causing water blister. It also contained a statement by an LPN which documented, .upper leg near groin - water blister 3 cm x (by) 1 cm noted where cath(eter) tubing was resting on leg with pants on - skin was indented where penis & cath had been resting - that part now resolved. An attached Skin Alteration Incident Investigation Directive was dated 7/9/18 at 10:00 PM. Resident #30's care plan area addressing urinary incontinence, revised 12/28/16, documented he wore a condom catheter during the day. Interventions revised on 7/10/18 documented the staff were to keep the catheter tubing free from kinks, place the tubing over the leg, and secure the tubing with tape or a leg strap. Resident #30's care plan area addressing his actual alteration in skin integrity, revised 7/10/18, documented a water blister to upper left leg with interventions for the staff to monitor the placement of the catheter to prevent skin issues and maintain proper placement. Resident #30's care plan addressing his actual alteration in skin integrity related to a stage 2 pressure ulcer on his left upper thigh, initiated 7/17/18, included interventions for the staff to follow physician orders [REDACTED]. Resident #30's active physician orders [REDACTED]. The active orders also included an order, starting on 7/12/18 and to be in place until the left thigh pressure ulcer resolved, for wound wash/skin prep to the unbroken blister and a foam border dressing every 3 days, and as needed for a missing or soiled dressing. On 7/24/18 at 10:37 AM, a clean, dry, and intact, approximately 4 inch by 4 inch padded bandage, dated 7/21/18, was observed on Resident #30's left upper thigh as RN #4 applied his condom catheter. The RN also applied a leg strap above the resident's left knee and attached the catheter tubing to the strap. RN #4 said the bandage covered a blister that was caused by the catheter tubing. A 7/17/18 weekly pressure ulcer report documented the left thigh pressure ulcer size increased to 3.1 cm by 3.1 cm, it was a bright red reabsorbed blister, and the skin was fragile. A 7/24/18 weekly pressure ulcer report documented the pressure ulcer size decreased to 2.5 cm by 2.5 cm, the intensity of the color decreased, and the skin remained intact. On 7/25/18 at 3:10 PM, the DNS said Resident #30's left thigh blister was caused by pressure from the catheter tubing laying on his skin and that the catheter was not secured then. The DNS said the catheter tubing was being secured now. The DNS provided the facility's External Catheter policy and said the policy did not address securing the catheter. The DNS said the facility followed the Lippincott Manual of Nursing Practice, 10th edition, guidelines for standard of practice regarding securing urinary catheters. The DNS provided a copy of page 781 from the Lippincott Manual regarding securing the catheter and tubing placement. The Lippincott Manual documented urinary catheters should be secured to the patient's thigh using tape, strap, adhesive anchor, or other securement device, and to allow some slack of the tubing to accommodate the patient's movement. The rationale was that properly securing the catheter prevents catheter movement and traction on the urethra. The Manual also documented to keep the tubing over the patient's leg and that this tubing position helps prevent kinking or forming loops of stagnant urine.

Based on record review and staff and family interviews, it was determined the facility caused harm when the facility failed to: * Promote healing of a Stage II pressure ulcer, on a resident's coccyx, that deteriorated to an "unstageable" pressure ulcer. * Prevent a Stage II pressure ulcer from developing on the resident's right ankle; and * Monitor and evaluate the effectiveness of interventions on the care plan and revise those interventions as appropriate. This was true for 1 of 7 (#4) residents sampled for skin breakdown. Findings include: Resident #4 was admitted to the facility with multiple [DIAGNOSES REDACTED]. NOTE: Interpretive Guidance for F314 states that current literature documents, "If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated... The clinicians, if deciding to retain the current regimen, should document the rationale to continuing the present treatment (for example, why some or all, of the plan's interventions remain relevant despite little or no apparent healing." The resident's Admission MDS, dated [DATE], coded in part: * Severely impaired cognition, with a BIMS score of 10; * Extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; * At risk for pressure ulcers (PU); * One unhealed stage II PU, present on admission; and * No other ulcers, wounds, or skin problems present on admission; * [MEDICATION NAME] tissue present indicative of, "New skin growing in superficial ulcer." The resident's Care Area Assessment (CAA), dated 12/31/13, documented, "Rsdt (Resident) was admitted with a stage 2 on coccyx which has resolved." The following was documented, under, provide input from resident and/or family/representative regarding this care area, "Rsdt (Resident) and family are aware of care needs and have no concerns at this time. Pleased at (sic) PU has healed." NOTE: The above CAA documented on 12/31/14, "Stage 2 (pressure ulcer) on coccyx resolved;" however, the resident's weekly skin check dated 1/2/14 documented, "Coccyx - Stage II open area, 2.0 x 0.2 x 1." On 2/27/14, at 2:15 PM, the DNS was interviewed related to discrepancy between the CAA and the weekly skin check form. The DNS said she was unsure why the CAA documented the pressure ulcer was healed and confirmed the pressure ulcer was still present and had not resolved. NOTE: For reading purposes, the following pressure ulcer wound measurements below are: length x width x depth and are measured in centimeters. The resident's Nursing Admission Assessment, dated 12/19/13, documented, "Pressure Ulcer present to coccyx measuring 1 cm x 0.1 cm x 0.01 cm open area (slit), surrounding skin pink/blanchable (4 x 4 x 0), foam bordered drsg (dressing) in place upon admit, heels firm..." The resident's Nursing Admission Assessment, Bates-Jensen Wound Assessment Tool (BWAT), Progress Notes (PM), Pressure Ulcer Investigation Report, and Weekly Skin Checks (WSC) documented the following: *12/19/13, BWAT & WSC - Coccyx, stage II, measuring 1 x 0.1 x 0.1, monitor and apply foam bordered dressing, change every 3 days and prn. *12/23/13, BWAT - Coccyx, stage II, measuring 1 x 0.2 x 0, continue current treatment. *12/26/13, WSC - Coccyx, stage II, measuring 1.0 x 0.2 x 0, continue with foam border dressing to coccyx, change every 3 days and prn... *12/30/13, BWAT - Coccyx, stage II, measuring 1.5 x 0.5 x 0, continue current treatment; *1/2/14, WSC - Coccyx, stage II 2.0 x 0.2 x 0.1, border foam dressing in place, change every 3 days and prn. *1/6/14, BWAT - Coccyx, stage II, measuring 2 x 3 x 0, continue current treatment; *1/9/14, WSC - "Ulcer care