Every finding on record at Life Care Center of Coeur d'Alene

Based on observation, review of records and interviews, it was determined the facility failed to ensure residents consistently received necessary care to prevent pressure ulcers and infection from developing. This was true for 1 of 1 resident (Resident #9) reviewed for pressure ulcer. This deficient practice caused harm to Resident #9 when he developed pressure wound and infection to his right palm which required use of antibiotics. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including right-hand contracture and aphasia (an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write) following a stroke. Resident #9's ADL care plan revised 4/12/25, directed staff to:Trim and file his nails weekly and as needed, initiated 6/17/25.Apply a right-hand grip splint eight hours a day during the day as he can tolerate, revised 7/11/25.A Communication with Physician note dated 7/31/25, documented an SBAR the nurse was concerned as Resident #9 had constricted fingers that have led to skin maceration noted with odorous smell. It documented Resident #9 complained of pain and discomfort when staff tried to clean his hand. The physician recommended Resident #9 to be evaluated and treated by OT for his contractures.A Communication to Physician note dated 10/6/25, documented an SBAR the CNAs reported Resident #9 refused to wear his brace every day. He showed high level of pain when the staff tried to even put their fingers into his contracted hand. The note documented a recommendation Re-evaluation for therapy options for resident. A Nursing Note dated 10/21/25, documented Resident refused to wear the brace, but he was using the carrot (a soft cone-shaped orthosis designed to treat severe hand contractures by gradually opening the hand) that was given to him from Physical Therapy.On 3/19/26 at 11:43 AM, the OT with the DOR present, stated Resident #9 was referred to the Therapy department in July 2025 for feeding and right-hand contracture. The OT stated Resident #9 discharged from the therapy on 7/15/25 and he was provided with orthotic/splint to keep his fingers in a resting position and prevent further contraction. OT stated the orthotic splint had to be worn during the day as he can tolerate. When asked if Resident #9 was referred to therapy after 7/15/25, both the DOR and OT stated he was not referred to the therapy after his discharge on [DATE]. When asked how the orthotic splint was placed on Resident #9's right hand, OT stated it was placed between his fingers and the thumb. Resident #9's TAR documented he refused to wear his hand grip orthotic as follows:14 out of 31 days in 10/202521 out of 30 days in 11/202518 out of 31 days in 12/202522 out of 31 days in 1/202620 out of 28 days in 2/202615 out 19 days in 3/2026A Monthly Summary Report, dated 1/27/26 and 2/27/26, documented Resident #9 had right contractures, and he refused to wear the hand grip orthotic. There was no further documentation in Resident #9's records, the physician, the therapy department, and/or his representative were notified of his refusal to wear the grip orthotic after 10/6/25. There was no documentation of further interventions or treatment for his pain related to his right hand contracture. A Communication Note with Physician dated 3/12/26 at 11:41 PM, documented an SBAR Resident's contracted hand swollen and painful. Upon limited assessment, noted nails digging in to [into] skin, with white/yellow drainage noted. The note documented the provider ordered the following: Trim resident's nails and file to dull.Apply triple antibiotic ointment to draining wounds twice a day and cover with island dressing, Tegaderm, or what dressing is available in floor stock to keep wound covered.Cephalexin (antibiotic) 250 mg/5 ml suspension, give 10 ml TID for seven days. The Communication Note included a handwritten note, We are unable to open (R) hand to trim nails D/T [due to] contraction and swelling. We cannot place antibiotic ointment D/T not able to access site. A Provider Note dated 3/13/26, documented Resident had right hand contracture, with nails embedding into palm causing skin infection. Soaked resident's hand in betadine and warm water solution, trimmed nails on both hands, placed triple antibiotic cream on gauze and placed in his palm. Nails were no longer embedded into palm. On 3/18/26 at 4:34 PM, RNA #1 stated she assisted Resident #9 with his range of motion for his right hand by stretching his fingers as much as he can. RNA #1 stated she could barely open his right hand and had not seen his palm or his fingernails. RNA #1 stated Resident #9 would complain when his fingers were stretched. When asked if the nurse was notified of Resident #9 complaint of pain during his restorative program. RNA #1 stated, I believed I informed the nurse, but I can't remember the specifics. On 3/20/26 at 9:21 AM, LPN #2 stated she was aware Resident #9 refused to wear his splint for his right hand and documented it in the TAR. When asked if Resident #9 and/or his representative were educated about the risks and benefits of refusing to wear the splint, or physician notification of his refusals to wear the splint, LPN #2 stated his family was informed but she did not document it in her nursing notes. On 3/19/26 at 9:57 AM, together with the IP, Resident was observed in the dining room. The resident's hand was observed to be closed in a fist. The IP asked Resident #9 if she could see his right hand. When the IP tried to open his right hand, Resident #9 stated, It hurts. The IP then asked Resident #9 to open his right hand. Resident #9 moved his thumb, but he was unable to move the rest of his fingers. A review of Resident #9's ADL records did not document his fingernails being trimmed or any referral to the physician the staff were unable to trim his fingernails. On 3/19/26 at 2:10 PM, the DON was asked for the documentation of Resident #9's fingernails being trimmed. The DON reviewed Resident #9's ADLs record and stated she was unable to find documentation his fingernails were being trimmed or documentation he refused for his fingernails to be trimmed. When asked if she was informed of the staff were unable to open his right hand, DON stated she would look for documentation. When asked if Resident #9's wound to his palm could have been avoided, the DON stated, I don't know. On 3/20/26 at 9:28 AM, the Nurse Practitioner stated Resident #9's wound to his right palm was due to his fingernails that digged on his palm. On 3/20/26 at 10:21 AM, during follow-up interview, the DON was asked if she was informed of Resident #9 refusing to wear his right-hand grip orthotic, the DON stated, I might have been, but I do not recall. The DON stated when a resident continued to refuse to wear their splint, they would refer to the therapy department and we will inform their representative. The DON also stated, Yes, education would be provided for the residents and if the residents were cognitively impaired, then we will notify their representatives. The DON stated the physician would also be notified.The National Library of Medicine web page, titled Healing hand ulcers caused by focal spasticity (involuntary stiffness, tightness, and spasms due to damaged nerve pathways in the brain or spinal cord), accessed on 3/24/26, documented, In some cases, spastic fingers in the hand press hard into the palm, resulting in skin breakdown, and atypical pressure ulcerations. It also documented, Over time, pressure from the fingers with the overgrown nails can cause skin breakdown resulting in atypical pressure ulceration in the palm of the hand.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medication refrigerator temperatures were routinely monitored and documented. This was true for 2 of 2 medication refrigerators (A-Wing and D-Wing Refrigerator) whose temperature logs were reviewed. This deficient practice created the potential for harm if residents received vaccines or medications which had reduced potency and safety from improper storage. Findings include:The facility's Medication Storage in Refrigerator/Freezer policy reviewed 9/9/25, documented the following:Medications and biologicals were stored at their appropriate temperatures according to their manufactures' specifications.The facility should monitor the temperature of medication storage areas at least once a day.The facility should monitor the temperature for vaccine storage twice a day.On 3/20/26 at 12:19 AM, the A-Wing Medication Storage room was inspected with RN #1. The Medication Storage room had two refrigerators: the Black refrigerator which stored the narcotics medications and the Silver refrigerator which stored the vaccines and insulins. The temperatures for the refrigerators were inconsistently documented. Review of the temperature logs documented that the temperatures were not recorded on the following days: Morning Shift:A. Silver Refrigerator:5 out of 28 days for 2/20268 out of 20 days for 3/2026 B. Black Refrigerator:5 out 28 days for the 2/202610 out of 20 days for 3/2026 PM ShiftA. Silver Refrigerator:2 out of 28 days for 2/20265 out of 20 days for 3/2026 B. Black Refrigerator:3 out of 28 days for 2/20265 out of 20 days for 3/2026 On 3/20/26 at 12:40 PM, the RCM reviewed the refrigerator's temperature logs and stated she did not think the temperature monitoring was being done as required. On 3/20/26 at 1:32 PM, the D-Wing Medication Storage room was inspected with the SDC. The temperatures for the medication refrigerator containing narcotics medications were inconsistently documented. Review of the temperature logs documented that the temperatures were not recorded on the following days:AM Shift15 of 30 days for 1/202616 of 28 days for 2/2026 PM Shift2 of 28 days for 2/20262 of 20 days for 3/2026 The SDC stated there should not be blanks on the medication room refrigerator temperature logs.

