Every finding on record at Life Care Center of Boise

Based on observation, record review, interview, and facility policy review, the facility failed to ensure one of one resident (Resident (R)34) reviewed for self-administration of medications out of a total sample of 20 had a self-administration assessment completed before medications were left at the resident's bedside. This had the potential for the resident to not take the correct medications per order with a potential for significant medication error.Findings include: Review of the policy titled, Administration of Medications, dated 2025, revealed, . 2. The Facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. 3. To ensure safe and appropriate self-administration, facility should educate residents to ensure that a resident is able to: 3.1 State the name, dose, strength, frequency, and purpose for use of their medications. 3.2. Understand the possible medication side effects and that they should notify facility staff if they experience any such side effects. 3.3 Correctly administer, inject, or apply all prescribed medications. 3.4. Correctly store their medications in a locked compartment . 5. Facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer . 9.1 The medication storage compartments should be located in the resident's room so that another resident is not able to access the medications. 9.2. The storage compartment should be locked when not in use . Review of R34's Medical Diagnosis record, located in the electronic medical record (EMR) under the Medical Diagnosis tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (Bipolar type), gastro-esophageal reflux disease (GERD), and chronic pain. Review of R34's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/07/25 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Review of R34's current physician's Orders, located in the EMR under the Orders tab, revealed an order for Excedrin migraine oral tablet 250 milligrams (mg)-65mg, give two tablets, two times a day for chronic pain, with a start date of 08/01/24. During an observation and interview on 07/14/25 at 10:30 AM, R34's bedside table's top drawer was open. Inside the drawer was a plastic cup with several white pills. R34 said they were Excedrin and Gas-X (for gas and/or bloating) pills. He stated staff give them to him and allow him to keep them in the drawer of his bedside table. During an observation and interview on 07/16/25 at 10:30 AM, the cup of pills was still in the R34's drawer. Licensed Practical Nurse (LPN)1 confirmed there were six Excedrin and six Gas-X pills in the plastic cup in the resident's top drawer of his bedside table. R34 again said that staff gave them to him to keep in his drawer. LPN1 confirmed R34 did not have an assessment completed to ensure his safety for keeping medications at the bedside. During an interview on 07/16/25 at 2:00 PM, the Director of Nursing (DON) confirmed R34 did not have a self-administer assessment and he was not to be administering his own medications. She said it was not safe for him to do so.

Based on record review, interview, and facility policy review, the facility failed to obtain and document urinary outputs as ordered for one of three residents (Resident (R) 42) reviewed for the management of indwelling urinary catheters out of a total sample of 20. Failure to obtain and document urinary output may result in delayed identification of complications such as urinary retention, dehydration, infection, or impaired kidney function.Findings include: Review of the facility's policy titled, Indwelling Urinary (Foley) Management, last revised 06/07/23, indicated, . The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for medical indication hill have the following areas addressed; . 4. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevent and control procedures . Additional care practices related to catheterization 1. Recognizing and assessing for complications and their causes and maintaining a record of catheter-related problems; 2. Recognizing and assessing whether residents are at risk for other possible complications resulting from the continuing use of the catheter, such as obstruction resulting from catheter encrustations, urethral erosion, bladder spasms, hematuria, and leakage around the catheter. The policy did not include specific guidance on obtaining and documenting urinary output. Review of R42's admission Record (Face Sheet), located under the Profile tab of the electronic medical record (EMR), indicated that the facility initially admitted R42 on 10/21/21. R42's pertinent diagnoses included bladder-neck obstruction and obstructive and reflux uropathy. Review of R42's Care Plan, last revised on 04/03/25 and located under the Care Plan tab of the EMR, indicated that R42 had an indwelling catheter related to urinary retention and incomplete bladder emptying due to bladder-neck obstructive uropathy, as well as functional urinary incontinence. The pertinent interventions directed staff to monitor output as per facility policy (every shift), observe for and report to medical doctor signs and symptoms of urinary tract infections: pain, burning, blood-tinged urine, cloudiness, no output. Review of R42's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/09/25 and located under the MDS tab of the EMR, revealed R42 did not have cognitive impairments as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. R42 required substantial/maximal assistance with toileting and had an indwelling catheter. Review of the Physician Order, dated 10/31/21 and located under the Orders tab of the EMR, directed staff to record catheter output every shift related to obstructive and reflux uropathy. Review of the Treatment Administration Records (TARs), located under the Orders tab of the EMR and dated 12/01/24 through 06/30/25, revealed staff did not obtain and or document urinary output as follows: 12/2024: Day shift: 12/19 and 12/28; Evening Shift: 12/13/, 12/14, and 12/20/24; and Night shift: 12/14 and 12/21/24.01/2025: Day shift: 01/03, 01/18, 01/28, and 01/30; and Night shift: 01/01/25.02/2025: Day shift: 02/07 and 02/09; and Night shift: 02/10, 02/11, 02/12/, 02/13/2503/2025: Day shift: 03/11; Evening shift: 03/05; and Night shift: 03/02, 03/03, 03/05, 03/13, and 03/19/25.04/2025: Day shift: 04/04, 04/18/, and 04/26/25.05/2025: Day shift: 05/03, 05/18, 05/18, 05/24, and 05/30; Evening shift:05/25; and Night shift: 05/10, 05/15, 05/23, 05/24, and 05/30/25. Review of the nursing Progress Notes, dated 12/01/24 through 06/30/25 and located under the Progress Notes tab of the EMR, revealed no documentation of the above missing urinary output amounts. During an interview on 07/16/25 at 10:14 AM, Licensed Practical Nurse (LPN) 4 stated that the certified nurse aides (CNAs) obtain the urine output and report it to the nurse at the end of their shift. LPN4 stated the nurse documents the resident's output on the TAR. LPN4 stated if a urinary output was not documented, either the CNA did not get it and report it to the nurse or the nurse did not document it on the TAR. During an interview on 07/16/25 at 11:36 AM, CNA1 stated that the CNAs are responsible for emptying the resident's catheter bag, measuring the urinary output, and reporting it to the nurse. She stated that the CNAs report the total amount of output to the nurse verbally or on a sticky note, they do not complete a specific form to document the resident's output, and they do not enter that information into their CNA charting. During an interview on 07/16/25 at 12:34 PM, in the presence of the Director of Nursing (DON), LPN6, the Unit Coordinator, stated that the facility tracks the output on all residents with an indwelling urinary catheter per their policy. LPN6 stated the CNAs are responsible for obtaining the resident's urinary output at the end of each shift and reporting it to the nurse, who documents the output on the TAR. The DON added that their goal is to have 90% of charting completed, ideally 100%. She confirmed that the CNAs were responsible for reporting urinary outputs to the nurse, who then documents the output in the computer. She stated that the standard of nursing is that if it was not documented, it was not done.

Based on observation, record review, hospital record review, interview, review of recommendations from the Mayo Clinic website for Huntington's disease (https://www.mayoclinic.org/diseases-conditions/huntingtons-disease/diagnosis-treatment), review of the recommendations from the Huntington's Disease Society of America website (https://www.hdsa.org), and facility policy review, the facility failed to ensure therapy orders and recommendations were completed for two of two residents (Residents (R)17 and R7) reviewed for rehabilitation out of a total sample of 20. This had the potential for both residents to decline in their mobility and range of motion (ROM).Findings include: Review of the Mayo Clinic recommendations revealed Huntington's Disease (HD) causes nerve cells in the brain to decay over time. The disease affects a person's movements, thinking ability, and mental health. The movement disorders may cause movements that cannot be controlled causing muscle rigidity, muscle contracture, and trouble with speech or swallowing. Physical Therapy can provide safe exercises that enhance strength, flexibility, balance, and coordination. These exercises can help maintain mobility as long as possible and may reduce the risk of falls. Occupational Therapy can provide eating and drinking utensils for people with limited fine motor skills. Review of the Huntington's Disease Society of America recommendations revealed there is currently no cure or treatment that can slow or reverse the progression of the disease. However, there are many treatments and interventions that can help to manage HD symptoms. Physical and Occupational therapists can work with patients to develop strength and to move safely. A person with HD may develop muscle and joint contractures (abnormal shortening of muscles that restrict joint movement). To prevent contractures, active range of motion (AROM) exercises should be performed daily. Review of the facility policy titled, Evaluation and Plan of Care, revised 03/2024, revealed, Procedure 1. Evaluations are completed in the Rehab EMR [electronic medical record] software . 3. Evaluations may be very comprehensive or may be problem-specific, depending on the resident's condition and/or the physician's orders. 4. Evaluations include but not limited to: a. The patient's prior level of function, b. The patient's current level of function c. An accurate description of the patient's functional limitations d. Standardized tests and objective about the resident, such as strength, range of motion, pain level, functional performance, communication status, swallowing ability, etc. e. Medical and treatment diagnosis f. Long term treatment goals . 1. Review of R17's Profile record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of Huntington's Disease and a history of falling. Review of R17's Hospital Discharge Summary, located in the EMR under the Documents tab and dated 02/07/25, revealed skilled nursing and rehab were required on a continuing basis as the resident was receiving skilled nursing care and Physical Therapy (PT) and Occupational Therapy (OT) services while at the hospital. Orders were noted for PT/OT to evaluate and treat. Review of R17's NRSG [Nursing] Admission/readmission Collection Tool, located in the EMR under the Assessment tab and dated 02/07/25, revealed PT and OT were marked under the admission details. Under the Admission/readmission Progress Note in the collection tool also revealed the resident was to be seen by PT/OT for an evaluation. Review of R17's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/13/25 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. There were no behaviors or rejection of care noted. R17 was noted with limited ROM bilaterally to both upper and lower extremities. Review of R17's Progress Note, located in the EMR under the Progress Note tab, dated 02/11/25, and written by the physician, revealed under the assessment plan an order for PT/OT to evaluate and treat. Review of R17's Care Plan, located in the EMR under the Care Plan tab and with a date initiated of 02/19/25, revealed the resident had an Activities of Daily Living (ADLs) self -care deficit related to her diagnosis of Huntington's Disease. The goal indicated that the resident would minimize decline in self-care and mobility through the next review date. Interventions included PT/OT. Review of R17's quarterly MDS, with an ARD of 05/16/25 and located in the EMR under the MDS tab, revealed a BIMS score of six out of 15, indicating severe cognitive impairment. She had no noted behaviors or rejection of care. She was noted to have limited ROM bilaterally to both upper and lower extremities. Review of R17's Care Plan, located in the EMR under the Care Plan tab and revised on 05/23/25, revealed the resident had an alteration in neurological status related to Huntington's Disease. The goal indicated the resident would show improvement with mobility by the review date. Interventions included Physical Therapy: to improve balance, coordination, and mobility; Occupational Therapy: to help with daily activities and self-care; and Speech Therapy: To address speech and swallowing problems. Review of R17's Progress Note, located in the EMR under the Progress Note tab, dated 06/24/25, and written by the physician, revealed under the assessment and plan an order for PT/OT to evaluate and treat. Review of R17's EMR revealed no evidence that the resident received a PT/OT evaluation or that she had received any therapy or restorative services since her admission over five months ago. During an observation on 07/14/25 at 12:05 PM, R17 was in the dining room being assisted with her lunch meal. She was observed to be able to drink by herself with her cup that had handles on both sides. During an interview on 07/15/25 at 12:45 PM, the Director of Rehabilitation (DOR) confirmed that R17 had not had a PT or OT evaluation, nor was she receiving any therapy or restorative services. She indicated she did not complete a PT evaluation because the resident was on straight Medicaid and she would not be paid for it. She said she did a brief screening on the resident after she admitted ; however, she did not document any findings in the resident's EMR because she would not be paid for it. She further said the resident did not have any contractures so a PT/OT evaluation was not necessary. The DOR said she can do some formal PT evaluations on Medicaid residents if the Administrator approves them, even though they are not reimbursed for them. During an observation and interview on 07/15/25 at 3:00 PM, R17 was able to answer simple questions appropriately. She indicated she enjoyed bingo with other residents and she just had a haircut and really liked it. She did not respond when asked if she had ever received any therapy services at the facility. During an interview on 07/17/25 at 9:00 AM, the Administrator revealed the facility provided therapy services for residents whose payor source was Medicaid; however, the Administrator confirmed R17 had not received any PT or OT services since being admitted over five months ago. The Administrator confirmed there was no way to show if the resident had a decline in her mobility per her Care Plan goals. The Administrator indicated he was having the DOR provide a statement regarding R17 in an email. Review of an email provided from the Administrator, dated 07/17/25, revealed the DOR had sent an email of a summary of her assessment of R17 to the Administrator. The email indicated that the DOR assessed R17 upon her admission to the facility on [DATE] (however, the resident was not admitted to the facility until 02/07/25). The email indicated she had full ROM on all extremities with a marked decrease in control of her extremities. There was nothing in the email of the assessment that could be measured to ensure the resident's goals were met, or that any therapy services were recommended. 2. Review of R7s' admission Record, located in the EMR under the admission Record tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of stroke with hemiparesis (muscle weakness/partial paralysis) affecting left non-dominant side and contracture of muscle to the lower legs. Review of R7's Hospital Record, located in the EMR under the Documents tab and dated 06/27/25, revealed orders for PT/OT to evaluate for safety, balance, and strength. Review of R7's NRSG [Nursing] Admission/readmission Collection Tool, located in the EMR under the Assessment tab and dated 06/27/25, revealed PT and OT were marked under the admission details. Under the Admission/readmission Progress Note in the collection tool, it was revealed the resident was to have PT/OT for strengthening. Review of R7's admission MDS, with an ARD of 07/03/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 12 out of 15, indicating moderate impaired cognition. R7 was noted with limited ROM on one side of her upper extremity and both lower extremities. Review of R7's Care Plan, located in the EMR under the Care Plan tab and with an initiated dated of 06/27/25 and with a revision date of 07/09/25, revealed the resident had an ADL self-care and mobility deficit related to hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left, non-dominant side, and contractures of lower leg muscles. The goal indicated the resident would maintain current level of function in self-care and mobility through the review date. Interventions included PT/OT evaluation and treatment per orders. Review of the Progress Note, located in the EMR under the Progress Note tab and dated 06/30/25, revealed the facility's Interdisciplinary team indicated the resident was working with PT and the goal was for her to maintain self-care and mobility through the review date. Review of the Progress Note, located in the EMR under the Progress Note tab, dated 07/01/25, and written by the physician, revealed an order for PT/OT to evaluate and treat the resident. Review of the Restorative Nursing Communication Tool, dated 07/01/25 and provided and completed by the DOR, revealed the resident had weakness to her upper extremities and stiffness in her lower extremities. The goal was to maximize strength and ROM. The resident was to receive restorative nursing six to seven days a week for 30 minutes per day of active ROM to the upper extremities and passive ROM to her lower extremities. Review of the Restorative Nursing Program Weekly/Monthly Summary Form, provided by the facility, revealed the resident received active and passive ROM to upper and lower extremities. The weekly notes for 07/07/25 and 07/14/25 did not have any details of what specific restorative nursing was provided. During an interview on 07/15/25 at 3:30 PM, R7 revealed she did not remember having a PT or OT evaluation since she had been in the facility. She did confirm that aides came in and worked with her occasionally. During an interview on 07/16/25 at 11:50 AM, the DOR revealed R7 was the same as R17 as her payor source was Medicaid. She confirmed she did not do a PT evaluation due to not being paid for it. She revealed she did an assessment screen and recommended Restorative Nursing. She further confirmed there was no way to measure the resident's progress to ensure her goals were met per her Care Plan. During an interview with the Restorative Nursing Assistant (RNA) on 07/16/25 at 12:30 PM, the RNA confirmed she did provide restorative nursing to R7, however there was no documentation of what each visit entailed. During an interview on 07/16/25 at 9:00 AM, the Regional Director of Clinical Services (RDCS) revealed the facility did treat residents whose payor source is Medicaid for therapy services. The RDCS stated if an order is received to evaluate and treat for PT/OT, it should be done and documented.

Based on record review and staff interview, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 1 of 6 residents (Resident #4) whose records were reviewed. This deficient practice resulted in incomplete documentation of the course of stay for Resident #4 and created the potential for harm should inappropriate care and/or treatments were provided to the resident. Findings include: The facility's Pronouncement of Death policy, revised [DATE], stated if a physician is not in the facility at the time of resident's death, the staff were directed to: -Observe and record the change and/or cessation of the resident's vital signs, record the time the vital signs ceased, and report it immediately to the attending physician. -Document the following: - the time all the vital signs ceased - time the physician was called - time the physician responded with the pronouncement of death This policy was not followed: Resident #4 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note, dated [DATE] at 11:02 PM, documented Resident #4 woke up at 10:15 PM as nursing cares were being provided to change his wet incontinent brief. The progress note documented LPN #1 attempted to administer Resident #4's bedtime medications which were held previously due to sedation. LPN #1 was unable to administer Resident #4's medication as he was unable to open his mouth, and unable to focus on taking the medications. The note documented the LPN #1 called and left a message for the hospice agency to give them an update on Resident #4 A nurse's progress note, dated [DATE] at 11:33 PM, documented the hospice nurse returned the call and was updated about Resident #4's inability to accept or swallow his oral medications. LPN #1 requested liquid medications for Resident #4. The note documented the hospice nurse agreed and was working on getting the medications ordered, filled, and delivered to the facility from the hospice pharmacy. A nurse's progress note, dated [DATE] at 3:05 AM, documented the hospice nurse arrived at the facility around 1:00 AM. The note documented Resident #4's expiration (death) was confirmed. The hospice nurse attempted to notify Resident #4's family and left a message. Cremation services were contacted and arrived at 2:30 AM to pick up Resident #4's body. The face sheet and mortuary receipt were completed. Resident #4's record did not include documentation the physician was notified of Resident #4's change of condition, time all vital signs ceased, and Resident #4's time of death. On [DATE] at 4:45 PM, LPN #1 stated during a telephone interview, she noticed Resident #4's breathing pattern changed on [DATE] around 10:00 PM, and notified the hospice provider as soon as he could. LPN #1 stated hechecked Resident #4's pulse and oxygen saturation (a measure of oxygenation in the blood) and it was below 90%, but he was not sure if he documented it. LPN #1 stated Resident #4 did not ask to go to the hospital but aske him and another RN not to leave him. LPN #1 stated he and another RN stayed with Resident #4 and rubbed his back until he passed away. On [DATE] at 11:55 AM, the DON stated when LPN #1 notified the hospice nurse, the hospice nurse should have notified the hospice physician about Resident #4's change of condition. The DON said she was notified of Resident #4's death on [DATE] at 12:30 AM. The DON said she would expect the nurses to document Resident #4's change of condition and who was notified. The DON said nursing documentation for a change of condition required documenting when the changes started, the resident's vital signs, what the resident was doing, intervention provided and what medications were given. The DON reviewed Resident #4's record and stated it did not have the necessary documentation for a resident's change of condition.

Based on policy review, record review, Incidents and Accidents (I&A) report review, and staff interview, it was determined the facility failed to ensure residents were free from abuse by other residents. This was true for 4 of 8 residents (#25, #30, #47 and #158) reviewed for abuse. This failure resulted in harm to Resident #47 when staff failed to supervise Resident #2 and he touched her breasts with his hands. Deficient practice also placed Residents #25, #30, #47 and #158, and all other residents in the facility at risk of psychosocial harm and/or physical harm. Findings include: The facility's policy and procedure, Protection of Residents: Reducing the Threat of Abuse and Neglect, revised 8/10/21, stated the facility practiced a hardline, zero-zero tolerance approach to resident abuse. The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined the following: *Physical Abuse: including but not limited to hitting, slapping, punching, biting, and kicking. *Sexual Abuse: non-consensual contact of any type with a resident. Including but not limited to sexual harassment, sexual coercion, or sexual assault. This policy was not followed. 1. Sexual abuse of Resident #47 by Resident #2: *Resident #47 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 6/2/21, documented Resident #47 was severely cognitively impaired. *Resident #2 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on 6/10/21, documented Resident #2 had a behavior problem of wandering related to dementia and the staff were directed to maintain line of sight supervision of him while he was up and out of bed. An I&A report, dated 8/4/21, documented Resident #2 entered the Activity Room. The Activity Director gave Resident #2 some cookies and he started to watch television. The Activity Director turned her head away from Resident #2, to take care of a couple of things prior to engaging Resident #2. Upon turning around, the Activity Director found Resident #2 had moved toward Resident #47 and touched her breasts with his hands. The Activity Director immediately intervened and separated the two residents. The facility's investigation of the 8/4/21 incident documented abuse was substantiated. On 12/2/21 at 3:11 PM, the Executive Director stated the direct line of sight to Resident #2 was not followed when the Activity Director turned away from Resident #2 for a brief period. The Executive Director said the Activity Director was provided with education regarding line of sight monitoring. The facility failed to ensure Resident #47 was free from sexual abuse. 2. Physical abuse by Resident #31 directed at Resident #25 and Resident #158: *Resident #31 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 7/12/21, documented Resident #31 was moderately cognitively impaired and had no physical or verbal behaviors symptoms such as hitting, kicking, pushing, grabbing, threatening, cursing or screaming towards others. *Resident #25 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment, dated 8/5/21, documented Resident #25 was cognitively intact. *Resident #158 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 8/10/21, documented Resident #158 was cognitively intact. An I&A report, dated 7/21/21 at 8:00 AM, documented Resident #31 punched Resident #158 on her shoulder in the dining room and was going to punch Resident #158 again when a CNA called his name. The Speech Therapist helped the CNA separate Resident #31 from Resident #158. After they were separated, Resident #31 was observed going after another resident. The CNA called the nurse and told the nurse what happened in the dining room. The nurse took Resident #31 and brought him back to his room. The nurse informed Resident #31 he could not go back to the dining room because he was trying to hit other people. The nurse instructed the staff members they needed to keep a close eye on Resident #31. An I&A report, dated 7/21/21 at 10:50 AM, documented Resident #31 was in the Activity Room participating in activities, when he approached Resident #25 and punched her in the nose. The I&A report documented Resident #25 thought she may have some bruising, but none had appeared at that time. Resident #25 was assessed and no injuries were noted. Resident #31 was subsequently transferred to the emergency room for evaluation related to his change in behavior The facility's investigations of the 7/21/21 incidents documented the incidents occurred and substantiated Resident #31 physically abused Resident #158 and Resident #25. On 12/3/21 at 8:11 AM, the Activity Director said she remembered the incident in the Activity Room when Resident #31 punched Resident #25's face. When asked if she was asked to keep an eye on Resident #31 while he was in the Activity Room or if she was aware of the incident in the dining room involving Resident #31 and the other residents, the Activity Director said she was not aware of the incident in the dining room and was not told to keep an eye on Resident #31 while he was in the Activity Room. On 12/3/21 at 1:32 PM, the Executive Director said Resident #31 had no history of physically hitting other residents in the facility. The Executive Director said they later found out Resident #31 became agitated when he was told by his family representative he would likely not be returning home and the facility was a great place for him. The Executive Director also stated the nurse was not told Resident #31 punched Resident #158 in the dining room, and it was a miscommunication between the staff. The Executive Director said staff were educated about proper reporting of abuse incidents. 3. Physical abuse by Resident #2 directed at Resident #30: *Resident #30 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 7/7/21, documented Resident #30 was cognitively intact. *Resident #2 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 6/2/21, documented Resident #2 was severely cognitively impaired. An I&A report, dated 6/10/21, documented Resident #2 entered Resident #30's room uninvited. Resident #30 yelled at Resident #2 to leave her room. Resident #2 reached for Resident #30's overbed table and Resident #30 grabbed the table from him. Resident #2 then grabbed Resident #30's arm creating a scratch on her arm. Staff were able to intervene and redirect Resident #2. The facility's investigation of the 6/10/21 incident documented the incident did occur and Resident #30's physical abuse by Resident #2 was substantiated. On 12/2/21 at 3:11 PM, the Executive Director stated Resident #2 had no history of wandering prior to above incident. The Executive Director stated Resident #2's care plan was updated and directed staff to maintain line of sight supervision while he was up and out of bed.