for coccyx continues..." *1/13/14, BWAT - Coccyx, unstageable, measuring 2 x 3 x 0, "New development of slough in wound bed, treatment order change requested from MD. Rsdt (Resident) is also comfort measures with likely metastatic malignancy which family is choosing to not aggressively treat. She is on dietary supplements, turning program, air mattress, and roho cushion." *1/16/14, WSC - "Continues with ulcer to coccyx..." *1/20/14, BWAT - Coccyx, unstageable, measuring 2.5 x 3.5 x 0, "Treatment changed last week, currently wound is stable from prior assessment. Rsdt is comfort care with metastatic [MEDICAL CONDITION]. All care plan interventions in place for skin." NOTE: The BWAT documents the wound was "stable;" however, the length and width of the wound had increased in size, in one week, from 2 x 3 x 0 to 2.5 x 3.5 x 0 and from 1 x 0.1 x 0.1 to 2.5 x 3.5 x 0 in 4 weeks. *1/23/14, WSC - "...Coccyx treament continues." *1/27/14, BWAT - Coccyx, unstageable, measuring 2.5 x 3.5 x 0, continue current tx. *1/30/14, WSC - "Continues with ulcer cares..." *1/30/14, BWAT -" Coccyx, unstageable, measuring 2.5 x 2.5 x 0.5. Wound continues to deteriorate, "Covered in slough but appears to be deepening. Mattressing (sic) being upgraded to low air loss air mattress. Will also request order change from MD. *2/2/14, PN - "Coccyx wound not improving, appears to have more slough and increasing depth. Unable to visualize wound bed due to yellow slough, but is obviously not attached to wound edges. Draining moderate amount of serious drng (drainage). Mattressing being upgraded to low air loss air mattress..." * 2/10/14, BWAT, - Coccyx, unstageable, measuring 3 x 2.5 x 1. "Treatment changed to [MEDICATION NAME] with foam dressing last week. Slough has become less attached and starting to autolytically debride (sic). Overall measurements, besides depth, have decreased, however undermining is now present along all wound margins." * 2/13/14, Weekly Skin Check (WSC), - "Skin is pale in color, continue treatment to ulcer on coccyx..." * 2/15/14, PN - "This afternoon while giving cares the CNA noted a sore to the Right outer ankle that was dry and scabbed over. The area shows no s/s infection. Area cleaned and dressed...Wound nurse to assess on Monday." *A facility provided document, "Pressure Ulcer Investigation," dated 2/15/14, documented the following, "Stage II pressure ulcer to the right lateral malleolus, measuring 0.5 x 0.5 x 0. Pressure Ulcer to right outer ankle bone noted when CNA removed socks at 11:30 AM. Area is several days old and scabbed. Rsdt has been sleeping in bed with her care boots on. Area cleansed and dressed."...When daughter was notified she stated its been there for about 1.5 weeks (and the daughter noticed it) when she had been lotioning her (Resident #4's) feet. I (RN #5) observed her feet on Feb(ruary) 2nd and it wasn't there." NOTE: The resident's Electronic Medical Record (EMR) and paper medical record, did not include any evidence of weekly skin checks (a total body assessment) between 1/30/14 and 2/13/14. *2/17/14, BWAT, - Coccyx, unstageable, measuring 4 x 2.5 x 1. "Wound continues to deteriorate. Currently using medi-honey with alginate and bordered foam. Will notify MD to see if any other tx (treatment) options may be indicated." *2/20/14, WSC, - Right ankle, stage II ulcer, see BWAT report. Ulcers to coccyx and Rt (right) outer ankle noted, see BWAT report... *2/24/14, BWAT, - Coccyx, unstageable, measuring 5 x 3 x 1X. "Current tx (treatment) is [MEDICATION NAME] with bordered foam q (every) day. See care plan for additional interventions." Additionally, documented on the BWAT for this day was, "Right ankle (outer), stage II, measuring 0.5 x 0.5 x 0. Continue bordered foam drsg (dressing)." The following was observed related to Resident #4's positioning: *2/25/14, 8:10 AM to 10:15 AM, 1:45 PM to 3:45 PM, resident lying in bed on her back, with heel boots on. *2/26/14, 1:10 PM to 3:10 PM, resident lying in her bed on her back/ right side, with heel boots on. On 2/26/14 at 3:40 PM, the wound nurse, DNS, and surveyor observed the resident's pressure ulcer to her buttocks and right ankle. The wound nurse measured each wound, listed below are the measurements: * Coccyx pressure ulcer - 5.5 x 3.5 x 1.5, "New eschar present at the superior/inferior edges. Undermining = 100 percent all the way around the wound and has a depth of 0.5 cm to 3.0 cm. The peri-wound is red/blanches, zero swelling and zero induration." * Right lateral ankle pressure ulcer - measured "0.6 x 0.9 x 0, and is unstageable." * 2/27/14, 8:30 AM to 10:00 AM, resident lying on her back/ right side, with heel boots on. The resident's Care Plan, dated 12/19/13 included the following: * Avoid scratching and keep hands and body parts from excessive moisture. * (Resident #4) needs pressure relieving/reducing mattress to protect the skin while up in chair and up in bed. * Turn and reposition every 2 hours when in bed. * Float heels when in bed, use heel lift boots or pillows (revised 1/22/14). * Skin inspection every week, observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. * Assess/record/monitor wound healing every week. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to MD. The facility failed to modify, change existing interventions, and/or add additional interventions when the resident's condition changed. For example, modifying, reposition every 2 hours and prn to reposition every hour; assist resident to off load pressure to buttocks when up in wheelchair; modify the head of bed or the back of the reclining chair to an angle of 30 degrees or less to decrease the amount of pressure exerted on the sacrum and coccyx; and utilizing dynamic pressure reduction surfaces if not clinically contraindicated. In addition, the facility faciled to ensure documentation of weekly skin inspections. During an interview with a family member regardingthe resident's care on 2/27/14 at 1:45 PM, the surveyor was provided with the following information. The family member knew the resident was admitted with a, "small opening" to her buttocks and the opening had gotten worse over time. The family member stated she would like (Physician's name) to look at the resident's pressure ulcer and she (the family member) would talk to the resident about it. The family member stated the resident did not want aggressive treatment for [REDACTED]." On 2/27/14, at 2:15 PM, the DNS and wound nurse were interviewed related to the above concerns. The surveyor asked the DNS about the resident's bed. The resident started on a pressure relieving facility mattress on 12/19/13, changed to a facility air mattress overlay on 1/13/14, and "upgraded" to a low air loss bed on 2/3/14. The DNS stated, when a resident at high risk for developing pressure ulcers, is admitted to the facility, the facility ensures the resident receives a pressure reducing mattress for his/her bed. The surveyor asked why the