Based on observation and staff interviews, it was determined the facility failed to ensure infection control practices were followed for donning and doffing PPE during an Influenza-A outbreak, compromising safe infection control practices. This failure affected all residents who received care and services, and the potential for adverse outcomes related to cross contamination when staff created an environment where Influenza-A spread to multiple resident's on different halls. Findings include:The Lippincott Nursing Center article Isolation Precautions (June 2025), accessed 3/25/26, documented the goal of droplet precautions is to prevent transmission of infectious organisms spread by droplets through close respiratory or mucous membrane contact. The article documented droplet precautions include:Private room or cohortWear a mask (surgical or isolation) if working within 3 feet of the patient or for all entries into the roomDroplet mask on the patient when leaving the roomLimit transport to essential purposesFollow respiratory hygiene/cough etiquetteGown and gloves as per standard precautionsIndications include infections such as seasonal influenza, pertussis, rhinovirus, and others.1. On 3/16/26 at 11:45 AM, CNA #3 was observed entering room [ROOM NUMBER] to assist a resident on droplet precautions wearing goggles and one glove. She picked up the urinal from A-beds nightstand and emptied it in the restroom. CNA #3 then proceeded to return the urinal to the nightstand with no gloves on. She walked over to B bed, applied gloves without performing hand hygiene picked up the second urinal, emptied it, and returned it to the bedside. After exiting the room, she removed her gown and gloves and performed hand hygiene. CNA #3 then removed her goggles and placed them into the storage bin. CNA #3 was not observed wearing a gown or sanitizing the multi-use goggles. On 3/16/26 at 11:46 AM, CNA #3 confirmed she should have performed hand hygiene before applying gloves and she should not have placed goggles back into the bin without sanitizing them. She proceeded to take the multi-use goggles out of the bin and after checking two PPE bins in the hall, CNA #3 stated the facility had not provided sufficient sanitation wipes to clean the multi-use goggles. 2. On 3/17/26 at 8:48 AM, the SDC was observed exiting room [ROOM NUMBER]. She removed her PPE, performed hand hygiene, applied clean gloves, used an alcohol wipe to wipe down the multi-use goggles, and placed them back in the storage bin. When asked what the contact time was, she stated goggles should remain out of the PPE bin on a clean barrier until dry or for 2 minutes, whichever occurs first. On 3/17/26 at 8:50 AM, the SDC confirmed she did not allow for the multi-use goggles to remain out of the PPE bin for the required contact time before being placed back into the bin. 3. On 3/15/26, the facility began infection prevention precautions for residents who had tested positive for COVID-19 and influenza A. On 3/16/26 at 10:57 AM, the following rooms were considered positive for influenza A and had droplet precaution signage directing staff to wear face masks and clean hands before entering rooms: 401, 404, 405, and 408. On 3/17/26 at 9:56 AM, room [ROOM NUMBER] was considered positive for influenza-A. On 3/17/26 from 9:56 through 10:10 AM, the Activities Assistant was observed consecutively entering Influenza A positive and negative rooms, offering coffee and coloring sheets to the residents, performing hand hygiene between rooms, but without changing her mask: She entered positive rooms [ROOM NUMBERS]. She entered negative rooms [ROOM NUMBER]. She entered positive rooms [ROOM NUMBERS]. She entered negative rooms [ROOM NUMBERS]. She entered positive room [ROOM NUMBER]. She entered negative room [ROOM NUMBER]. On 3/17/26 at 10:01 AM, the Activities Assistant stated she was not performing cares, so she did not need to wear a gown, and she only needed to perform hand hygiene when entering a resident's room, her mask did not need to be changed. On 3/17/26 at 12:14 PM, the IP confirmed the facility should have implemented precautions to include hand hygiene, face mask, gown, eye protection, and gloves. On 3/18/26 at 5:00 PM, the DON confirmed new positive influenza A cases for the roommates of rooms [ROOM NUMBERS], and for rooms [ROOM NUMBERS].

Based on observation, review of the FDA Food Code, and staff interview it was determined the facility failed to provide employee hand hygiene, remove ice build-up in the freezer, and clean dust from the air condensing units. This was true for 75 of 76 residents who received food prepared by the facility's kitchen. This deficient practice created the potential for harm by placing residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include:1. The FDA Food Code Section 2-301.14 When to Wash documented food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils.On 3/18/26 from 11:15 AM to 11:47 AM, Diet Aide #1 was observed with a hair net not covering the front portion of her head, with tendrils of hair framing her face. She was also observed taking food carts out of the kitchen and returning without performing hand hygiene.On 3/18/26 at 11:50 AM, the Dietary Manager observed Diet Aide #1 enter the kitchen without performing hand hygiene or wearing her hair net appropriately, and stated all food service employees are required to wear their hair nets appropriately and to perform hand hygiene when entering the kitchen.2. The FDA Food Code Section 3-303.12 ______ documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water.On 3/16/26 at 10:26 AM, and on 3/20/26 at 12:39 PM, pillars of 2-inch icicles were observed melting from the air condenser unit in the freezer and dripping down into an opened box of frozen egg patties.On 3/20/26 at 12:44 PM, the Dietary Manager stated the trays under the air condenser should catch the ice, but sometimes it doesn't, and maintenance should monitor the units more regularly while food services cleans the ice. He stated the food should be wrapped up and not left open.3. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 3/20/26 at 12:52 PM, it was observed in the Resident Fridge on A-Wing:Refrigerator had brown streaks on the interior of the upper door. Staff food (Celcius) drink was unlabeled/dated stored in fridge. Resident food, undated labeled, stored in fridge (A jar of pickles, and Frappuccino coffee drink.)Freezer had resident food with only a room number, no name or date (Frozen meals - 2 banquet meals/2 [NAME] pot pies). On 3/20/26 at 12:56 PM, the Dietary Manager stated all resident food should be dated and labeled with resident's name; however, nursing staff are supposed label the food items with resident name and date food before placing it into the refrigerator or freezer. 4. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed.On 3/16/26 at 10:32 AM, and on 3/20/26 at 12:42 AM, dust particles were observed on the refrigerator air condenser unit hanging off the bolts which secure the unit to the ceiling.On 3/20/26 at 12:44 PM, the Dietary Manager stated the unit should have been cleaned more frequently to avoid the dust build-up.5. The SOM Appendix PP revised 2/3/23, documented equipment can become contaminated in various ways including improper sanitation.On 3/20/26 at 1:02 PM, it was observed in the Resident D-Wing, Refrigerator, brown spots were located on the interior door and back wall of the refrigerator. On 3/20/26 at 1:04 PM, the Dietary Manager stated housekeeping is responsible for cleaning the refrigerators and should do it daily.

Based on observation and staff interview, it was determined the facility did not ensure resident shower areas were maintained in a clean and sanitary condition. This failure affected 1 of 1 shower rooms observed and created the potential for harm if residents were exposed to black microbial substances on the grout of the shower walls. Findings include: On 3/20/26 at 9:33 AM, during an inspection of a resident shower room, a black substance was observed on the lower portion of the shower wall.On 3/20/26 at 9:36 AM, the Maintenance Director used the tip of a thermometer to scrub the black substance and stated, the shower is not clean.On 3/20/26 at 9:57 AM, the Housekeeping Director stated the showers are scheduled to be cleaned daily and confirmed the shower room was not clean.

Based on observation, record review, policy review, and staff interviews, it was determined the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and comprehensive person-centered care plan. This was true for 2 of 18 residents (#55 and #103) reviewed for standards of practice.Resident #55 had a wrong route of administration on two medication orders.Resident #103's vitals signs were not checked prior to administration of her anti-hypertensive medication.These failed practices created the potential for these residents to experience adverse effects when their medications were not administered according to physician's orders. Findings include:1. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including hypertension and acute pancreatitis. The National Library of Medicine web page titled Metoprolol accessed on 3/25/26, documented blood pressure and heart rate should be measured at rest, during exercise, and before and after taking metoprolol. A physician's order dated 3/10/26, documented Resident #103 was to receive the following medications including: Lisinopril oral tablet 10 mg, give one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure less than 100. Metoprolol succinate extended-release oral tablet, give one tablet by mouth one time a day. Hold for heart rate less than 55 or systolic blood pressure less than 100. On 3/19/26 at 8:45 AM, LPN #1 administered Resident #103's medications which included metoprolol ER 25 mg and lisinopril 10 mg. LPN #1 was not observed to check Resident #103's blood pressure and heart rate. On 3/19/26 at 8:55 AM, LPN #1 stated Resident #103's vital signs were taken by the CNA earlier and it was 132/78. LPN #1 stated she did not check her vital signs since it was within the parameter of the physician's order. When asked if Resident #103's vitals signs should have been check prior to administration of her anti-hypertensive medications, LPN #1 stated I probably should have check it. 2. Resident #55 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, kidney disease, and had an ileostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall, bringing the end of the small intestine (ileum) to the surface to allow waste to exit the body). The National Library of Medicine web page titled Nursing Rights of Medication Administration, accessed 3/25/26, documented the five traditional rights for medication administration are, Right Patient, Right Drug, Right Route, Right Time, Right Dose. Resident #55's record documented the following orders: Dulcolax Suppository 10 MG (Bisacodyl) Insert 10 mg rectally as needed for constipation, order date, 5/8/23 Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for constipation, order date, 5/8/23 On 3/20/26 at 1:40 PM, the SDC agreed, Resident #55 should not have any orders to give medications rectally and the route on the bisacodyl and enema order are wrong. The SDC added Resident #55, should not even have those orders.

Based on record review and staff interview, it was determined the facility failed to ensure residents and/or their representatives were provided written notice of the facility's bed-hold policy. This was true for 3 of 6 residents (#5, #39, and #98) whose records were reviewed for discharges. This failure placed the residents at risk for psychosocial harm and possible financial distress when they were not provided documentation of the cost of holding their bed or their right to return to the facility. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including dementia, heart disease, and diabetes. Resident #5's record documented she was hospitalized from [DATE]-[DATE]. Resident #5's record did not include documentation a bed-hold notification was provided to her or her representative. On 3/20/26 at 10:07 AM, the Admissions Director stated, I spoke with [Resident #5's] POA, I did not provide a bed-hold document. 2. Resident #39 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (complete paralysis on one side of the body, and partial weakness on the other side), COPD, ESRD, depression, bipolar disorder, and anxiety disorder. A review of Resident #39's record documented she was admitted to the hospital on [DATE]. There was no documentation a bed-hold notification was provided to Resident #39 or her representative. 3. Resident #98 was admitted to the facility on [DATE] with multiple diagnoses including urinary tract infection, diabetes, heart failure, and chronic kidney disease. A review of Resident #98's record documented she was admitted to the hospital on [DATE]. There was no documentation a bed-hold notification was provided to Resident #98 or her representative. On 3/19/26 at 10:56 AM, the Administrator stated the facility did not have any record of a bed-hold notification being provided to Resident #39 or Resident #98.