Based on policy review, record review, I&A report review, and staff interview, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 3 residents (Resident #23) reviewed for falls. This resulted in harm to Resident #23 when she had multiple falls and fractured her wrist and shoulder. Findings include: The facility's Fall Management policy, dated 6/4/20, documented the facility ensured the residents' environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Adequate supervision was defined as an intervention and means of mitigating the risk of accident. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a surgical procedure to repair a right femur (thigh bone) fracture, Lennox-Gastaut syndrome (a type of [CONDITION(S)] with multiple different types of seizures, intellectual development is usually delayed and often worsens over time. Behavioral problems including [CONDITION(S)], agitation, aggression and autism are common) intractable (hard to control), intellectual disabilities, difficulty walking, and repeated falls. A Fall Risk Evaluation, dated 6/24/21, documented Resident #23 was at high risk for falls. An Admission MDS assessment, dated 6/30/21, documented Resident #23 had moderate cognitive impairment, she required extensive assistance of two persons with bed mobility, transfers, dressings and toileting, she was unsteady and only able to stabilize with human assistance when moving from seated to standing and when transferring from surface to surface, and she had fallen in the previous one to six months prior to admission to the facility. Resident #23's physician's orders included the following: * [CONDITION(S)] precaution. Keep vagus nerve stimulator (VNS - implanted to a patient and the patient will have a magnet that can be used at the time of the [CONDITION(S)]), magnet at bedside and swipe the magnet past VNS if event occurs, ordered 6/24/21. * [MEDICATION(S)] (anti-[CONDITION(S)]) 10 mg (milligrams) tablet, two times a day for [CONDITION(S)], ordered 10/31/21. * [MEDICATION(S)] (anti-convulsant) XR (extended release) 600 mg at bedtime for symptomatic [CONDITION(S)] and epileptic syndrome, ordered 10/14/21. * [MEDICATION(S)]-XR 600 mg in the morning for symptomatic [CONDITION(S)] and epileptic syndrome, ordered 10/22/21. Resident #23's care plan documented she had diffuse psycho motor delays (slowing of movement) and mild to moderate [CONDITION(S)], [CONDITION(S)] which resulted in multiple fractures and she was at risk for falls or had actual falls. Interventions included the following: * Initiated on 6/24/21: Assist Resident #23 with ADLs as needed, place her call light within reach, and complete fall risk assessment. * Initiated on 6/30/21: Educate Resident #23 that she is not strong enough to transfer self and that she needs to ask for assistance. * Initiated on 7/1/21: Anticipate Resident #23's needs and educate her family and caregivers about safety reminders and what to do if a fall occurs. Resident #23's I&A reports, dated 7/18/21 to 9/29/21, documented she had a total of 11 falls in 3 months, as follows: An I&A report, dated 7/18/21 at 9:10 PM, documented Resident #23 had an unwitnessed fall. Resident #23 reported she went to the bathroom using her wheelchair and did not lock the brakes of her wheelchair. Resident #23 picked herself up and reported the event to the staff. Resident #23's care plan was updated on 7/19/21, and directed staff to place anti-roll back bars on her wheelchair for safety. An I&A report, dated 7/23/21 at 11:00 AM, documented a CNA reported Resident #23 was noted on the floor in the hallway having a [CONDITION(S)]. Resident #23 was assisted to bed after her [CONDITION(S)]. The physician was notified and gave an order to obtain [MEDICATION(S)] level stat (immediately). A Physician's progress note, dated 7/23/21 at 11:24 AM, documented Resident #23 had an unwitnessed fall secondary to [CONDITION(S)]. The progress note documented the facility staff reported Resident #23 generally was having seizures nightly. The physician gave an order to obtain Resident #23's [MEDICATION(S)] level. The physician also gave an order to increase Resident #23's [MEDICATION(S)] to 800 mg (milligrams) at bedtime and 600 mg in the morning. The physician documented based on Resident #23's records she had a history of frequent seizures especially at night. An I&A report, dated 7/29/21 at 1:30 PM, documented Resident #23 had an unwitnessed fall. She was found sitting on the floor between her bed and the window. Resident #23 reported she was getting up from her wheelchair to get her walker which was located across the room, the walker slid out from under her hands and she fell and bumped against the footboard. The I&A report documented Resident #23 did not use her call light to call for assistance. Resident #23's care plan was updated on 7/29/21, and directed staff to move her to a room closer to the nurse's station so that the staff could monitor her for safety, provide her with activities that would minimize the potential for falls, and provide diversion and distraction by encouraging her to attend activities and dine with other residents. An I&A report, dated 8/5/21 at 6:57 AM, documented Resident #23 had an unwitnessed fall. The nurse heard Resident #23 moaning and she was found on the floor beside her bed having a [CONDITION(S)]. Facility staff used the VNS magnet to stop Resident #23's [CONDITION(S)] and she was assisted to her bed. Resident #23 denied any pain from the fall. Resident #23's care plan was updated on 8/9/21, and directed staff to provide her with a lipped mattress to help her define the bed borders for safety. An I&A report, dated 8/14/21 at 3:00 PM, documented Resident #23 had an unwitnessed fall. A loud noise was heard from Resident #23's room and staff members found her on the floor beside her bed. The I&A report documented the bedside mat caused Resident #23 to trip and she fell on the floor. Resident #23's care plan was updated on 8/14/21, and directed staff to remove her fall mats during waking hours to avoid tripping hazard. An I&A report, dated 8/28/21 at 7:30 AM, documented Resident #23 had an unwitnessed fall. Resident #23 called out for help and staff found her on the floor lying on her back between the room's two beds. Resident #23 stated she was going to the bathroom. The I&A report documented the light in Resident #23's room was off when she had the fall. Resident #23's care plan was updated on 8/28/21, and directed staff to keep her night light on while sleeping in bed for safety. An Unusual Occurrence Report, dated 8/30/21 at 5:30 PM, documented Resident #23 was noted to have a bruise to her left arm the following day after her fall on 8/28/21. Resident #23 complained of pain which was effectively treated with [MEDICATION(S)] (narcotic pain medication). An order to X-ray Resident #23's left wrist was received, and revealed she had fracture on her left wrist. The Unusual Occurrence Report documented Resident #23 fractured her left wrist from the fall she had on 8/28/21. The root cause of the fall was related to her impulsivity and not using her call light, and when she attempted to be independent she might not be able to see clearly in a darker room. On 8/30/21 at 5:10 PM, a handwritten note documented an order was received to splint Resident #23's left wrist and refer her to an orthopedic physician. Subsequently, on 10/19/21, Resident #23 was seen by a physician in a hand center clinic and it was recommended to discontinue using the splint on her left wrist and she could use the wrist and thumb brace for comfort. An I&A report, dated 9/22/21 at 8:40 AM, documented Resident #23 had an unwitnessed fall. She was heard screaming from her room and when staff entered her room, she was on her knees on the floor between the window wall and her bed. Resident #23 was not wearing her slipper socks. Resident #23's care plan was updated on 9/22/21, and staff were directed place non-skid strips on the floor on the window side of her bed to help with traction and safety. On 9/24/21, staff were directed place a sign on her walker to remind her to take her walker with her when walking. An Unusual Occurrence report, dated 9/23/21, documented that at approximately 4:00 AM a CNA heard a commotion coming from Resident #23's room and checked on her. Resident #23 was found in her bathroom wearing five briefs. The one brief that was on the bottom was wet. The CNA redirected Resident #23 and removed the briefs and changed her. Resident #23 was reeducated to wear only one brief and assisted her back to bed. The CNA removed the remaining briefs from Resident #23's room. At approximately 4:50 AM, the CNA heard a commotion from Resident #23's room. When the CNA entered the room, Resident #23 rummaging through her roommate's drawers looking for more incontinence briefs. As the CNA walked in, Resident #23 repositioned herself by putting her hand on a can of nuts located on her over-bed table. The table rolled causing Resident #23 to lose her balance and fall on the floor onto her back and right shoulder. Resident #23 was assessed for pain and injury, and was assisted back to bed as she was not complaining of any pain. When the oncoming nurse checked on Resident #23, she complained of pain in her left shoulder. The nurse noted that Resident #23's left shoulder appeared to be out of socket. An order was received to perform an X-ray on Resident #23's left shoulder. The X-ray result, dated 9/23/21, showed a fracture on Resident #23's left shoulder involving the neck of the humerus (bone of the upper arm). The Unusual Occurrence report documented the root cause analysis of Resident #23's injury was her disabilities which led to her having an emotional outburst leading to poor choices. Resident #23 would often impulsively get up, being fiercely independent, lose her balance and fall. Resident #23 resisted redirection and often became angry when provided with 1:1 assistance. The Unusual Occurrence report also documented Resident #23 was very demanding for her independence, demonstrated behaviors that frequently compromised her safety, and when staff intervened her behavior frequently escalated. On 10/2/21, Resident #23 had a repeat X-ray of her left shoulder to compare with 9/23/21 result. The repeat X-ray result documented Interval displacement of the humeral neck fracture without healing demonstrated. An I&A report, dated 9/26/21 at 9:15 PM, documented Resident #23 had an unwitnessed fall. A loud bang was heard from Resident #23's room and when staff entered her room, she was found sitting on the floor by the privacy curtain. Resident #23's bedside table tipped over and there was water on the floor. Resident #23 stated she turned on her call light by mistake and she was trying to get up to turn it off. Resident #23's care plan was updated on 9/27/21, and staff were directed to move her roommate to another room, encourage her to keep her privacy curtain open for better line of sight, and to place a silent alarm to her bed and wheelchair to help notify the staff when she was getting up. Staff would carry the pagers with them. Staff were also educated on de-escalation of anger and emotional agitation. An I&A report, dated 9/29/21 at 3:00 PM, documented Resident #23 had a witnessed fall in her room. Resident #23 fell before the staff could reach her. Interdisciplinary Team reviewed the falls and decided to place a 1:1 (one to one) staff within line of sight supervision to manage Resident #23's safety. Resident #23's care plan was updated on 9/30/21, and directed staff to provide 1:1 line of sight supervision to her during waking hours and periods of agitation. On 11/16/21, a physician's progress note for Resident #23's follow-up check-up for her left shoulder fracture, documented her left shoulder's active range of motion was severely restricted and there was tenderness on palpation on her left shoulder. The physician's progress note also documented Resident #23 was not a good surgical candidate at this time. Resident #23 had to continue wearing her left shoulder immobilizer, as needed, for comfort and continue her physical therapy. Resident #23's record did not include documentation of additional falls after the initiation of 1:1 supervision. On 12/3/21 at 11:20 AM, the DON stated Resident #23 had multiple interventions to prevent falls in her care plan, and reviewed what those interventions were. The DON stated the 1:1 staff supervision for Resident #23 was not initiated earlier, such as after she fractured her left wrist from the fall on 8/28/21, as the interdisciplinary team thought it would make her behaviors worse. The facility failed to ensure Resident #23 received the level of supervision necessary to prevent falls, which resulted in a fracture of her left wrist from a fall on 8/28/21, and a fracture of her left shoulder from a fall on 9/23/21.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents' advance directive information was periodically reviewed with the residents and/or their representatives and was accurate. This was true for 5 of 14 residents (#2, #10, #12, #20 and #27) whose records were reviewed for advanced directives. This failed practice created the potential for harm if the residents' documented wishes were not accurate and up-to-date regarding their advance care planning. Findings include: The Centers for Medicare and Medicaid Services 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . A POLST [POST] [MEDICATION(S)] form is not an advance directive. The facility's Advance Directive policy, updated 10/20/21, documented the following: *The Admissions Director or designee would interview the resident and/or family upon admission to determine the need and knowledge relative to advance directives and advanced care planning, including the resident's goals of care. *If the resident had an advance directive, the facility requested a copy and kept it in the resident's medical chart accessible to the physician and facility staff. *If the resident did not have an advance directive, the facility provided an opportunity to formulate an advance directive with the assistance of the medical director, executive director, director of nursing, director of social services, chaplain or other personnel as appropriate. *The facility reviewed the information with each admission, quarterly, annually, and during significant changes in condition. The social services director or designee should document the conversation in the medical record. *The POLST form was not an advance directive. This policy was not followed. a. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS assessment, dated 11/23/21, documented Resident #2 had severe cognitive impairment. Resident #2's record included a POST, which documented his code status of DNR (do not resuscitate). Resident #2's record did not include an advance directive or documentation one was discussed with him or future care decisions were discussed with his representative. b. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 9/17/21, documented Resident #10 was cognitively intact. Resident #10's record contained a DPOA (durable power of attorney) related to managing her finances and property and a POST which documented her code status of DNR. Resident #10's record did not include a copy of a DPOA for healthcare or living will, or documentation advance care planning had been discussed with her. c. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's Significant Change in Status MDS assessment, dated 9/8/21, documented he was cognitively intact. Resident #12's care plan, updated 7/9/19, documented he had Advance Directives, DNR, living will, and DPOA in his record. Resident #12's record included a DPOA related to managing his finances and property and a POST which documented his code status of DNR. Resident #12's record did not include a copy of a DPOA for healthcare or living will, or documentation advance care planning had been discussed with him. d. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly MDS assessment, dated 9/21/21, documented Resident #20 had moderate cognitive impairment. Resident #20's record included a POST which documented her code status of DNR. Resident #20's record did not include an advance directive or documentation one had been discussed with her. e. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27's Significant Change in Status MDS assessment, dated 10/1/21, documented she was cognitively intact. Resident #27's care plan, dated 2/4/20, updated 7/3/21, documented she was full code per her signed POST. Resident #27's record included a POST which documented her status as full code. There was no advance directive in her medical record or documentation one had been discussed with her. On 12/2/21 at 2:30 PM, the DON said the advance directive was discussed with the residents and/or their representatives on admission and during their quarterly care conferences. She stated the facility offered to assist with creating an advance directive if the resident did not have one. The DON stated the facility considered the resident's POST form to be the advance directive. The DON reviewed the DPOA documents for Residents #10 and #12 and said they were for financial services. The DON said Resident #2, #20 and #27 had a POST form. Care conference notes were reviewed with the DON and there was no documentation the advance directives were discussed.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medication. This was true for 1 of 2 residents (#19) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if Resident #19 self-administered inhaler medication inappropriately. Findings include: The facility's Self Administration of Medications policy, revised 5/10/10, stated the Interdisciplinary Team (IDT) would assess each resident and determine whether self-administration of medications was safe and clinically appropriate, based on the resident's functionality and health condition. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 3/30/21, documented Resident #19 was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/2/21 at 8:40 AM, the [MEDICATION(S)] inhaler was observed on top of Resident #19's overbed table. Resident #19 stated he used the inhaler every six hours. A Self-Administration of Medications assessment was not found in Resident #19's record. On 12/2/21 at 9:15 AM, the DON reviewed Resident #19's record and said Resident #19 did not have an assessment to self-administer his inhaler medication and he should have one.

Based on policy review, record review, and staff interview, it was determined the facility failed to immediately notify the physician and the resident's representative when there was a significant change in a resident's condition. This was true for 1 of 2 residents (Resident #159) reviewed for notification of changes in condition. This deficient practice placed Resident #159 at risk of harm due to lack of physician involvement and lack of advocacy and support from her representative when she was unable to make decisions for herself due to decreased health status and level of consciousness. Findings include: The facility's policy entitled Changes in Resident's Condition or Status, reviewed 4/2/21, documented the facility would notify the resident, his/her primary care provider and resident/resident representative of changes in the resident's condition or status. Changes included deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. This policy was not followed. Resident #159 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #159's annual MDS assessment, dated 5/27/21, documented she was moderately cognitively impaired. A health status note, dated 6/20/21 at 6:52 AM, stated: All evening and all night [Resident #159] has been very confused. Her speech is slurred. All she wants to do is sleep [sic] Her lungs are wet. Her lungs have always been wet but before she was always able to cough to clear them. Now she is so out of it that she no longer has a strong cough to clear her lungs. She has this whitish phlegm that is constantly stuck on the roof of her mouth. A nursing alert note, dated 6/20/21 at 2:34 PM, documented Resident #159 was having difficulty breathing at 12:55 PM. Staff attempted to suction Resident #159 and determined she had no vital signs and a weak pulse. Staff called Emergency Medical Services (EMS), the on-call nursing supervisor, the DON, the Executive Director, and the Nurse Practitioner on call. Staff began to use a defibrillator but stopped when told Resident #159's code status was Do Not Resuscitate. Resident #159 was pronounced dead at 1:25 PM. Resident #159's son and Nurse Practitioner on-call were notified of her death, along with the DON and Nursing Supervisor. On 12/3/21 at 10:05 AM, the DON stated the on-call physician and Resident #159's representative should have been notified when Resident #159 began to show symptoms of decline in her health. Resident #159's health and cognitive status began to decline the evening of 6/19/21. Resident #159's physician and representative were not notified when her health and cognitive status began to decline. Resident #159's representative and physician were notified of her change in status after she passed away.

Based on policy review, record review, review of grievances, and resident and staff interview, it was determined the facility failed to ensure grievances were responded to and investigated, and prompt corrective action was taken to resolve grievances. This was true for 1 of 2 residents (Resident #29) reviewed for grievances. This failure created the potential for psychosocial harm if residents' grievances were not acted upon. Findings include: The facility's Grievance policy, dated 8/7/21, documented the social services staff and/or Executive Director were responsible to maintain records of all grievances received, including a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the findings or conclusions including whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken, and the date the written decision was issued. They were to respond to an individual who expressed a concern and contact all parties with the outcome of the investigation. This policy was not followed. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29's annual MDS assessment, dated 10/5/21, documented he was cognitively intact. On 11/30/21 at 3:25 PM, Resident #29 stated he filled out two complaint cards when he felt a staff member was rude to him. He attempted to give the cards to the Executive Director in the hallway. He stated the Executive Director laughed at him and defended the staff member. He stated the Executive Director did not listen to him. The facility's grievance file from 6/1/2021 through 12/1/2021 was reviewed. There was no grievance for Resident #29 regarding his complaints. On 12/3/21 at 9:50 AM, the Executive Director said he spoke with Resident #29 regarding the incident. The Executive Director stated he told Resident #29 he made the staff member cry and the Executive Director told Resident #29 he should not speak to others that way. The Executive Director stated he took the grievance cards from Resident #29, and he did not know where they went. The cards were not entered in the facility's grievance log and he did not follow up on the grievances.

Based on policy review, record review, and resident and staff interview, it was determined the facility failed to ensure an investigation was conducted after an allegation of neglect was reported to a department director. This was true for 1 of 8 residents (#156) reviewed for abuse and neglect. This failure had the potential to place residents at increased risk for physical and/or psychosocial harm. Findings include: The facility's Protection of Residents: Reducing the Threat of Abuse & Neglect policy, undated, documented the facility would promptly and thoroughly investigate reports of abuse, neglect, mistreatment, exploitation and misappropriation of property. This policy was not followed. Resident #156 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #156's annual MDS assessment, dated 11/5/21, documented she was cognitively intact. Resident #156 was continent of urine and bowel, required physical assistance of one person for toileting, and extensive assistance from one person for personal hygiene. On 11/30/21 at 11:40 AM, Resident #156 stated about a month ago she was left on the toilet for over an hour. Resident #156 stated she reported the incident to the Activities Director (AD). On 11/30/21 at 12:00 PM, the AD stated she recalled Resident #156's complaint about being left on the toilet for over an hour. The AD stated she immediately reported the incident verbally to RN #1. On 11/30/21 at 1:10 PM, RN #1 stated she did not recall receiving a complaint verbally or in writing from the AD about Resident #156 being left on the toilet for an hour. On 11/30/21 at 1:45 PM, the DON stated she expected a blue card (a complaint card system utilized by the facility) to be filled out and discussed at the Interdisciplinary Team meeting for further investigation when a complaint or grievance was received. The DON verified a blue card was not filled out for this allegation. The facility failed to ensure an investigation was conducted after an allegation of neglect was reported.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for nursing assessment and monitoring of residents when their condition changed. This was true for 1 of 14 residents (Resident #159) reviewed for nursing care. This resulted in lack of care and services of Resident #159 when her cognitive status declined and she was unable to clear her lungs impeding her ability to breathe. Findings include: Resident #159 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #159's annual MDS assessment, dated 5/27/21, documented she was moderately cognitively impaired. A health status note, dated 6/20/21 at 6:52 AM, documented: All evening and all night [Resident #159] has been very confused. Her speech is slurred. All she wants to do is sleep [sic] Her lungs are wet. Her lungs have always been wet but before she was always able to cough to clear them. Now she is so out of it that she no longer has a strong cough to clear her lungs. She has this whitish phlegm that is constantly stuck on the roof of her mouth. The term wet lung, is a lay term for [CONDITION(S)] (ARDS), which is when the lungs fill up with fluid, instead of air. A nursing alert note, dated 6/20/21 at 2:34 PM, documented Resident #159 was having difficulty breathing at 12:55 PM. Staff attempted to suction Resident #159 and determined she had no vital signs and weak pulse. Staff called Emergency Medical Services (EMS), the on-call nursing supervisor, the DON, the Administrator, and the Nurse Practitioner on call. Staff began to use a defibrillator, but EMS staff told them to stop because Resident #159 had a code status of DNR. Resident #159 was pronounced dead at 1:25 PM on 6/20/21. Resident #159's son, Nurse Practitioner on-call, the DON, and Nursing Supervisor, were notified of her death. Resident #159's record did not include other nursing notes regarding Resident #159's condition. There was no documentation frequent checks, increased monitoring of vital signs, or other increased nursing oversight for Resident #159 prior to 6/20/21 at 6:52 AM, or between 6:52 AM and 12:55 PM on 6/20/21. On 12/3/21 at 10:05 AM, the DON stated there was no documentation of other interventions between 6:52 AM and 2:34 PM on 6/20/21. The DON stated she was told by staff they did not intervene because Resident #159's code status was DNR. The DON stated she expected Resident #159 to be monitored and she, the on-call physician, and Resident #159's representative, notified when Resident #159 began to show symptoms of decline in her health status.