facility waited until the wound had deteriorated to implement the air bed overlay and then the low air loss bed." The DNS stated, "Low air loss beds are slippery and they are more expensive." The wound nurse added, "We don't get out the big guns (Cadillac bed) until the resident really needs it." The surveyor asked how does the staff know when revisions had been made to the care plan. The DNS and wound nurse stated there would be an initiated date followed by a revision date and/or deleted/resolved date. The wound nurse stated the facility had not, "deleted or resolved" anything related to interventions on the resident's skin care plan. No further information was provided at the time to resolve the issue. On 3/3/14 the Bureau of Facility Standards received additional information from the facility for review. The resident's (Local Hospital) Admission note, dated 2/27/14, documented, "...After an independent reviewer did look at the decubitus (ulcer) and discussed with this particular (family member). She (the resident) was sent down to the ER where she was noted to have UTI, [MEDICAL CONDITION] and [MEDICAL CONDITION] with a high white count and also her decubitus was noted to be quite substantial and quite deep with the decubitus likely, I believe, going down to bone. I believe I could palpate bone when I palpated the decubitus... She has an ankle with a small pressure sore with a small rim of surrounding [DIAGNOSES REDACTED]..." The additional information provided by the facility did not resolve concerns related to the resident's pressure ulcers. The resident was harmed when the facility failed to identify changes in the resident's condition which required additional or different interventions and to validate the effectiveness of current interventions. This resulted in: *A stage II coccyx pressure ulcer that was present on admission deteriorating to an "unstageable" pressure ulcer that was noted to be, "quite substantial and quite deep...going down to bone" and resulted in a hospital admission; and *The development of stage II pressure on her right ankle.

Based on observation, record review, Resident Event Report Worksheet (RERW) and staff interview, it was determined the facility failed to ensure 1 of 4 sample residents (#4) reviewed for pressure ulcer prevention did not develop an avoidable pressure ulcer. Resident #4 was harmed when a Stage IV pressure ulcer developed on the right outer calf under the orthosis (brace) while at the facility. Findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident had a Stage IV pressure ulcer that was not present on admission. A RERW, dated 2/12/12, documented a CNA was adjusting Resident #4's clothes after toileting. The Resident's leg gave out and and the CNA assisted the Resident to the floor. A [MEDICAL CONDITION] report, dated 2/12/12, documented a fracture to the distal femur (above the knee) and proximal tibia (shinbone just below the knee). The hospital report documented the resident's right knee was locked in position with a Knee Ranger (device for protected range of motion) and was to follow up on 2/17/12 for orthopaedic care. A "Report Of Consultation" (ROC), dated 2/17/12, documented in the "Report" section, "...Right leg in orthosis-continuous, except skin care....May loosen orthosis for skin care - bed bath only." Another ROC, dated 3/16/12, "Cont (continuous) brace x (for) 6 weeks. The third ROC, dated 4/25/12, documented the brace was to be discontinued. The facility's 4/26/12 Resident Progress Notes (RPN) documented a CNA notified the RN of a wound on Resident #4's outer calf that measured 10 cm (centimeters) by 4 cm x 0 cm. A Follow Up Visit Note from the orthopaedic physician, dated 4/25/12, was faxed to the facility on [DATE]. The Note documented in the Plan section "... is having some skin pressure issues with the brace. It was decided to discontinue the brace at this time." The facility's Weekly Pressure Ulcer BWAT Report (WPUR) documented, on 4/26/12, an unstageable/Deep Tissue injury in the heading of the report. The information for the weekly checks for 4/26/12 documented a Stage IV pressure ulcer that was 10 cm x 4 cm x 0 cm that had soft black eschar (dead tissue) without drainage and less than 25% of the wound was covered with [MEDICATION NAME] (healing layer of skin). Weekly WPURs were completed for 9 months and documented on 1/30/13 the pressure ulcer was 5 cm x 1.5 cm x 0.4 cm with no visible necrotic tissue, and a moderate amount of thin watery red/pink drainage with 25% to 50% of the wound covered with [MEDICATION NAME]. A report, dated 4/26/12, from the physician who provided wound care documented the resident's brace was initially uneventful "... but apparently with the last change it got quite tight." On 1/30/13 at 1:35 p.m. the surveyor observed the wound and documented the same information as on the WPUR for 1/30/13. At that time Resident #4 expressed to the surveyor she suffered with pain from the pressure ulcer. On 1/31/13 at 11:05 a.m. the DON stated the brace for Resident #4 was an upper thigh hinged brace. She stated the brace was loosened and opened at the top so it was not possible to see the side or underneath Resident #4's leg. When asked about skin care for Resident #4 the DON stated the facility had followed the physician orders [REDACTED]. When asked if the facility had informed the physician the brace would need to be removed for skin checks the DON stated no. The DON stated the Administrator and the DON had met with the physician group practice prior to being aware of Resident #4's pressure ulcer to discuss the facility's concerns about physicians not allowing the facility to remove the brace. At the meeting the physician group informed the facility that they were going to continue to not allow any facility to remove a brace. On 1/31/13 the DON provided Treatment Records (TARs) for 3/12 and 4/12 for Resident #4. The TARs included to "Check skin under brace Q (every) shift for s/sx (signs and symptoms) Breakdown." The TARs were initialed for each shift that the skin check had been completed. On 1/31/13 at 5:35 p.m. the Administrator and the DON were informed of the above concern. The Administrator stated at the meeting with the Orthopedic group (OG), around 4/2/13, the facility had informed the OG the facility needed to remove the brace. The OG stated they were not going to allow the facility to remove braces. When asked for notes regarding the meeting the Administrator stated there were no notes from the meeting but she could provide the date as it had been scheduled on her calendar. Resident #4 developed a Stage IV pressure ulcer, causing her pain, that continued for more than 9 months. The facility was unable to provide documentation they had requested clarification to remove the brace (for skin care as ordered) from the physician for Resident #4. However the resident's TARs were initialed for skin checks completed each shift for 3/12 and 4/12.