Based on record review and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 1 of 1 residents (Resident #1) reviewed for physician orders. When the facility failed to administer insulin as ordered and administered an incorrect dose of morphine, creating the potential for uncontrolled blood sugars and overmedication. Findings include: 1.Resident #1 was admitted to the facility with multiple diagnoses, including diabetes, severe protein calorie malnutrition, and a need for assistance with personal care.a)A review of Resident #1's diabetic care plan, revised 1/22/26, directed staff to provide timely notification to the physician for any change in condition.A physician's order dated 2/2/26 directed staff to administer Insulin Aspart Injection Solution 100 units/mL sliding scale as follows:0-150 = 0 units151-200 = 2 units201-250 = 4 units251-300 = 6 units301-350 = 6 units351-999 = 6 units If greater than 351, give 6 units and notify the provider.A review of Resident #1's MAR dated 2/2/26-3/18/26 documented no insulin administrations or blood sugar checks on the following evening shifts:2/2/262/8/262/9/262/12/262/15/262/23/262/27/263/5/263/6/263/12/263/15/263/16/26On 3/19/26 at 5:35 PM, the DON confirmed Resident #1's insulin administration record contained multiple blanks. She provided documentation of blood sugar readings, but no documentation of insulin doses administered.b) A nursing progress note dated 3/4/26 at 5:31 PM, documented that Resident #1 was given the wrong dose of PRN morphine.Resident #1's record included the following physician orders:Morphine Sulfate Oral Tablet 15 mg: Give 0.5 tablet by mouth every 1 hour as needed for pain/dyspnea.Morphine Sulfate Oral Tablet 15 mg: Give 15 mg by mouth three times a day for pain.A medication error report dated 3/4/26 at 3:15 AM, documented the licensed nurse (LN) administered a full morphine tablet instead of the ordered half tablet. The report documented that Resident #1 asked the nurse whether he had been given a whole or half tablet and informed her he should have received only half.The LN verified the order, acknowledged the medication error, notified the provider, and monitored Resident #1 for adverse effects.The medication error report also documented the LN was educated on the importance of uninterrupted medication administration and adherence to the rights of medication administration.On 3/19/26 at 6:29 PM, the DON confirmed the medication error occurred and provided documentation of the LN's education.

Based on record review and staff interview, it was determined the facility did not ensure provider notification was completed according to the physician's order for 1 of 2 residents (Resident #1) whose record was reviewed for provider notification. This failure created the potential for harm when elevated blood glucose levels were not communicated to the attending physician as required. Findings include:Resident #1 was admitted to the facility with multiple diagnoses, including diabetes, severe protein calorie malnutrition, and a need for assistance with personal care.A review of Resident #1's diabetic care plan, revised 1/22/26, directed staff to provide timely notification to the physician for any change in condition.A physician's order dated 2/2/26 directed staff to administer Insulin Aspart Injection Solution 100 units/mL per sliding scale as follows:0-150 = 0 units151-200 = 2 units201-250 = 4 units251-300 = 6 units301-350 = 6 units351-999 = 6 unitsIf greater than 351, give 6 units and notify the provider.A review of Resident #1's MAR dated 2/2/26-3/18/26 documented the following blood glucose levels:2/5/26 at 11:30 AM - 3842/5/26 at 5:30 PM - 3782/12/26 at 11:30 AM - 3662/16/26 at 11:30 AM - 3652/18/26 at 5:30 PM - 3622/24/26 at 5:30 PM - 5063/1/26 at 5:30 PM - 409which all met the threshold requiring provider notification.A request was made for documentation of provider notification related to the elevated blood glucose.On 3/19/26 at 7:29 PM, the DON confirmed via email she was unable to locate documentation that the provider had been notified.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received information and assistance to formulate an Advance Directive. This was true for 1 of 4 residents (Resident #74) reviewed for Advance Directive. This deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated. Findings include:The facility's Advance Directives and Advance Care Planning policy reviewed 9/26/25, documented residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directives upon admission.Resident #74 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy (malfunction of the brain that alters mental state, causing symptoms like confusion, memory loss and personality changes), diabetes, retention of urine and urinary tract infection.A Social Services assessment dated [DATE], documented Resident #74 did not have an Advance Directive. There was no documentation in her record she was provided with information to formulate an Advance Directive.On 3/18/26 at 10:45 AM, the SSD stated Resident #74 did not have an Advance Directive. The SSD stated Resident #74 and/or her representative should have been offered to formulate an Advance Directive.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided with an appropriate adaptive call light due to inability to use the push button call light. This was true for 1 of 1 residents (Resident #15) observed for accommodations. This deficient practice had the potential to cause harm when Resident #15 was not able to call for assistance when needed or experienced an adverse medical event that required attention. Findings include: Resident #15 was admitted to the facility on [DATE] with multiple diagnoses including cognitive communication deficit, history of TIA, adult failure to thrive, and dementia.Resident #15's Annual MDS assessment dated [DATE] documented, Resident #15 had a BIMS score of 5 indicating she was severely cognitively impaired.A Social Services progress note dated 3/9/26 documented, Resident #15 used her call light appropriately to make needs and preferences known.On 3/17/26 at 3:49 PM, upon entering Resident #15's room a distinct odor of stool was noted and brown colored stool was observed leaking out of the left side of her incontinence brief. Resident #15 pointed to her incontinence brief and said mess. When asked how long she had been soiled, Resident #15 stated she didn't know. When asked if Resident #15 used her call light to ask for help, Resident #15 didn't respond and shrugged her shoulders.On 3/17/26 at 4:44 PM, CNA #2 entered Resident #15's room and provided incontinence care.On 3/17/26 at 5:02 PM, when asked if Resident #15 could use the call light, CNA #2 stated Resident #15 was able to use the call light. When asked to have Resident #15 demonstrate how to use the call light, Resident #15 smiled at CNA #2 and the surveyors. CNA #2 then pointed to the call light and asked Resident #15 to use the call light. Surveyors asked CNA #2 not to point to the call light. CNA #2 asked Resident #15 again to use the call light and Resident #15 smiled at CNA #2 and the surveyors.Cross Reference F550

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 1 residents (Resident #15) observed during cares. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Findings include: Resident #15 was admitted to the facility on [DATE] with multiple diagnoses including cognitive communication deficit, history of Transient Ischemic Attack (TIA- a temporary blockage of blood flow to the brain, causing stroke-like symptoms-such as weakness, confusion, or vision loss), adult failure to thrive, and dementia.Resident #15's Annual MDS assessment dated [DATE] documented, Resident #15 had a BIMS score of 5 indicating she was severely cognitively impaired.On 3/17/26 at 3:49 PM, Resident #15 was observed sitting in bed watching TV with blankets folded back and linens soiled with stool. A distinct odor of stool was noted and brown colored stool was observed leaking out of the left side of the incontinence brief. Resident #15 pointed to her incontinence brief and said mess. When asked how long she had been soiled, Resident #15 stated she didn't know. When asked if Resident #15 used her call light to ask for help, Resident #15 didn't respond and shrugged her shoulders.On 3/17/26 at 4:44 PM, CNA #2 was observed entering Resident #15's room for bowel and bladder rounds. CNA #2 was observed performing incontinence care. Resident #15's window blinds were noted to be open with the courtyard visible during incontinence care. Resident #15's privacy curtain was noted to the left corner of the room above Resident #15's bed.On 3/17/26 at 5:02 PM, when asked if CNA #2 used the privacy curtain when providing cares for Resident #15, CNA #2 stated she did not use the privacy curtain. When asked about the open blinds observed during cares, CNA #2 stated resident's rooms could not be seen from outside.CNA #2 accompanied the surveyor outside to the courtyard. Resident #15 was observed through the open blinds lying in bed. When asked if Resident #15 was visible, CNA #2 stated she could see part of the resident through the open blinds and stated she should have closed the blinds or used the privacy curtain during cares.

Based on record review and staff interview, it was determined the facility did not ensure residents assessments were accurately documented. This was true for 2 of 3 residents (#4 and #39) reviewed for MDS accuracy. This failure resulted in inaccurate transmission of assessment data, as Resident #4's MDS assessment documented the use of physical restraints, and Resident #39 did have a PASRR level II. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including anxiety, depression, and a need for assistance with personal care. A review of Resident #4's Quarterly MDS assessment dated [DATE] documented in Section P0100 (Physical Restraints) Resident #4 used restraints when in a chair or in bed, and the restraints were used less than daily. On 3/20/26 at 8:47 AM, the DON confirmed that Resident #4's Quarterly MDS assessment was coded inaccurately regarding the use of physical restraints. 2. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder. A review of Resident #39's record documented a PASSR level II had been completed on 7/13/21. An Annual MDS assessment dated [DATE] documented at A1500, No, Resident #39 did not have a PASSR level II. On 3/18/25 at 9:51 AM, the DON stated the Annual MDS assessment completed on 11/28/25 was not accurately filled out and it should have been marked, Yes at A1500.

Based on observation, policy review, and staff interviews, it was determined the facility failed to provide a PASRR level II to the designated state agency. This was true for 1 of 2 residents (Resident #79) whose record was reviewed for PASRR documentation. This deficient practice created the potential for harm if Resident #79's coordination of care was not completed between the facility and the designated state agency, with interventions appropriately documented in Resident #79's care plan. Findings include:Resident #79 was admitted to the facility on [DATE] with multiple diagnoses including PTSD, anxiety, and depression.A PASRR level I, dated 3/27/25, documented Resident #79 did not document he have PTSD or an anxiety disorder.On 3/18/26 at 9:34 AM, the SSD stated Resident #79 should have had a corrected PASRR level I completed along with a PASRR level II, as Resident #79 had diagnoses of PTSD and anxiety.