Based on record review and policy review, it was determined the facility failed to ensure staff recognized and acted on signs and symptoms of a persistent [CONDITION(S)]. This was true for 1 of 2 residents (Resident #1) reviewed for urinary catheter care. Resident #1 was harmed when she required hospitalization for [CONDITION(S)] due to a [CONDITION(S)]. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's record documented she had an indwelling urinary catheter (a hollow partially flexible tube that collects urine from the bladder and leads to a drainage bag). The facility's policy for Indwelling Urinary Catheter Care and Management, revised 11/20/20, documented to monitor the catheter daily and assess for complications resulting from the use of an indwelling catheter such as catheter-associated urinary tract infection (CAUTI), pain, discomfort, and bleeding. The U.S. National Library of Medicine [MEDICATION(S)] Plus website, accessed on 5/14/21, stated common symptoms of a urinary tract infection are: * Abnormal urine color or cloudy urine * Blood in the urine * Foul or strong urine odor * Pressure, pain, or spasms in the back or lower part of the belly The website also documented other symptoms that may occur with a [CONDITION(S)]: * Fever * Flank pain (pain in the areas around the sides of the body from the upper abdomen to the back) * Mental changes or confusion (these may be the only signs of a [CONDITION(S)] in an older person) The website also stated to contact the medical provider for any symptoms of a [CONDITION(S)], back or flank pain, fever, or vomiting. The facility did not follow this policy and guidance. A physician order, dated 11/16/19, documented to monitor Resident #1's [urinary] output and to notify the physician if her output was less than 240 ml in eight hours. Resident #1's record included documentation her catheter had become displaced and she was sent to the hospital for a new catheter after staff were unsuccessful at placing a new catheter in the facility. A nurse's progress note, dated 1/13/20 at 11:28 PM, documented Resident #1 returned from the hospital with a new indwelling urinary catheter and it was draining pale yellow urine. A nurse's progress note, dated 1/14/20 at 7:08 AM, documented Resident #1's urinary output since returning from the hospital was 200 ml. The note documented Resident #3's bladder was scanned by ultrasound 3 times and showed 86 ml of urine was in her bladder. The nurse practitioner was called and stated to discontinue the order to notify a provider when Resident #1's urinary output was less than 240 ml. A nurse's progress note, dated 1/14/20 at 2:53 PM, documented Resident #1 was alert but confused compared to her baseline. The progress note documented urine remains cloudy looking after [new] catheter from possible sediment build up. There was no documentation the physician was notified about Resident #1's change in urine clarity and her confusion. A nurse's progress note, dated 1/15/20 at 3:05 AM, documented Resident #1's urinary catheter was patent with slightly hazy yellow urine and had a small amount of white sediment. There was no documentation the physician was notified about Resident #1's change in urine clarity. A nurse's progress note, dated 1/19/20 at 3:01 PM, documented Resident #1 refused to eat her breakfast, ate little for lunch, and was lethargic (sleepy, drowsy, lack of energy) from the time she woke up. Resident #1's representative requested for her to be transferred to the hospital. This was 6 days after it was initially identified and noted Resident #1's urine was cloudy. A nurse's progress note, dated 1/19/20 at 2:05 AM, documented Resident #1 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital history and physical, dated 1/19/20, documented Resident #1 had acute likely toxic metabolic [CONDITION(S)] possibly due to a new [CONDITION(S)]. Toxic metabolic [CONDITION(S)] is a condition when the electrolytes, hormones or other chemicals in the body were off their normal balance, which could lead to an altered mental state. A progress note, dated 1/22/20 at 4:23 PM, documented Resident #1 was readmitted to the facility after a short stay in the hospital due to decreased level of consciousness and decreased ability to perform ADLs. This was contrary to the hospital's admission report. A nurse practitioner's progress note, dated 1/24/20, documented Resident #1 was admitted to the hospital on 1/19/20 and readmitted to the facility on [DATE]. The note documented Resident #1's family thought she had some changes in her consciousness and she was sent to the emergency room . The note further documented the hospital found some possible toxic metabolic [CONDITION(S)] which was potentially from a [CONDITION(S)]. A nurse's progress note, dated 2/14/20 at 6:01 PM, documented Resident #1's urine was noted to be hazy (cloudy), without a strong odor. A urine dipstick test (a rapid urine test) was performed as ordered by the physician and it was noted to have white blood cells (WBCs) (a sign of infection). A nurse's progress note, dated 2/15/20 at 3:19 PM, documented Resident #1's urinary catheter was draining amber (yellow to orange) colored urine. Resident #1's urine was noted to be cloudy without foul odor. The nurse's note documented Resident #1 had an appointment with her urologist on Monday (2/17/20). There was no documentation the physician was notified Resident #1's urine continued to be cloudy. A nurse's progress note, dated 2/16/20 at 11:10 AM, documented Resident #1 was noted to have an acute functional decline, her temperature was 99.1 F (degrees Fahrenheit) and she was leaning to one side of her wheelchair. Resident #1 was administered acetaminophen and her temperature went down to 98.9 F in 30 minutes. Resident #1 complained of pain down there when her catheter was flushed and complained of lower abdominal pain. Resident #1 was encouraged to take fluids. The note was unclear what was meant by an acute functional decline. There was no documentation the physician was notified about Resident #1's functional decline and pain. A progress note by the urologist, dated 2/17/20, documented Resident #1 was seen for follow-up due to urinary retention and recurrent [CONDITION(S)]. The note stated over the past six months Resident #1 was treated three times for infections, two bacterial and one fungal infection. One of the bacterial infections required her to be hospitalized . The urologist discontinued Resident #1's current antibiotic and was prescribed a different one. A nurse's progress note, dated 2/19/20 at 3:40 PM, documented Resident #1 complained of nausea and vomited that morning. The note stated Resident #1 was administered [MEDICATION(S)] (an anti-nausea medication) and it took about an hour for her to report it helped her. The note further stated Resident #1 reported she was not feeling well and did not participate in her therapy program. A nurse's progress note, dated 2/19/20 at 4:46 PM, documented Resident #1 vomited two times and she did not have an appetite, which were possible side effects of the new antibiotic. The note stated Resident #1's representative was notified. A nurse's progress note, dated 2/23/20, at 6:47 AM, documented Resident #1's urinary catheter was draining a slightly hazy amber colored urine with small amounts of sediment. There was no documentation the physician was notified about Resident #1's hazy color in her urine. A nurse's progress note, dated 2/23/20 at 6:59 PM, documented Resident #1's urinary catheter was flushed without issue, the urine was yellow in color, and cloudy with a foul smell. Resident #1's representative requested a urinalysis for Resident #1. The note documented the urinalysis showed Resident #1's urine was positive for WBCs, protein, and blood. Resident #1's urine was sent to the laboratory for a complete urinalysis and C&S. Resident #1 was encouraged to take fluids. A nurse's progress note, dated 2/25/20 at 11:25 AM, documented Resident #1 had enterococcus faecalis (bacteria) and [MEDICATION(S)] in her urine and the facility was waiting for the C&S report. The physician gave an order to administer [MEDICATION(S)] (antibiotic) one gram by intramuscular injection to Resident #1 and to also continue the antibiotic ordered by the urologist. The following order was received from the nurse practitioner after the results were received for the C&S on 2/26/20, as follows: *Discontinue [MEDICATION(S)]. *Nitrofurantoin (antibiotic) capsule 100 mg, one capsule two times a day for seven days for [CONDITION(S)]. *Cranberry tablet two tablet once a day for recurrent [CONDITION(S)] and chronic urinary catheter use. *Monitor urine output every shift. A nurse's progress note, dated 2/26/20 at 10:52 AM, documented Resident #1 fell asleep in her chair and was transferred to her bed. The note documented Resident #1's representative was upset and asked why Resident #1 was tired and not up for breakfast. The progress note documented Resident #1's representative was informed Resident #1 did not want to be woken. The nurse's note also stated Resident #1 was up early for a shower and she did get tired on shower days for a short period, but this is not her norm [normal] today. It was unclear what was meant by this was not Resident #1's norm. Resident #1's care plan, dated 2/26/20, was revised to include she had a urinary tract infection related to an indwelling urinary catheter. The care plan directed staff to encourage her to take fluids, give her medications as ordered, perform laboratory/diagnostic work-up as ordered and report results to the physician and follow up as indicated, observe her for signs and symptoms of [CONDITION(S)] such as urgency, malaise, foul smelling urine, dysuria (painful or difficult urination), fever, nausea and vomiting, cloudy urine, altered mental status, loss of appetite, suprapubic pain, hematuria (blood in urine) and behavioral changes and report to the physician. This was not included on Resident #1's care plan previously. A nurse's progress note, dated 2/27/20 at 2:22 PM, documented Resident #1 was tired, but ate her meals and attended the facility's activities. Resident #1's urinary catheter was draining slightly cloudy urine. There was no documentation Resident #1's physician was notified about the cloudy urine. A nurse's progress note, dated 2/29/20 at 1:01 PM, documented Resident #1's representatives requested she be transferred to the hospital related to possible dehydration. The report documented Resident #1's representatives were informed the facility was able to administer intravenous fluids (a medical technique that delivers fluids directly into a person's vein, commonly used for rehydration or nutrition for those who cannot consume food or water by mouth) in-house, but the representatives wanted Resident #1 to be sent to the hospital. A nurse's progress note, dated 2/29/20 at 4:44 PM, documented Resident #1 was admitted to the hospital. A hospital discharge summary, dated 3/26/20, documented Resident #1 was diagnosed with severe [CONDITION(S)] with shock. The report further stated the source of [CONDITION(S)] was a urinary catheter associated [CONDITION(S)]. The report documented Resident #1 was discharged from the hospital on 3/26/20, 27 days later.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented to provide a safe and sanitary environment. This was true for 3 out of 3 residents (#5, #6, and #7) reviewed for transmission precautions, and 1 of 3 residents (Resident #8) observed for a blood glucose check. This failure created the potential for negative outcomes by exposing other residents and staff in the facility to the risk of infection and cross-contamination. Findings include: 1. The facility's Coronavirus (COVID-19) policy under the section titled Bed Management Strategies and Cohorting plan, revised 4/4/21, documented the Yellow Zone housed residents whose COVID-19 status was unknown. These were the residents who were admitted or readmitted to the facility and placed in a 14-day quarantine (separates and restricts the movement of people who were or may have been exposed to a contagious disease to see if they become sick) even if they had a negative COVID-19 test upon admission. All residents in this category were placed in transmission-based precautions (droplet plus contact with eye protection). The Green Zone housed residents who were fully vaccinated with the COVID -19 vaccine, asymptomatic residents and not suspected to have COVID-19, and residents who have recovered from COVID-19. The policy stated all recommended PPE should be worn during care of residents under quarantine, which included an N95 respirator (facemask if a respirator was not available), eye protection (goggles or a disposable face shield), gown, and gloves. The Centers for Disease Control and Prevention (CDC) website, accessed on 4/28/21, included a section titled Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE (personal protective equipment) During Shortages, updated on 12/29/20. The website stated Contingency Capacity Strategies can be used during periods of anticipated PPE shortages. This is the practice of wearing the same eye protection and N95 respirators for repeated close contact encounters with several different patients, without removing the eye protection and N95 respirators between patient encounters. The website stated Contingency Capacity Strategies could only be implemented after first implementing Conventional Capacity Strategies wherein eye protection should be cleaned and disinfected after each patient encounter. The CDC guidance and facility's policy were not followed. On 4/26/21 at 8:15 AM, the DON said the facility had three residents on transmission-based precautions. Resident #5 was on contact isolation due to the presence of ESBL (extended-spectrum beta-lactamases: enzymes produced by some bacteria that may make them resistant to some antibiotics) in her urine. Resident #6 and Resident #7 were new admissions to the facility and were placed on contact and droplet precautions in the Yellow Zone for a 14-day quarantine period. The DON said Resident #6 and Resident #7 had not received their COVID-19 vaccine. On 4/26/21 at 8:19 AM, a yellow line was observed on both entrances on the floor that delineates the Yellow Zone from the Green Zone. A Designated Yellow Zone was posted at the entrance of the Yellow Zone and a sign directed staff to wear an N95 respirator and a face shield. Resident #6 and Resident #7's rooms had Contact and Droplet Precaution signs on their doors. A PPE container was hanging on the wall in the Yellow Zone instead of located at the entrance of the Yellow Zone. The PPE container contained bleach wipes, yellow isolation gowns, and gloves. There were no surgical masks, N95 respirators, and eye protection in the PPE container. On 4/26/21 at 8:23 AM, CNA #1 was wearing an N95 respirator and a face shield when she exited Resident #7's room with a breakfast tray in her hand. CNA #1 left the Yellow Zone and walked through the Green Zone to the soiled utility room next to the nurse's station. CNA #1 did not remove or disinfect her N95 respirator and face shield before leaving Resident #7's room in the Yellow Zone and walking through the Green Zone. On 4/26/21 at 8:24 AM, CNA #1 said she did not remove her N95 respirator and remove or disinfect her face shield when she left each room in the Yellow Zone. CNA #1 said they were instructed to reuse their N95 respirator and face shield for a maximum of five times. CNA #1 said she should have removed her N95 respirator and cleaned her face shield with a bleach wipe before leaving each room in the Yellow Zone for reuse the next time. On 4/26/21 at 8:26 AM, CNA #2 said the charge nurse for the Yellow Zone was responsible for restocking the PPE container. On 4/26/21 at 9:14 AM, two plastic bags were observed hanging on the mobility bar near the Yellow Zone exit. The plastic bags were labeled with CNA #1 and LPN #1 names on them. These plastic bags were not observed earlier. On 4/26/21 at 9:15 AM, LPN #1 said she was the charge nurse in the Yellow Zone and part of the Green Zone. LPN #1 said the face shield should be removed and cleaned with a bleach wipe and stored in a plastic bag before exiting the Yellow Zone. On 4/26/21, LPN #1 was observed between 11:36 AM to 11:56 AM as follows: * At 11:36 AM, LPN #1 walked from the Green Zone to the Yellow Zone, removed her surgical mask, and put on an N95 respirator and face shield from a plastic bag with her name on it. LPN #1 put on an isolation gown and entered Resident #6's room to deliver a lunch tray. * At 11:41 AM, LPN #1 exited Resident #6's room carrying a bag of trash. LPN #1 left the Yellow Zone and walked through the Green Zone to the soiled utility room. LPN #1 did not remove or clean her face shield before leaving the Yellow Zone. * At 11:45 AM, LPN #1, wearing the same N95 respirator and face shield, entered room [ROOM NUMBER], which was in the Green Zone, to answer the call light. LPN #1 exited room [ROOM NUMBER], went to the medication storage room, and walked back to room [ROOM NUMBER] to deliver an orange juice * At 11:48 AM, LPN #1 prepared the medication in the Green Zone hallway and administered them to the resident in room [ROOM NUMBER]. LPN #1 exited room [ROOM NUMBER], carried a lunch tray to the food cart in front of the nurse's station. * At 11:53 AM, LPN #1 entered room [ROOM NUMBER], which was in the Green Zone, to answer the call light. * At 11:54 AM, LPN #1 took the lunch tray from CNA #1 who was standing at the Yellow Zone exit and brought it to the food cart by the nurse's station. * At 11:56 AM, LPN #1 entered room [ROOM NUMBER], which was in the Green Zone, to answer the call light. LPN #1 did not change or clean her face shield when leaving the Yellow Zone and entering the Green Zone to provide cares to residents. On 4/26/21 at 12:01 PM, LPN #1 said the facility did not have a COVID-19 positive resident, so she did not need to clean or wipe her face shield before leaving the Yellow Zone if she did not remove it. On 4/26/21, at 2:06 PM, the RDCS said staff could leave the Yellow Zone with the same N95 respirator and face shield on when leaving the Yellow Zone because the facility had declared a shortage of the PPE with the National Healthcare Safety Network. The RDCS said the facility was on Extended PPE use. On 4/26/21 at 3:16 PM, the ICP said the facility had a PPE shortage, but the staff should clean their face shield before leaving the Yellow Zone to enter the Green Zone. The facility failed to follow their policy and CDC guidance to prevent prevent potential cross-contamination. 2. The facility's policy, Cleaning and Disinfecting of the Glucometer, revised 7/30/20, directed staff to clean and disinfect the glucometer after each use and to place a barrier such as paper towel, wax paper or a plastic barrier before putting the glucometer on a table or other surface. This policy was not followed. On 4/26/21 at 8:20 AM, LPN #2 was at a medication cart preparing for a blood glucose check. A glucometer with a test strip inserted in it was on top of a medication cart. There was no barrier between the glucometer and top of the medication cart. LPN #2 picked up the glucometer and the other blood glucose testing supplies and entered Resident #8's room. LPN #2 placed the glucometer on top of Resident #8's bedside table. There was no barrier between the glucometer and top of the bedside table. LPN #2 cleaned Resident #8's middle finger with an alcohol swab and pricked it with a lancet to obtain a blood sample and performed a blood glucose test. LPN #2 then removed her gloves, washed her hands, and exited Resident #8's room. On 4/26/21 at 11:14 AM, LPN #2 said she placed the glucometer on top of the medication cart while preparing the other supplies for a blood glucose check. LPN #2 said she entered Resident #8's room and placed the glucometer on top of his bedside table. LPN #2 said she arrived at about 6:00 AM in the facility and cleaned the top of the medication cart before starting her medication pass, so the top of the medication cart was clean. LPN #2 said she did not put a barrier between the glucometer and Resident #8's bedside table.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were reviewed and revised as needed to reflect their current urinary status and needs. This was true for 2 of 8 residents (#1 and #5) reviewed for care plan revisions. This created the potential for harm if care was not provided or decisions made based on inaccurate or outdated information on the care plan. Findings include: The facility's Care Planning and Interventions policy, revised 7/23/09, stated residents' care plans were updated as needed, but no less than quarterly as their condition changed, goals were met, interventions were determined to be ineffective or needed to be revised and specific treatable causes of nutrition related problems were identified. This policy was not followed: 1. Resident #1 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's care plan documented she had an indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), size 16 French (French gauge system commonly used to measure the size of a catheter). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's care plan was not revised to reflect the size changes of her urinary catheter as ordered by the physician. On 4/27/21 at 9:08 PM, the DON said Resident #1's care plan was not updated. The DON said he expected the staff to update residents' care plans quarterly, as needed, or when there was a change in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including [CONDITION(S)] (a disorder affecting nerve cell activity in the brain causing seizures) and dementia. Resident #5's quarterly MDS assessment, dated 4/5/21, documented she was moderately cognitively impaired. Resident #5's Urine Culture result, dated 4/16/21, documented the presence of E-Coli (escherichia coli: bacteria that is a common cause of urinary tract infections) with ESBL (extended-spectrum beta-lactamases: enzymes produced by some bacteria that may make them resistant to some antibiotics). The report alerted the staff of the need for Contact Infection Prevention for appropriate isolation protocol [precautions taken when caring for patients with known or suspected infections that have an increased risk for contact transmission]. A nurse's note, dated 4/20/21 at 12:09 PM, documented Resident #5 was placed in a private room with contact precautions. The note documented Resident #5's urine culture result showed the presence of E. Coli with ESBL. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/26/21 at 8:39 AM, Resident #5's room had a Contact Precautions sign on the door, which directed staff to wear PPE when entering her room. Resident #5's care plan did not include documentation she had an E-Coli with ESBL urinary tract infection and was to be in contact precautions. On 4/27/21 at 2:45 PM, the DON stated Resident #5's care plan did not include she was to be in contact precautions and had a urinary tract infection related to E-Coli with ESBL. He said the care plan should be updated as soon as residents' care needs changed.

Based on record review and staff and resident interview, it was determined the facility failed to ensure residents' urinary catheter care needs were met. This was true for 1 of 2 residents (Resident #3) reviewed for urinary catheter care. This failure created the potential for harm should residents experience urinary tract infections or skin breakdown. Findings include: The Potter and Perry Fundamentals of Nursing 10th edition, page 1169 and 1170, stated patients with indwelling catheters (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) required regular perineal hygiene, especially after a bowel movement, to reduce the risk of catheter associated urinary tract infections. To maintain the patency of indwelling catheters, it is sometimes necessary to irrigate or flush with a sterile solution. The health care provider was to determine that irrigation was needed to keep the catheter patent. Resident #3 was admitted to the facility, on 11/6/20, with multiple diagnoses, including diabetes and neuromuscular dysfunction of the bladder (bladder dysfunction caused by neurologic damage). Resident #3's urinary catheter care plan, initiated on 11/10/20, directed staff to provide urinary catheter care every shift. Resident #3's quarterly MDS assessment, dated 3/30/21, documented he was cognitively intact and had a urinary catheter. Resident #3's March 2021 and April 2021 ADLs flow sheet and TAR did not include documentation he was provided catheter care. On 4/26/21 at 11:16 AM, Resident #3 stated he was not provided catheter care by the staff. Resident #3 said he cleaned his urinary catheter once every three days during his shower. On 4/27/21 at 3:27 PM, the DON stated he could not find documentation catheter care was provided to Resident #3. The DON said the staff were to follow the care plan.

Based on observation, policy review, nationally recognized standards of practice, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. A guideline from the CDC on Use of PPE When Caring for Patients with Confirmed or Suspected COVID-19, dated 3/30/20, directed staff to put on an isolation gown and tie all ties on the gown. A guideline from the CDC on How to Safely Remove PPE, undated, directed staff to unfasten the gown ties, taking care to ensure the sleeves did not touch the body when reaching for the ties, and pull the gown away from the neck and shoulders by touching the inside of the gown only. These directions were not followed. On 7/20/20 at 10:02 AM, a sign was on Resident #1's door indicating she was on droplet precautions, and another sign directed staff to use alcohol-based hand rub and apply PPE, including a gown, prior to entering the room. On 7/20/20 at 12:29 PM, CNA #1 entered Resident #1's room. Three cloth isolation gowns were hanging on the bathroom door on individual hooks, and 2 hooks were labeled CNA and the third hook was labeled nurse. CNA #1 was wearing a face shield and face mask, and she took a gown from a hook labeled CNA and put it on by pulling it over her head. On 7/20/20 at 12:32 PM, CNA #1 removed her gloves, removed the gown by pulling it over her head, hung the gown on the middle hook on the bathroom door in Resident #1's room, and then washed her hands. CNA #1 said there were 3 gowns hanging on the bathroom door, and 2 gowns were for CNAs and 1 gown was for the nurse. CNA #1 said she did not think about it when she pulled the gown over her head, and that was not the way she was trained to put on a gown. CNA #1 said she should have untied the gown. On 7/20/20 at 3:24 PM, the IP said it was not acceptable for staff to put on a gown by pulling it over their head. 2. The facility's Transmission-Based Precautions and Isolation Procedures, dated 5/7/20, stated when a resident is placed on transmission-based precautions, the staff should place the type(s) of precaution signage to be initiated outside the resident room in a conspicuous place, such as on the door or on the wall next to the doorway, identifying the CDC categories of transmission-based precautions (e.g. contact, droplet), the instructions for use of PPE, and/or instructions to see the nurse before entering. Resident #2's Progress Notes, dated 7/19/20 at 4:17 PM, documented a COVID-19 swab was collected and sent to the lab. On 7/20/20 at 10:58 AM, there were three drawers containing PPE and receptacles for trash and dirty linen outside of Resident #2's door. There were no precaution signs on Resident #2's door or on the wall nearby. On 7/20/20 at 12:50 PM, RN #2 said Resident #2 returned from the hospital that morning and was on droplet and contact precautions. When asked why no signs were on the door, RN #2 replied Resident #2's COVID-19 test results were negative. Resident #2's Progress Notes, dated 7/20/20 at 2:37 PM, documented COVID-19 test results were not yet received and Resident #2 continued with droplet precautions. On 7/20/20 at 3:50 PM, The IP said Resident #2's door should have signage on it indicating the type of precautions to follow when entering. 3. The facility's Housekeeping Services policy, dated 6/10/20, stated when cleaning isolated rooms staff were to remove their PPE before leaving the room and follow hand hygiene protocol. The facility's Hand Hygiene Policy, dated 5/7/20, stated the facility should provide education on hand hygiene and include when to perform hand hygiene with alcohol-based hand rub and with soap and water, including: * before and after all resident contact, * after contact with potentially infectious material, * after removal of gloves. The facility's Transmission-Based Precautions and Isolation Procedures, dated 5/7/20, under Standard Precautions, stated hand hygiene must be performed before and after all resident contact and contact with potentially infectious material. The facility's Stop - Droplet Precautions sign, and the Stop - Contact Precautions sign, undated, stated everyone must clean their hands before entering and when leaving the room. These policies and directions were not followed. On 7/20/20 at 12:43 PM, Driver #1 entered Resident #3's room. Three signs were on Resident #3's door: Stop - Droplet Precautions, Stop - Contact Precautions, and a list of PPE to put on and take off, including hand hygiene after removing PPE. Driver #1 proceeded to clean surfaces and equipment in Resident #3's room. Driver #1 then removed his PPE and placed it in a bin inside Resident #3's room. He then exited Resident #3's room and returned to his cart without performing hand hygiene. Driver #1 said he was the facility resident driver, but he was not driving residents anywhere, due to the pandemic, and was reassigned to disinfect room surfaces. Driver #1 said he did not perform hand hygiene when he came out of Resident #3's room but he should have. On 7/20/20 at 4:00 PM, the Administrator said when Driver #1 entered Resident #3's room he should follow the prescribed precautions, and he should have practiced hand hygiene when he exited the room. 4. The facility provided a CDC document on the Sequence for Putting on PPE, including a gown, which required staff to fasten the back of neck and waist. On 7/20/20 at 1:15 PM, Driver #1 put on a black gown and entered Resident #4's room who had signage on her door indicating she was on droplet and contact precautions. Driver #1's gown was not tied at the waist and hung to his sides without covering his backside. He proceeded to clean surfaces and equipment in Resident #4's room and when the task was completed he exited the room. When asked, Driver #1 said he did not tie the back of his gown. On 7/20/20 at 3:47 PM, the IP said gowns with ties must be tied at the top and the bottom.