Based on record review, observation, staff and resident interview, it was determined the facility failed to ensure residents with pressure ulcers received the assessment, care and services necessary to ensure existing pressure ulcers healed and new pressure ulcers did not occur. This was true for 4 of 4 sampled residents reviewed for pressure ulcers (#1, 6, 7, & 9.) All 4 identified residents were harmed as a result of insufficient pressure ulcer prevention and developed avoidable ulcers. Resident #6 developed 3 Stage II ulcers, one of which was recurring, and a Stage IV ulcer which became infected. Resident #7 developed 2 Stage II pressure ulcers which became infected with [MEDICAL CONDITION] (MRSA). Resident #1 developed a Stage III coccyx pressure ulcer while in the facility. Resident #9 developed 2 Stage II coccyx ulcers. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's 3/21/11 quarterly MDS assessment stated the resident was totally dependent on 1 staff assistance for personal hygiene, dressing and bed mobility, and 2 staff for transfers. The MDS also documented the resident was at risk for pressure ulcers and had no unhealed ulcers. The resident's 9/20/11 Comprehensive Care Plan Report identified the potential for impaired skin integrity, dated 12/23/09, and stated the approaches in place, as of 12/23/09, were a Broda pressure reduction cushion in the wheelchair, the use of a turn sheet for repositioning and a turning/repositioning schedule every hour and as needed. The Pressure Ulcer Risk Assessment Tool, Braden Scale, dated 12/23/09, identified the resident as being at high risk for pressure ulcer development with a score of 12. The form stated, "Total score of 12 or less represents HIGH RISK." The most recent Pressure Ulcer Risk Assessment, date 6/11/11, also indicated high risk with a score of 11. A 4/21/11 Incident /Accident report documented the resident was noted to have a ? cm (centimeter) by ? by 1/8 cm deep pressure ulcer to the sacrum. In the section of the report for "Caregiver Questions," staff stated, "I don't know how she got the pressure ulcer." and "I don't know? Possibly needs more turning." The plan in response to the pressure ulcer was documented on a Condition Change Form attached to the report, and stated an alternating air mattress would be implemented. A 4/26/11 Incident /Accident report documented the resident was noted to have a hardened, yellow coloration area present on the left heel which was not blanchable. The plan in response to the pressure ulcer was documented on a Condition Change Form attached to the report, dated 4/27/11, and stated a heel lift mat would be implemented. Resident Weekly Skin Check Sheet documentation included the following: 4/7/11 - No new skin issues. 4/14/11 - Red area to left heel. 4/21/11 - ? cm x ? cm x 1/8 cm pressure ulcer to sacrum. 4/28/11 - 2 cm reddened area to left heel. .5 cm diameter pressure ulcer to sacrum. 5/5/11 - [MEDICATION NAME] dressing applied to coccyx (sacrum). Left heel noted to have 2 ? x 2/14 x ? cm area. 5/12/11 - Left heel noted to be darker than previous skin check. Wound is 2.5 x 2 x ? cm. 5/19/11 - Left heel wound approximately 2.5 x 0.1 x 1/8 cm. 5/26/11 - Left heel wound approximately 2.5 x 0.1 x 1/8 cm. 6/2/11 - Left heel is very superficial and approximately 4 cm on top layer of skin. Weekly Pressure Ulcer Condition Reports documented the sacrum/coccyx wound was a Stage II on 4/21/11, 4/27/11 and resolved on 5/2/11. On 10/6/11 at 11:45 a.m. the DON and regional clinical consultant provided interview information and a time line on the left heel wound. They stated an air mattress and Sage boot were implemented on 4/25/11 and the heel wound resolved on 6/3/11. The 6/8/11 quarterly MDS assessment documented the resident had 1 unstageable pressure ulcer with deep tissue injury and necrotic tissue. Weekly Pressure Ulcer Condition Reports documented the left heel was again open on 7/27/11, and described the wound as a Stage II, 3 x 2 x ? cm in size. The wound was described as a Stage II on 7/29/11, 8/5/11, and 8/12/11. The form documenting the left heel wound from 8/19/11 through 9/9/11 documented the wound as a Stage IV from 8/19 - 9/2/11. The report documented the resident experienced pain from the wound on the 8/5/11 entry and indicated the resident had required medication for the pain. Note: The Weekly Pressure Ulcer Report form had drawings of figures at the top of the form. A circle was hand drawn around the left heel to indicate the location of the wound identified and being documented on the form covering 7/27/11 through 8/12/11. The report form covering 8/19/11 through 9/9/11 identified the wound as "left heel" in writing in the "Location" section of the form, but had a large, hand drawn circle around the left buttock of the figure on the page. During the interview on 10/6/11 at 11:45 a.m. the DON and regional clinical consultant stated the heel was noted to have a purple blister on 7/27/11. The heel lift boots were discontinued and a heel lift mat put in place. On 8/1/11 the staff reportedly noted wear patterns on the wound dressing and determined the resident was moving the foot on the mat. At that time a foam wedge replaced the lift mat. Physical therapy was consulted for splinting and positioning. The wound was reportedly resolved on 9/9/11. The resident's annual MDS assessment, dated 8/18/11, documented 1 unstageable pressure ulcer with deep tissue injury and necrotic tissue and "yes" to 1 healed Stage IV pressure ulcer. An 8/24/11 Incident /Accident report documented the resident was noted to have a 1 x .5 x .1 open area on the inner left leg. In the section of the report for "Caregiver Questions", staff stated the resident was propped by pillows for the heel but the leg was laying on the bony part of the other leg causing an open area. The plan in response to the pressure ulcer was documented on a Condition Change Form attached to the report, and stated a dermasaver sleeve would be applied to the left leg at all times except to shower, and turning/repositioning would occur every hour. Weekly Pressure Ulcer Condition Reports documented the left leg wound as a Stage II weekly from 8/24/11 through 9/16/11, at which time it was documented as an "unstageable" Stage IV with 75% - 100% of the wound covered by necrotic tissue, moderate amounts of foul, purulent thick opaque drainage. Pain was described as being present on 9/23/11 and 9/30/11. A Physician Telephone Orders form, dated 9/23/11, documented the order for antibiotic treatment with [MEDICATION NAME] 500 mg (milligrams) 3 times daily for 7 days for wound infection, a culture and sensitivity test and referral to a wound specialist. The 9/26/11 final laboratory report documented the left leg wound had "heavy growth" of Proteus Mirabilis and Pseudomonas Aeruginos bacteria. Resident Progress Notes for 9/30/11 stated the wound physician had been in to see Resident #6 on that date. The note further stated the physician wanted to explore the option of maggot debridement therapy with the resident and family. The physician reportedly debrided the wound with a sharps instrument at the bedside. On 10/6/11 at 10:30 a.m. the wound nurse was observed during a dressing change to the left leg wound. The wound was on the inner calf, approximately 3 inches up from the ankle. The resident complained of some discomfort with the positioning of the leg required by the nurse to access the wound for treatment. The nurse measured the wound as 5 x 2 to 3 cm in area. No depth was measured. Approximately 2/3 of the wound was covered by eschar. Serosanguineous drainage was noted to be present on the dressing removed from the wound. Resident #6 was assessed as being at high risk for pressure ulcer development upon admission to the facility. The resident experienced harm when an air mattress and protective heel boots/wedges were not implemented until after the resident developed a Stage II ulcer to her heel and a Stage II ulcer to the sacrum/coccyx. The left heel ulcer recurred less than 2 months later and advanced to a Stage IV, with pain reported. The resident's improper positioning in bed resulted in the development of a Stage IV pressure ulcer to the left leg, which became infected and caused the resident pain. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's 3/17/11 quarterly MDS assessment documented the resident was at risk for pressure ulcer development. The resident's most recent quarterly MDS assessment, dated 8/16/11, documented the resident required extensive assist of 1 person for bed mobility, transfers, dressing, personal hygiene and bathing. The assessment also documented the resident was at risk for pressure ulcer development and had 1 Stage II pressure ulcer. The Pressure Ulcer Risk Assessment Tool, Braden Scale, dated 9/11/11, identified the resident as being at high risk for pressure ulcer development with a score of 11. The form stated "Total score of 12 or less represents HIGH RISK." A 4/27/11 Incident /Accident report documented the resident was noted to have a bruise to the right buttock which was described as being the result of skin being pinched under the incontinent brief while being repositioned in bed. In the section of the report for "Caregiver Questions," staff stated, "Rsdt(resident) may not have been 100% compliance (sic.) with cares." The plan in response to the pressure ulcer was documented on a Condition Change Form attached to the report and dated 4/29/11, stated the resident had lost a lot of weight over the years and the skin was very loose. An alternating air mattress and a Roho cushion to the wheelchair were planned to be implemented. The resident's 4/19/11 Comprehensive Care Plan Report for skin integrity had a hand written entry, dated 5/7/11, for an alternating air mattress. The Care Plan did not include mention of the Roho cushion to the wheelchair, however, the resident's 9/15/11 Care Plan documented the Roho cushion had been added on 5/7/11. A Weekly Non-pressure Skin Condition Report documented the 8 x 5 cm wound to right buttock on 4/27/11. Weekly Pressure Ulcer Condition Reports documented the wound as an 8.5 x 4 cm open Stage III on 5/7/11 and 5/13/11, and as a Stage IV from 5/20/11 through 7/1/11. Pain during treatment was described as being present on 6/3/11, 6/17/11 and 6/24/11. A note on 5/20/11 on the report stated the wound physician had been consulted. On 7/1/11, Weekly Pressure Ulcer Condition Reports documented the wound as a Stage IV with undermining of 0.7 cm, with a small amount of purulent drainage. Pain during treatment was documented on 7/8/11, 7/15/11, and 8/19/11. On 7/8/11 and on all weekly reports through 9/30/11, the wound was documented as a Stage III. Note: CMS's RAI Version 3.0 Manual instructions to providers for staging pressure ulcers stated, in part, "Pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g. muscle, fat and dermis) that were lost during the pressure ulcer development ...Current clinical standards do not support reverse staging or backstaging." According to this Federal guidance, the sacral/coccyx wound remained a Stage IV. During the interview on 10/6/11 at 11:45 a.m. the DON and regional clinical consultant stated the air bed and Roho cushion were implemented on 4/29/11. On 5/16/11 the wound physician was contacted for a consultation, but the resident was not seen until 5/26/11. As stated above, the 4/19/11 Care Plan dated the addition of the air mattress as 5/7/11. The 4/19/11 Care Plan also identified an approach to address impaired skin integrity as turning/repositioning every hour when in bed. This intervention was dated 6/21/11 in handwriting, and marked as discontinued in handwriting on 6/21/11. The next intervention was to change the resident ' s position every 2 hours when out of bed. This intervention was documented as discontinued in handwriting, on 5/9/11. The current 9/15/11 Care Plan included repositioning every 2 hours when out of bed, the use of the Roho cushion in the wheelchair and the air mattress. The Care Plan included the 6/21/11 instructions to reposition every hour when in bed. It was difficult to determine which interventions were implemented in response to the pressure ulcer development and subsequent deterioration of the wound, and what interventions were actually in place throughout the time period. Resident #1 was assessed as being at high risk for the development of pressure ulcers. The resident was harmed and experienced pain when the facility failed to implement pressure relieving methods to prevent the development of a Stage IV wound, and failed to recognize the weight loss as increasing the resident's risk prior to the pressure ulcer development. The facility also failed to accurately stage and document the wound. 3. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's 2/28/11 admission MDS assessment documented the resident had 1 Stage II and 1 Stage III pressure ulcers on admission. The MDS also documented the resident required extensive assistance by one staff for personal hygiene, bathing and transfers. The resident reportedly used both a walker and wheelchair for mobility. The resident's 2/25/11 Comprehensive Care Plan Report identified skin integrity as a problem and initiated approaches of turning/repositioning every 2 hours, use of a turn sheet for repositioning, pressure reduction cushion in wheelchair, float heels or use heel lift boots when in bed and a pressure relieving mattress. During interview on 10/6/11 at 11:45 a.m. the DON and regional clinical consultant stated the 2 pressure ulcers present on admission to the resident's right and left buttocks were healed within 3 weeks. A 3/18/11 Interdisciplinary Progress Notes entry documented the wounds as healed. Resident Progress Notes contained a Condition Change Form, dated 4/21/11, documented the resident had a 0.3 x 1 cm stage II pressure ulcer in area of previous breakdown. The resident was described as having nausea and shingles at that time, and was resistant to turning/repositioning. The note stated the cushion to the resident's wheelchair was changed to a Roho cushion, and the mattress was to be "upgraded" to an alternating air mattress. During the interview on 10/6/11 at 11:45 a.m. the DON and regional clinical consultant stated the pressure ulcer, described as left sacral, was healed on 5/13/11. A [MEDICATION NAME] dressing was ordered to be in place to protect the area from further breakdown. Resident Weekly Skin Check Sheets for 6/11 and 7/11 showed no coccyx/sacrum breakdown. An 8/6/11 Incident /Accident report documented the resident was found to have an open area to the coccyx due to the [MEDICATION NAME] dressing rolling up at night. In the section of the report for "Caregiver Questions," staff stated, "Rsdt(resident) drsg(dressing) was changed 8/5/11 (no) open area noted, aids stated that the dressing on coccyx was all rolled up, nurse removed drsg and found a 0.5 x 0.5 x 0.1 open area under drsg (it was not there yesterday) mepalex was all rolled up." The plan in response to the pressure ulcer was documented on a Condition Change Form attached to the report and dated 8/8/11, stated staff education on making sure the dressings were dry and intact when each care contact was provided, and staff were instructed to notify the nurse if the dressing needed to be changed. Weekly Pressure Ulcer Condition Reports for 8/6/11 described the following for what was identified as the "Central" sacrum and coccyx pressure ulcer: 0.5 x 0.5 x 0.1 cm Stage II, no pain. Weekly entries were present through 9/30/11, at which time the wound was described as 2.5 x 1.5 x 0 cm Stage II with scant amount of Serosanguineous drainage. Pain was documented as being present in relation to the wound on 8/19/11. During the 9 week period, notes on the report indicated the resident was educated on off loading multiple times, however, no changes to the treatment were documented. An 8/13/11 Incident /Accident report documented the resident was found to have a sore while changing the resident. In the section of the report for "Caregiver Questions," staff stated, "Rsdt(resident) sitting too long on buttocks." The plan in response to the pressure ulcer was documented on a Condition Change Form attached to the report and dated 8/15/11, stated a 1 x 1 x 0.2 cm sore was found on the buttocks just above and to the right of the current sore. The resident was educated on the importance of off loading pressure and encouraged to go to bed between meals. Weekly Pressure Ulcer Condition Report for 8/13/11 through 9/2/11 described a wound as R(right) superior, 1 x 1 x .2 cm and a Stage II. Pain was documented as present in relation to the wound on 8/13/11 and 8/19/11. The wound was documented as healed on 9/2/11. Note: The resident's Care Plan included the approach to remind her of the importance of lying down between meals and every 2 hours, however, the Care Plan did not contain specific interventions to address refusals by the resident to change position or go to bed to relieve pressure or identify refusals as a problem area. Resident #9 was harmed when 2 Stage II pressure ulcers developed to the sacrum/coccyx. As described by the facility, an "upgraded" pressure relieving wheelchair cushion (Roho) and alternating air mattress were not put in place until after breakdown occurred, despite the presence of 2 buttocks pressure ulcers on admission. The documentation failed to show changes in the facility's approach to wound treatment beyond resident education to off load pressure. 4. Resident #7 was readmitted on [DATE] to the facility after a hospitalization to treat pneumonia, urinary tract infection and dehydration. Other [DIAGNOSES REDACTED]. The most current quarterly MDS assessment, dated 9/26/11, documented the resident was incontinent of bowel and bladder, required total assist for ADL care including dressing, was moderately cognitively impaired and did not have pressure sores coded. The most recent annual MDS assessment, dated 1/10/11, documented the resident had one Stage II pressure sore that was not present for the prior assessment and she required extensive assist for ADL care. A Braden Scale assessment for predicting pressure sores was included in the "Patient Nursing Evaluation" dated 5/25/11. The resident received a score of 12, which indicated high risk for pressure sores. The resident returned from the hospital on [DATE] with three open areas on her right lateral leg and a fourth open area developed on the right lateral leg on 9/1/11. The fourth open area measured "0.1 x 0.1 x 0.1" centimeters (cm) for length, width and depth. The fourth wound was described as red moist and grainy. By 9/30/11 the wounds to the right lateral leg were all healed. However, on 6/24/11 the resident was found with a open area to the first toe on her left foot. The size was documented as 0.5 cm and staged at II. The next week the wound was measured as 0.4 x 0.4 x 0.1 centimeters and was a Stage II. This was the largest measurement until the wound was healed as of 8/4/11. A second wound was identified on 6/24/11 as a Stage II on the left foot, second toe. This was also measured at 0.5 cm. with the largest measurement being 0.5 x 0.5 x 0 cm on 7/7/11. This wound was healed as of 7/29/11. The resident did receive treatment from a wound clinic for the above wounds. A progress note from the 8/23/11 visit indicated: "The patient comes in for follow-up on problems: 1) She has multiple distal lateral calf ulcerations. That is the primary problem. 