Based on policy review, record review, and staff interview, it was determined the facility failed to revise residents care plans and to provide care conferences. This was true for 4 of 18 residents (#10, #69, #79, and #91) whose care plans were reviewed. This deficient practice created the potential for harm if resident's care plans were not updated to direct staff with appropriate care interventions for Resident #10, Resident #69, and Resident #91, and a potential for harm for Resident #79 when quarterly care conferences were not completed with the resident and/or their representative. Findings include: The facility's Comprehensive Care Plan and Revisions policy, reviewed 8/29/25, documented care plans should be reviewed and revised when changes occur to update the plan of care to reflect the change in care delivery. 1. Resident #10 was admitted on [DATE] with multiple diagnoses including heart disease, difficulty walking, abnormal posture, and kyphosis (an exaggerated, forward-rounding curvature of the upper back, often appearing as a hunchback or severe slouch). Resident #10's care plan documented the following: Under Activities of Daily living; Ambulates with therapy only revised 12/12/25 Under Restorative Nursing; Walking Program #1 ambulate for 120-175 ft for 3-6 day per week for 15 min or as tolerated, revised 3/17/26 Under Activities of Daily Living; Resident to wear neck brace for ten minutes two times per day as tolerated. Staff to encourage use, initiated 6/23/23 On 3/17/26 at 10:41 AM, Resident #10 was observed in her room, her head was held at an angle to the right with her right hand frequently holding it up. A neck brace was not observed in her bedroom. On 3/20/26, at 1:46 PM, the SDC stated, when Resident #10's new restorative program was initiated, the old directions Ambulate with therapy only should have been discontinued. On 3/20/26, at 2:03 PM, the SDC stated, Resident #10's neck brace was discontinued in December 2025 and the care plan was not updated. 2. Resident #69 was admitted to the facility on [DATE] with multiple diagnoses including cellulitis of the right limb, muscle weakness, and a need for assistance with personal care. A physician order dated 10/28/25 directed staff to apply offloading boots to both feet at all times. A review of Resident #69's care plan did not include documentation of the physician ordered intervention requiring offloading boots to be applied at all times. Resident #69 was observed not wearing her offloading boots on the following dates: 3/18/26 at 11:23 AM 3/18/26 at 5:16 PM 3/19/26 at 9:33 AM 3/19/26 at 1:05 PM On 3/19/26 at 2:05 PM, the DON confirmed that Resident #69's care plan did not include the offloading boots and stated the care plan should have been revised to reflect the intervention. 3. Resident #91 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following a stroke. A progress note dated 2/27/26, documented Resident #91 transitioned to hospice services. A review of Resident #91's care plan did not include documentation of the hospice/comfort care interventions. On 3/19/26 at 1:18 PM, the ADON confirmed that Resident #91's care plan did not include hospice/comfort care interventions and stated the care plan should have been revised as soon as Resident #91 was admitted for hospice/comfort care services. 4. Resident #79 was admitted to the facility on [DATE] with multiple diagnoses including PTSD, anxiety, and depression. A review of Resident #79's record did not document quarterly care conferences were completed in July and October 2025. On 3/18/26 at 4:14 PM, the SSD stated care conferences for July and October 2025 were overlooked and not completed.

Based on record review and staff interview it was determined the facility failed to ensure a resident was provided quality treatment and care in accordance with professional standards of practice related to timely physician response. This was true for 1 of 18 residents (Resident #98) whose record was reviewed for quality of care. This deficient practice created the potential for harm due to delayed medical intervention when Resident #98 experienced a change of condition. Findings include: The National Library of Medicine website accessed on 3/25/26, defined standard of care as the benchmark that determines whether professional obligations to patients have been met.Resident #98 was admitted to the facility on [DATE] with multiple diagnoses including urinary tract infection, diabetes, heart failure, and chronic kidney disease.A nursing progress note, dated 4/15/25 at 12:42 AM, documented an SBAR (Situation, Background, Assessment, Recommendation) note was sent to Resident #98's physician, identifying Resident #98 was hard to arouse and appeared somnolent (drowsy/sleepy), having slept most of the entire shift and eating no dinner, and that she might be showing signs and symptoms of sepsis or a [urinary tract infection], requesting the physician provide further evaluation and treatment.A nursing progress note, dated 4/15/25 at 3:45 PM, documented an SBAR to Resident #98's physician identifying symptoms of congestion, refusal of medication and food throughout the day, as she had been sleeping most of the day. The nursing progress note questioned if the physician could see the resident, get some laboratory work completed, or have a portable chest X-ray completed.On 4/15/25 at 4:10 PM, the nurse documented Resident #98 was found in bed catatonic (a set of neuropsychiatric symptoms characterized by severe abnormalities in motor activity, movement, and communication), and unresponsive when brought to the nurse at 3:20 PM. The nurse called the physician who approved sending Resident #98 to the emergency room via emergency transport. There was no documentation in Resident #98's record her physician communicated with the facility between the first SBAR at 12:24 AM and the second SBAR at 3:45 PM. On 3/20/26 at 8:31 AM, an email sent by the Administrator acknowledged the facility had no record the [physician] responded to the SBAR sent at 12:42 AM on 4/15/25 before the resident was sent to the ER.

Based on observation, review of records, and interviews, it was determined the facility failed to ensure residents received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was true for 1 of 1 residents (Resident #9) reviewed for range of motion services. This failure created the potential for Resident #9 to experience a further decrease in mobility and function due to his refusals to participate in the restorative nursing program and to wear his right hand grip orthotic were not addressed accordingly. Findings include:The facility's Restorative Nursing policy reviewed 9/18/25, documented the following:Restorative Nursing Functions can be within one of the following categories: Range of Motion (Active and Passive), Splint or brace assistance, bed mobility, transfers etc.Communicate the restorative care plan and care directives to other members of the interdisciplinary team.The licensed nurse will conduct an evaluation on a routine basis to include progress towards goal and response to the program. Any change will be documented in the medical record.Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including right-hand contracture and aphasia following a stroke.A care plan revised 7/11/25, directed staff to apply the right-hand grip splint to Resident #9 for eight hours as he can tolerate.An Occupational Therapy Discharge summary dated [DATE], documented, tolerating right grip orthotic (resting hand splint designed to support, position, and rehabilitate the hand and wrist) during the daylight hours, good follow through with staff application/removal and ROM that patient will allow. The discharge summary also documented Resident #9's prognosis to maintain his current level of function was excellent with consistent staff support.A Communication with Physician note dated 7/31/25, documented an SBAR the nurse was concerned as Resident #9 had constricted fingers that have led to skin maceration noted with odorous smell. It documented Resident #9 complained of pain and discomfort when staff tried to clean his hand. The physician recommended Resident #9 to be evaluated and treated by OT for his contractures.A Communication to Physician note dated 10/6/25, documented an SBAR the CNAs reported Resident #9 refused to wear his brace every day. He showed high level of pain when the staff tried to even put their fingers into his contracted hand. The note documented a recommendation, Re-evaluation for therapy options for resident.A Nursing Note dated 10/21/25 documented Resident refused to wear the brace, but he was using the carrot that was given to him from Physical Therapy.On 3/19/26 at 11:43 AM the OT with the DOR present, stated Resident #9 was referred to the Therapy department in July 2025 for feeding and right-hand contracture. The OT stated Resident #9 discharged from the therapy on 7/15/25 and he was provided with orthotic/splint to keep his fingers in a resting position and prevent further contraction. OT stated the orthotic splint had to be worn during the day as he can tolerate. When asked if Resident #9 was referred to therapy after 7/15/25, both the DOR and OT stated he was not referred to the therapy after his discharge on [DATE]. When asked how the orthotic splint was placed on Resident #9's right hand, OT stated it was placed between his fingers and the thumb. Resident #9's TAR documented he refused to wear his hand grip orthotic as follows:14 out of 31 days in 10/202521 out of 30 days in 11/202518 out of 31 days in 12/202522 out of 31 days in 1/202620 out of 28 days in 2/202615 out 19 days in 3/2026A Monthly Summary Report, dated 1/27/26 and 2/27/26, documented Resident #9 had right contractures, and he refuses to wear the hand grip orthotic.There was no further documentation in Resident #9's records, the physician, the therapy department, and/or his representative were notified of his refusal to wear the grip orthotic after 10/6/25.A Restorative Program Note dated 1/8/26 at 12:23 PM, documented, New program added for PROM to the right hand.A care plan initiated 1/8/26, directed staff to perform PROM to his right hand due to its tightness and approach him by asking if you can hold his hand.A Restorative Nursing Program Evaluation, dated 2/3/26 and 3/5/26, documented Resident #9 participated with restorative program this month. He had done the PROM program for 2-15 minutes for 6-75 reps[etitions]. Will continue current program.On 3/20/26 at 9:44 AM, the Restorative Coordinator stated when a resident refused their RNA program, the expectation was to approach the resident at least three times and notify the nurse. The RNA Coordinator stated she was not aware of the length of time Resident #9 was unable to open his right hand. She stated Resident #9 was referred to RNA program in 1/2026 due to tightness of his right hand.On 3/20/26 at 10:21 AM, when asked if she was informed of Resident #9 refusing to wear his right-hand grip orthotic, the DON stated, I might have been, but I do not recall. The DON stated when a resident continued to refuse to wear their splint, they would refer to the therapy department. We will inform their representative. The DON stated, Yes, education would be provided to the resident and if the resident was cognitively impaired, then we will notify their representatives. The DON also stated the physician would also be notified.Cross reference F686