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms of cough, fever, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. In addition, the facility failed to establish a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Specifically, 1. Review of the facility's infection control logs for March 2020 and April 2020 showed the facility failed to accurately track and trend infections of the residents in the facility. 2. Facility failed to develop a system for resident and staff surveillance for COVID-19 symptom monitoring and intervention. 3. Facility staff (Certified Nursing Aide (CNA)1, CNA2, CNA3, CNA4, CNA5) failed to properly wear cloth face masks and/or did not perform hand hygiene after touching cloth face masks. 4. Failed to disinfect reusable blood pressure (BP) cuff after use on 5 of 5 unsampled residents (R) (R8, R9, R10, R11, R12) observed for vital sign monitoring. 5. Failed to ensure personal protective equipment (PPE) gown fully covered staff (CNA3)'s uniform when providing cares to sampled resident (R1) and changing linen in sampled resident (R2)'s room. Both R1 and R2 were on droplet transmission based precautions. 6. Failed to wash hands for at least the required 20 seconds after providing cares to sampled resident (R1) who was on droplet transmission based precautions. 7. Failed to wear PPE mask when (Licensed Nurse (LN)1 provided cares to sampled resident (R1) who was on droplet transmission based precautions. 8. Failed to provide cares that prevented urinary tract infections for 1 of 1 unsampled resident (R6) observed for mechanical lift transfers. 9. Failed to change gloves when moving from dirty to clean tasks during incontinence care for 1 of 1 unsampled resident (R5) observed for incontinence care. These failures represented systemic failures which increased the risks for the spread of COVID-19 and other communicable diseases and infections amongst residents and staff. Findings include: During an interview on 5/7/20 at 1:30 PM Administrator, Director of Nursing (DON), Infection Preventionist (IP) and Unit Manager 1 (UM)1 stated that facility census was 57, facility was still admitting residents, the facility had no current COVID-19 positive residents or staff. It was further stated, none of staff had been tested for COVID-19 but all were asymptomatic. Only one resident tested for COVID-19 with test results negative. New residents admitted to the facility or who go out into the community for [MEDICAL TREATMENT] [MEDICAL CONDITION] treatments are placed in droplet transmission based precautions. 1. Infection control logs Review of facility policy, Surveillance of Infections, last reviewed 7/25/19, showed The Infection Preventionist (IP) conducts surveillance of infections among residents and associates to ensure appropriate follow-up actions are taken to prevent the spread of infection. The IP conducts surveillance of healthcare-associated infections (HAIs) by: .reviewing culture reports and other pertinent lab data . Review of facility's Healthcare-Associated Infection Summary Report by Resident Days, dated March 2020, included Line Listing of Patient Infections, dated March 2020, showed resident's name, admitted , type of infection, symptoms/onset, cultures date/site/results), treatment, precautions, if infection criteria was met, and if infection was healthcare acquired infection or community acquired infection. An entry was shown for R13 for skin infection for symptoms of red, pus drainage, painful, warm with culture sent on 3/19/20. The results of the culture, such as type of organism, was not entered, but the form showed the infection was a healthcare-associated infection. In addition, an entry was shown for R14 for wound infection. Under symptoms wound infection [MEDICAL CONDITION] redness was entered, under culture (date/site/results), a circle with a line through the circle was entered, under treatment, antibiotic was listed and the form showed the infection was a healthcare-associated infection. The date for symptom onset was not shown. None of the 17 infections listed had an organism listed. The log failed to document if the ordered antibiotic was appropriate to treat the infection or if, and when, the infection was resolved. The March 2020 report also included a map of the facility color coded with type of infection, but there was no organism identified on the map and therefore the facility map was very limited to assess the potential relationship and spread of infection in the facility. Review of facility's Infection Control Tracking-Resident, Antibiotic and Organism Cultured Out, as part of Healthcare-Associated Infection Summary Report by Resident Days, dated April 2020, showed a column for date, resident, room #, date of onset, site, organism, antibiotic, and length of tx (treatment) for each of the 11 infections listed on the form. Under the column for organisms, no data was entered for any of the 11 infections listed. The Line Listing of Patient Infections, dated April 2020, showed resident's name, admitted , type of infection, symptoms/onset, cultures (date/site/results), treatment, precautions, if infection criteria was met, and if infection was healthcare acquired infection or community acquired infection. No culture data was entered for any of the 11 infections listed. Two of the infections listed C&S (culture and sensitivity) but the organism was not entered or shown. When asked to explain the lack of organisms or cultures, IP stated that he was not employed by the facility in April when the infections occurred and he would have to look at the lab results to find the organisms. The facility's, Infection Control Tracking-Resident, Antibiotic and Organism Cultured Out, dated April 2020, showed the specific issue or infection trends identified this month (if any) with increased skin rash, fungal, increased UTI (urinary tract infection) entered. Under actions taken relating to the specific issues or trends identified, the report showed increased hygiene, pericare. It is unclear how the issues or infection trends and action required or indicated could have been determined without the organisms identified. The log failed to document if the ordered antibiotic was appropriate to treat the infection or if, and when, the infection was resolved. The April 2020 report also included a map of the facility color coded with type of infection, but there was no organism identified for the month and therefore the facility map was very limited to assess the potential relationship and spread of infection in the facility. During an interview on 5/8/20 between 12:45 PM and 1:30 PM with DON and IP, when asked if April 2020 Infection control report was complete, IP stated, no. When asked about the limited data for tracking infection such as type of organism, if antibiotic resolved infection, date of symptom onset and if this negatively impacted the tracking, identification of trends and evaluation of appropriate interventions, DON stated absolutely, should have more data for analysis. 2. Resident and staff surveillance for COVID-19 symptoms During an interview on 5/8/20 between 12:45 PM and 1:30 PM with DON and IP, in response to surveyor request for staff surveillance for monitoring COVID-19 symptoms, or staff line listing of illnesses, call-ins, staff leaving work mid-shift due to illness, or did not pass initial shift COVID-19 screening, DON stated that when staff calls in sick a tracking sheet is completed. A three colored form is completed which goes to the supervisor, personnel file and employee health. DON provided copies of several Absence Report forms. When asked who tracks the absence report forms, DON stated that Staffing Coordinator has been keeping track of these. When asked if IP, DON, or someone from nursing reviewed the forms as a surveillance system of staff illnesses that might indicate COVID-19, DON stated she has been the DON since April and previously was MDS (Minimum Data Set, assessment and data reporting) Coordinator and has also been fulfilling IP role until 5/4/20 when IP started and Unit Manager Role until 5/4/20 when UM1 started and just hasn't had the time to get everything done. Review of Absence Report forms showed: *LN2 reported on 4/18/20 that her spouse was sick and COVID-19 test was pending. Facility did not provide documented evidence of follow-up to ensure staff did not have any exposure to persons with known or presumed COVID-19, and needed to take additional precautions or actions, before returning to work. *CNA3 reported on 4/9/20 that her mother-in-law was exhibiting symptoms of COVID. Notation by DON on form that I requested she get tested and stay home for her next two scheduled days and contact me on Monday 4/13/20. Facility did not provide documented evidence of follow-up about COVID-19 testing of staff or mother-in-law. *CNA6 reported on 4/29/20 that she was not feeling well. Facility did not provide documented evidence that staff did not experienced any COVID-19 symptoms. *CNA3 reported on 4/25/20 being hospitalized due to heart versus respiratory. Facility did not provide documented evidence if hospitalization was related to COVID-19. *LN5 reported on 4/25/20 of diarrhea. Facility did not provide documented evidence if there were any other COVID-19 symptoms and how facility ensured return to work criteria was met. *CNA7 reported on 3/29/20 that daughter was hospitalized . Facility did not provide documented evidence of reason for hospitalization or if hospitalization was related to COVID-19. *CNA8 reported on 4/21/20 that her son has been up all night not feeling well. Facility did not provide documented evidence if son's illness was related to COVID-19. *CNA5 reported on 4/23/20 of fever. Facility did not provide documented evidence that CNA's fever was not related to COVID-19. *LN6 reported on 3/26/20 that she had nausea and low grade temp(erature). Facility did not provide documented evidence that symptoms were not related to COVID-19. Facility staff screening prior to start of shift included taking temperature and questions about contact with known COVID-19 person and if SOB or coughing was present. During the same interview with DON and IP, when asked how resident's COVID-19 symptoms were tracked, if resident had increased temperature, low oxygen saturation level, or cough/shortness of breath based on monitoring, DON stated that electronic health record has a respiratory user defined assessment that enables an automatic alert to DON for any increases in temperature or other symptoms and she follows up on to see if chronic issue such as [MEDICAL CONDITION] or allergy and does research and documents in chart. This data was not aggregated so data could be trended or analyzed. When asked if facility was utilizing CDC's Respiratory Surveillance Line List for staff and resident data collection and monitoring to help identify trends and cases to identify an outbreak, IP stated, no, I just came across it a few days ago and will start that. IP stated that no other system for staff and resident data collection for monitoring COVID-19 specific symptoms was used. CDC Symptoms of Coronavirus, https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html, accessed 5/15/20, showed people with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, new loss of taste or smell. This list is not all possible symptoms. Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea. CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 5/14/20, showed Address asymptomatic and pre-symptomatic transmission, implement source control for everyone entering a healthcare facility (e.g., healthcare personnel, patients, visitors), regardless of symptoms. As part of routine practice, HCP (Healthcare personnel) (including consultant personnel and ancillary staff such as environmental and dietary services) should be asked to regularly monitor themselves for fever and symptoms of COVID-19. HCP should be reminded to stay home when they are ill . 3. Failed to properly wear cloth face masks and/or did not perform hand hygiene after touching cloth face masks. Observation on 5/7/20 at 2:50 PM showed CNA1 coming out of dirty utility room with cloth face covering/mask below her nose with her nares (opening of nose) exposed. CNA1 walked about 15 feet down the hall and emptied trash bags. CNA1 then entered room [ROOM NUMBER] with mask still below her nares. Observation on 5/7/20 at about 3:10 PM showed CNA1 enter R5's room. CNA1 touched her cloth mask and moved it to better cover her nose, CNA1 did not perform hand hygiene after touching cloth mask. CNA1 provided incontinence cares to R5. During a concurrent observation and interview on 5/7/20 at about 3:20 PM CNA1's mask was not covering her nares and CNA1 stated that her mask was not staying on and giving her problems. During a concurrent observation and interview on 5/7/20 at 2:05 PM showed CNA2 in 100 Hall with cloth mask very loose and not covering her nares. CNA2 stated that facility provides cloth masks and stated, my mask is too big and it's loose and acknowledge mask was not covering her nares. Observation on 5/7/20 at 2:25 PM showed CNA4 with his bandanna not covering his nares, CNA4 looked at surveyor and repositioned bandanna to cover his nares and went into R6's room. Surveyor entered R6's room and observed CNA4's bandanna not covering his nares and CNA4 repositioned bandanna to cover his nares, no hand hygiene was performed after touching bandanna. CNA4's bandanna was positioned at the nape of his neck. CNA4 and CNA1 assisted R6 using mechanical lift to transfer from bed to wheelchair. After R6 was positioned in her wheelchair, CNA1's mask was observed not covering her nares and just above her upper lip. CNA4's bandanna was observed not covering his nares and just above his lip. CNA4 repositioned his bandanna, and did not perform hand hygiene after, and then removed linen from resident's bed and gave resident her purse. During a concurrent observation and interview on 5/7/20 at about 2:30 PM showed CNA3 touching cloth mask and entering clean utility room. No hand hygiene was performed after touching mask. CNA3 retrieved large blue long-sleeve shirt with buttons the length of the shirt and then again touched cloth mask. No hand hygiene performed after touching mask. Observation on 5/7/20 at 5:00 PM showed LN1 in R5's room with same home made cloth mask he was wearing earlier in R1's room. R5 also had Droplet precautions sign on the door. LN1 was within two feet of R5. During an observation on 5/7/20 between 3:20 PM and 3:45PM CNA5 pulled down her cloth mask and her nares were uncovered. At 3:22 PM, CNA5 again pull down cloth mask and expose her nares. No hand hygiene was performed after either observation of touching cloth mask. CNA5 moved several papers at the nursing station. At 3:25 PM, CNA5 again pull down cloth mask and expose her nares. No hand hygiene was performed after touching mask. Unit Manager 2 looked at CNA5 with CNA5 mask below her nose exposing her nares and didn't say anything to CNA5. CNA5 wheeled vital sign machine and clipboard into R8's room. CNA5 performed hand hygiene and stood within 6 feet of R8 with her mask not covering her nares. CNA5 performed hand hygiene and went to R9's bed. CNA5 performed the same steps for taking vital signs and applied maroon BP cuff on R9's arm. CNA5's mask was not covering her nares while CNA5 stood within 6 feet of R9. CNA5 entered R11's room and placed blue BP cuff on R11's arm. CNA5 touched cloth mask and did not perform hand hygiene after touching mask. CNA5 took oxygen saturation and level and was observed with mask not covering nares while standing about 3 feet away from R11. CNA5 entered R12's room. CNA5's cloth mask was again below CNA5's nose with her nares exposed, her mask was near her mouth. R12's had a mask on but it was below her chin. CNA5 stood about 2 feet away from R12 while taking her BP with her mask not covering her nares. Concurrent observation and interview on 5/7/20 at 4:55 PM showed CNA4 with bandana with nares exposed, the top of the bandana was near his chin. When asked about his bandana, CNA4 stated, I have to breathe, is it a good to be breathing your own carbon [MEDICATION NAME]? CNA4 stated that he didn't use a mask as liked using a bandana instead. During an interview on 5/7/20 at 5:15 PM CNA5 stated mask supposed to cover nose and mouth, but it gets hot and bothers my chin. When asked about hand hygiene after touching mask, CNA5 stated, yes, supposed to do hand hygiene after touching mask. During an interview on 5/8/20 at 12:05 PM when asked about staff training for how to wear cloth masks and performing hand hygiene after touching masks to prevent contamination, DON stated that masks should fully cover staff nose and hand hygiene should be done after touching masks. DON stated that education was done via staff meeting and now writing up more specific instructions and placing in staff mail boxes. During an interview on 5/8/20 at 10:25 PM with DON and IP, both stated that hand washing or sanitizing hands should be done after touching masks, staff should be wearing masks when in facility. CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 5/14/20, showed Address asymptomatic and pre-symptomatic transmission, implement source control for everyone entering a healthcare facility (e.g., healthcare personnel, patients, visitors), regardless of symptoms. As part of source control efforts, HCP (healthcare personnel) should wear a facemask or cloth face covering at all times while they are in the healthcare facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Facility policy, Chapter 4: Standard and Transmission-Based Precautions, undated, showed cloth face covering: textile (cloth) covers that are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing, or coughing Associates who enter the facility wearing a personal face mask or covering, should remove their personal face mask/covering and store with personal belongings and apply a facility face mask or cloth face covering at the beginning of their shift They (associates) should also be instructed that if they must touch or adjust their facemask or cloth face covering they should perform hand hygiene immediately before and after HCP should wear a facemask at all times while in the healthcare facility . Facility policy, Hand Hygiene, dated 5/7/20, showed hand hygiene should be performed after touching your face mask or cloth face covering. 4. Failed to disinfect reusable blood pressure (BP) cuff During an observation on 5/7/20 between 3:25 PM and 3:45 PM CNA5 wheeled vital sign machine and clipboard into R8's room. CNA5 took R8's oxygen saturation with pulse oximeter, temperature with scanner that touched resident's forehead, pulse and blood pressure with blood pressure (BP) cuff placed around resident's arm. CNA5 wiped thermometer and pulse oximeter with alcohol swabs. CNA5 did not clean BP cuff. CNA5 performed hand hygiene and went to R9's bed. CNA5 performed the same steps for taking vital signs and applied maroon BP cuff on R9's arm. Again CNA5 did not clean BP cuff. CNA5 then entered R10's room and performed same steps for taking vital signs and applied the same maroon BP cuff just used of R9 on R10's arm. CNA5 exited room and did not clean BP cuff. CNA entered R11's room and placed blue BP cuff on R11's arm. BP cuff was not cleaned. CNA5 entered R12's room and placed same blue BP cuff, not cleaned after use of R11, on R12. During an interview on 5/7/20 at 5:25 PM CNA5 stated, I should have wiped BP cuff after using it on residents. CNA5 stated that she would use sani wipes to clean BP cuffs but there were no sani-wipe container on the vital signs machine that she used earlier. When asked where the sani-wipe containers are located, CNA5 stated, I don't know. During an interview on 5/8/20 at 10:25 PM with DON and IP, both stated that staff should have used sani-wipe to clean BP cuff after using on residents and sani-wipe is preferred to be on the vital sign cart. Facility policy, Cleaning and Disinfection of Non-Critical Patient Care Equipment, revised date 3/13/20, showed non-critical reusable patient care equipment (defined by CDC as items that come into contact with intact skin but not mucous membranes) is cleaned daily and before and after reuse with an EPA (Environmental Protection Agency)-registered hospital disinfectant .Examples of non-critical items include .blood pressure cuffs . 5. Failed to ensure PPE gown fully covers uniform R1 Record review of Medication Administration Record [REDACTED]. On 4/29/20 resident changed rooms to allow isolation and grouping secondary to out of the facility for [MEDICAL TREATMENT]. A holder with gloves hung on resident's door and red colored trash bags in containers were in resident's room. Droplet precautions sign showed eyes and nose and mouth should be fully covered before entry. Observation on 5/7/20 at about 2:15 PM showed CNA3 in R1's room. CNA3 donned gloves and large long-sleeved shirt with buttons covering the length of the shirt. CNA3 placed one arm in the shirt and then the other arm. CNA3 wore the shirt with the buttons in the back. CNA3 donned surgical face mask and goggles. CNA3 stood next to R1's bed within six feet of R1. CNA3 did not fully have the shirt over both arms and shoulders. The shirt did not fully cover CNA3's uniform with CNA3's upper chest and shoulders exposed. CNA3 was observed holding R1's television remote control and standing next to R1's bed. CNA3 doffed gloves, doffed shirt, hung shirt on hooks inside resident's room, doffed goggles and then washed hands at hand sink in resident's room. R1 was heard coughing. During an interview on 5/7/20 at about 2:20 PM, immediately following above observation, when asked how shirt fit her, CNA3 stated the shirt was too small and she couldn't fully get her arms through. CNA3 said that she got a clean shirt from the clean utility room at the start of her shift but will need to get something else that is larger sized. CNA3 stated, I'm one of the bigger ones, and should have grabbed something bigger. When asked if there are shirts that could completely cover and protect her uniform, CNA3 stated that there is sometimes, but wanted to grab something quickly because she wanted to answer the resident's call light. CNA3 stated that shirts are being used as isolation gowns. R2 Record review of Medication Administration Record [REDACTED]. On 4/29/20 resident changed rooms secondary to VOVID-19 cohorting. A holder with gloves hung on resident's door. Droplet precautions sign showed eyes and nose and mouth should be fully covered before entry. During a concurrent observation and interview on 5/7/20 at about 2:30 PM showed CNA3 retrieving large blue long-sleeve shirt with buttons the length of the shirt. CNA3 entered R2's room. CNA3 donned blue shirt by placing one arm and then the other arm into sleeves with buttons on the back. CNA3 was overheard saying the shirt fit much better. CNA3 donned goggles and gloves and picked up meal cover and manila folder from resident's over bed table. CNA3 straightened up resident's room by moving several items around and the made resident's bed and straightened linens and bed covers. Observed shirt/gown falling off CNA3's shoulders while CNA3 moved her arms and bent over. The back of CNA3's uniform was completely exposed and not covered by the shirt/gown. CNA3's upper chest and shoulders were exposed and not covered by the shirt/gown. Surveyor asked Unit Manager (UM)1 to observe CNA3. When asked if CNA3's uniform was protected while in droplet precautions room, UM1 said no. UM1 further stated that her gown is not covering or protecting her uniform and it should be. During an interview on 5/8/20 at 10:25 PM with DON and IP, both stated that gowns should be fully covering staff's uniforms. Facility policy, Transmission-based Precautions and Isolation Procedures, revision date of 5/7/20, showed droplet precautions .gloves and gown as well as goggles (or face shield .) should be worn. CDC's Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/ppe.html, accessed 5/18/20, showed isolation gown should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. 6. Failed to wash hands for at least the required 20 seconds after providing cares to sampled resident (R1) who was on droplet transmission based precautions. Observation on 5/7/20 at about 2:15 PM showed CNA3 in R1's room. CNA3 was observed holding R1's television remote control and standing next to R1's bed. After being in R1's room for several minutes, CNA3 doffed gloves, doffed shirt, hung shirt on hooks inside resident's room, doffed goggles and then washed hands at hand sink in resident's room. CNA3 washed her hands for eight seconds. R1 was heard coughing. During an interview on 5/7/20 at about 2:20 PM, immediately following above observation, when asked how long CNA3 washed her hands, CNA3 said, I'm supposed to wash hands for 20 seconds, probably did it too short, and supposed to wash for the 'happy birthday' song. When informed happy birthday song is supposed to be done twice, CNA3 stated that she didn't know that. During an interview on 5/8/20 at 10:25 PM with DON and IP, both stated hands should be washed for 20 seconds. Record review of the World Health Organization's How do I wash my hands properly, https://www.who.int/gpsc/clean_hands_protection/en/, accessed 5/14/20 showed Washing your hands properly takes about as long as singing Happy Birthday twice. 7. Failed to wear PPE mask when (Licensed Nurse (LN)1 provided cares to sampled resident (R1) who was on droplet transmission based precautions. Observation on 5/7/20 at 2:20 PM showed LN1 outside R1's room. LN1 was wearing homemade cloth mask. R1 was asking for pain medication. LN1 got pain medication and entered R1's room with homemade cloth mask. LN1 washed hands, donned gloves, donned shirt/gown and goggles. LN1 did not don surgical face mask and continued to wear homemade cloth mask. LN1 stood within 6 feet of R1 and gave R1 her medication. Observation on 5/7/20 at 5:00 PM showed LN1 in R5's room with same homemade cloth mask he was wearing earlier in R1's room. R5 also had Droplet precautions sign on the door. LN1 was within two feet of R5. During an interview on 5/7/20 at about 2:40 PM UM1 stated that staff should be wearing paper mask when in droplet precautions room and if cloth mask is used then the cloth mask is contaminated and should be removed. When informed of observation showing LN1 wearing cloth mask in R1's room, UM1 stated she will talk with LN1. During an interview on 5/8/20 at 10:25 PM with DON and IP, DON also stated she talked with LN1 and LN1's mask should have been changed after it was used and therefore contaminated when it was worn in R1's room. CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 5/14/20, showed Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn by HCP when PPE is indicated. 8. Failed to provide cares that prevented urinary tract infections for 1 of 1 unsampled resident (R6) observed for mechanical lift transfers. Observation on 5/7/20 at 2:25 PM showed CNA4 and CNA1 assisting R6 using mechanical lift to transfer from bed to wheelchair. R6's indwelling urinary catheter bag was observed hanging from mechanical lift hooks. R6's urinary catheter bag was observed above her bladder. Review of facility's Infection Control Tracking-Resident, Antibiotic and Organism Cultured Out, dated April 2020, showed R6 had a urinary tract infection on 4/8/20 that was treated with an antibiotic for 7 days. During an interview on 5/8/20 at 10:25 PM with DON and IP, DON stated that urinary catheter bag should be below the bladder at all times to prevent infections and R6 is known to have urinary tract infections. Facility policy, Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management, dated 5/5/20, showed keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of catheter associated urinary tract infection. 9. Failed to change gloves when moving from dirty to clean tasks during incontinence care for 1 of 1 unsampled resident (R5) observed for incontinence care. Observation on 5/7/20 at about 3:10 PM showed CNA1 enter R5's room. CNA1 provided incontinence cares to R5. CNA1 donned gloves, lowered the head of R5's bed and raised the bed up, opened R5's wet brief and repositioned trash can closer to the bed with same gloved hands, wiped R5's periarea with several wipes. With same gloved hands, CNA1 took off resident's pants, and rolled resident towards the window and said that the brief was wet and wiped the resident's skin several times with wipes and then placed clean new briefs under resident's buttocks with same gloved hands. Without changing gloves, CNA1 then rolled resident towards the door and fastened briefs, placed wipe container in drawer, repositioned two pillows under resident's legs, covered resident with covers, touched resident's bed control and raised head of bed and lower bed, placed stuffed animals next to resident, gave resident her call light and then bagged trashed and doffed gloves. CNA1 then washed hands and exited the resident's room. During a concurrent observation and interview on 5/7/20 at about 3:20 PM CNA1 stated that she should have brought two gloves in and didn't change her gloves after removing soiled briefs but should have. During an interview on 5/8/20 at 10:25 PM with DON and IP, DON stated gloves should be changed after touching dirty briefs and before touching clean briefs. Facility policy, Hand Hygiene, dated 5/7/20, showed hand hygiene should be performed after contact with body fl(TRUNCATED)

Based on review of facility documents, policy review, and staff interview, it was determined the facility failed to ensure the Infection Control policies and Infection Control Surveillance plan were reviewed annually by the Infection Control Committee, which had the potential to affect the 63 residents in the facility. This deficient practice had the potential of placing residents and staff at risk for infectious diseases. Findings include: The facility's Infection Control Plan, revised 3/2017, documented the Infection Control Surveillance Plan was reviewed at least annually and whenever significant changes occurred. The facility's Infection Control Policy Manual was reviewed. An Annual Review sheet located in the front of the manual was not dated or signed, it was left blank. On 2/20/20 at 4:00 PM and on [DATE] at 10:16 AM, the ICP said the annual review sheet was not signed. The ICP said the Quality Assessment and Assurance (QAA) meeting minutes should have also documented when the Infection Control policies were reviewed and they were not. On [DATE] at 12:56 PM, the RDCS said the QAA minutes lacked documented evidence the Infection Control Policies and Plan were reviewed annually.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents records included an Advance Directive or documentation an Advance Directive was discussed or offered. This was true for 3 of 9 residents (#36, #37, and #40) whose records were reviewed for an Advance Directive. 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. The State Operations Manual also states a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an Advance Directive. The facility's Advance Directive policy, dated 8/21/19, documented the following: * The social worker requested a copy of the Advance Directive so that it became a part of the medical record. * Copies of the Advance Directive remained in the resident's record, even if the chart was thinned. * Each time the resident was admitted , had a significant change, quarterly or as needed, Social Services reviewed the Advance Directive for accuracy. This policy was not followed. 1. Resident #36 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #36's physician orders, dated 3/1/19, documented her status was do not resuscitate. Resident #36's care plan conference, dated 3/5/19, documented Resident #36's daughter would bring in a copy of her living will. The most recent care plan conference, dated 11/26/19, documented Resident #36 had no living will. Resident #36's record did not include an Advance Directive or documentation that one was offered or discussed with her. On [DATE] at 1:47 PM, the MDS Coordinator and the Social Worker were interviewed. The MDS Coordinator stated she facilitated the care conferences for residents. She stated there was no documentation an Advance Directive was discussed or offered to Resident #36. The Social Worker stated there was no documentation of an Advance Directive in Resident #36's chart. 2. Resident #37 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #37's care plan conferences dated, 8/23/18, 12/24/18, 3/14/19, and 1/18/20 documented none for Advance Directive. Resident #37's record did not include an Advance Directive, or documentation that one was offered or discussed with her. On [DATE] at 12:46 PM, UM #1 stated there was an Idaho POST, but no Advance Directive in Resident #37's chart. 3. Resident #40 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #40's care plan conference, dated 4/7/19, documented he had no Advance Directive. Resident #40's record did not include an Advance Directive or documentation that one was offered or discussed with him. On [DATE] at 12:48 PM, UM #1 stated Resident #40's record did not include documentation about an Advance Directive. On [DATE] at 1:47 PM, the MDS Coordinator stated she facilitated the care conferences for residents. She stated there was no documentation that an Advance Directive was discussed or offered to Resident #40.

Based on record review, policy review, family interview, and staff interview, it was determined the facility failed to ensure residents were not involuntarily transferred and/or discharged . This was true for 4 of 8 residents (#224, #225, #226, & #227) who were admitted to the facility after 2/1/19. Resident #225 was harmed when he was unnecessarily discharged prior to his completion of therapy. The deficient practice had the potential to cause physical or psychosocial harm for residents #224, #226, and #227 when they were unnecessarily discharged and/or transferred to another setting. Findings include: The facility's Transfers and Discharges policy, dated 9/1/17, documented the facility provided equal care regardless of payment source. Transfers and discharges may occur when: * Residents' welfare and needs could not be met * Residents' health improved sufficiently to return home or to a less restrictive environment and no longer needed the services provided by the facility * Residents' health or safety or the health or safety of individuals were endangered due to the clinical or behavioral status * Residents' failed to pay for their stay * When the facility ceased to operate This policy was not followed. On 2/19/19 at 4:15 PM, the SW said she was told by the DON and the Administrator on 2/13/19 the facility was not going to be paid for residents who were admitted after 2/1/19, due to a non-payment status. She said she was told by the DON and the Administrator to approach residents and families to transfer the non-payment status residents to a sister facility, transfer to another facility, or discharge them home. The SW said some of the residents said, So you're kicking us out? The SW said she tried to educate the residents and explained the payment issues to them. The SW said she felt bad and said it was difficult for her to explain the situation to the residents and their representatives. The SW said some of the residents and their representatives agreed to be transferred to their sister facility and some were discharged home. On 2/19/19 at 5:30 PM, the DON said during a meeting with several staff members, which included corporate staff on 2/13/19, the decision was made to approach residents and family members and initiate transfers and discharges of residents admitted after the facility's non-payment date of 2/1/19. She said the residents and families were approached with options to transfer, discharge, or stay in the facility. The DON said she was not personally involved with discussing these options with the residents and/or their family members. The DON said the facility staff did not approach or attempt to discharge or transfer any newly admitted residents who received peritoneal [MEDICAL TREATMENT]. On 2/19/19 at 5:59 PM, the Administrator said there was a meeting with their regional staff on 2/13/19, regarding the results of their revisit survey combined with a complaint survey. He said because of their non-payment status he directed his staff to talk to the residents and their representatives and give them the option to be transferred to their sister facility, stay in the facility, or to go home if they were able to. He said these discharges were facility initiated discharges. The Administrator said the facility did not attempt to discharge or transfer any resident who required peritoneal [MEDICAL TREATMENT] since they had a contract with a local [MEDICAL TREATMENT] center. Residents were either discharged home or transferred to another facility. Examples include: 1. Resident #225 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #225 was discharged to home with home health on 2/14/19, 8 days later. Resident #225's PT evaluation and treatment plan, dated 2/7/19, documented short and long-term goals, with target dates of 3/6/19 and 4/5/19 respectively. The goals were as follows: * Safely perform bed mobility tasks with maximum assistance and 75% tactile cues (prompting by touch). * Safely propel his wheelchair 50 feet with moderate assistance. * Improve his bilateral lower extremity strength from 3/5 to 4/5 (muscle strength grade). * Ambulate 25 feet over even surfaces with a rolling walker with one-person maximum assistance. Resident #225's PT discharge summary, dated 2/15/19, documented he was discharged from PT on 2/13/19, and the status of his short and long-term goals were: * Bed mobility tasks required total dependence on others with 90% tactile cues and he lacked the trunk strength and coordination to perform without total assistance. * He could safely propel his wheelchair 20 feet with maximum assistance and he lacked bilateral upper extremity strength and activity tolerance to perform independently. * His bilateral lower extremity strength was 3/5. * He required two-person assistance to stand. Resident #225's OT evaluation and treatment plan, dated 2/7/19, documented his spouse wanted him to be able to sit on and use a bedside commode. The Occupational Therapist documented Resident #225 demonstrated good rehabilitation potential due to strong family support, stable medical condition, and compliance with skilled training. Resident #225's OT short-term goals, with a target date of 2/20/19, were as follows: * Safely and efficiently perform upper body dressing with maximum assistance and 25% verbal cues for initiation or termination of tasks * Safely perform bed mobility tasks and 25% verbal cues * Safely complete transfers with maximum assistance of one-person from his bed to his bedside commode Resident #225's OT discharge summary, dated 2/15/19, documented he was discharged from OT on 2/13/19 and the status of his short-term goals were as follows: * He required total dependence without any attempts to initiate the task with 50% verbal cues * He could safely perform bed mobility tasks with total dependence with 50% verbal cues * He could safely transfer to the bed side commode with total dependence of staff Resident #225's OT discharge recommendations, dated 2/15/19, were for home health to follow up with continued therapy, a low bed, and 24-hour care. Resident #225's physician progress notes [REDACTED]. Resident #225's Social Services note, undated, documented the SW told his spouse the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and the facility was not getting paid for Resident #225's stay. The note documented his spouse was given the option to transfer him to another rehabilitation facility or discharge him home. The spouse did not want to have Resident #225 taken to a new environment with different staff and was going to take him home with home health. The note did not include documentation there was an option given to stay in the facility. Resident #225's discharge summary, dated 2/14/19, documented he was sent home with a referral to a home health agency for outpatient rehabilitation. The summary documented his spouse requested the discharge home after the facility informed them of the facility's revisit survey. Resident #225's Notice of Resident Transfer or Discharge form, dated 2/14/19, documented he was discharged home due to CMS denial of payment. A progress note, dated 2/17/19, documented the Regional Director of Business Development called to check on Resident #225's status at home. The spouse said PT had completed their evaluation and was scheduled to start in-home therapy on 2/18/19, and OT was scheduled to evaluate him on 2/18/19. The spouse was informed if she had any difficulties, Resident #225 was welcome to return to the facility for further care. On 2/19/19 at 1:10 PM, Resident #225's spouse said the SW approached her on 2/13/19 to arrange a transfer for him to a sister facility that week to continue his therapy and care. She said she was told by the SW the facility was in trouble with the state and was not going to get paid for Resident #225's stay, along with 5 other residents. She said she was very upset because Resident #225 needed at least one more week of therapy. She was told Resident #225 could not remain in the facility but could be discharged home with a home health agency and outpatient therapy. The spouse said Resident #225 could not handle the stress to be transferred to yet another facility because the changes were really hard on him. The spouse said she had opted to take him home instead and said had he been allowed to stay in the facility, he could have progressed quicker with his therapy. On 2/19/19 at 4:15 PM, the SW said she approached Resident #225's spouse to transfer to another facility because he still needed rehabilitation services and staying in the facility was not an option. She said Resident #225's spouse chose to take him home with home health services and outpatient rehabilitation. The SW said on 2/15/19 she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. Resident #225 was discharged on [DATE]. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #225 did not document they were given an option to stay in the facility. The DON said she thought Resident #225 was ready to go home when he was discharged . Resident #225 required additional therapy services and was involuntarily discharged prior to the completion of those services. 2. Resident #227 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #227 was discharged home on[DATE] with outpatient physical therapy, 8 days later. Resident #227's care plan, dated 2/8/19, stated she expressed pain related to her total knee replacement and staff were directed to put ice to her knee and to educate her and her family on pain management. The care plan also stated Resident #227 needed assistance and therapy services to maintain or attain her prior level of function and staff were directed to assess her needs for therapy services. Resident #227's OT plan of treatment, dated 2/9/19, documented the following short-term goals with a target date of 2/22/19. The goals were written as follows: *Safely perform upper body/lower body bathing with stand by assist *Safely perform toileting tasks using raised toilet seat *Safely and efficiently perform upper body dressing *Safely and efficiently perform lower body dressing, including sock/shoes and retrieving all items from closet/drawers *Exhibit a decrease in pain with movement to 3 out of 10, on a 1-10 pain scale with 1 being the lowest and 10 the highest, in the right shoulder to increase patient's ability to perform upper body dressing with set-up *Demonstrate ability to safely complete functional transfers and ambulation up to 100 feet with least restrictive assistive device *Enhance balance abilities An OT discharge summary, dated 2/15/19, documented Resident #227 had made consistent progress with her skilled interventions. Resident #227's PT plan of treatment documented the following short-term goals with a target date of 3/2/19. The goals were written as follows: *Decrease risk of falls *Safely perform functional transfers *Safely ambulate on level surfaces 100 feet using a two-wheeled walker with stand by assist with continuous steps and with normalized gait pattern 85% of the time to increase independence within household environment *Improve her right lower extremity gross strength to 4/5 to allow her to safely ambulate using an assistive device A PT discharge summary, dated 2/14/19, documented Resident #227 had met her short and long-term goals, and she needed a reacher (a long handle with a grabber on one end) and a two-wheeled walker. A social services note, dated 2/15/19 at 4:10 PM, documented the SW told Resident #227 and her family the facility was on a non-payment status due to the result of the facility's revisit survey combined with a complaint survey resulting in 2 minor tags and because of that they have the option of transferring Resident #227 to another facility or home as she was able to ambulate with her front wheeled walker independently. Resident #227 chose to go home with outpatient rehabilitation therapy. On 2/19/19 at 1:38 PM, during a telephone interview, Resident #227's representative said the facility kicked us out. The family representative said they were told by facility staff the facility was not getting paid by Medicare and Resident #227 had to move to another facility or go home. The family representative also said Resident #227 was [AGE] years old and just had knee replacement surgery and he wanted her to stay more days in the facility to complete her physical therapy. The family representative said Resident #227 decided to go home with outpatient physical therapy. On 2/19/19, at 4:17 PM, during a telephone interview, the SW said she told Resident #227 and her family representative the facility was in a non-payment status due to the 2 minor tags the facility received after their revisit survey and Resident #227 had to move to another facility or go home. The SW said Resident #227 was able to use her 2-wheeled walker independently and chose to go home with outpatient physical therapy. 3. Resident #226 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED].#226 was transferred to another facility on 2/14/19, 6 days later. Resident #226's OT short-term goals, dated 2/9/19, with a target date of 2/15/19, included sitting upright in her wheelchair for 1-2 hours, self-perform activities of daily living, and use a bedside commode with one-person assistance. Resident #226's PT short-term goals, dated 2/10/19, with a target date of 3/2/19 and 3/9/19, included increased sitting balance and posture, safely transferring with assistance, and improve bilateral lower extremity strength. Resident #226's OT and PT discharge summary recommendations, dated 2/15/19, documented she was transferred to a sister facility for continued therapy care. Resident #226's physician progress notes [REDACTED]. A social services note, undated, documented the SW told Resident #226's responsible party the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and was not getting paid for Resident #226's stay. The note documented the responsible party and Resident #226 were given the option to transfer her to another rehabilitation facility or discharge her home. The SW documented Resident #226 was going to be provided the same OT and PT and the same doctors if she was transferred to the sister facility. The responsible party and Resident #226 agreed to the transfer. The note did not include documentation an option was given to stay in the facility. Resident #226's Discharge/Transfer Order and Notice of Resident Transfer or Discharge forms, dated 2/13/19 and 2/14/19, documented she was discharged due to CMS denial of payment. Resident #226's nurse progress note, dated 2/15/19, included a late entry for 2/14/19, regarding her transfer. The note documented the responsible party and Resident #226 were given the option to transfer her to a sister facility or another rehabilitation facility. The note documented they chose to go to a sister facility. On 2/19/19 at 1:30 PM, Resident #226's responsible party said the SW informed him and Resident #226 the facility failed an inspection and was not going to get paid for her stay. He said the SW told them Resident #226 needed to be transferred to a sister facility to continue her therapy and care. He said the SW did not offer them any other choice and he would have preferred not to have her transferred because it was closer to him than the sister facility. He said it was inconvenient, but Resident #226 was doing well at the new facility. On 2/19/19 at 4:15 PM, the SW said she spoke to the responsible party and Resident #226 regarding the transfer due to the non-payment status. She said at first, they were confused with the need to transfer and thought she was being kicked out but they were reassured Resident #226 was going to receive the same level of care at the sister facility and then they agreed to the transfer. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #226 did not include documentation the responsible party or Resident #226 was given an option to stay in the facility. 4. Resident #224 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #224 was discharged to another facility on 2/15/19, 8 days later. A Perspective Pay Status assessment, dated 2/14/19, documented Resident #224 was cognitively intact and he required the assistance of 1-2 staff members with activities of daily living and set-up for eating. Resident #224's care plan, dated 2/7/19, documented he needed assistance and therapy services to maintain his prior level of function and staff were directed to assess his needs for therapy and PT and OT services were ordered. A social services note, dated 2/15/19 at 3:10 PM, documented the SW told Resident #224 the facility was in a non-payment status due to the result of their revisit survey combined with the complaint survey resulting in 2 minor tags and Resident #224 had the option to go to their sister facility or go to another facility of his choice. The progress note documented Resident #224 asked the SW if he was going to receive the same kind of therapy at the other facility, and the SW said he would receive the same therapy and the same physician was going to see him at their sister facility. The progress note documented Resident #224 agreed to go to the sister facility. On 2/19/19 at 5:30 PM, the Unit Manager, with the DON, said Resident #224 was not ready to go home and he was given the option to move to their sister facility or to another facility of his choice. The Unit Manager said Resident #224 chose to transfer to their sister facility to continue his therapy.