2) She has had chronic intermittent problems with dorsal interphalangeal joint ulcers and I noted in the past that she had had a problem on the left second toe. She has some problems noted again with this today. 3) The patient has [MEDICAL CONDITION]-resistant staph aureus (MRSA). Dr. (name) just gave her another round of antibiotics starting on the 19th of August... 4) Fungal changes on skin of lower legs and feet. Dr. (name) ordered [MEDICATION NAME] cream 1% to apply to extremities at time of dressing changes... Last visit when she was here there was concern about [MEDICAL CONDITION] and as a result of that single layer Comperm was switched to double layer Comperm on the right lower extremity." During interview with the DON and nurse consultant on 10/5/11 at 1:40 pm, the nurse consultant said Resident #7 came in with wounds on her right leg but developed the wounds to her toes related to her footwear. The nurses were asked to provide a time line of information that would determin what preventative measures were implemented by the facility and how the wounds on the resident's toes were unavoidable. Later, the nurse consultant provided a copy of a "Weekly Physical Therapy Progress Note" form. The form was dated from 6/22/11 to 6/29/11. The nurse consultant indicated this was when the resident developed the wounds that were related to sit to stand exercise being done in therapy and the shoes worn by the resident at the time. Documentation on the form indicated exercises were for strengthening and to help the resident support her weight while standing. Notes indicated it was difficult to motivate the resident to participate and wheel chair mobility was difficult due to the resident's shoes, which lacked traction and the shoes were discussed with the resident's family. The care plan was dated 7/29/11 and contained evidence of several revision dates. The care plan identified a problem dated 6/24/11 for abrasions to the 1st and 2nd toes. However, the intervention was not documented until 7/27/11 and documented, "Slippers only; No shoes until toe abrasions are healed." (Note: This was over a month after the wounds to the resident's toes were discovered on 6/24/11). The resident was observed throughout survey observation days of 10/3/11 through 10/6/11 to have blue soft slippers on with Velcro adjustable flaps over the top. This was the case whenever Resident #7 was out of bed and seated in her wheel chair. The facility did not provide further information to indicate what interventions were in place to prevent the resident from developing wounds to her feet when she was at high risk for pressure sores and also had [MEDICAL CONDITION]. The [MEDICAL CONDITION] may have made it difficult to put shoes on the resident. There was daily documentation of skin checks after the wounds were found but nothing provided for the period prior to the onset of the wounds on 6/24/11. The resident was not able to put her own shoes on or take them off independently. The facility did not address how staff failed to notice red areas to the resident's toes before they progressed to Stage II sores. The resident was harmed when she developed multiple Stage II pressure sores that also became infected [MEDICAL CONDITION].

Based on review of accident and incident reports (Post-Event Assessments), review of clinical records, and staff interview, it was determined the facility failed to develop and implement interventions to prevent falls. This was true for 1 of 4 residents (#5) reviewed for falls. This failure resulted in harm to Resident #5, who fell and sustained a left hip fracture which required surgical repair. Findings include: Resident #5 was initially admitted to the facility on [DATE]. The resident was readmitted on [DATE], following a facility fall which resulted in injury and required an ORIF (Open Reduction and Internal Fixation) surgical repair of the left hip. The resident was also readmitted on [DATE] following a hospitalization for pneumonia and sepsis. The resident's current [DIAGNOSES REDACTED]. The resident's 10/20/09 admission MDS assessment documented the resident had dementia with both short term and long term memory loss, as well as moderately impaired cognition for daily decision making. The MDS documented the resident required extensive assistance of at least one person for transferring, and had an unsteady gait. A Fall Risk Assessment, dated 10/21/09, documented the resident was disoriented daily and ambulated/transferred safely when accompanied by staff. The box for "Knows how to transfer safely (on own)" was not marked. The total fall risk score was 23, which, according to the Assessment, indicated the resident was at high risk for falls. The resident's 11/18/09 CCP for Falls documented the resident was at risk for falls due to dementia, weakness, medication regime, and a high risk assessment score. The CCP listed the following interventions: * "Bed/wheelchair alarm at all times... respond to alarm promptly" * "Blue fall mat at bedside at all times..." * "Do not leave alone in bathroom." * "Keep adjustable bed in low position for safe transfers." * "Lock bed brakes." A significant change MDS assessment, dated 12/7/09, documented the resident had a decline in her ability to perform ADLs, was not able to stand without assistance, and had a fall within the past 30 days. (NOTE: During an interview on 8/25/10 at 2:45 pm, the DON stated the resident slipped from her wheel chair onto the floor in November 2009.) During review of Post Event Assessments (PEA) for March 2010 through August 2010, it was determined that Resident #5 experienced falls on 5/25/10 and 5/26/10, and a fall again on 6/10/10 which resulted in a left hip fracture. Clinical records reviewed for April 2010 through June 2010 documented the facility was aware of Resident #5's continued confusion and attempts to self transfer. However, the resident's 4/9/10 CCP in place for 5/25/10 through 6/10/10 had not been updated to address the resident's attempts to self-transfer, or interventions put into place to prevent further falls. For example: * 4/12/10 IPNs documented -"(Decrease) HS (Bedtime) Seroquel to 25 mg (milligrams) PO (by mouth...) " *4/14/10, 1:00 pm, IPNs documented - "... Noted slight increase in agitation (related to) decrease in Seroquel. Also (increase) in attempt to self-transfer. Set off pull tab alarms on (two) occassions (sic)... " * 4/16/10 Resident Review for Inclusion in the Falling Star Program form - documented that residents must meet 4 of the 5 criteria to be included in the Falling Star Program. According to the documentation on the form, the resident met 4 of