Based on record review and staff interview, it was determined the facility did not ensure hospice documentation was complete and available in the resident's medical record. This was true for 1 of 1 residents (Resident #1) reviewed for hospice services. The absence of required hospice documents created the potential for delayed or incomplete care due to lack of access to the hospice plan of care and current terminal certification. Findings include:Resident #1 was admitted to the facility with multiple diagnoses, including diabetes, severe protein calorie malnutrition, and a need for assistance with personal care.A review of Resident #1's hospice care plan, revised [DATE], documented he was receiving hospice services and had a Do Not Resuscitate (DNR) code status.A review of Resident #1's medical record showed no documentation of:A current hospice plan of care.A current terminal diagnosis certification.Both of which are required to initiate and maintain hospice services.On [DATE] at 4:03 PM, the surveyor requested the terminal certification and hospice plan of care.On [DATE] at 10:18 AM, the DON provided a terminal certification with a benefit period ending [DATE], which had expired 23 days earlier. The DON also provided the facility generated care plan but did not provide a hospice plan of care.On [DATE] at 1:45 PM, the Administrator stated he did not have a current terminal certification or hospice plan of care in the resident's record and reported he would request the documents from the hospice agency.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure a grievance was thoroughly investigated. This was true for 1 of 1 residents (Resident #52) reviewed for grievance investigations. This deficient practice created potential for psychosocial harm if residents' concerns were not investigated completed to avoid future occurrences. Findings include:Resident #52 was re-admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease, diabetes, hypothyroidism, pulmonary hypertension, and chronic kidney disease.On 8/2/25, a grievance was filed with the facility documenting 4 medication cups were found on Resident #52's bedside, labeled with her name. A review of Resident #52's MAR, dated 8/2/25, documented she had received her medications.On 8/4/25, the grievance investigation and response documented the residents involved had missed their medications and the LPN involved had been educated, and the provider was notified. No additional information was provided. On 3/20/26 at 12:05 PM, the Administrator stated there was no record of a medication error report or staff education related to medication storage, administration, and medications left at Resident #52's bedside and there should have been. Additionally, the staff involved was terminated for continued infractions.

Based on interview and job description review, the facility failed to ensure a qualified director of food and nutrition services was in place to oversee the dietary department with the potential to effect 82 census residents. Findings include: Review of the Food Service Director Job Description, date 09/28/22, indicated that the position required a minimum course of study in food safety before October 1,2023 (e.g., Serv Safe Food Manager Certification). During an interview on 10/01/24 at 11:18 AM, the Dietary Manager (DM) stated that he had been employed at the facility for one and a half years. The DM stated that he was not certified and did not have any Serv-Safe courses completed. The DM stated that he worked six months straight without a day off and had no time to do any training. During an interview on 10/01/24 at 11:45 AM, the Registered Dietitian (RD) stated that she was in the facility two days a week and was aware the DM was not certified. The RD stated that the DM needed to be certified so he could understand how to run the kitchen for long-term residents. The RD stated that she completed the resident assessments and did not manage the kitchen.

Based on observation, staff, resident, and interested party interview, record review, and policy review, it was determined the facility failed to ensure residents did not develop avoidable Pressure Ulcer (PU). This was true for 1 of 4 sample residents (#2) reviewed for PU's. Resident #2 was harmed when she developed a suspected deep-tissue injury pressure ulcer (SDTI PU) which deteriorated and worsened. Findings include: Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's Physician Order, dated 10/31/16, documented staff was to complete a weekly skin assessment on Wednesdays. Resident #2's 10/31/16 Risk for Pressure Ulcers Care Plan documented she was at risk for pressure ulcers related to [DIAGNOSES REDACTED]. An intervention documented staff was to complete weekly skin assessments. Resident #2's 11/8/16 admission Minimum Data Set (MDS) assessment documented no cognitive impairment and she was at risk for skin breakdown. The admission MDS assessment documented interventions of using a pressure reducing device while in bed. Resident #2's Physician Order, dated 12/15/16, documented Resident #2 was to be up in a chair for 15 minutes in morning and the afternoon when her interested party was present and when she allowed. Between 12/16/16 and 1/13/17 Resident #2's Nurse's Notes documented she was turned and repositioned in bed every two hours on 13 of 84 shifts. Repositioning or refusal to be repositioned were not documented between 1/10/17 and 1/13/17. Resident #2's Skin Team Nurse's note, dated 1/13/17 at 2:55 pm, documented the Team was called to assess an area of her mid spine/back. The note documented the area was a deep red/purple intact area (100 cm by 60 cm). The note documented a shower aide noticed the area when Resident #2 was placed into the shower chair and she vocalized pain. The note documented she was resistive to repositioning techniques. The note documented the MD saw Resident #2 and confirmed the SDTI was from her back lying position. The note documented a low loss air mattress was ordered and the skin team would be following Resident #2. On 4/18/17 at 12:35 pm, LPN #3 stated the 100 cm by 60 cm measurement was a mistake in the skin team's note on 1/13/17. LPN #3 referred to the Pressure Ulcer Status Record documentation for the correct measurements. Resident #2's Physician Order, dated 1/13/17, documented Resident #2 was to have an air mattress for pressure ulcers. Resident #2's 1/13/17 significant change MDS assessment documented she had an unstageable DTI and she did not reject cares. The significant change MDS documented interventions of a pressure reducing device while in bed, a turning and repositioning program, and adequate nutrition. Resident #2's Risk for Pressure Ulcers Care Plan, updated on 1/13/17, documented, Refuses repositioning techniques .prefers to be on her back while in bed, spends most of every day, all day in bed. The interventions on the care plan did not include dates of when the interventions were added. The interventions on the care plan were undated and it was unable to be determined when they were put into place. Interventions included: * Staff was to complete weekly skin assessments. * Provide pressure reduction mattress- low loss air mattress. * Staff were to provide a turning and repositioning program q (every) 2-3 hours as she (Resident #2) will allow. Resident #2's physician progress notes [REDACTED].#2's back, which shows an area that they (the skin team) think is pressure or possibly injury from lifting. The MD note documented in his assessment he was not sure where the DTI came from; he speculated it was from transferring to a shower chair or prolonged bed rest. Resident #2's Pressure Ulcer Status Record entry, dated 1/14/17, documented the deep-tissue injury pressure ulcer (DTI PU) was 5 cm x 6 cm. Resident #2's Risk for Pressure Ulcer Care Plan included an updated intervention on 1/17/17, which documented, administer treatment to back/spine per MD. Resident #2's care plan did not include the SDTI injury to the mid spine/back except to administer the treatment on 1/17/17. Resident #2's January 2017 Treatment Administration Records (TAR) documented weekly skin assessments had been completed on 1/4/17, 1/11/17, 1/18/17, and 1/25/17. Resident #2's Weekly Skin Integrity Data Collection Record, where LNs were to document the condition of Resident #2's skin at the time of each assessment, such as whether Resident #2's skin was intact, or which areas of skin were dry, red, where skin tears were found, etc., was blank on 1/18/17. Resident #2's Incident and Accident report, dated 1/19/17, documented a shower aide found Resident #2 had a purple area on her spine. The report documented the skin team assessed the area and determined it was a SDTI. The report documented Resident #2 was at high risk for pressure related injuries due to refusals to get out of bed, failure to thrive, and need for nutritional support. The report documented actions taken included: * Resident #2 was to be placed on an alternating air mattress. * The RD (Registered Dietician) was to review Resident #2 to verify adequate nutrition was being provided through her nutrition support. * Staff was to provide a repositioning schedule as Resident #2 would allow. * Staff were to encourage her to get out of bed throughout the day. Resident #2's Physician Note, dated 1/19/17, documented her Interested Party asked the MD to look at Resident #2's back due to a concern about her getting an infection. The note documented staff removed the dressing and it created a mild abrasion due to the stickiness of the dressing. The note documented new orders for the treatment of [REDACTED]. Resident #2's Physician Note, dated 1/20/17, documented the DTI PU to her back was due to lying for prolonged periods of time in one position. The 1/24/17 Pressure Ulcer Status Record documented a small part of Resident #2's DTI PU worsened to a stage II of 1.6 cm x 2 cm by 0.2 deep. Resident #2's Braden Scale for Predicting Pressure Sore Risk, dated 1/26/17, scored her at moderate risk. Resident #2's February 2017 TAR documented weekly skin assessments had been completed on 2/1/17, 2/8/17, 2/15/17, and 2/22/17. Resident #2's Weekly Skin Integrity Data Collection Record did not document the results of the skin assessments on 2/1/17 and 2/22/17. The 2/2/17's Pressure Ulcer Status Record documented a small part of Resident #2's DTI PU measured 1.8 cm x 0.7 by 0.2 cm deep and remained a stage II pressure ulcer. The 2/10/17 Pressure Ulcer Status Record documented a small part of Resident #2's DTI PU worsened to an unstageable wound of 0.3 cm x 0.3 cm. The 2/14/17 Pressure Ulcer Status Record documented Resident #2's DTI PU remained an unstageable wound. A Notifications Fax to the Physician, dated 3/2/17, documented Resident #2 had multiple [DIAGNOSES REDACTED]. The fax continued to document Resident #2 was very self-directing in her cares and she chooses not to follow care planned interventions. The fax asked the MD to reference a 3/2/17 Skin Team Nurse's Note which documented the reason Resident #2's wound was unavoidable and to please write an order for [REDACTED].>Resident #2's Skin Team Nurse's note, dated 3/2/17, documented .Floor staff requested to strongly and consistently encourage Pt (patient) to follow medically recommended Plan of care, Due to Pts usual failure to follow recommended Plan of Care Skin Team is requesting an order for [REDACTED]. Resident #2's Pressure Ulcer Status Record entries on 2/21/17, 3/2/17, 3/9/17, 3/14/17, 3/21/17, 3/27/17, 4/4/17, and 4/11/17 documented progressive healing of the wound. Resident #2's March 2017 TAR documented weekly skin assessments were to be completed on 3/1/17, 3/8/17, 3/15/17, and 3/29/17. Resident #2's March 2017 TAR did not include documentation of a weekly skin assessment on 3/22/17. Resident #2's Weekly Skin Integrity Data Collection Record did not document the results of a weekly skin assessment on 3/22/17. On 4/17/17 at 2:45 - 3:24 pm, Resident #2 was observed in her bed laying on her right side with a pillow behind her back. Resident #2 stated she depended on staff for most everything. She stated she got up in a chair about once a week. Resident #2's Pressure Ulcer Status Record final entry on 4/18/17, documented the DTI PU had resolved. On 4/18/17 at 9:36 - 11:30 am, Resident #2 was in her room with her Interested Party and she was observed laying on her right side throughout the observation. Resident #2's Interested Party stated a CNA had come in at about 11:00 to ask Resident #2 if she wanted to get up out of bed and Resident #2 had declined. On 4/18/17 at 12:35 pm, LPN #3 stated the main conclusion the Skin Team had determined the cause of Resident #2's DTI PU to her back was due to her refusal to be turned and repositioned and refusal for other cares. She stated Resident #2 managed her cares and only did what she wanted. LPN #3 was asked to provide documentation of the refusals and LPN #3 provided copies of the refusals to get out of bed and weight refusals as documentation. She stated she could not find documentation of refusals to reposition and turn prior to the discovery of the DTI PU. She stated nurses had documented in Nurse's notes, after the PU discovery that Resident #2 had been refusing to reposition and turn. On 4/18/17 at 12:40 pm, the Director of Nursing (DON) stated when the SDTI PU was discovered they ordered the air mattress and the treatments did not get ordered until the SDTI PU worsened. On 4/19/17 at 9:45 am, RCM (Resident Care Manager) #1 stated when skin checks were completed nurses were to initial the TAR, and then fill out the Weekly Skin Integrity Data Collection Record which showed the RCM's that nurses had actually looked at residents' skin and not just signed off that they had completed it. RCM #1 said if nurses found no new skin issues the nurse was still to complete the Weekly Skin Integrity Data Collection Record. In addition, he said if nurses found pressure related injuries or non-pressure related injuries there was another form that staff were to fill out in addition to the Weekly Skin Integrity Data Collection Record and signing off on the TAR. RCM #1 stated the missing dates above should have contained entries on the Weekly Skin Integrity Data Collection Record. On 4/19/17 at 10:15 am, the Director of Nursing (DON) stated when skin checks were completed nurses were to initial the TAR, and then fill out the Weekly Skin Integrity Data Collection Record. She stated if the TAR was signed off as completed, then a skin check was completed, and the dates above, with the exception of 3/22/17, was just missing documentation. On 4/19/17 at 3:40 pm, the DON stated Resident #2 got the SDTI PU related to Resident #2's refusal to get up out of bed, failure to thrive, and her lack of subcutaneous tissue (innermost layer of skin made up of fat) on her back. On 4/20/17 at 11:15 am, the House MD stated it was a mystery how Resident #2 got the area on her back. He stated the nursing staff told him it was due to her refusals to be turned or repositioned. He stated he knew she required staff assistance with repositioning. The MD said he would expect nurses to be monitoring her for refusals to reposition before making that determination. The MD stated he personally did not monitor Resident #2 for refusals but expected nursing staff to monitor for it. b. The facility's resistance to cares monitoring included: * Resident #2's January - February 2017 Treatment Administration Record (TAR) documented staff monitored when Resident #2 was up in a chair for 15 minutes in morning and the afternoon, and staff were to document refusals. Resident #2 did not get out of bed 81 times out of 118 opportunities throughout January and February 2017. The TAR did not include Resident #2's acceptance or refusal of turning and/or repositioning. * Resident #2's 3/1/17 - 4/17/17 TAR documented staff was monitored when Resident #2 was up in a chair for 15 minutes in morning and the afternoon, and were to document refusals. Resident #2 did not get out of bed 81 times out of 94 opportunities throughout time frame. The TAR documented an intervention of the staff re-approaching Resident #2 on 4/15/17, which was 1 out of 81 opportunities. On 4/20/17 at 8:59 am, Resident #2 stated she did not mind being turned in bed. She stated she depended on staff to transfer and reposition her in bed. Resident #2's clinical record, prior to the discovery of the DTI PU, did not document a pattern of Resident #2 refusing to be turned or repositioned. The facility determined Resident #2's pressure ulcer was unavoidable due to her refusals to be turned or repositioned. Resident #2's clinical record did not include documentation of such refusals. The facility failed to ensure Resident #2, who was at high risk for PUs, did not develop a PU, and did not modify interventions to increase Resident #2's compliance with her care planned interventions.