Based on record review, policy review, family interview, and staff interview, it was determined the facility failed to ensure residents were not involuntarily transferred and/or discharged . This was true for 4 of 8 residents (#224, #225, #226, & #227) who were admitted to the facility after 2/1/19. Resident #225 was harmed when he was unnecessarily discharged prior to his completion of therapy. The deficient practice had the potential to cause physical or psychosocial harm for residents #224, #226, and #227 when they were unnecessarily discharged and/or transferred to another setting. Findings include: The facility's Transfers and Discharges policy, dated 9/1/17, documented the facility provided equal care regardless of payment source. Transfers and discharges may occur when: * Residents' welfare and needs could not be met * Residents' health improved sufficiently to return home or to a less restrictive environment and no longer needed the services provided by the facility * Residents' health or safety or the health or safety of individuals were endangered due to the clinical or behavioral status * Residents' failed to pay for their stay * When the facility ceased to operate This policy was not followed. On 2/19/19 at 4:15 PM, the SW said she was told by the DON and the Administrator on 2/13/19 the facility was not going to be paid for residents who were admitted after 2/1/19, due to a non-payment status. She said she was told by the DON and the Administrator to approach residents and families to transfer the non-payment status residents to a sister facility, transfer to another facility, or discharge them home. The SW said some of the residents said, So you're kicking us out? The SW said she tried to educate the residents and explained the payment issues to them. The SW said she felt bad and said it was difficult for her to explain the situation to the residents and their representatives. The SW said some of the residents and their representatives agreed to be transferred to their sister facility and some were discharged home. On 2/19/19 at 5:30 PM, the DON said during a meeting with several staff members, which included corporate staff on 2/13/19, the decision was made to approach residents and family members and initiate transfers and discharges of residents admitted after the facility's non-payment date of 2/1/19. She said the residents and families were approached with options to transfer, discharge, or stay in the facility. The DON said she was not personally involved with discussing these options with the residents and/or their family members. The DON said the facility staff did not approach or attempt to discharge or transfer any newly admitted residents who received peritoneal [MEDICAL TREATMENT]. On 2/19/19 at 5:59 PM, the Administrator said there was a meeting with their regional staff on 2/13/19, regarding the results of their revisit survey combined with a complaint survey. He said because of their non-payment status he directed his staff to talk to the residents and their representatives and give them the option to be transferred to their sister facility, stay in the facility, or to go home if they were able to. He said these discharges were facility initiated discharges. The Administrator said the facility did not attempt to discharge or transfer any resident who required peritoneal [MEDICAL TREATMENT] since they had a contract with a local [MEDICAL TREATMENT] center. Residents were either discharged home or transferred to another facility. Examples include: 1. Resident #225 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #225 was discharged to home with home health on 2/14/19, 8 days later. Resident #225's PT evaluation and treatment plan, dated 2/7/19, documented short and long-term goals, with target dates of 3/6/19 and 4/5/19 respectively. The goals were as follows: * Safely perform bed mobility tasks with maximum assistance and 75% tactile cues (prompting by touch). * Safely propel his wheelchair 50 feet with moderate assistance. * Improve his bilateral lower extremity strength from 3/5 to 4/5 (muscle strength grade). * Ambulate 25 feet over even surfaces with a rolling walker with one-person maximum assistance. Resident #225's PT discharge summary, dated 2/15/19, documented he was discharged from PT on 2/13/19, and the status of his short and long-term goals were: * Bed mobility tasks required total dependence on others with 90% tactile cues and he lacked the trunk strength and coordination to perform without total assistance. * He could safely propel his wheelchair 20 feet with maximum assistance and he lacked bilateral upper extremity strength and activity tolerance to perform independently. * His bilateral lower extremity strength was 3/5. * He required two-person assistance to stand. Resident #225's OT evaluation and treatment plan, dated 2/7/19, documented his spouse wanted him to be able to sit on and use a bedside commode. The Occupational Therapist documented Resident #225 demonstrated good rehabilitation potential due to strong family support, stable medical condition, and compliance with skilled training. Resident #225's OT short-term goals, with a target date of 2/20/19, were as follows: * Safely and efficiently perform upper body dressing with maximum assistance and 25% verbal cues for initiation or termination of tasks * Safely perform bed mobility tasks and 25% verbal cues * Safely complete transfers with maximum assistance of one-person from his bed to his bedside commode Resident #225's OT discharge summary, dated 2/15/19, documented he was discharged from OT on 2/13/19 and the status of his short-term goals were as follows: * He required total dependence without any attempts to initiate the task with 50% verbal cues * He could safely perform bed mobility tasks with total dependence with 50% verbal cues * He could safely transfer to the bed side commode with total dependence of staff Resident #225's OT discharge recommendations, dated 2/15/19, were for home health to follow up with continued therapy, a low bed, and 24-hour care. Resident #225's physician progress notes [REDACTED]. Resident #225's Social Services note, undated, documented the SW told his spouse the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and the facility was not getting paid for Resident #225's stay. The note documented his spouse was given the option to transfer him to another rehabilitation facility or discharge him home. The spouse did not want to have Resident #225 taken to a new environment with different staff and was going to take him home with home health. The note did not include documentation there was an option given to stay in the facility. Resident #225's discharge summary, dated 2/14/19, documented he was sent home with a referral to a home health agency for outpatient rehabilitation. The summary documented his spouse requested the discharge home after the facility informed them of the facility's revisit survey. Resident #225's Notice of Resident Transfer or Discharge form, dated 2/14/19, documented he was discharged home due to CMS denial of payment. A progress note, dated 2/17/19, documented the Regional Director of Business Development called to check on Resident #225's status at home. The spouse said PT had completed their evaluation and was scheduled to start in-home therapy on 2/18/19, and OT was scheduled to evaluate him on 2/18/19. The spouse was informed if she had any difficulties, Resident #225 was welcome to return to the facility for further care. On 2/19/19 at 1:10 PM, Resident #225's spouse said the SW approached her on 2/13/19 to arrange a transfer for him to a sister facility that week to continue his therapy and care. She said she was told by the SW the facility was in trouble with the state and was not going to get paid for Resident #225's stay, along with 5 other residents. She said she was very upset because Resident #225 needed at least one more week of therapy. She was told Resident #225 could not remain in the facility but could be discharged home with a home health agency and outpatient therapy. The spouse said Resident #225 could not handle the stress to be transferred to yet another facility because the changes were really hard on him. The spouse said she had opted to take him home instead and said had he been allowed to stay in the facility, he could have progressed quicker with his therapy. On 2/19/19 at 4:15 PM, the SW said she approached Resident #225's spouse to transfer to another facility because he still needed rehabilitation services and staying in the facility was not an option. She said Resident #225's spouse chose to take him home with home health services and outpatient rehabilitation. The SW said on 2/15/19 she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. Resident #225 was discharged on [DATE]. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #225 did not document they were given an option to stay in the facility. The DON said she thought Resident #225 was ready to go home when he was discharged . Resident #225 required additional therapy services and was involuntarily discharged prior to the completion of those services. 2. Resident #227 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #227 was discharged home on[DATE] with outpatient physical therapy, 8 days later. Resident #227's care plan, dated 2/8/19, stated she expressed pain related to her total knee replacement and staff were directed to put ice to her knee and to educate her and her family on pain management. The care plan also stated Resident #227 needed assistance and therapy services to maintain or attain her prior level of function and staff were directed to assess her needs for therapy services. Resident #227's OT plan of treatment, dated 2/9/19, documented the following short-term goals with a target date of 2/22/19. The goals were written as follows: *Safely perform upper body/lower body bathing with stand by assist *Safely perform toileting tasks using raised toilet seat *Safely and efficiently perform upper body dressing *Safely and efficiently perform lower body dressing, including sock/shoes and retrieving all items from closet/drawers *Exhibit a decrease in pain with movement to 3 out of 10, on a 1-10 pain scale with 1 being the lowest and 10 the highest, in the right shoulder to increase patient's ability to perform upper body dressing with set-up *Demonstrate ability to safely complete functional transfers and ambulation up to 100 feet with least restrictive assistive device *Enhance balance abilities An OT discharge summary, dated 2/15/19, documented Resident #227 had made consistent progress with her skilled interventions. Resident #227's PT plan of treatment documented the following short-term goals with a target date of 3/2/19. The goals were written as follows: *Decrease risk of falls *Safely perform functional transfers *Safely ambulate on level surfaces 100 feet using a two-wheeled walker with stand by assist with continuous steps and with normalized gait pattern 85% of the time to increase independence within household environment *Improve her right lower extremity gross strength to 4/5 to allow her to safely ambulate using an assistive device A PT discharge summary, dated 2/14/19, documented Resident #227 had met her short and long-term goals, and she needed a reacher (a long handle with a grabber on one end) and a two-wheeled walker. A social services note, dated 2/15/19 at 4:10 PM, documented the SW told Resident #227 and her family the facility was on a non-payment status due to the result of the facility's revisit survey combined with a complaint survey resulting in 2 minor tags and because of that they have the option of transferring Resident #227 to another facility or home as she was able to ambulate with her front wheeled walker independently. Resident #227 chose to go home with outpatient rehabilitation therapy. On 2/19/19 at 1:38 PM, during a telephone interview, Resident #227's representative said the facility kicked us out. The family representative said they were told by facility staff the facility was not getting paid by Medicare and Resident #227 had to move to another facility or go home. The family representative also said Resident #227 was [AGE] years old and just had knee replacement surgery and he wanted her to stay more days in the facility to complete her physical therapy. The family representative said Resident #227 decided to go home with outpatient physical therapy. On 2/19/19, at 4:17 PM, during a telephone interview, the SW said she told Resident #227 and her family representative the facility was in a non-payment status due to the 2 minor tags the facility received after their revisit survey and Resident #227 had to move to another facility or go home. The SW said Resident #227 was able to use her 2-wheeled walker independently and chose to go home with outpatient physical therapy. 3. Resident #226 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED].#226 was transferred to another facility on 2/14/19, 6 days later. Resident #226's OT short-term goals, dated 2/9/19, with a target date of 2/15/19, included sitting upright in her wheelchair for 1-2 hours, self-perform activities of daily living, and use a bedside commode with one-person assistance. Resident #226's PT short-term goals, dated 2/10/19, with a target date of 3/2/19 and 3/9/19, included increased sitting balance and posture, safely transferring with assistance, and improve bilateral lower extremity strength. Resident #226's OT and PT discharge summary recommendations, dated 2/15/19, documented she was transferred to a sister facility for continued therapy care. Resident #226's physician progress notes [REDACTED]. A social services note, undated, documented the SW told Resident #226's responsible party the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and was not getting paid for Resident #226's stay. The note documented the responsible party and Resident #226 were given the option to transfer her to another rehabilitation facility or discharge her home. The SW documented Resident #226 was going to be provided the same OT and PT and the same doctors if she was transferred to the sister facility. The responsible party and Resident #226 agreed to the transfer. The note did not include documentation an option was given to stay in the facility. Resident #226's Discharge/Transfer Order and Notice of Resident Transfer or Discharge forms, dated 2/13/19 and 2/14/19, documented she was discharged due to CMS denial of payment. Resident #226's nurse progress note, dated 2/15/19, included a late entry for 2/14/19, regarding her transfer. The note documented the responsible party and Resident #226 were given the option to transfer her to a sister facility or another rehabilitation facility. The note documented they chose to go to a sister facility. On 2/19/19 at 1:30 PM, Resident #226's responsible party said the SW informed him and Resident #226 the facility failed an inspection and was not going to get paid for her stay. He said the SW told them Resident #226 needed to be transferred to a sister facility to continue her therapy and care. He said the SW did not offer them any other choice and he would have preferred not to have her transferred because it was closer to him than the sister facility. He said it was inconvenient, but Resident #226 was doing well at the new facility. On 2/19/19 at 4:15 PM, the SW said she spoke to the responsible party and Resident #226 regarding the transfer due to the non-payment status. She said at first, they were confused with the need to transfer and thought she was being kicked out but they were reassured Resident #226 was going to receive the same level of care at the sister facility and then they agreed to the transfer. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #226 did not include documentation the responsible party or Resident #226 was given an option to stay in the facility. 4. Resident #224 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #224 was discharged to another facility on 2/15/19, 8 days later. A Perspective Pay Status assessment, dated 2/14/19, documented Resident #224 was cognitively intact and he required the assistance of 1-2 staff members with activities of daily living and set-up for eating. Resident #224's care plan, dated 2/7/19, documented he needed assistance and therapy services to maintain his prior level of function and staff were directed to assess his needs for therapy and PT and OT services were ordered. A social services note, dated 2/15/19 at 3:10 PM, documented the SW told Resident #224 the facility was in a non-payment status due to the result of their revisit survey combined with the complaint survey resulting in 2 minor tags and Resident #224 had the option to go to their sister facility or go to another facility of his choice. The progress note documented Resident #224 asked the SW if he was going to receive the same kind of therapy at the other facility, and the SW said he would receive the same therapy and the same physician was going to see him at their sister facility. The progress note documented Resident #224 agreed to go to the sister facility. On 2/19/19 at 5:30 PM, the Unit Manager, with the DON, said Resident #224 was not ready to go home and he was given the option to move to their sister facility or to another facility of his choice. The Unit Manager said Resident #224 chose to transfer to their sister facility to continue his therapy.

Based on record review, policy review, family interview, and staff interview, it was determined the facility failed to ensure residents were given at least 30 days notice before discharge and/or the intent to discharge and failed to notify the State Long Term Care Ombudsman. This was true for 6 of 8 residents (#222, #224, #225, #226, #227 & #229) who were admitted to the facility after 2/1/19. Resident #225 was harmed when he was unnecessarily discharged without proper notice and prior to his completion of therapy. The deficient practice had the potential to cause physical or psychosocial harm for residents #222, #224, #226, #227, and #229 when they were not made aware of or able to exercise their rights related to transfers and discharges. Findings include: The facility's Transfers and Discharges policy, dated 9/1/17, documented for facility initiated transfers or discharges, the facility must provide a notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State Long Term Care Ombudsman at least 30 days prior to the discharge. The notice must also be sent to the ombudsman at the same time. Written notice of transfers and discharges from the facility must include contact information for advocacy for individuals with intellectual and developmental disabilities, mental disorders or other related disabilities. This policy was not followed. On 2/19/19 at 4:15 PM, the SW said she was told by the DON and the Administrator on 2/13/19, the facility was not going to be paid for residents who were admitted after 2/1/19, due to the non-payment status. She said she was told by the DON and the Administrator to approach residents and families to transfer the non-payment status residents to a sister facility, transfer to another facility, or discharge home. The SW said on 2/15/19, she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. She said she notified the ombudsman of transfers and discharges at the beginning of each month for the previous month and was not aware facility initiated discharges required a 30 day notice. On 2/19/19 at 5:30 PM, the DON said during a meeting with several staff members, which included corporate staff on 2/13/19, the decision was made to approach residents and family members and initiate transfers and discharges of residents admitted after the facility's non-payment date of 2/1/19. She said the residents and families were to be approached with options to transfer, discharge, or stay in the facility. The DON said she was not personally involved with discussing these options with the residents and/or their family members. The DON said the SW handled notification to the ombudsman and knew she sent a monthly list. The DON said she was not aware prior to a facility initiated discharge a 30 day notice was required. On 2/19/19 at 5:59 PM, the Administrator said there was a meeting with their regional staff on 2/13/19, regarding the results of their revisit survey combined with a complaint survey. He said because of their non-payment status he directed his staff to talk to the residents and their representatives and give them the option to be transferred to their sister facility, stay in the facility, or to go home if they were able to. He said these discharges were facility initiated discharges. The Administrator said the facility did not attempt to discharge or transfer any resident who required peritoneal [MEDICAL TREATMENT] since they had a contract with a local [MEDICAL TREATMENT] center. Residents were not provided at least 30 days notice before their discharge and/or intent to discharge. Examples include: 1. Resident #225 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION], muscle weakness, difficulty in walking, post-traumatic stress disorder, [MEDICAL CONDITION] (brain malfunction), and malignant neoplasm of the brain ([DIAGNOSES REDACTED]). Resident #225 was discharged to home with home health on 2/14/19, 8 days later. A social services note, undated, documented the SW told Resident #225's spouse the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and was not getting paid for Resident #225's stay. The note documented his spouse was given the option to transfer him to another rehabilitation facility or discharge him home. The spouse did not want to have him introduced to a new environment with different staff and was going to take him home with home health. The note did not include documentation an option was given to stay in the facility. Resident #225's discharge summary, dated 2/14/19, documented he was sent home with a referral to a home health agency for outpatient rehabilitation. The summary documented his spouse requested the discharge home after the facility informed them due to the facility's revisit survey, Resident #225 needed to be transferred to a sister facility or another rehabilitation facility. Resident #225's Notice of Resident Transfer or Discharge form, dated and signed by Resident #225's spouse on 2/14/19, documented he was to be discharged on [DATE] due to CMS denial of payment. The notice did not document it was sent to the ombudsman and did not document the correct contact information for the state agency for developmentally disabled residents and the state agency for mentally ill residents. Resident #225's progress note, dated 2/17/19, documented the Regional Director of Business Development called to check on his status at home. The spouse said PT had completed their evaluation and was scheduled to start on 2/18/19 and OT was scheduled to evaluate him on 2/18/19. The spouse was informed if she had any difficulties, Resident #225 was welcome to return to the facility for further care and the spouse denied concerns. On 2/19/19 at 1:10 PM, Resident #225's spouse said the SW had approached her on 2/13/19, to arrange a transfer for him to a sister facility to continue his therapy and care. She said she was told by the SW the facility was in trouble with the state and was not going to get paid for Resident #225's stay, along with 5 other residents. She said she was very upset because Resident #225 needed at least one more week of therapy and they were told he could not remain in the facility that long but could be discharged home with home health and outpatient therapy. The spouse said Resident #225 could not handle the stress to be transferred to yet another facility because the changes were hard on him. The spouse said she had opted to take him home instead and said had he been allowed to stay in the facility, he could have progressed quicker with his therapy. On 2/19/19 at 4:15 PM, the SW said she approached Resident #225's spouse to transfer to another facility because he still needed rehabilitation services and staying in the facility was not an option. She said his spouse chose to take Resident #225 home with home health services and outpatient rehabilitation. The SW said on 2/15/19, she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. Resident #225 was discharged on [DATE]. The SW said she had not notified the ombudsman in writing of Resident #225's discharge. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #225 did not document the spouse was given an option to stay in the facility. The DON said she thought Resident #225 was ready to go home when he was discharged . Resident #225 required additional therapy services and was involuntarily discharged , without proper notice and prior to the completion of therapy services, which resulted in physical harm to him when he was not provided those services. 2. Resident #227 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #227 was discharged home on[DATE] with outpatient physical therapy, 8 days later. A social services note, dated 2/15/19 at 4:10 PM, documented the SW told Resident #227 and her family the facility was on a non-payment status due to the result of the facility's revisit survey combined with a complaint survey resulting in 2 minor tags and because of that they have the option of transferring Resident #227 to another facility or home as she was able to ambulate with her front wheeled walker independently. Resident #227 chose to go home with outpatient rehabilitation therapy. A Notice of Resident Transfer or Discharge Form, dated 2/15/19, documented Resident #227 was discharged home on[DATE], due to her health improving sufficiently that she no longer needed the services provided by the facility. The notice did not document it was sent to the ombudsman and did not document the correct contact information for the state agency for developmentally disabled residents and the state agency for mentally ill residents. Resident #227's clinical record did not include an advance 30 day notice of her discharge. On 2/19/19 at 1:38 PM, during a telephone interview, Resident #227's representative said the facility kicked us out. The family representative said they were told by facility staff the facility was not getting paid by Medicare and Resident #227 had to move to another facility or go home. The family representative also said Resident #227 was [AGE] years old and just had knee replacement surgery and he wanted her to stay more days in the facility to complete her physical therapy. The family representative said Resident #227 decided to go home with outpatient physical therapy. On 2/19/19, at 4:17 PM, during a telephone interview, the SW said she told Resident #227 and her family representative the facility was in a non-payment status due to the 2 minor tags the facility received after their revisit survey and Resident #227 had to move to another facility or go home. The SW said Resident #227 was able to use her 2-wheeled walker independently and chose to go home with outpatient physical therapy. 3. Resident #226 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED].#226 was transferred to another facility on 2/14/19, 6 days later. A social services note, undated, documented the SW told Resident #226's responsible party the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and was not getting paid for Resident #226's stay. The note documented the responsible party and Resident #226 were given the option to transfer her to another rehabilitation facility or discharge her home. The SW documented Resident #226 was going to be provided the same OT and PT and the same doctors if she was transferred to the sister facility. The responsible party and Resident #226 agreed to the transfer. The note did not include documentation an option was given to stay in the facility. Resident #226's Discharge/Transfer Order and Notice of Resident Transfer or Discharge forms, dated 2/13/19 and 2/14/19, documented she was discharged due to CMS denial of payment. Resident #226's nurse progress note, dated 2/15/19, included a late entry for 2/14/19, regarding her transfer. The note documented the responsible party and Resident #226 were given the option to transfer her to a sister facility or another rehabilitation facility. The note documented they chose to go to a sister facility. On 2/19/19 at 1:30 PM, Resident #226's responsible party said the SW informed him and Resident #226 the facility failed an inspection and was not going to get paid for her stay. He said the SW told them Resident #226 needed to be transferred to a sister facility to continue her therapy and care. He said the SW did not offer them any other choice and he would have preferred not to have her transferred because it was closer to him than the sister facility. He said it was inconvenient, but Resident #226 was doing well at the new facility. On 2/19/19 at 4:15 PM, the SW said she spoke to the responsible party and Resident #226 regarding the transfer due to the non-payment status. She said at first, they were confused with the need to transfer and thought the resident was being kicked out, but they were reassured Resident #226 was going to receive the same level of care at the sister facility and then they agreed to the transfer. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #226 did not include documentation the responsible party or Resident #226 was given an option to stay in the facility. 4. Resident #224 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #224 was discharged to another facility on 2/15/19, 8 days later. A social services note, dated 2/15/19 at 3:10 PM, documented the SW told Resident #224 the facility was in a non-payment status due to the result of their revisit survey combined with the complaint survey resulting in 2 minor tags and Resident #224 had the option to go to their sister facility or go to another facility of his choice. The progress note documented Resident #224 asked the SW if he was going to receive the same kind of therapy at the other facility, and the SW said he would receive the same therapy and the same physician was going to see him at their sister facility. The progress note documented Resident #224 agreed to go to the sister facility. A Notice of Resident Transfer or Discharge, dated 2/14/19, was signed by Resident #224. The notice documented Resident #224 was transferred Per CMS denial of payment. On 2/19/19 at 5:30 PM, the Unit Manager, with the DON, said Resident #224 was not ready to go home and he was given the option to move to their sister facility or to another facility of his choice. The Unit Manager said Resident #224 chose to transfer to their sister facility to continue his therapy. 5. Resident #229 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A social services note, dated 2/15/19, documented the SW explained to the family and Resident #229 there were changes regarding a possible transfer to a sister facility and offered for Resident #229 to stay in the facility. A family member said it did not matter to him and asked the SW to ask Resident #229 her choice. Resident #229 said she wanted to stay in the facility and finish her rehabilitation. No other progress notes were found regarding a possible transfer. On 2/19/19 at 3:25 PM, Resident #229's responsible party said the SW informed him on 2/13/19, Resident #229 needed to be transferred to a sister facility on 2/15/19, to continue her therapy and care. He said it did not matter to him where she was moved to. He said on 2/15/19, the SW told him about a new option to have her stay in the facility and he told the SW to ask Resident #229 what she wanted to do. Resident #229 said she wanted to stay. He said he was told by facility staff it was some sort of Medicare mix-up. He said he thought he had signed discharge paperwork but could not be sure. On 2/19/19 at 4:15 PM, the SW said she spoke to Resident #229's responsible party on 2/13/19, regarding the transfer due to the non-payment status. The SW said on 2/15/19, she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. She said she asked Resident #229 her preference and she said she wanted to remain in the facility and was not transferred to the sister facility. On 2/19/19 at 5:30 PM, the DON said Resident #229 was not ready to be discharged and the family was approached to transfer her due to their non-payment status or to stay in the facility and she stayed in the facility. 6. Resident #222 was admitted to the facility on [DATE], and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. A social services note, dated 2/15/19 at 3:56 PM, documented the SW told Resident #222 and her family the facility was in a non-payment status due to the result of the facility's revisit survey combined with a complaint survey resulting in 2 minor tags. The progress note documented the SW spoke to Resident #222 and her family regarding the possibility of transferring her to a sister facility or a facility of their choice. The progress note documented Resident #222's representative considered an assisted living facility but because of the status of her wound, the assisted living facility was not going to accept Resident #222. The progress note documented Resident #222's representatives were called and told she could stay at the facility until she was cleared to go to the assisted living facility. On 2/19/19 at 2:52 PM, during a telephone interview Resident #222's family representative said on 2/13/19, they were told by facility staff the facility was in a non-payment status due to the result of their revisit survey combined with complaint survey resulting to 2 minor tags and they were given the option of transferring Resident #222 to their sister facility or to another facility of their choice by 2/15/19. Resident #222's family representative said they asked the facility staff to give them more time until Monday, 2/18/19, to sort things out. The family representative said the facility staff apologized and said the corporate people were putting pressure on the staff to talk to the residents regarding transferring them to their sister facility, to a facility of their choice, or go home if they were able to. The family representative said they thought of moving Resident #222 to an assisted living facility instead of another nursing facility and started to make arrangements however, they found out the assisted living facility would not accept Resident #222 due to the status of her wound. The family of Resident #222 were advised to transfer her to their sister nursing facility which was next to the assisted living facility. Another family representative joined the telephone interview and said on 2/17/19, they received a call from the facility's Regional Nurse who apologized and said Resident #222 could stay in the facility as long as she needed.