the 5 listed criteria: Fall risk assessment of 14 or above with mental changes; history of multiple falls; resident moves regularly about facility, walking or propelling wheelchair; and decreased cognitive/safety awareness - resident unable to make safe choices or follow safety precautions such as not getting up unassisted. NOTE: Although the 4/14/10 IPNs documented the resident attempted to self-transfer and the resident's 4/16/10 Falling Star review documented the resident met the criteria for the program, the resident's 4/9/10 CCP was not updated to reflect those changes. In addition, a 5/5/10 IPN documented, "resident has had (no) recent attempts to get (out of bed) or w/c (wheelchair). Alarms (discontinued) from bed and w/c." The 4/9/10 CCP was revised to reflect the alarms were discontinued on 5/5/10. However, the 4/14/10 IPNs and 4/16/10 Falling Star review documented that she was still at risk. The resident's 5/19/10 quarterly MDS assessment documented the resident continued to have short and long term memory problems, impaired ability for daily decision making, required extensive assistance with transfers, and had an unsteady gait. * A 5/25/10 Condition Change form, documented, "Found on floor mat at bedside by CNA who related he had assisted her back to bed... " The associated PEA form, initiated on 5/25/10, documented the fall was not witnessed but the resident stated, "I was trying to get up and slipped off the bed." A Condition Change form, dated 6/7/10, documented, "IDT (Interdisciplinary Team) met to discuss recent events (fall on 5/25/10). (Resident) has a history of weakness, difficulty walking, mental disorder. Upon investigation (resident) was observed on fall mat (at 6:10 am) at bedside. (Resident) was assisted to (bathroom) at 5:30 am, then helped back to bed. It appears (resident) was ready to get (up) for the morning and attempted to self-transfer.... Plan - (sic) Inservice staff to ask resident, after the morning toileting, if she would like to stay up for morning." The 4/9/10 CCP was not updated to instruct staff to ask the resident if she wanted to get up for the day after her early morning trip to the toilet. In addition, There was no documentation that staff received the planned inservice until 6/7/10. * A 5/26/10, 7:00 pm Condition Change form documented - "Resident observed on floor in hallway on left side... no injuries from fall... (resident) states, 'I was going to the kitchen'..." The associated PEA form initiated on 5/26/10, documented the PI (Performance Improvement) Committee recommended a physical therapy evaluation, an evaluation for a urinary tract infection (UTI), and that the resident ambulate with the restorative program. No documentation was found in the resident's record to indicate the physical therapy evaluation was completed, or that the resident was evaluated for a UTI. In addition, the resident's 4/9/10 CCP was not revised to include the falls on 5/25 or 5/26, or to include planned interventions to prevent further falls. * 5/27/10 and 5/28/10 IPNs documented the resident was monitored for 72 hours, after the 5/25/10 fall, for attempts to get out of bed or self-transfer. There was no other documentation in the resident's IPNs between 5/28/10 and 6/10/10. * A 6/8/10 Condition Change Status From documented - "IDT met to discuss recent event (fall on 5/26/10). (Resident) with history of mental disorder, muscle weakness, difficulty walking, urinary tract infections. Upon investigation resident observed on floor in hall way, near w/c. PT to evaluate fit of w/c, evaluated for UTI.... It appears the psyc(hiatric) med(ications) have been dose reduced. (Resident) is more (alert and oriented) and thought she could ambulate on her own. No injuries occurred. (Resident) currently ambulatory (with) restorative." * A 6/10/10 Condition Change form later documented, "(resident's) roommate put on call light. Stated (resident) tried to stand up for w/c and fell to the ground. Observed laying on back on floor (with) left foot externally rotated, (complains of) severe pain. Sent to (hospital) to eval(uate) and treat." The associated PEA form, initiated on 6/10/10, documented the fall occurred at 7:35 am and, "(Resident) has attempted to self transfer in the past. Roommate states (resident) attempted to transfer herself to the bed and fell on the floor." * 6/10/10 IPN documented the resident was admitted to the hospital for a fractured left hip, "Will have surgery tomorrow." * A readmission IPN, dated 6/14/10, documented, "... readmitted from (hospital). On 6/10/10 resident had attempted to transfer herself from her w/c to her bed (and) fell ... found to have external rotation of left leg, shortening of left leg, (and) severe pain. She was transferred to (hospital) via ambulance (and) found to have an acute intertrochanter fracture of the proximal left femur... underwent a left ORIF surgery on 6/11/10. She was also found to have a UTI and began (antibiotic therapy)." On 8/25/10 at 2:45 pm, concerns regarding the resident's falls, fracture, and lack of interventions to prevent falls, were discussed with the DON and Corporate RN Consultant. The DON was asked if there was any additional documentation of care plan revisions and/or interventions put into place to prevent further falls. The DON and RN consultant stated they would review the resident's record and talk to the surveyor at a later time. On 8/26/10 at 8:30 a.m., the DON, Administrator, and RN Consultant explained that the resident's alarms were discontinued on 5/5/10 because the resident had not had a fall since November 2009. The DON stated that other than an informal inservice provided to involved staff immediately after the fall on 5/25/10, and the documented inservice on 6/8/10, no other interventions were added to the resident's CCP or implemented. The Administrator confirmed the PT evaluation was not completed, nor was the resident assessed for a UTI, as recommended by the PI Committee on 5/26/10. The DON, Administrator, and RN Consultant stated that following the resident's 6/10/10 fall, the PI Committee developed and implemented an action plan to prevent falls. The action plan dealt both with the resident's issues, as well as facility issues. Resident #5 was harmed when the facility failed to increase interventions to prevent falls after the resident fell on [DATE] and 5/26/10. Ultimately, Resident #5 fell again on 6/10/10 and sustained a fracture of the left hip. The fracture resulted in severe pain for the resident and required surgical intervention.