Based on record review, interviews and observation, it was determined the facility failed to ensure a resident was not catheterized without a valid medical justification and received treatment to restore as much normal bladder function as possible. This was true for 1 of 7 sampled residents for urinary incontinence (#7). Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/20/15, a Urinary Incontinence Assessment documented the resident had stress incontinence; occasional bladder incontinence; recognized the urge to void; could learn to control the urge; and could contract her pelvic muscles. A schedule of toileting the resident before or after meals, at nighttime, and as needed was implemented. On 4/22/15, the MDS admission assessment documented the resident did not have an indwelling catheter; was in a toileting program or trial; had frequent urinary incontinence; and required extensive assistance of one person for toileting. On 8/3/15, an urologist documented the resident was assessed for recurrent UTI's and nocturnal enuresis (urinary incontinence). A urinalysis was ordered and the urologist advised decreasing the resident's liquid intake in the evening. On 8/13/15, 10/6/15, and 1/7/16, Bladder Training Assessments documented the resident: * had stress incontinence; * was a candidate for toileting; * was a candidate for timed or scheduled voiding; and * was to be offered toileting before or after meals, at nighttime and as needed. The assessments did not include decreasing the resident ' s fluid intake at night as an intervention. On 9/4/15, a physician progress notes [REDACTED]. Alarms have been placed on her recliner, wheel chair, and bed. There was also an alarmed mat placed at the feet of her recliner. The physician documented the resident had a history of [REDACTED]. On 9/15/15, a physician progress notes [REDACTED]. It documented the resident had short-term memory loss and when she experienced the urge to urinate she has to go immediately and did not use her call light for help. Apparently she is up frequently to use the restroom and likely has overflow incontinence. On 10/5/15, a physician progress notes [REDACTED]. On 11/19/15, physician progress notes [REDACTED]. On 12/5/15, a Fall Risk Evaluation documented the resident fell on [DATE], 11/24/15, and 12/05/15. The evaluation documented the resident required assistance for elimination. On 12/24/15, a physician progress notes [REDACTED]. difficile [MEDICAL CONDITION]. On 1/12/16, a physician progress notes [REDACTED]. The physician ordered a UA with C&S. On 1/22/16, a physician progress notes [REDACTED]. The plan was to consider Foley catheter because she goes from 1 UTI to the other primarily because she doesn ' t notify staff of needing to use the restroom frequently enough. On 1/24/16, an Incident and Accident report documented the resident fell at 3:30 am. On 1/25/16, a physician progress notes [REDACTED]. The physician progress notes [REDACTED].it may be reasonable to put a Foley in her because of previous observations that she tends to cross contaminate herself between her rectum and her vaginal area and this may decrease her incidence of recurrent UTIs .unfortunately she had another slight fall over the weekend which was no-injury. On 2/29/16, a physician progress notes [REDACTED]. Neither the resident ' s admission nor her quarterly MDS, dated [DATE] and 1/5/16 respectively, documented the resident had a [DIAGNOSES REDACTED]. On 1/26/16, a Catheter Justification form documented the resident had a [MEDICAL CONDITION] bladder resulting in [MEDICAL CONDITION]. All previous documentation noted urgency, overflow, and bladder incontinence, but did not contain documentation of [MEDICAL CONDITION] or [MEDICAL CONDITION] bladder. On 2/2/16, a Progress Note documented the Foley catheter was changed due to the resident pulling it out. On 2/8/16, a Resident/Family Education Assessment & Interdisciplinary Flow Record documented nursing had spoke (sic) with resident about her alarms and her safety, that we (the facility) are not holding her hostage. She has many falls. On 3/14/16 at 9 am, the resident stated she had the catheter because she was wetting the bed. On 3/16/16 at 8:50 am, the resident stated she was stuck in the (her) room, and could not go where she wanted because of the many alarms and because she was tied down with the catheter. She stated she did not want the catheter and that the aides helped her with cleaning herself after toileting. On 3/16/16 at 8:55 am, CNA #8 stated the resident typically fell while getting up to use the bathroom without using the call light for help. She stated the resident required assistance of one staff to toilet and that staff performed peri-care. On 3/16/16 at 12:10 pm, the DON stated the resident had a quick succession of falls; shuffled her feet; and could not safely toilet without assistance. She stated aides performed peri-care for the resident and that the physician ordered the Foley catheter to remove issues with the bladder. She stated that prior to the insertion of the catheter, the resident had not been seen by an urologist, had a bladder scan had not been performed, and post-void residuals had not been determined. On 3/17/16 at 8:30 am, the resident stated she felt like a prisonerwho was blocked everywhere I turn. The catheter does not even reach the dresser. She repeated that she did not want the catheter, which was inserted because she was wetting the bed. The resident stated she could feel the urge to toilet and had wet the bed only because staff did not respond to her call light in a timely manner. On 3/17/16 at 11 am, the DON stated the resident voiced that she felt like a prisoner since she was admitted . She stated the physician wanted to try the Foley to keep the resident from acquiring C- Difficile. The DON stated staff performed peri care on the resident, who had not had an UTI or fall since the catheter was inserted. The DON noted the physician wanted a catheter because the resident could get an infection that would kill her. On 3/18/16 at 12:20 pm, Physician #14 stated the resident fell multiple times since admission, typically while trying to access the bathroom. He stated the resident had repeated UTIs and despite trying every means to keep her dry, she was continually incontinent. He stated he had assumed she continued to cross contaminate herself. He stated he ordered the catheter: because the resident had recurrent UTIs; increased risk of resistance to bacteria from high doses of IV antibiotics; and to keep her from cross-contaminating herself. He stated the resident had not experienced any UTIs or falls since the catheter had been placed. Physician #14 stated that although staff performed peri-care for the resident, and the catheter did not prevent the resident from putting her hands in her peri area, he thought the benefits outweighed the risks. Physician #14 stated the facility had not performed a bladder scan or PVR prior to the Foley catheter's placement, and had not been referred to an urologist after seeing one in August for UTIs. He stated he was unaware the resident had pulled out the catheter on 2/2/16. When asked about the notation on 1/25/16 asserting the resident had a [MEDICAL CONDITION] bladder, the physician stated that although the resident did not have any neurological issues, and had not had any tests performed, he thought she probably had a [MEDICAL CONDITION] bladder and there were no plans to remove the catheter. The facility provided a letter from Physician #14, dated 3/22/16, that documented the Foley catheter was a trial measure. The resident's clinical record did not include any such trial reference or contradict Physician #14's statement on 3/18/16 that there were no plans to attempt removing the catheter.