Based on record review, policy review, family interview, and staff interview, it was determined the facility failed to ensure residents were given at least 30 days notice before discharge and/or the intent to discharge and failed to notify the State Long Term Care Ombudsman. This was true for 6 of 8 residents (#222, #224, #225, #226, #227 & #229) who were admitted to the facility after 2/1/19. Resident #225 was harmed when he was unnecessarily discharged without proper notice and prior to his completion of therapy. The deficient practice had the potential to cause physical or psychosocial harm for residents #222, #224, #226, #227, and #229 when they were not made aware of or able to exercise their rights related to transfers and discharges. Findings include: The facility's Transfers and Discharges policy, dated 9/1/17, documented for facility initiated transfers or discharges, the facility must provide a notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State Long Term Care Ombudsman at least 30 days prior to the discharge. The notice must also be sent to the ombudsman at the same time. Written notice of transfers and discharges from the facility must include contact information for advocacy for individuals with intellectual and developmental disabilities, mental disorders or other related disabilities. This policy was not followed. On 2/19/19 at 4:15 PM, the SW said she was told by the DON and the Administrator on 2/13/19, the facility was not going to be paid for residents who were admitted after 2/1/19, due to the non-payment status. She said she was told by the DON and the Administrator to approach residents and families to transfer the non-payment status residents to a sister facility, transfer to another facility, or discharge home. The SW said on 2/15/19, she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. She said she notified the ombudsman of transfers and discharges at the beginning of each month for the previous month and was not aware facility initiated discharges required a 30 day notice. On 2/19/19 at 5:30 PM, the DON said during a meeting with several staff members, which included corporate staff on 2/13/19, the decision was made to approach residents and family members and initiate transfers and discharges of residents admitted after the facility's non-payment date of 2/1/19. She said the residents and families were to be approached with options to transfer, discharge, or stay in the facility. The DON said she was not personally involved with discussing these options with the residents and/or their family members. The DON said the SW handled notification to the ombudsman and knew she sent a monthly list. The DON said she was not aware prior to a facility initiated discharge a 30 day notice was required. On 2/19/19 at 5:59 PM, the Administrator said there was a meeting with their regional staff on 2/13/19, regarding the results of their revisit survey combined with a complaint survey. He said because of their non-payment status he directed his staff to talk to the residents and their representatives and give them the option to be transferred to their sister facility, stay in the facility, or to go home if they were able to. He said these discharges were facility initiated discharges. The Administrator said the facility did not attempt to discharge or transfer any resident who required peritoneal [MEDICAL TREATMENT] since they had a contract with a local [MEDICAL TREATMENT] center. Residents were not provided at least 30 days notice before their discharge and/or intent to discharge. Examples include: 1. Resident #225 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION], muscle weakness, difficulty in walking, post-traumatic stress disorder, [MEDICAL CONDITION] (brain malfunction), and malignant neoplasm of the brain ([DIAGNOSES REDACTED]). Resident #225 was discharged to home with home health on 2/14/19, 8 days later. A social services note, undated, documented the SW told Resident #225's spouse the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and was not getting paid for Resident #225's stay. The note documented his spouse was given the option to transfer him to another rehabilitation facility or discharge him home. The spouse did not want to have him introduced to a new environment with different staff and was going to take him home with home health. The note did not include documentation an option was given to stay in the facility. Resident #225's discharge summary, dated 2/14/19, documented he was sent home with a referral to a home health agency for outpatient rehabilitation. The summary documented his spouse requested the discharge home after the facility informed them due to the facility's revisit survey, Resident #225 needed to be transferred to a sister facility or another rehabilitation facility. Resident #225's Notice of Resident Transfer or Discharge form, dated and signed by Resident #225's spouse on 2/14/19, documented he was to be discharged on [DATE] due to CMS denial of payment. The notice did not document it was sent to the ombudsman and did not document the correct contact information for the state agency for developmentally disabled residents and the state agency for mentally ill residents. Resident #225's progress note, dated 2/17/19, documented the Regional Director of Business Development called to check on his status at home. The spouse said PT had completed their evaluation and was scheduled to start on 2/18/19 and OT was scheduled to evaluate him on 2/18/19. The spouse was informed if she had any difficulties, Resident #225 was welcome to return to the facility for further care and the spouse denied concerns. On 2/19/19 at 1:10 PM, Resident #225's spouse said the SW had approached her on 2/13/19, to arrange a transfer for him to a sister facility to continue his therapy and care. She said she was told by the SW the facility was in trouble with the state and was not going to get paid for Resident #225's stay, along with 5 other residents. She said she was very upset because Resident #225 needed at least one more week of therapy and they were told he could not remain in the facility that long but could be discharged home with home health and outpatient therapy. The spouse said Resident #225 could not handle the stress to be transferred to yet another facility because the changes were hard on him. The spouse said she had opted to take him home instead and said had he been allowed to stay in the facility, he could have progressed quicker with his therapy. On 2/19/19 at 4:15 PM, the SW said she approached Resident #225's spouse to transfer to another facility because he still needed rehabilitation services and staying in the facility was not an option. She said his spouse chose to take Resident #225 home with home health services and outpatient rehabilitation. The SW said on 2/15/19, she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. Resident #225 was discharged on [DATE]. The SW said she had not notified the ombudsman in writing of Resident #225's discharge. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #225 did not document the spouse was given an option to stay in the facility. The DON said she thought Resident #225 was ready to go home when he was discharged . Resident #225 required additional therapy services and was involuntarily discharged , without proper notice and prior to the completion of therapy services, which resulted in physical harm to him when he was not provided those services. 2. Resident #227 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #227 was discharged home on[DATE] with outpatient physical therapy, 8 days later. A social services note, dated 2/15/19 at 4:10 PM, documented the SW told Resident #227 and her family the facility was on a non-payment status due to the result of the facility's revisit survey combined with a complaint survey resulting in 2 minor tags and because of that they have the option of transferring Resident #227 to another facility or home as she was able to ambulate with her front wheeled walker independently. Resident #227 chose to go home with outpatient rehabilitation therapy. A Notice of Resident Transfer or Discharge Form, dated 2/15/19, documented Resident #227 was discharged home on[DATE], due to her health improving sufficiently that she no longer needed the services provided by the facility. The notice did not document it was sent to the ombudsman and did not document the correct contact information for the state agency for developmentally disabled residents and the state agency for mentally ill residents. Resident #227's clinical record did not include an advance 30 day notice of her discharge. On 2/19/19 at 1:38 PM, during a telephone interview, Resident #227's representative said the facility kicked us out. The family representative said they were told by facility staff the facility was not getting paid by Medicare and Resident #227 had to move to another facility or go home. The family representative also said Resident #227 was [AGE] years old and just had knee replacement surgery and he wanted her to stay more days in the facility to complete her physical therapy. The family representative said Resident #227 decided to go home with outpatient physical therapy. On 2/19/19, at 4:17 PM, during a telephone interview, the SW said she told Resident #227 and her family representative the facility was in a non-payment status due to the 2 minor tags the facility received after their revisit survey and Resident #227 had to move to another facility or go home. The SW said Resident #227 was able to use her 2-wheeled walker independently and chose to go home with outpatient physical therapy. 3. Resident #226 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED].#226 was transferred to another facility on 2/14/19, 6 days later. A social services note, undated, documented the SW told Resident #226's responsible party the facility was in a non-payment status due to the result of the facility's revisit and complaint survey which resulted in 2 minor deficiencies and was not getting paid for Resident #226's stay. The note documented the responsible party and Resident #226 were given the option to transfer her to another rehabilitation facility or discharge her home. The SW documented Resident #226 was going to be provided the same OT and PT and the same doctors if she was transferred to the sister facility. The responsible party and Resident #226 agreed to the transfer. The note did not include documentation an option was given to stay in the facility. Resident #226's Discharge/Transfer Order and Notice of Resident Transfer or Discharge forms, dated 2/13/19 and 2/14/19, documented she was discharged due to CMS denial of payment. Resident #226's nurse progress note, dated 2/15/19, included a late entry for 2/14/19, regarding her transfer. The note documented the responsible party and Resident #226 were given the option to transfer her to a sister facility or another rehabilitation facility. The note documented they chose to go to a sister facility. On 2/19/19 at 1:30 PM, Resident #226's responsible party said the SW informed him and Resident #226 the facility failed an inspection and was not going to get paid for her stay. He said the SW told them Resident #226 needed to be transferred to a sister facility to continue her therapy and care. He said the SW did not offer them any other choice and he would have preferred not to have her transferred because it was closer to him than the sister facility. He said it was inconvenient, but Resident #226 was doing well at the new facility. On 2/19/19 at 4:15 PM, the SW said she spoke to the responsible party and Resident #226 regarding the transfer due to the non-payment status. She said at first, they were confused with the need to transfer and thought the resident was being kicked out, but they were reassured Resident #226 was going to receive the same level of care at the sister facility and then they agreed to the transfer. On 2/19/19 at 5:30 PM, the DON said the SW note for Resident #226 did not include documentation the responsible party or Resident #226 was given an option to stay in the facility. 4. Resident #224 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #224 was discharged to another facility on 2/15/19, 8 days later. A social services note, dated 2/15/19 at 3:10 PM, documented the SW told Resident #224 the facility was in a non-payment status due to the result of their revisit survey combined with the complaint survey resulting in 2 minor tags and Resident #224 had the option to go to their sister facility or go to another facility of his choice. The progress note documented Resident #224 asked the SW if he was going to receive the same kind of therapy at the other facility, and the SW said he would receive the same therapy and the same physician was going to see him at their sister facility. The progress note documented Resident #224 agreed to go to the sister facility. A Notice of Resident Transfer or Discharge, dated 2/14/19, was signed by Resident #224. The notice documented Resident #224 was transferred Per CMS denial of payment. On 2/19/19 at 5:30 PM, the Unit Manager, with the DON, said Resident #224 was not ready to go home and he was given the option to move to their sister facility or to another facility of his choice. The Unit Manager said Resident #224 chose to transfer to their sister facility to continue his therapy. 5. Resident #229 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A social services note, dated 2/15/19, documented the SW explained to the family and Resident #229 there were changes regarding a possible transfer to a sister facility and offered for Resident #229 to stay in the facility. A family member said it did not matter to him and asked the SW to ask Resident #229 her choice. Resident #229 said she wanted to stay in the facility and finish her rehabilitation. No other progress notes were found regarding a possible transfer. On 2/19/19 at 3:25 PM, Resident #229's responsible party said the SW informed him on 2/13/19, Resident #229 needed to be transferred to a sister facility on 2/15/19, to continue her therapy and care. He said it did not matter to him where she was moved to. He said on 2/15/19, the SW told him about a new option to have her stay in the facility and he told the SW to ask Resident #229 what she wanted to do. Resident #229 said she wanted to stay. He said he was told by facility staff it was some sort of Medicare mix-up. He said he thought he had signed discharge paperwork but could not be sure. On 2/19/19 at 4:15 PM, the SW said she spoke to Resident #229's responsible party on 2/13/19, regarding the transfer due to the non-payment status. The SW said on 2/15/19, she was informed by the DON residents and families were now being allowed to stay in the facility as an option instead of transferring or discharging residents. She said she asked Resident #229 her preference and she said she wanted to remain in the facility and was not transferred to the sister facility. On 2/19/19 at 5:30 PM, the DON said Resident #229 was not ready to be discharged and the family was approached to transfer her due to their non-payment status or to stay in the facility and she stayed in the facility. 6. Resident #222 was admitted to the facility on [DATE], and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. A social services note, dated 2/15/19 at 3:56 PM, documented the SW told Resident #222 and her family the facility was in a non-payment status due to the result of the facility's revisit survey combined with a complaint survey resulting in 2 minor tags. The progress note documented the SW spoke to Resident #222 and her family regarding the possibility of transferring her to a sister facility or a facility of their choice. The progress note documented Resident #222's representative considered an assisted living facility but because of the status of her wound, the assisted living facility was not going to accept Resident #222. The progress note documented Resident #222's representatives were called and told she could stay at the facility until she was cleared to go to the assisted living facility. On 2/19/19 at 2:52 PM, during a telephone interview Resident #222's family representative said on 2/13/19, they were told by facility staff the facility was in a non-payment status due to the result of their revisit survey combined with complaint survey resulting to 2 minor tags and they were given the option of transferring Resident #222 to their sister facility or to another facility of their choice by 2/15/19. Resident #222's family representative said they asked the facility staff to give them more time until Monday, 2/18/19, to sort things out. The family representative said the facility staff apologized and said the corporate people were putting pressure on the staff to talk to the residents regarding transferring them to their sister facility, to a facility of their choice, or go home if they were able to. The family representative said they thought of moving Resident #222 to an assisted living facility instead of another nursing facility and started to make arrangements however, they found out the assisted living facility would not accept Resident #222 due to the status of her wound. The family of Resident #222 were advised to transfer her to their sister nursing facility which was next to the assisted living facility. Another family representative joined the telephone interview and said on 2/17/19, they received a call from the facility's Regional Nurse who apologized and said Resident #222 could stay in the facility as long as she needed.

Based on staff interview, resident interview, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 18 residents (Resident #10) reviewed for quality of care. Resident #10 was harmed when steps were not taken to determine the cause of her right knee pain for 9 weeks and was subsequently diagnosed as having a medial tibial plateau fracture (break of the upper part of the tibia (shinbone) that involves the knee joint, typically caused by trauma). Findings include: Resident #10 was admitted to the facility under hospice services on 4/12/18 with multiple diagnoses, including severe dysphagia (swallowing difficulty,) [MEDICAL CONDITION]/developmental disability, [MEDICAL CONDITION], and pain in unspecified lower leg. A Potential for Pain care plan, dated 4/12/18, documented Resident #10 stated she has pain in her lower extremities and knees. The approaches included administration of medication, education to resident and family to request pain medication early, observe and report signs and symptoms of pain, and report changes in pain to the physician. An admission MDS assessment, dated 4/20/18, documented Resident #10 was on hospice services, moderately cognitively impaired, dependent on staff for transfers and bed mobility, had frequent pain rated at a 6 on a rating scale of 1-10 (6/10), and did not have a fracture. A Hospice Comprehensive Assessment and Plan of Care Update Report, dated 4/20/18, documented Resident #10 complained of severe right knee pain that was palliated with [MEDICATION NAME]. A Hospice Comprehensive Assessment and Plan of Care Update Report, dated 4/23/18, documented Resident #10 complained of her right knee aching, had been medicated with [MEDICATION NAME] 45 minutes prior to the assessment, and the [MEDICATION NAME] order was changed to every hour. A Hospice Comprehensive Assessment and Plan of Care Update Report, dated 5/5/18, documented Resident #10 exhibited increased pain with movement, she was otherwise calm, and pain decreased when she did not move. An undated Hospice Comprehensive Assessment and Plan of Care Update Report documented Resident #10 complained of right knee pain at 11/10, visual signs were not consistent with the pain score, Resident #10 was distracted with TV and conversation, and did not mention pain again. A physician telephone order, dated 6/22/18, documented Resident #10's hospice care was discontinued with a change in her primary care physician. A nursing note, dated 6/26/18, documented Resident #10's physician ordered a right knee x-ray and [MEDICATION NAME] 1% gel (an anti-[MEDICAL CONDITION] medication) to the affected areas two times daily as needed for pain. An addendum to the nursing note documented the x-ray results were reviewed with Resident #10's primary care provider, and an order for [REDACTED].#10's father was notified of the x-ray results. Resident #10's father told the staff Resident #10 had previously been to an orthopedic physician due to a separated meniscus (C-shaped pieces of cartilage that act like a cushion between the shinbone and thighbone). A bedside x-ray obtained on 6/26/18 documented an acute [MEDICAL CONDITION] medial tibial plateau. A Family Nurse Practitioner (FNP) note, dated 6/29/18, documented Resident #10 had complained of right leg pain while on hospice. Resident #10's knee pain was treated but an x-ray was never ordered to determine the cause of pain. An orthopedic physician Office History and Physical note, dated 7/26/18, documented Resident #10 had suffered some activity with some physical therapy, has had an injury to her knee. The note documented Resident #10 was now following up roughly 5-6 weeks later since initial injury. On 10/22/18 at 1:38 PM, Resident #10 stated she had arthritis in her right knee. Resident #10 stated the pain in her knee was there 24 hours a day. Resident #10 stated she had not had any falls. On 10/26/18 at 3:06 PM, UM #1 stated Resident #10 exhibited pain from the date of admission and it became more severe as time progressed while she was receiving hospice services. UM #1 stated Resident #10 had pain medication provided but it did not help. UM #1 stated she had requested an order from Resident #10's hospice physician to x-ray her right knee, but the request was denied. UM #1 stated Resident #10 had no falls since her admission, had used a Hoyer lift for transfers, and was non-weight bearing. UM #1 was aware Resident #10 had resided at another care facility prior to her hospitalization , and stated they did not call the facility to inquire about any injury or event. UM #1 stated the facility's Medical Director was not approached regarding Resident #10's continued pain or denial of an x-ray order from the hospice physician. On 10/26/18 at 3:45 PM, the DON stated residents on hospice were not treated any differently than anyone else. The DON stated the staff could have gone to the Medical Director and he could have overridden the hospice physician and ordered an x-ray for Resident #10. The DON stated, we thought it was a pathological fracture. Resident #10 experienced ongoing right knee pain, rated by her as 6/10 to 11/10, from no less than 4/20/18 to 6/26/18 (9 weeks and 4 days), without the initiation of medical interventions to determine the cause of the pain and treat it.

Based on observation, interview and record review, it was determined the facility failed to implement policies and procedures and thoroughly investigate abuse and neglect allegations for 1 of 20 (#18) residents sampled for staff treatment. This deficient practice resulted in the potential for psychosocial harm to Resident #18, who reported she was verbally abused by two different staff members and her reports were not thoroughly investigated. Findings included: 1. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 12/18/15, documented Resident #18 received staff assistance with connecting and disconnecting her Peritoneal [MEDICAL TREATMENT] machine. The 1/29/16 MDS coded Resident #18 as cognitively intact. During the group interview on 2/2/16 at 1:00 pm, Resident #18 stated she had an argument with LPN #2 in her room. The resident stated since the incident, LPN #2 no longer worked with her directly, but did work in the dining room during meals on Saturdays and she felt LPN #2 intentionally ignored her and served her last. Resident #18 stated she no longer felt comfortable going to the dining room for meals while LPN #2 was working because it made her feel bad. Resident #18 stated she told administrative staff about her concerns with LPN #2. She said administrative staff's response was to no longer schedule LPN #2 to work with the resident. During an individual interview on 2/4/16 at 2:00 p.m. Resident #18 said she had a confrontation with LPN#2 in her room over having to wait one and a half hours for her [MEDICAL TREATMENT] treatment. She said LPN #2 came into her room with another staff person and told her she would have to wait twice as long now because 2 people needed to be in her room to care for her. Resident #18 said she was very upset and crying after the conversation with LPN #2 and felt the nurse was verbally abusive towards her. Resident #18 said she told the ADON what happened between her and LPN #2. She said the ADON asked her if she could get along with the nurse since she only worked every other Saturday. Resident #18 said she told the ADON she did not feel comfortable with LPN #2 and did not want to work with her. Resident #18 said she still had to interact with LPN #2 in the dining room and she continued to be rude to her. She said she avoided going to the dining room for her meals when LPN #2 worked. During this interview, Resident #18 also stated she had an incident with RN #3 regarding unhooking the resident from her [MEDICAL TREATMENT] machine. The resident said she waited 90 minutes to be unhooked from her machine. She said when RN #3 came to unhook her she was upset and asked why it took her so long to come. RN #3 responded she had come into the room and attempted to wake Resident #18 but she did not awaken. Resident #18 said she told RN #3 she did not attempt to wake her up and that she had been awake the whole time. Resident #18 said when she told RN #3 this, RN #3 replied. I did too try to wake you up. The resident said RN #3 got very close to her face and screamed at her. The resident said she was very upset after the interaction and told the ADON about it. Resident #18 said RN #3 was moved to another hall and did not work with her for about a month. The facility was unable to provide evidence that the two allegations which were reported to the ADON were thoroughly investigated. During an interview on 2/4/16 at 3:15 pm the ADON said if a resident made an accusation or complaint regarding abuse the facility staff would immediately ensure the resident was safe, remove the accused staff person and send them home, report the incident to the DNS, fill out an incident report, interview other staff and residents and assess the resident before allowing the staff to come back on duty. The ADON said she did not document her meeting with Resident #18 regarding LPN #2 or RN #3. She said both nurses were removed from Resident #18's room. The ADON did not consider Resident #18's concerns as allegations of abuse by either nurse and as a result no investigation was initiated.