Based on staff interview, record review, review of facility policy and review of accident reports, it was determined the facility failed to provide supervision and assistive devices, identify and evaluate potential environmental hazards and/or develop and implement plans to prevent falls with fractures for 3 of 4 (#s 1, 3 & 4) residents reviewed for falls. Resident #4 was harmed when she fell and fractured her pubic bone and right hip. Resident #3 was harmed when he fractured his left leg while being assisted to the bathroom. Resident #1 was harmed when he fell and sustained a left hip fracture. The findings include: 1. Resident #4 was admitted to the facility on [DATE] for, "Aftercare for healing traumatic fracture of the left arm." The resident's [DIAGNOSES REDACTED]. Review of the resident's medical record for the hospital stay of [DATE] to [DATE] revealed the resident fell while with friends at a restaurant. Prior to falling the resident's speech was incoherent and she leaned to her left side. During her hospital stay, Physician Notes documented her speech and physical symptoms improved and it was determined she had a TIA versus a stroke. Intervention and Assessment notes documented the resident was intermittently confused, required a bed alarm due to a high fall risk score, was forgetful, had short term memory deficits and occasional long term memory deficits, had a foley catheter due to urinary retention problems which was discontinued on [DATE], experienced significant pain in her left arm and required frequent reminders to keep the arm immobilized. The facility Inquiry and Pre-Admission Information Form for Resident #4, dated [DATE], documented the resident was pleasantly confused, had memory issues, and required a bed alarm at the hospital. The facility's Initial Data Collection Tool/Nursing Service for Resident #4, dated [DATE] at 4:15 PM, documented the resident: * Had short and long term memory loss. The data collection form did not indicate the resident had intermittent confusion. * Was occasionally incontinent of urine. The data collection form failed to document, in the space provided, the resident had a foley catheter in the hospital which was discontinued on [DATE]. * Required the assistance of ,[DATE] people with transfers. The form documented that the resident "Understands need to wait for assistance to transfer." * Required the assistance of ,[DATE] with ambulation, had an unsteady gait and decreased endurance and strength. The form documented the resident, "Understands need to wait for assistance to ambulate." The Initial Data Collection Tool/Nursing Service form did not document how the resident's understanding of the need to wait for assistance with transferring and/or walking was determined in light of her intermittent confusion and short term/long term memory issues. A Fall Risk Evaluation dated [DATE] documented the resident scored 22 out of a possible 38. The form documented, "A resident who scores a 10 or higher is at risk.... If a score is 10 or higher interventions should promptly be put in place." The back of the form listed only one intervention, "Call light in reach." The Fall Risk form did not document if the resident could use the call light and how that was determined in light of her intermittent confusion and short term/long term memory issues. Resident #4's Interim Care Plan, dated [DATE], listed the resident need, "At risk for physical injury from falls," relating to, "Fall risk score of 24 (sic), Unsteady Ambulation, Recent fall(s), History of fall(s) with injury, Use of high risk medications (Norco)." Interventions were generic in nature and included: * Educate the resident/family on fall precautions * Assist of 2 for transferring and ambulation * Monitor and encourage use of proper foot wear, * Glasses/hearing aides prior to getting out of bed * Assist of (blank) for toileting Individualized interventions included: * NWB LUE (No weight bearing left upper extremity) for 2 months, and * One hour round for 3 Ps (Pain, Positioning, Potty) Intermittent confusion and short term/ long term memory issues were not addressed on this care plan area or anywhere else in the resident's Interim Care Plan. Progress Notes (PNs) * [DATE] at 6:12 pm - An LN documented, "New admit, oriented to room, staff, and call bell. Demonstrated call bell use. Alert but confused and forgetful, cooperative with care, up to 2 person moderate assist. * [DATE] at 3:20 am - An LN documented, "Alert with some confusion. Calling out and when I went to her room she had forgotten where she was at..... Removes her arm out of sling. Staff attempts to keep (left) arm stabilized with pillow and sling... Compliant with use of call light, and waiting for assistance." * [DATE] at 10:47 am- LN #1 documented, "Resident Calling out, found on floor (in her room), resident stated she was trying to get up and go to her room, and chair went out from under her, resident was lying on floor on right side (complained of) pain in right lower extremity. An Incident Follow-up & Recommendation Form (Incident Report), dated [DATE], documented the resident was in her room, stood up without calling for assistance and fell to the floor. The resident was found at 10:45 am, seen by a physician, and then was sent to the emergency room of a local hospital and found to have a fractured hip. The incident form documented the resident: * Was "seen" 3 minutes prior to the fall. * Was alone in her room at the time of the fall * Was alert but confused * Attempted to transfer herself * The call light was in place but not used * The resident had last been assisted to toilet at 8:30 am The [DATE] Incident form documented the root cause of the incident as, "Resident confused, attempting to self transfer, poor safety awareness." The [DATE] incident form also documented the resident used the bedpan and ate breakfast that morning and then was evaluated by, "therapy." The report documented, "Therapy got patient up and dressed," before the fall. OT, PT, and ST Therapy Plan of Care (TPOC) and Treatment Notes (TN) notes for the morning of [DATE] (no specific times were provided) documented the resident: * Had fallen when out with a group and fractured her left arm. The resident's speech was incoherent and she leaned to the left before suddenly falling. (OT, ST, PT) * Was alert and oriented to self only. (OT, PT, ST) * Had severe deficits in orientation and memory and mild deficits in comprehension and attention. (ST) * Able to follow clear, concise, one step commands. (OT, PT) * Was educated to call light and able to demonstrate use. (OT, PT) * Was unable to recall educated on situation with her fractured arm and unable to put her immobilize on. (PT) * Was experiencing a high level of pain in her left arm. (OT, PT, ST) Note: Based on the resident's MAR, the resident had not been medicated for pain since the night before leaving the hospital. * Required increased supervision (OT) and a CNA was notified of the need for increased supervision. A Physician's handwritten Progress Note, dated [DATE] at 11:15 am, documented, "Pt (resident) was sitting in her chair (with) a fractured humerous. She attempted to transfer self and fell injuring her right hip... right hip pain, ... probable hip fracture... To (hospital) ER for evaluation and treatment. A hospital Admission Physician Note, dated [DATE], documented, "The patient... is well known to me as I discharged her from my service yesterday... She went to a TCU... and apparently during a transfer, she fell ... Unfortunately, during the fall she fractured her right hip as well as fractured her pelvic rami... On my evaluation the resident is confused, although pleasantly. She does not believe she broke her hip. She complains of no pain... she denies any symptoms posed to her... I discussed the complexity of (the resident's) medical condition with her (family) and also discussed the 2-month mortality of this type of injury in the orthopedic literature is extremely high and certainly greater than 50 %... and I suspect it will even be larger given the fact she has multiple fractures as well as recent (TIA)... " During an interview on [DATE] at 2:00 pm, LN #1 stated he was the medication cart nurse on the day of the incident and was the nurse notified by the CNA that the resident had fallen. LN #1 stated he assessed the resident, notified the physician (who was in house) and later completed the incident report. When asked if he was aware that morning that the resident was a high fall risk and had short term memory issues as well as confusion, LN #1 stated he had not been informed during shift change of the resident's fall history, high risk for falls, or short term memory issues. He stated he was informed that the resident used the call light appropriately during the night and not informed of any concerns. In addition, LN #1 stated he was not made aware of the therapists' recommendations for increased supervision. On [DATE] at 2:15 pm, the DON was interviewed regarding the resident's fall risk status, cognitive and memory issues, and Interim Care Plan. During the interview, the DON stated she was aware the resident was a high fall risk and had some cognitive issues. The DON stated: * The resident was assessed upon admission for her fall risk and her ability to use the call light. The DON stated that the admission nurse, as well as the subsequent shifts stated the resident had no problems using the call light. When the DON was asked about the LN documentation on [DATE], about the resident calling out, rather than using the call light, and then not remembering what she had called out for, the DON had no comment. * Information regarding a newly admitted resident's high fall risk, confusion, and memory loss, would be shared generally shared with staff during the shift to shift report. The information would also be placed on the interim care plan. The Interim Care Plan, which did not address the resident's confusion, short and long term memory problems, was shared with the DON who stated she would look for other documentation indicating this information was shared with staff caring for the resident. No additional information was provided. * Regarding the generic nature of Resident # 4's fall care plan, the facility has standard procedures for each resident at risk for falls which are indicated on the care plan but the care plan should also be individualized to the resident. When asked about the 1 hour checks, the DON stated that the 1 hour checks is a new program they are testing for all new admits and people requiring increased supervision. When asked if there was documentation of Resident #4's 1 hour checks, the DON stated, "No." When asked if the resident's plan for falls had been otherwise individualized, the DON indicated that nothing, in addition to the interim care plan, was documented to address the resident's fall history, confusion, short term memory problems. She felt the resident was safe because she had demonstrated the use of the call light. * The facility was still in the process of evaluating the resident and had not considered using a chair alarm. The DON stated they found alarms very intrusive for the residents and attempted to avoid them when ever possible. At the point of the resident's first 24 hours no other