Based on staff interview and record review, it was determined the facility failed to ensure the physical needs of residents were recognized and thoroughly addressed to maintain their highest practicable physical well-being. This was true for 1 of 7 residents (#17) reviewed during the on-site follow-up survey. The deficient practice resulted in harm to Resident #17, when he did not receive continued antibiotic treatment for [REDACTED]. Findings included: On 4/11/16 Resident #17 was transported to an emergency room , where he was diagnosed with [REDACTED].#17 was treated at the hospital with IV antibiotics and fluids and returned to the facility on [DATE] after refusing admission to the hospital. On 4/20/16, Resident #17 was admitted to the hospital with [REDACTED]. Resident #17's Nurses Notes (NN), Nurse Practioner (NP) notes, lab results, emergency room (ER) records, and hospital records from 4/8/16 to 4/24/16 documented: * NN - 4/7/16 at 11:34 pm: Increased lethargy late in the afternoon, decreased oxygen saturation, and difficulty staying awake. Resident #17 refused transport to the ER twice and the physician (MD) was notified. Vital signs were not documented. * NP #1 - 4/8/16 - Nursing staff report . that (Resident #17) had an issue on 4/7/16 where he was very somnolent and he was having difficulty staying aroused. The resident stated he was extremely sleepy and had felt some chills before this had come on. (On 4/7/16) the resident was noted to have [MEDICAL CONDITION] with a blood pressure of 86/42. Resident #17's BP was later rechecked and was 118/70. * NN - 4/9/16 at 10:44 pm: Resident #17, who had been lethargic and sleepy all day, was observed sleeping in his w/c slumped over with his chin against his chest. He became verbally aggressive towards staff when they offered assistance. Resident #17 dropped his nightly medication and had to be wakened 5 times within a 3-4 minute time span to finish the medications. His vital signs, except blood pressure, were assessed; oxygen saturation was 72% on room air, but rose to 88% after he was provided with oxygen at 2 liters/minute. The MD was contacted and ordered staff to monitor Resident #17 and hold any pain medication if sedation continued. * NN - 4/10/16 at 3:07 am: Resident #17 was sitting in his bathroom at 12:00 am and when the nurse approached the resident to offer assistance, he stated he was ok, he was fine, and did not need help. Resident #17 remained in the bathroom through most of the shift and when his oxygen was checked it was 74% on room air. He was provided with a portable oxygen tank, and remained in the bathroom. The nurse documented, (nursing staff) will check oxygen saturation after the resident is out of the bathroom and back where saturation can be checked. Will continue to monitor. Vital signs were not documented and there was no documentation the MD was notified. * NN - 4/11/16 at 7:00 am: Resident #17, who was sitting in the bathroom, became verbally aggressive towards staff and refused their offers of assistance. Resident #17 presented with tremors, involuntary movement, incontinence of bowel and bladder, confusion with decreased level of consciousness, difficulty following directions, and was unable to stand or bear weight. Vital signs included: Temperature 101.8 F, pulse 108/bpm, respiratory rate 24/minute, blood pressure 93/54 mmHg, and oxygen saturation 74% on room air. The nurse administered Tylenol at 4:00 am and documented at 7:00 am that Resident #17 was afebrile, the NP was notified, and an order was received to monitor the resident. * NP - 4/11/16: Nurse Practioner was asked by staff to assess Resident #17, who was described as being very drowsy, not waking up, having bowel and bladder incontinence. NP #1 was told Resident #17 received Tylenol for a temperature of 101.8 F and that he stated he had some fevers and chills but is feeling fine now. Vital signs included: Blood pressure of 98/45 mmHg, pulse of 108 bpm, respiratory rate of 24/min., and a temperature of 101.8 F. NP #1 documented, It seems (Resident #17) is developing signs and symptoms [MEDICAL CONDITION] with his febrile illness, [MEDICAL CONDITION] and [MEDICAL CONDITION] but I am not certain as to the source of this yet and Stat (immediate) laboratory studies were ordered. * NN - 4/11/16 at 4:30 pm: Resident #17 was observed with shakes, chills, had returned to his confused state, continued to be incontinent, continued to nod off frequently, and had a temperature of 94.6 F. NP #1 was contacted and Resident #17 was transported to the ER for a blood draw, evaluation, and treatment. * An emergency room report, dated 4/11/16, documented: - 1:51 pm - Blood pressure of 128/64 mmHg, pulse of 109/bpm, respiratory rate of 22/minute, oxygen saturation of 93% on 3 liters, and a temperature of 103.1 F. - 1:55 pm - Multiple blood tests were drawn, including blood cultures. - 2:25 pm to 3:00 pm - The hospital lab reported to the ER physician that Resident #17 had critical potassium and lactic acid levels, additional blood cultures were pending. - 3:00 pm - The ER physician documented, It was at this point the resident was identified as having shock secondary [MEDICAL CONDITION]. - 3:17 pm - The ER physician and the facility MD discussed Resident #17's history, diagnostic assessments, findings, and diagnosis. The ER physician stated Resident #17 was adamant that he does not want to stay in the hospital and wants to be sent back to the facility. Resident #17 stated he was willing to accept the antibiotics that were prescribed and some IV fluids in the ER, but did not want continued therapy in the hospital. The ER physician told Resident #17 that should he discharge him back to the facility there is strong possibility he could die secondary [MEDICAL CONDITION]. The ER physician noted the facility MD felt that the patient should be discharged back to the facility . and asked that the IV remain in and the IV antibiotics and fluids be given prior to the patient being sent back. - 3:42 pm - Resident #17 received antibiotic [MEDICATION NAME] via IV. - 4:27 pm - Resident #17 received antibiotic [MEDICATION NAME] via IV. - 6:30 pm - The IV was removed from Resident #17. * NN - 4/11/16 at 7:50 pm: Resident #17 returned to the facility with orders to follow-up with his primary physician. The hospital reported he had a [DIAGNOSES REDACTED]. * An emergency room note, dated 4/12/16 at 6:07 am, documented the facility was contacted and staff were informed that Resident #17's blood cultures showed signs of infection. Facility staff stated Resident #17's POST stipulated he was to receive comfort care only with no antibiotics. Resident #17's facility record did not include documentation of this contact. * On 4/13/16, NP #2 documented, Staff noted the resident has a POST form for comfort only with no antibiotics and no IV fluids but the resident has been pursuing active treatment and they would like to have a discussion with him. The assessment/plan section of the note stated the POST was discussed with Resident #17. He stated he wanted to be DNR but did want antibiotics and IV fluids and would fill out a new POST form. The note also stated, (There are) also concerns over whether or not he should be on continued antibiotics. The note did not document whether NP #2 addressed continued antibiotic treatment. * A emergency room note, dated 4/14/16, documented: - 7:29 am - Blood cultures were positive for Extended Spectrum Beta-Lactamase Escherichia coli infection and included a list of antibiotics for treatment of [REDACTED]. - 10:09 am - Hospital staff documented the facility was contacted and was aware of the positive blood cultures. Resident #17's clinical record did not include documented assessments by an NP, MD, or nursing related to the infection, monitoring vital signs, and follow-up on the positive blood cultures from 4/14/16 until 4/18/16. * On 4/18/16, NP #1 documented Resident #17 was diagnosed with [REDACTED]. NP #1 noted, It was believed the antibiotic would be continued at the facility. * A NN, dated 4/20/16, documented Resident #17 was transported to the hospital per his request due to a temperature of 103.1 F and a pulse of 122 bpm, and was admitted for [MEDICAL CONDITION]. * A hospital History and Physical, dated 4/20/16, documented Resident #17 had [MEDICAL CONDITION] with an underlying cause related to Extended Spectrum beta-Lactamase bacteremia Escherichia coli based on blood cultures from 4/11/16. The History and Physical documented, As far as I can tell, he was not on medications to treat this. The patient meets [MEDICAL CONDITION] criteria and is at risk for progression to septic shock or death. * A hospital Discharge Summary, dated 4/23/16, documented, On 4/11/16 the patient presented to the emergency room with shaking, chills, a cough, and met the criteria for [MEDICAL CONDITION]. The emergency room was notified by the lab and subsequently documented a call on 4/12/16 at 6:07 am to the facility staff to notify them of the finding of positive blood cultures. Actions thereafter are unknown, as review of nursing progress notes from the facility for that day do not document the call. Regardless, the patient eventually returned to the emergency roiagnom on [DATE] for [MEDICAL CONDITION] oxygen desaturation, fever, and altered mental status. * On 4/25/16, NP #1 documented, Nursing staff reported the hospital was quite angry as we had not provided treatment for [REDACTED]. after his last emergency room visit. Nursing staff inform me that (they) were never informed the resident had an infection by the emergency room , we never received a phone call or follow-up on his labs. On 5/11/16 at 11:10 am, NP #2 was asked about the reason Resident #17 was not administered antibiotics for the positive blood cultures. NP #2 stated, The emergency room did not inform the facility that further antibiotic treatment was needed. The NP stated it was the hospital's responsibility to notify the facility of positive lab results and/or critical lab values. NP #2 stated it was determined on 4/13/16 that Resident #17 did not require antibiotics. When asked if she had reviewed the emergency room report for Resident #17, NP #2 stated she had not because the facility did not have it. On 5/11/16 at 4:00 pm, NP #2 was asked if the facility had a policy and procedure for following up on emergency room reports, hospital records, and/or lab results. NP #2 stated the facility did not have such a policy. On 5/11/16 at 4:15 pm, the facility MD was asked about Resident #17's 4/11/16 emergency room visit. The MD stated the emergency room had not informed him that blood cultures were drawn on Resident #17. The MD stated the emergency room physician informed him only that Resident #17 did not want to be admitted to the hospital nor was there any reason to admit him. The MD stated the emergency room physician informed him that Resident #17 would receive some fluid and then return to the facility. The MD stated he was not sure if he was even informed about Resident #17 needing antibiotics. The emergency room report was then read to the MD. The MD stated none of that information had been reported to him. When asked if he was informed on 4/14/16 of the positive blood cultures for Resident #17, the facility MD stated he was not provided with the results. When asked if Resident #17 should have received antibiotic treatment based on the positive blood culture results, the MD stated it depended on whether the resident was symptomatic or not and he would need to look at the resident to determine whether the antibiotics were necessary. The physician stated the NP saw Resident #17 on 4/13/16 and determined the resident was asymptomatic. When asked what the facility's policy and procedure was for following up on emergency room visits and/or hospital admission, the MD stated he participated in the development of policies and procedures for the facility, but was not aware of one related to the transfer of information between the facility and the hospital. When asked if he saw Resident #17 after the 4/11/16 emergency room visit and/or the 4/20/16 hospital admission, he stated his NP, rather than him personally, saw Resident #17 at those times. Resident #17's facility record did not include documentation by the facility's MD regarding his discussion with the ER physician. On 5/11/16 at 4:45 pm, the DNS was asked how the facility received and processed verbal or faxed information from outside providers. The DNS stated Medical Records staff delivered faxes to the nurse on the floor for review. She stated the nurse reviewed and noted the faxed information and any pending labs were documented in a book for follow-up by the facility. She stated critical labs or positive cultures were reported to the physician for orders. On 5/11/16 at 5:00 pm, Medical Records Staff #1 was asked how the facility received and processed faxed information from outside providers. Medical Records Staff #1 stated providers/hospitals were given a few days to generate the report(s), which were then given to the DNS for review. Medical Records Staff #1 stated she did not recall when Resident #17's ER/hospital/lab report were requested or received. The facility failed to develop and implement written policies and procedures to ensure communication with other healthcare providers was received, documented, and follow up on. Resident #17 was harmed when he failed to receive necessary treatment for [REDACTED].

Based on observation, record review, and staff interview, the facility failed to ensure 2 of 7 (#s 9 & 11) sampled residents were adequately supervised to prevent falls. Resident #9 was harmed when the facility failed to prevent or adequately supervise the resident resulting in multiple falls, including a fall with fracture requiring hospitalization . Resident #11 sustained injuries including a laceration, skin tear, and swelling from multiple falls. Findings included: 1. Resident #9 was admitted to the facility 11/3/14 with [DIAGNOSES REDACTED]. The most recent annual MDS, dated [DATE], documented the resident was not able to be interviewed but had no problems with long- or short-term memory and had modified independence with decision making. The resident required extensive assistance with transfers, did not ambulate in her room, and had multiple falls since the last assessment, including one with a major injury. The most recent quarterly MDS assessment, dated 8/13/15, documented the resident was cognitively intact, required extensive assistance for transfers and had multiple falls since the previous assessment with no injuries. The DNS provided a document that had a list of the falls the resident had from 11/17/14 until 1/2/16, a total of 17 falls. Review of the falls that had occurred in the previous 6 months revealed that the facility documented the falls, then wrote in the recommendations/ actions portion of the incident reports what they were to do. Interviews with the resident were not included as part of the investigation to implement actions to prevent further falls, and no root cause analysis of the multiple falls was documented. The fall investigations and conclusions included: - NN 8/30/15 at 7:03 am, Staff heard calls coming from resident's room, Resident found in room sitting on floor near bed, leaning on left elbow. Stated she was reaching for tissues . The corresponding incident report documented: Resident walking with RNA. Are having (name of mental health group) come in for (psychiatric evaluation) (No explanation provided as to how this was determined as a pertinent fall prevention measure). (Family member) does not want walker used in room, will discuss fall prevention with son and staff regarding putting safety equipment within reach for safety and self-transferring. - NN 9/13/15 at 6:40 pm, This nurse was walking down the hall looked into resident's room and saw that she was sitting on the floor between her wheelchair and bed. She was more on her right hip facing her bed. The corresponding incident report documented: Resident would not let a sitter be around her. Will do (urinalysis). Alarm would scare her. (Family member) refused to send her out for (psychiatric evaluation) . - 9/22/15 at 9:45 am, the IDT met to discuss the recent falls the resident had. The documentation lacked any reference or documentation to show staff were trying to determine the root cause of the frequent falls. The decision documented, Will increase supervision to 15 minute checks for safety as resident has had repeat falls. Review of the resident's care plan revealed it was not revised, (Refer to F280) and at the time of the survey, the care plan continued to call for checks on an hourly basis, rather than the additional supervision of 15-minute checks. The nursing staff documented the resident was self-transferring or found walking in her room and hallway without supervision on 10/3/15, 10/10/15 (three times), 10/16/15, 10/22/15, and 10/27/15. On 11/7/15 at 10:33 am, a NN documented, At 9:45 am CNA alerted this nurse that resident is on the floor. This nurse went to room noted resident lying on the floor on her right side. Resident was going through her roommate's dresser before the fall. Resident took all her roommate's belonging from dresser and put them on the floor. Resident lying on the floor on a bedside mat for her roommate. Assessed resident for ROM and injuries. Resident refused ROM no visible injuries noted. Floor with clutter due to resident had put stuff form (sic) dresser. Resident transferred to bed with assist of 4 person due to not tolerating transfers well .gait unsteady . Further review of the clinical record revealed that as a result of this fall, the resident sustained [REDACTED]. The resident was readmitted to the facility on [DATE] and was in a wheelchair with few attempts to stand or transfer until incident reports documented: 11/30/15 at 9:20 am, Resident yelling help me and found him (sic) on her hands and knees on the floor. Recommended interventions were: Lipped mattress placed on bed. Continues with 15 minute checks . 12/26/15, no time documented, Resident found on floor in room stated she was reaching for something and slipped off of bed. Recommended interventions were: Will educate staff to assist resident with needs after meals . 1/2/16 , no time documented, Resident fell forward in wheelchair in hallway, stated she was attempting to pick up a book. No book in sight. Balance in chair compromised due to kyphosis. Recommendations were: 1) OT to eval WC for appropriateness, 2) will initiate sitter in evening. The resident's clinical record contained multiple documentations by nursing staff where the resident was found standing, ambulating and leaning out of the wheelchair almost falling. Review of the fall risk assessments completed after the recorded falls revealed the resident was at high risk for falling, with an increase in her risk score between 11/30/15 and 1/2/16. The resident's care plan for falls, dated 11/3/14 documented, at risk for fall related injury as evidenced by hx of fall with left hip pinning required, and At risk for falls r/t impaired mobility, Parkinson's disease, fall risk score and hx of osteoporosis. Resident will independently self-transfer without calling for assistance. The second problem, added 8/26/15, documented, Normal progression of disease process with unavoidable and/or predictable decline. The third problem, added 11/16/15, documented, Recent readmit with dx right femoral fracture with replacement and HTN. The fourth problem, dated 12/21/15, documented, WBAT to right LE precautions. The care plan had more than twenty interventions; most of the interventions could not be determined whether they made a significance in preventing the resident from falling or when they were initiated for the resident. Interventions the facility had in place at the time of the survey were: - Provide/observe use of adaptive devices · Walker · Wheelchair with auto locking brakes. 5/13/15 - Remind resident and reinforce safety awareness · Lock brakes on bed, chair, etc. before transferring · Educate remind resident to request assistance prior to ambulation · Appropriate footwear · Other: Non-skid socks - Extensive assist of one person to transfer from bed to chair and back - Staff to check resident every hour and monitor for pain, toilet repositioning, and fluid needs (4 P ' s) 12/13/14 - Rug at bedside to prevent sliding - Low bed in place with lipped mattress. 11/18/14 - Do not leave alone in bathroom or on bedside commode - Falling star/leaf program - Continue to educate staff to assist with needs after meals. 12/28/15 - Assure items are within reach at resident ' s level, 12/28/15 - RNA program per plan of care 1/15/16. Anaother Falls care plan problem area, dated 1/2/16, documented, At risk for fall injury as evidenced by: previous fall . Normal progression of disease process with unavoidable and/or predictable decline. The care plan provided a space for the disease process(es) to be listed, but that space was blank. The interventions were: - Report falls to physician and responsible party. - Remind resident and reinforce safety awareness: ·Educate/remind resident to request assistance ·Other: will start sitter female in the evening. Therapy to reeval(uate) for positioning. The DON provided a document, dated 12/11/15 that documented, . (R #9) has a history of delusions which have caused psychosocial distress and falls. She believes that her stuffed bear and her stuffed cat are real .She climbs on the floor and crawls around to find her cats .We have assessed the need for a 1:1 sitter and due to resident's paranoia and delusions we have determined that a 1:1 would not benefit for her. At the time of the survey, the resident had a sitter in the evening. Observation of Resident #9 on 2/2/16 at 12:20 pm revealed the resident was up and propelling her wheelchair throughout the facility. No supervision was provided as the resident propelled herself out of the restorative dining room and headed toward her room. On 2/4/16 at 12:30 pm, the resident was observed sitting in her wheelchair outside her room. No staff were observed to be present to provide supervision. On 2/3/16 at 2:30 pm, the DNS and ADON asked to provide evidence that the 15-minute supervision checks were completed after the need was identified on 9/22/15, as well as information about the date when the resident actually started with a sitter. The supervision checks were provided and revealed they were being completed hourly, not every 15 minutes as recommended by the IDT in 9/22/15. The sitter was started on 1/2/16 with the resident; however only on afternoons. 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 11/24/15, documented the resident had moderately impaired cognitiom and required limited assistance with transfers and ambulation. The resident had multiple falls since the previous assessment with minor injuries. Resident #11's care plan for falls had multiple problems listed. The first problem, dated 10/21/14, documented, (R #11) is at risk for falls r/t impaired vision, dementia, depression unsteady gait at times, hx of falls, and fall risk score assessment 25. (R #11) is taking antipsychotic and antidepressant medications, ASE of these medications inclluded increase risk of falls. The second problem, dated 1/29/15, documented, Family encouraged to bring in non-skid slippers secondary to non-compliant with calling and waiting for assistance. Resident has poor safety awareness, poor insight to own limitations. The third problem, dated 5/27/15, documented, Resident awaiting for memory care placement, on waiting list. The fourth problem, dated 12/7/15, documented, Resident has hx of frequent falls. The resident's current care plan documented 28 interventions with several that had multiple components to them. Most of the interventions were the same as those listed in example #1 of this deficiency. The different interventions of significance were: - (Name) has 1:1 sitter from 7am to 9pm for added supervision, then on every 15 minute checks when sitter is not with her. (8/26/15) - Staff to stay with her when she is toileting, as resident allows. (9/18/15) - Staff to look in on (R #11) when passing room, assessing safety and potential needs, continue with 15 minute checks. (5/27/15) - Auto lock brakes to W/C. (9/18/15) - (Name) has a history of crawling around on the floor looking for items. (No date) - Encourage resident to eat in hallway by nurse's station as she allows for increased supervision. (9/18/15) Review of the resident's record for documentation of falls revealed a history of falls, including the following: - 8/25/15 at 9:24 pm, Nurse said that she was walking past her room and saw resident on the floor sitting with her head against her bed and her feet out in front of her. ROM WNL and no complaints of pain. However she has a laceration on the back of her head, bottom right (behind her ear and a little bit down.) Resident reported no pain. Resident said that she was 'putting her tissue away.' Nurse cleaned her up and noticed that it was about 1/4 inch long . - 8/27/15 at 9:47 pm, .Resident assisted to floor after losing balance in hallway. Resident with dementia, blind, and poor safety awareness. 15 minute checks in place . - 9/10/15 at 5:43 pm, at approx., 4:45 pm this nurse was alerted that resident was on the floor in the hallway by her room. When this nurse arrived, resident had been assessed by another nurse and staff was assisting the resident off the floor . - 9/19/15 at 11:27 pm, At approx. 5 pm another nurse heard a 'thud' while standing at nurses station, she looked to her left and noted resident on the floor in front of outside door . The location where the resident was found was on a different unit within the facility from where she resided. - 10/10/15 at 3:19 pm, .at 1240 this staff heard a loud thud and returned to room with co-worker nurse. Resident was sitting on the floor with her back against the wall. Stated that she was attempting to go wash face. Stated she hit her head - 10/19/15 at 10:17 pm, Hears noise and when staff entered room, res lying on floor next to rolling table on left side/back. Swelling around right eye starting. Res bleeding from skin tear 1.5 cm over right eye, 1/8 cm skin tear to bridge of nose and 2 cm skin tear to rt wrist . - 10/20/15 at 9:53 pm, At approx(imately) 3:15 pm this nurse was alerted to resident's room. This nurse observed resident sitting on the floor legs out and both hands on the floor, there was a health shake on the floor to the left of her and a puddle of it next to the container . Review of facility documentation did not reflect if the resident had sitters or whether they had been in place when the six falls occurred after 8/26/15. In addition, since the resident's last fall on 10/20/15, the resident's record also contained documentation where she was found ambulating in her room and hallways on many occasions, although, per the care plan, a sitter was to be present as an intervention to prevent accidents. The DON was interviewed on 2/4/16 at 11:00 am about the resident's multiple falls and injuries, which included skin tears, lacerations, and swelling. The DON was also interviewed about the lack of 15 minute checks and a sitter as were care planned for this resident. The DON stated the sitters were not CNAs so were only to observe and remind resident not to stand and walk around because sitters have no training in caring for personal needs and transferring a resident.

Based on observation, record review and staff interview, it was determined the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop 2 unstageable pressure ulcers to the heels, and residents who entered the facility with pressure ulcers received initial assessments and weekly assessments of those existing pressure ulcers. This was true for 3 of 3 (#s 3, 5 & 16) sampled residents reviewed for pressure ulcers. Resident #3 was harmed when he developed bilateral unstageable pressure ulcers to the heels less than 3 months after admission to the facility, which prolonged the timeframe in which he could receive bilateral hip surgery to relieve pain caused by chronic [MEDICAL CONDITION]. In addition, the failed practice created the potential for harm when Resident #5 did not receive an initial pressure ulcer assessment, and Resident #16 did not receive weekly pressure ulcer assessments. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #3's admission MDS assessment, dated 1/3/14, documented: * Intact cognition with a BIMS of 13; * Extensive assistance needed with 2 or more people for bed mobility, transfers, dressing and toilet use; * Range of motion impairments to bilateral lower extremities; and, * At risk for pressure ulcer development with no pressure ulcers on admit. Resident #3's most recent quarterly MDS assessment, dated 3/31/14, documented: * Intact cognition with a BIMS of 15; * Total assistance needed with 2 or more people for transfers; * Extensive assistance needed with 2 or more people for bed mobility, dressing and toilet use; * Range of motion impairments to bilateral lower extremities; and, * Two unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. A Pressure Ulcer Prevention Checklist for Resident #3, dated 12/24/13, documented interventions of, "Preventative mattress/overlay (pressure reduction); Turn & reposition schedule (Q (every) 2 Hours); Initiate weekly skin integrity assessment check form; Physical/Occupational/Speech Therapies consult(s)." Note: "Elevate heels off bed surface" was not ordered or checked on the form. The Initial Care Plan for Resident #3, dated 12/27/13, documented: * Resident Need - "At Risk for Break in Skin Integrity;" * Interventions - "Pressure reduction mattress; Elevate heels off bed surface and 'float' heels- no pressure on heels; Weekly skin check; Therapy consult: PT/OT (Physical Therapy/Occupational Therapy); Bariatric bed to enhance bed mobility; DM (Diabetes Mellitus) foot checks daily; DM nail care by LN." The Care Plan for Resident #3, dated 12/24/13, documented: * Problems - Self care deficit r/t (related to) dx (diagnosis) of [MEDICAL CONDITION], difficulty in walking, pain and limited physical mobility r/t [MEDICAL CONDITION]; * Approaches - 1/4 SR (side rails) x 2 to assist with bed mobility; Requires extensive 1-2 person assist with bed mobility, dressing, toileting, and personal hygiene depends on staff needs.; Overbed trapeze to assist with bed mobility; * Problems - At risk for impaired skin integrity r/t dx of DM, restricted mobility, dx of difficulty in walking; * Approaches - Special protective devices used: pressure reducing mattress, cushion to wheelchair; LN will evaluate weekly; DM foot checks daily. A February 2014 Monthly Flow Report for Resident #3 documented repositioning every 2 hours. There is a row for the day shift, evening shift and night shift to chart repositioning occurred every 2 hours and was as follows: * Day shift repositioning occurred 5 times for the month of February on 2/3/14, 2/8/14, 2/22/14, 2/24/14 and 2/27/14; * Evening shift repositioning occurred 10 times for the month of February on 2/14/14-2/16/14, 2/18/14, 2/21/14-2/25/14 and 2/28/14; * Night shift repositioning occurred 1 time for the month of February on 2/16/14. Note: Boggy and red heels were noted on 2/19/14. The resident was not repositioned on 2/17/14, was repositioned during the evening shift on 2/18/14, and was not repositioned on 2/19/14. The following documentation was gathered from Resident #3's Progress Notes (PN), Nurse Practitioner Office Progress Notes (NPPN), Pressure Ulcer Status Records (PUSR), Physician order [REDACTED]. 12/25/13 - WSIDC, Bilateral heels intact and free from redness; 12/26/12 - MD orders, Check skin every week in the evening; 12/30/14 - MD orders, Over bed trapeze to aid in bed mobility; 12/30/13 - TAR, Diabetic foot checks every day. (Note:Initials documented this was completed every day for the month of February 2014 and March 2014); 12/31/13 - MD orders, Diabetic foot check every day - day shift; 1/13/14 - MD orders, Ensure liquid lactose free liquid. Drink 237 ML (milliliters) every day as a replacement for noon meal; 2/13/14 - WSIDC, Bilateral heels intact with no redness noted; 2/19/14 - PTDTN, "...Redness/purple coloration/depression [MEDICATION NAME] longer than 15 min(utes) noted on bilateral heels...PT consulted with nursing/OT (Occupational Therapy) staff about such coloration/depression on bilateral heels. End of bed bolster put in pt's (patient's) bed to prevent further coloration/depression. Importance of bed repositioning throughout day to prevent further coloration/depression briefly discussed with pt..." 2/19/14 - TMD orders, Heel foam lift, when in bed to promote skin integrity; 2/19/14 - TAR, Heel foam lift when in bed r/t skin integrity. This was discontinued on 2/24/14. (Note: This was written as an FYI (For Your Information) and did not require initials); 2/20/14 - WSIDC, Bilateral heels dry and intact; 2/24/14 - TMD orders, Discontinue heel foam list device. Prevalon boots while in bed; - MD orders, Prevalon boots while in bed, monitor for placement document refusals by circling; 2/24/14 - CP revision, "Prevalon boots in bed;" 2/24/14 - TAR, Prevalon boots while in bed. (Note: This was written as an FYI and did not require initials); 2/27/14 - WSIDC, Bilateral heels red and intact; 3/6/14 - WSIDC, Bilateral heels intact with no redness noted; 3/13/14 - WSIDC, Bilateral heels red and intact; 3/17/14 - CP revision, "Bariatric air mattress for skin integrity antisheer surface;" 3/18/14 - NN, "Patient identified to have impaired skin integrity to bilateral heels. Right heel noted to have an 0.8cmx1.5cm deep purple intact area. No drainage or [DIAGNOSES REDACTED] noted. Left heel noted 1.8cmx1.5cm intact deep purple area. No drainage or [DIAGNOSES REDACTED]. Patient denied pain with wound assessment although has pain with turning and repositioning. patient has end stage arthritis pending hip replacement. Patient has had recent weight loss which is intentional secondary to pending surgery. No [MEDICAL CONDITION] to bilateral lower extremities. Patient has oral controlled diabetes. Patient was identified to have mushy heels on 2/19/14 where heels foam lift was initiated and changed to prevalon boots on 2/24/14 due to inability to tolerate heels foam lift. Patient stated that he rubs heels back (and) forth on mattress when he gets charlie horses and feels wounds are secondary to the back and forth rubbing. Airbed was placed with antisheer surface. Patient educated regarding importance of elevating heels and current plan of care with treatment. Will have dietary interventions evaluated. Will continue to monitor;" 3/18/14 - PUSR, First date of observation, Unstageable due to the coverage of wound bed by slough and/or eschar, Location: Right heel, Surface Area (Length x width): 0.8 cm x 1.5 cm with no depth, Debridement required: Yes, % of Necrotic Tissue: 100%; - First date of observation, Unstageable due to the coverage of wound bed by slough and/or eschar, Location: left heel, Surface Area (Length x width): 1.8 cm x 1.5 cm with no depth, Debridement required: No, % of Necrotic Tissue: 100%; 3/18/14 - MD orders, Full air mattress, dx: Skin integrity; - TMD orders, Prevalon boots while in bed, monitor for placement document refusals by circling initials; [MEDICATION NAME] PO (by mouth) mixed in fluid of choice three times daily; 3/18/14 - CP revision, "Problems - Alteration in skin integrity: suspected, deep tissue injuries to bilateral heels;" "Approaches - Wound care as ordered. Observe effectiveness of/response to treatment as ordered; Prevalon boots while in bed; Bariatric air bed with antisheer surface; Encourage resident to wear prevalon boots; and [MEDICATION NAME] per MD order;" 3/18/14 - TAR, Prevalon boots while in bed, monitor for placement, document refusals by circling initials. (Note: No refusals were documented on the TAR for the month of March); 3/20/14 - WSIDC, Bilateral heels red and intact; 3/20/14 - PUSR, Right heel, unstageable, 0.8 cm x 1.5 cm, no depth, 100% necrotic (eschar), no change in response to treatment; - Left heel, unstageable, 1 cm x 1 cm, no depth, necrotic, debride by NP, improved; 3/20/14 - PN, "Wound Assessment... Right heel measured 0.8cmx1.5 cm with no measurable depth. Wound noted to be 100% necrotic tissue with small amount of serousangeous drainage. Periwound intact with dry flaky skin. NO s/sx (signs and symptoms) of infection. Wound to left heel measured 1cmx1cm with 100% necrotic tissue. No periwound [DIAGNOSES REDACTED] or drainage. Patient wearing prevalon boots and was started on [MEDICATION NAME] to support wound healing. Airbed in place. Patient provided with education regarding importance of elevating heels. Patients pain medications were adjusted due to patient stated that when he has muscle spasms he rubs his heels back and forth which may attribute to cause. Will continue to monitor; 3/20/14 - NPPN, History of Present Illness: "...About a month ago was noted to be at boggy heels and efforts were made at that time to offload. He has Prevalon boots in place as well as an air mattress. They were trying to turn him but again, the patient has significant pain...He does not have a history of issues with wound healing per the patient," Assessment: "Unstageable pressure ulcers of the heels," Plan: "Due to significant devitalized tissue in heels, he did require a superficial debridement with a 5 mm (millimeter) curet to remove devitalized tissue. Post-debridement measurements essentially remained the same, except for the depth that is about 0.1 or less bilaterally. There was no bleeding, some devitalized tissue remains in both heels and I stopped due to patient discomfort. The facility has done a good job offloading him, unfortunately he developed these rather quickly and progressed rather quickly. We will continue to have the Prevalon boots and the air mattress in place. We will utilize simple cover dressings and continue to try and turn him frequently;" 3/27/14 - WSIDC, Bilateral heels red with old open areas. 3/27/14 - PUSR, Right heel, unstageable, 1 cm x 1.2 cm, no depth, 100 % necrotic with periwound maceration, no change; - Left heel, unstageable, 1.5 cm x 1.5 cm, no depth, 100% necrotic, no change; 3/27/14 - PN, Wound Assessment: Patient laying in bed with prevalon boots and heels elevated. Dressings removed for assessed. Wound to right heel measured 1cmx1.2cm with no measurable depth. Wound bed covered with 100% moist necrotic tissue. Periwound noted to have maceration. Moderate amount of serous drainage. Wound to left heel measured 1.5cm x 1.5cm with no measurable depth. Wound bed covered with 100% moist necrotic tissue. Small serous drainage. periwound noted to have light purple bruising. no undermining or tunneling noted. Patient continues to receive [MEDICATION NAME] to support wound healing. Patient has adequate offloading measures in place include airbed with antisheer surface, prevalon boots, elevation of heels, and trapeze to aide in bed mobility. Per interview of nurse patient has been observed removing prevalon boots and rubbing heels on bed. Nurse states she provided on the spot education regarding importance of prevalon boots. Wound heeling (sic) complicated by DM, pain with mobility secondary to bilateral hip arthritis. Will request alternate treatment orders due to masceration (sic). Will continue to monitor;" 4/3/14 - PUSR, Right heel, unstageable, 1.5 cm x 1.2 cm, no depth, necrotic with decreased periwound maceration, improved; - Left heel, unstageable, 1.5 cm x 1.5 cm, no depth, necrotic, improved; 4/3/14 - PN, "Wound Assessment: Wounds to bilateral heels assessed. Wound to Rt (right) heel measured 1.5cmx1.2cm with no measurable depth. Wound bed noted to have 100% eschar with periwound bruising noted. Wound edges noted to have decreased maceration. Wound to Left heel measured 1.5cm x 1.5cm with no measurable depth. Wound bed noted to have 100% eschar. Wound noted to have decreased maceration to wound edges. No drainage or s/sx of infection. Patient has adequate offloading interventions in place including airbed, prevalon boots. Patient receiving adequate pain control although turning and repositioning continues to be difficult. patient receiving [MEDICATION NAME] to support wound healing. patient has difficulty turning and repositioning secondary to severe arthritis to bilateral hips. Wound healing impeded by [MEDICAL CONDITION], Non-insulin dependent DM. No concerns at this time. Will continue to monitor;" 4/10/14 - PUSR, Right heel, unstageable, 1 cm x 1.5 cm, no depth, necrotic, improved; - Left heel, unstageable, 1 cm x 1.5 cm, no depth, necrotic, improved; 4/10/14 - PN, "Wound Note: (Nurse Practitioner's name) present for wound assessment. Wound to right heel measured 1cmx1.5cm with 100% eschar secured to wound base. Periwound noted to have a 1.5cm area of maceration. Small amount of serous drainage. No odor or [DIAGNOSES REDACTED] noted to periwound. Patient denied pain with wound assessment. Wound to left heel measured 1.5cmx2cm with no measurable depth. Wound bed covered with 100% secure eschar. Periwound intact with no s/sx of [DIAGNOSES REDACTED] or infection noted. New treatment orders obtained. Adequate offloading measures in place including prevalon boots, bariatric airbed, and trapeze to aide in bed mobility. Patient provided with education regarding wound healing. Continues with [MEDICATION NAME] to support wound healing. New treatment orders obtained. Will continue to monitor;" 4/17/14 - PUSR, Right heel, unstageable, 1 cm x 1.5 cm, no depth, necrotic, wound debride by NP, improved; - Left heel, unstageable, 1.5 cm x 1.2 cm, no depth, 100% necrotic, no change; 4/17/14 - MD orders, Resource [MEDICATION NAME] packet - Give 2 packets by mouth three times daily mix with choice of fluids; - TMD orders, Discontinue [MEDICATION NAME] one packet three times daily. Increase [MEDICATION NAME] two packets three times daily per dietician recommendation; 4/17/14 - PN, "Wound Assessment: Wound to bilateral heels assessed by (Nurse Practitioner's name). Wound to left heel measured 1.5cmx1.2cm with no measurable depth. Wound bed covered with 100% secure eschar. No periwound [DIAGNOSES REDACTED] or induration noted. Wound was debride by NP (Nurse Practitioner). Wound to right heel measured 1.5cmx1.2cm with no measurable depth. Wound bed covered with 100% eschar. Periwound intact with no s/sx of infection. Wound was debride by NP. No change in treatment. Patient has adequate offloading measures including airbed and prevalon boots when in bed. Patient receiving [MEDICATION NAME] to support wound healing. No concerns at this time. Will continue to monitor;" 4/24/14 - PUSR, Right heel, unstageable, 1.5 cm x 3 cm, no depth, necrotic,debride by NP, no change; - Left heel, unstageable, 1 cm x 2 cm, no depth, 100% necrotic, debride by NP, improved; 4/24/14 - PN, "Wound Assessment: (NP's name) present for wound assessment. Wound to right heel measured 1.5cmx3cm with no measurable depth. Wound bed covered with 100% eschar with no drainage. Wound was debride by (NP's name) with no bleeding. Wound to left heel measured 1cmx2cm with no measurable depth. Wound bed noted to have 100% eschar with no drainage. No s/sx of infection noted to either wounds. patient has adequate offloading interventions to include prevalon boots, and airbed. Patient receives [MEDICATION NAME] to support wound healing. No concerns at this time. Wounds showing improvement. Will continue to monitor;" 4/24/14 - NPPN, Subjective: "...wounds continue to have significant eschar. I did debrided the eschar away last week; however, he continues to form and eschar. We have been using Dakin's wet-to-dry with no improvement. He has no signs and symptoms of infection;" Plan: "...We will change to Santyl and cover dressing from the Dakin's wet-to-dry. My hope is that it will soften this more and we can get into good granulation tissue. Continue to utilize an air mattress, as well as Prevalon boots. Continue to follow weekly and p.r.n. (as needed);" 5/1/14 - PUSR, Right heel, unstageable, 2 cm x 3.5 cm, no depth, 100% slough, deteriorated, treatment changed with new order for x-rays to bilateral heels; - Left heel, unstageable, 1.5 cm x 3.5 cm, no depth, 100% slough, deteriorated, treatment changed and new order to x-ray bilateral heels; 5/1/14 - PN, "(NP's name) present for wound assessment. Wound to Rt heel measured 2cmx3.5cm with no measurable depth. Wound bed covered with 100% white/light brown slough with moderate amount of serous drainage. Periwound intact with no bogginess or s/sx of infection. Patient denied pain to wound although has significant pain to hips with repositioning. Wound to Lt (left) heel measured 1.5cmx3.5cm with no measurable depth. Wound bed covered with 100% light brown/white slough. Periwound intact with no s/sx of infection. Moderate amount of serous drainage. Wound measurements greater than last week which is anticipated due to moistening of eschar per treatment and debridement by NP last week. Patient is adequately being offloaded with bariatric airbed and prevalon boots at all times. New order for [MEDICATION NAME] three times daily to support wound healing. Patient provided with education regarding plan of care with verbalized understanding. New treatment orders obtained and order for x-ray to bilateral heels to rule out osteo[DIAGNOSES REDACTED] and abscess. Will continue to monitor;" 5/1/14 - NPPN, Subjective: "...continues to have significant wounds of his wound bed. We did soften that with Santyl; however, he still has fairly fixed slough in these wounds, definitely mobility problems and is difficult to move down. He has not had x-rays of his heels any time for these wounds that I can find. He has no signs and symptoms of infection;" Plan: "No debridement today. We have debrided a significant amount of eschar previously. The eschar and slough is softer today. I believe he would benefit from Dakin's wet-to-dry, change daily. I would like to x-rays of his heels to rule out any gross abnormalities to include abscess or obvious osteo[DIAGNOSES REDACTED]. If there are any suspicious findings on the x-ray we will go to MRI. We will continue to follow him weekly and p.r.n. Continue to recommend offloading with air mattress and frequently turning;" 5/1/14 - TMD orders, X-ray bilateral heels; 5/8/14 - PUSR, Right heel, unstageable, 2 cm x 3.5 cm, no depth, 100% necrotic, no change; - Left heel, unstageable, 1.5 cm x 3.2 cm, no depth, 100% necrotic, no change, treatment changed; 5/8/14 - PN, "Wound Assessment: (NP's name) present for wound assessment. Wound to Rt heel measured 2cmx3.5cm with no measurable depth. Wound bed noted to have 100% eschar with no drainage. Periwound intact with no s/sx of infection. Wound to left heel measured 1.5cmx3.2cm with no measurable depth. Wound bed covered with 100% eschar. No [DIAGNOSES REDACTED] or s/sx of infection. NP concerned that patient continues to develop eschar with mechanical debridement and chemical debridement. x-rays negative for concerns. Patient has adequate offloading in place with airbed, prevalon boots. Turning and repositioning painful for patient due to hip pain. Will continue current treatment at this time and continue to monitor;" 5/8/14 - NPPN, Subjective: "...heels continue to be a problem for him. He is bed bound due to significant hip disease. He has a significant eschar of his heels bilaterally, debrided multiples times but his heels generate significant eschar tissue. I did order an X-ray, which was completed on 05/02/2014 due to the fact that he has had longstanding heel ulcerations. These were negative for any signs of osteo[DIAGNOSES REDACTED]...For now we are utilizing padded heel protectors for offloading and we (are) utilizing with Dakin's wet-to-dry. We have also utilized Santyl in the past, which he has not really seemed to clean this wound up;" Plan: "No change. Continue the same. We will try to keep these stable until he transfers. Unfortunately we have had no luck with multiple debridements and unfortunately I do not follow at(local facility)...;" 5/15/14 - PUSR, Right heel, unstageable, 1.8 cm x 3.6 cm, no depth, necrotic, improved; - Left heel, unstageable, 2.1 cm x 3.6 cm, no depth, necrotic, no change; 5/15/14 - PN, "Wound Assessment: (NP's name) present for wound assessment. Wounds to Rt heel measured 1.8cmx3.6cm with no measurable depth. Wound bed covered with soft eschar. Periwound intact with no s/sx of infection. Wound to left heel measured 2.1cmx3.6cm with no measurable depth. Wound bed covered with soft eschar. Periwound intact with no s/sx of infection. Patient has adequate offloading measures in place to include airbed, prevalon boots, and trapeze to assist with bed mobility. Patient requested to have his spouse bring in a concoction of medication to put onto ulcers. Patient educated that it was not approved and it could not happen. Patient verbalized understanding. Patient receives [MEDICATION NAME] three times daily to support wound healing. Current treatment of [REDACTED]. No changes at this time. Will continue to monitor;" 5/15/14 - NPPN, Subjective: "I have had a difficult time with (Resident's name) wounds. He continues to produce significant eschar. I debrided the eschar on more than 1 occasion;" Plan: "Will utilize Santyl to no avail. Currently, we are utilizing Lipogel which does appear to be softening some of this eschar. He tells me that his wife believes that she can put some sort of 'poultice' that will heal this much more quickly than I can. i explained to the patient that unfortunately it is not a medically approved treatment and so we will not be able to use a poultice here in the skill nursing facility;" Recommendations: "Continue with Lipogel daily. My hope is this will do the job for debridement. I have not had any success with sharp debridement. I am open to [MEDICATION NAME] sharply in the future, if needed. We will continue to follow him weekly and p.r.n. Again, I explained that a poultice is not appropriate in this setting. He voices his understanding;" 5/22/14 - PUSR, Right heel, unstageable, 2.2 cm x 3.8 cm, no depth, 100% slough, improved; - Left heel, unstageable, 2 cm x 3.4 cm, no depth, slough, necrotic, improved; 5/22/14 - PN, "Wound Assessment: (NP's name) present for wound assessment. Bilateral heels assessed with [REDACTED]. Wound to Right heel measured 2.2cmx3.8cm with no measurable depth. Wound bed covered with 100% secure brown/white slough. Wound edges attached with no undermining or tunneling. Periwound note to have decreased masceration (sic). No [DIAGNOSES REDACTED] or s/sx of infection noted. Wound to left heel measured 2cmx3.4cm with no measurable depth. Wound bed covered with 100% secured white/brown slough. No periwound [DIAGNOSES REDACTED] or s/sx of infection. Current treatment successful at softening Eschar to support autolytic debridement. Patient has adequate offloading in place including airbed with antisheer surface, prevalon boots. Trapeze to enable bed mobility. No change in current treatment. Patient educated on current wound status and what to expect. No concerns or questions verbalized. No concerns at this time. Will continue to monitor;" 5/22/14 - NPPN, Subjective: "We stopped sharp debridement on (Resident's name) because he continued to form significant eschar. We have trialed wet-to-dry dressings as well as Santyl. We finally started LipoGel, which does appear to be improving. The wound bed he continues to have slough; however, the slough is decreasing;" Plan: "No change. Continue with LipoGel. Continue to cover. Continue to offload. We will continue to follow him weekly and p.r.n.;" 5/29/14 - PUSR, Right heel, unstageable, 3.2 cm x 4 cm, no depth, 100% slough, improved; - Left heel, unstageable, 2.2 cm x 3.5 cm, no depth, 100% soft slough, improved; 5/29/14 - PN, "Wound Assessment: (NP's name) present for wound assessment. Upon entry to patients room patient noted to be laying in bariatric air bed with prevalon boots in place. Wound to right heel measured 3.2cmx4cm with no measurable depth. Wound bed covered with 100% soft slough with moderate amount of serous drainage. Periwound intact with no s/sx of infection. Wound was debride by NP. No change in current treatment, patient will continue with lipogel to continue to autolytic debridement of wounds. Wound to left heel measured 2.2cmx3.5cm with no measurable depth. Wound bed covered with 100% soft slough with moderate amount of serous drainage. Periwound intact with no s/sx of infection. Wound was debride by NP with no change in treatment at this time. patient denied pain with wound assessment although pain was noted with repositioning of lower extremities. Patient is on routine pain medication and pain is well managed. Patient utilized trapeze to move around in bed although repositioning is limited due to pain in hips and patient prefers laying on his back. Surgery has been placed on hold to bilateral hips until wounds are healed. Upon assessment bilateral lower extremities noted to be hairless and shiny. Pedal pulses very faint and difficult to palpate. New orders to obtain ABI due to suspicion of vascular component to wound attributing to cause of wound and impeding wound healing. Patient continues to receive [MEDICATION NAME] to support wound healing. Patient educated to current plan of care and questions were answered. No concerns at this time. Will continue to monitor;" 5/29/14 - NPPN, Subjective: "We have been utilizing Lipogel on his heels. his wound appears to be stable. The LipoGel has been softening the slough. He has no questions or concerns today;" Plan: "I did debride using a 3 mm curet to remove slough superficially. I did not get into deep subcutaneous tissue...Patient tolerated this well. I did get rid of approximately 60% to 70% of the loosened slough and eschar to visualize some areas of granular tissue. I would like to continue with LipoGel as I believe this is cleaning up the wound bed nicely. I do believe it is also promoting granular tissue growth. I am not palpating excellent pulses today and I would like an ABI to help assess his flow. We will get vascular studies as needed. I will follow up on him in 2 weeks;" 5/29/14 - CP revision, "Problems - ABI (Ankle, Brachial Index) revealed moderate obstruction attributing cause of poor wound healing due to poor vascularization;" 6/5/14 - PUSR, Right heel, unstageable, 2.8 cm x 3.5 cm, no depth, 100% soft necrotic, no change; - Left heel, unstageable, 2.8 cm x 3.5 cm, no depth, 100% soft necrotic, no change. 6/5/14 - PN, "Wound Assessment: Patient resting in bed with prevalon boots to bilateral lower extremities upon entering room. Wounds to bilateral heels assessed. Wound to right heel measured 2.8cmx3.5cm with no measurable depth. Wound bed covered with 100% secure soft eschar. Wound edges attached with no undermining or tunneling identified. Small amount of serosanguinous drainage. Wound to Left heel measured 2.8cmx3.5cm with no measurable depth. Wound bed covered with 100% soft brown eschar with small amount of serosanguinous drainage. Wound edges attached with no undermining or tunneling. Periwound intact with no s/sx of infection. ABI study completed last week indicated moderate obstruction which will impede wound healing. Patient denied pain with assessment of wounds although does have pain with repositioning. Patient utilizes trapeze to aide in bed mobility although repositioning is limited due to pain in hips which he is pending hip surgery for [REDACTED]. Patient receives [MEDICATION NAME] to support wound healing. Suspect patient has vascular insufficiency impeding wound healing. Will refer patient for vascular studies. No change in current treatment. Lipogel effective in autolytic debridement. No s/sx of infection present. Will continue to monitor." 6/5/14 - Referral to vascular surgeon for vascular studies of BLE (bilateral lower extremities). On 6/11/14 at 12:05 p.m., UM (Unit Manager) #7 was interviewed regarding the pressure ulcers to Resident #3's bilateral heels. When asked what risk factors were identified for the resident prior to the development of the pressure ulcers, the UM said initially on admit the resident was more mobile, which meant he was up in his wheelchair (w/c) frequently and participated in activities. The resident would spend up to 2 hours in the w/c when his wife and son came to visit. After some time the resident did not tolerate being up in the w/c well due to bilateral hip pain. The UM added that the resident made little progress in therapy, and the facility put in an overhead trapeze for increased bed mobility. UM #7 was asked what initial interventions were put into place to prevent pressure ulcers. The UM said the resident would allow staff to turn and reposition him, had a heel foam lift device which was changed to prevalon boots and the resident received moisturizer to his feet and legs. The UM said the resident used a regular house mattress which was a general cushion mattress which was supposed to be helpful in the prevention of pressure ulcers, but not as helpful as other mattresses. When asked why the resident received an air mattress, the UM said it was for skin integrity. UM #7 said the resident was on a turning schedule but had issues with turning and refused it often. He added the refusals should have been charted in the nurses notes. (Note: Review of the Nurses Notes showed no documented refusals of turning in February or March prior to the development of the unstageable pressure ulcers) The UM was informed a turning schedule and approach was not identified on the resident's care plan at which the UM said the resident could turn himself but also needed assistance due to pain. After reviewing the resident's medical record, the UM noted a handwritten addition on the resident's Risk for Impaired Skin Integrity care plan, dated 6/10/14, which instructed staff to cue and assist resident to turn every 2 hours while in bed and, "Resident has often refused to be turned." (Note: The handwritten addition was not in place when the care plan was copied by the surveyor.) UM #7 said refusals to be turned should be reported by the CNA staff to nurses who would then chart it, and the nurse would reapproach the resident. The UM was asked when the approach of [MEDICATION NAME] was added to the care plan. He looked through the physician's orders [REDACTED]. (Note: The care plan did not include dates when approaches were added.) The UM was asked how the area on the heels were identified as SDTIs (Suspected Deep Tissue Injuries), as documented on the care plan, if the wound was covered with 100% eschar, and the UM referred the surveyor to the wound nurse. On 6/11/14 at 3:30 p.m., UM #7 provided a copy of Resident #3's Risk for Impaired Skin Integrity care plan which had a printed approach of, "Observe skin weekly and PRN, report any red or broken areas to nurse; Turn & reposition Q (every) 2 hours or more frequently as resident will allow. Resident has often refused to be turned." There was not a date included on the approach and when asked, the UM could not say when it was added to the care plan. On 6/12/14 at 10:00 a.m., the wound nurse, LN #2, was interviewed regarding Resident #3. She said she became involved with the resident's care after the unstageable pressure ulcers developed. The LN said Resident #3 was identified at risk for pressure ulcers and was reviewed for adequate interventi

Based on observation, record review, and staff interview, it was determined that the facility failed to ensure residents did not develop recurring pressure ulcers. This was true for 1 of 3 residents (#5) sampled for pressure ulcers. Resident #5 developed a recurrent pressure ulcer to her coccyx that was not discovered by the facility until the wound had deteriorated into a large Stage II ulcer. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 10/31/11, documented the following: * Severely impaired cognitive skills for daily decision making * Range-of-motion limitation of one upper extremity and both lower extremities * Extensive assistance of one staff member required for bed mobility and personal hygiene * Extensive assistance of at least two staff members required for bathing and toileting * Total assistance of at least two staff members required for transfers * "Always" incontinent of bowel and bladder * No pressure ulcers Braden Scale for Predicting Pressure Ulcer Risk assessments for Resident #5, dated 2/23/11, 5/19/11, and 9/19/11, each documented a score of "13," which designated the resident was at "moderate risk" for developing pressure ulcers. Scores of 10-12 designated a "high risk" for the development of pressure ulcers. Recapitulated physician's orders [REDACTED]. A Physician's Telephone Order, dated 12/21/11, documented, "Cleanse coccyx wound (with) wound cleanser ... change (dressing) every 72 (hours) and PRN (as needed)." No other physician's orders [REDACTED].#5's record. Resident #5's Skin at Risk Care Plans, dated 5/26/11 and 11/8/11, were compared. The 11/8/11 Skin at Risk Care Plan did not contain any preventative or treatment interventions that were not already documented on the 5/26/11 Skin at Risk Care Plan. Those interventions, as applied to the resident's coccyx only, documented, "Skin cares & tratments (sic) per order; observe skin daily and monitor for any changes - CNA's (sic) to report any changes during direct care to LN; evaluate skin weekly by LN; airbed to maintain skin integrity." NOTE: Although not included on the resident's Skin at Risk Care Plan, Monthly Flow Reports for September through December 2011 documented the resident was to be repositioned every two hours. Those Reports, however, failed to document that the resident was repositioned every two hours in September for six day shifts, nine evening shifts, and four night shifts; in October for nine day shifts, 11 evening shifts, and one night shift; in November for eight day shifts, 24 evening shifts, and three night shifts; nor from 12/1/11 through 12/27/11 for 11 days shifts, 16 evening shifts, and three night shifts. The resident's Pressure Ulcer Status Record documented that a "Stage II" pressure ulcer measuring "6.5 (by) 2.5 (by) 0.1" (centimeters) was "first observed" on 9/29/11. Measurements of the wound were documented on 10/5/11, 10/13/11, 10/19/11, and 10/29/11, at which time the wound was documented as "resolved." On 12/21/11, the Pressure Ulcer Status Record documented a non-staged ulcer that measured 1.5cm by 1cm, and had slough. The record did not document the ulcer's depth or anatomical location. A Weekly Skin Integrity Data Collection form, dated 12/21/11, documented an "old, re-opened, open area" and included a drawn figure with a mark indicating a wound on the resident's coccyx. On 12/28/11, at 5:15 p.m., the DON was interviewed. When asked why Resident #5's coccyx wound was not discovered prior to having already developed into a 6.5cm by 2.5cm by 0.1cm Stage II ulcer, the DON stated, "We should have caught it at Stage I." On 12/29/11, at 8:22 a.m., the surveyor observed the facility's ADON perform a dressing change to the resident's coccyx. The ADON measured the wound and stated the periwound measured 4cm by 5 cm and the open portion of the wound measured 1cm by 0.75cm by 0.25cm. Following the dressing change, the ADON was interviewed. When asked about the pressure ulcer, the ADON stated, "She's (Resident #5) at extreme risk for wounds because she was admitted with many, many wounds." When asked to explain the pathology of the wound, the ADON stated the wound may have "re-opened" from the resident's recurrent bouts of incontinent diarrhea and a general decline in the resident's condition, including an inability to any longer feed herself. (NOTE: Please refer to F312 and F325). Resident #5's Monthly Bowel Flow Reports for September through December 2011 documented almost daily bowel incontinence, however the resident's November 2011 MAR indicated [REDACTED]'s orders or on the resident's Skin at Risk Care Plan. Resident #5's December 2011 MAR indicated [REDACTED]. On 12/28/11, the ADON provided surveyors with a three-page handwritten statement that documented, in part, "(Resident #5) was admitted ,[DATE]. On admit she had multiple wounds ... Resident had airbed and was being turned every 2 hours and PRN (as needed). On assessment an open area was shown on admit to coccyx. Admit wounds were resolved on 1/6/09. Resident admitted with multiple risk factors, ie: impaired mobility, refusal to eat, dementia, cognitive impairment, incontinence bowel and bladder with exposure of skin to urinary and fecal incontinence. Braden assessments were done on admit and done quarterly since then. Residents are always changed every two hours and PRN and barrier cream is used for incontinent episodes and PRN. Resident was admitted on 2008, June wounds healed by 1/6/09. Skin remained intact until 2011, due to air bed, pressure relieving w/c (wheelchair) cushion, turning schedule, barrier cream and constant monitoring. Skin checks are done weekly. The first wound to her coccyx appeared 9/30/11. On 9/27/11 skin check completed and skin intact. Wound measured 6.5 X 2.5 (cm). Shower was given 9/28 and coccyx was intact. Assessed by wound team on 10/5/11 measured 5cm X 2.5cm, including redness to redness. By 10/13 had decreased ... wound resolved 10/29/11. Resident was turned every 2 hours, continued to have an airbed and pressure relieving w/c cushion. Wound resolved and remained intact until 12/21/11. Resident had been having loose stools ... and has an average of 3 stools per day. Due to wt (weight) loss and incontinent loose stools breakdown occurred. We anticipate wound to resolve but will continue with interventions due to history of reoccurrance (sic)." On 12/29/11, at 3:30 p.m., the Administrator and DON were apprised of the findings. On 1/3/12, the facility provided a hand-delivered letter signed by MD #6 that documented, "(Resident #5) is frail, elderly, demented female who is max(imum) assist with all activities of daily living. It was recommended in 2008 on arrival to our facility that she be on palliative care due to her poor cognition. She has been expected to decline due to her comorbidities and lack of ability to care for herself. She has been in the facility and has been fairly stable for the last little while due to her wounds it is my opinion that her breakdown in the coccyxsacral area is unavoidable due to her condition as well as complicated by bouts of diarrhea. It appears that the wound care team has attempted numerous and appropriate precautions and has done their best considering circumstances. I do not expect (Resident #5) to ever care for herself and will continue to decline. I also believe that she probably is a hospice candidate." Resident #5 was admitted to the facility with a known history of-, moderate risk of-, and presence of pressure ulcers. The resident was assessed with [REDACTED]." weight loss after the emergence of the pressure ulcer without adequate facility interventions (Please refer to F325 and F312); the resident was not repositioned every two hours as directed in the Monthly Flow Reports; and the resident began receiving almost daily treatments for incontinent diarrhea - cited as a possible cause or aggravating factor in the development of the resident's pressure ulcer - three weeks prior to when the wound was discovered. The facility failed to prevent a recurrent and avoidable Stage II pressure ulcer.