safety measures had been considered (i.e.. line of site supervision, increased frequency of checks, self release belt ... ). On [DATE] at 10:50 am, CNA #1, who was assigned to Resident #4 on the morning of [DATE], stated she had she had seen the resident frequently between 6:00 am and 8:30 am. She had provided the resident fresh ice water, assisted her to use the bedpan, and placed the resident's breakfast tray at the resident's bedside and picked it up when the resident was finished. When asked if she assisted the resident to get up, the CNA stated, "No, Therapy got her up and dressed her." CNA #1 stated the night shift had told her the resident used the call light appropriately during the night and did not mention her high fall risk status or her confusion and memory issues. When asked if any of the therapists had talked to about the need to increase the resident's supervision, CNA #1 stated, "No, but they could have talked to another CNA that day." 2. Resident #3 was re-admitted to the facility on [DATE] after hospitalization for pneumonia and a urinary tract infection. The resident's chronic [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], assessed the resident as requiring extensive assistance (including physical assistance) of two people with transfers, extensive assistance (staff providing weight bearing support) with locomotion, and extensive 2 person, physical assist with toilet use. Resident #3's readmission Initial Data Collection Tool/Nursing, dated [DATE], documented the resident required ,[DATE] person assistance with ambulation. Nurse's Notes, dated [DATE] at 6:45 pm, documented the resident, "Requires(s) extensive assist of ,[DATE] aides to transfer..." A [DATE] Care Plan for falls documented, "(Resident) is at risk for falls r/t (related to) weakness, pain with decline in mobility..." Interventions included, "Ext (extensive) assist of (2 was handwritten in) transfers/toileting/gait with use of walker." The use of a gait belt or other safety devices, other than the walker, were not listed on the Care Plan. A Fall Risk Evaluation was not completed for the [DATE] re-admission. The last Fall Risk Evaluation documented in the resident's chart was completed on [DATE] (3 days prior to the resident's hospitalization for pneumonia and urinary tract infection). This evaluation scored the resident as an 18 (high risk for falls) documenting the resident ambulated with problems and devices (gait is unsteady, slow, lurching) and the resident did not have adequate balance to stand, sit, or transfer without physical help. The only Fall Risk Evaluation documented after the resident's readmission was completed on [DATE], the same date the resident fell and fractured his left hip. This evaluation scored the resident at 16, and documented the resident still ambulated with problems and devices, his balance was not steady and he was only able to stabilize with physical assistance. On [DATE] Resident #3 was assessed by physical therapy (PT) for a treatment [DIAGNOSES REDACTED]. Max cues for pivoting walker fully vs falling into chair diagonally. Max A for all dressing except shirt." The PT documented, "60 - 79 % impaired mobility, walking and moving around functional limitation..." On [DATE] the PT documented, "Patient previously requiring min (minimum) assist with ambulating to and from bathroom and recliner with FWW (front wheel walker). Is now demonstrating deficits in bed mobility, transfers, and gait that limit mobility..." On [DATE] the PT documented, " (Resident) required total assist for (lower body) clothing and pericare... pericare was completed with seated rest break due to increased shortness of breath and low endurance. The resident's fall prevention care plan did not reflect that the resident would experience shortness of breath or decreased endurance with exertion On [DATE] the PT documented, (Resident) performed gait x 20 feet x 2 with report of left knee pain... (Resident) requires CGA (Contact Guard Assistance) to min A with w/c follow due to fatigue/breathlessness, and pain." The resident's fall prevention care plan did not reflect that the resident required CGA and/or w/c follow. It also did not address how staff should ensure a wheel chair was behind the resident during ambulation and still maintain CGA. Contact guard assistance is a protective safeguard and a variation of minimal assistance where the resident requires hand or physical contact to maintain balance or dynamic stability. On [DATE] the PT documented, "Gait training with fww... requiring frequent rest breaks due to shortness of breath..." The last PT note was dated [DATE] at 1:19 pm. This note was a Functional Level (End of billing period) Progress Report for service dates [DATE] through [DATE]. Under #3, "Gait Tasks: Distance - Surfaces," the report documented, " Patient is able to demo(nstrate) gait for up to 20 feet with fww and CGA with w/c (wheel chair) follow." Under, "Caregiver Education," the report documented, "Patient and CNAs educated with need for continued CGA for all transfers and gait to/from bathroom with fww and CGA for safety." An Incident Follow-up & Recommendation Form, dated [DATE], documented the resident experienced a fall with injury. The Incident report documented, "The CNA was walking resident to the br (bathroom) (with) his fww; he fell to the floor to buttocks without any indication that he was about to fall. CNA tried to catch him but could not prevent fall. Had non-skid slipper socks on at the time of incident. Was gotten up with Hoyer lift; body check completed, (resident complaining of) (left) hip pain - sent to ER (emergency room ) for eval(uation)." The "Factors observed at the time of the fall," portion of the [DATE] incident report documented the resident, "Lost strength/appeared to get weak?" The FSI (Fall Scene Investigation Report) documented, "Appears accidental in cause walking (with) staff to restroom, either was weak of hip gave out when ambulating." The [DATE] incident report did not document that, other than his walker, an assistive device, such as a safety device or w/c follow, or other protective safeguards (CGA), was used when ambulating the resident to the bathroom. A [DATE] Witness Interview/Statement Form completed by the CNA who was ambulating the resident (alone) when he fell , documented, " I was assisting the resident... to the restroom... using his walker and (was) by his side to assist him. He was walking to the restroom and was turning to go into the restroom when his foot slipped and he fell on to his back. I tried to grab him to slide him to the floor, but it happened too fast. (The resident) tried to get off the floor, but I told him to lay there while I went to get another aide to assist me. I also got the nurse... so she could check him...." The Incident report documented the facility notified the resident's physician and called for a portable x-ray because the resident was complaining of pain. The x-ray report, dated [DATE], documented the resident had an, "Acute comminuted left intertrochanteric fracture with mild displacement." A [DATE] telephone order instructed staff to transfer the resident, per ambulance, to the hospital for evaluation and treatment of [REDACTED]. Resident #3 also had an incident report, dated [DATE], which documented a CNA was transferring the resident from a recliner to his wheel chair. The resident's legs, "slid out from under him," and the CNA lowered him to the floor without injury. The incident report documented the CNA was transferring the resident alone and the resident was wearing, "no skid socks" on his feet at the time of the incident. The incident report did not mention if the staff was using an assistive device (such as a gait belt) during the transfer. The recommendations on the incident report included non-slip sock/slippers on at all times, 2 person transfers. The follow-up section on the incident report documented, "2 (two) person transfer at all times x (times) 24 hrs. Non-slip socks/slippers at all times. The Resident's Care Plan was updated on [DATE] with a hand written note, in the prevent falls section, that documented,"NIF (non injury fall), slid to floor (with) assist from CNA. Will have 2 CNAs for transfers." The resident's medical records documented the resident was discharged to the hospital on [DATE], had hip surgery, and did not return to the facility. The discharge MDS indicated the facility anticipated the residents return but a PT note, dated [DATE], noted the patient, had "expired." On [DATE] at 2:20 pm, the DON was interviewed regarding Resident #3, his fall history, the incident reports and care plan, and the facility's policy/practice regarding the use of gait belts. During the interview the DON stated: * The facility did not really consider the resident's slip to the floor on [DATE] as a fall. He just slid off the recliner. * The use of gait belts was the facility's standard of practice for all residents who needed assistance with ambulating and/or transfers and the use of gait belts would not necessarily be listed on the resident's care plan because it was a common practice. * The non-use of a gait belt would be placed on the care plan if an individual resident did not want the gait belt used and/or there was a medical reason for not using the gait belt. When told that the use/or non-use of a gait belt could not be found on the resident's [DATE] and [DATE] incident reports, the DON stated she would review the reports to check if they were listed. The DON later returned stating the gait belt use was not addressed on either incident report. * The resident's care plan was wrong and had not been updated to omit the 2 persons needed for transfers. The PT had been working with the resident and he needed less assistance. The DON provided the PT notes listed above to indicate the resident did not require 2 person assistance any longer. * The CNA listed on the [DATE] incident report had been counseled regarding not using the gait belt during the transfer. 3. Resident #1 was admitted to the facility on [DATE]. His multiple [DIAGNOSES REDACTED]. Resident #1's annual MDS assessment, dated [DATE], coded: *BIMS of 9, indicating moderately impaired cognitive skills; *Extensive assistance of 2 for bed mobility; *Did not ambulate; *Extensive assistance of 1 for wheelchair mobility, on and off the unit; and *Needed physical assistance to move from a seated to standing position, and for surface to surface transfers. Information for this deficiency was obtained from physician's progress notes (MDPN), Fall Risk Evaluations (FRE), resident care plan (CP), ADL Monthly Flow Reports (ADL MFR), care area assessments (CAA), nurse's progress notes (PN), Fall Scene Investigation (FSI), and Incident Follow-Up and Recommendation Forms (I/A). On [DATE], an MDPN documented the resident had ongoing symptoms from hypotension, complained to the physician about his level of forgetfulness and fatigue, and used a wheelchair due to ongoing muscle weakness. On [DATE], a FRE for Resident #1 documented a score of 14, indicating the resident was at risk for falls. The instructions on the form documented, "A resident who scores 10 or higher is at risk. Consider environmental factors in resident's interventions." Resident #1's CP for falls, initiated on [DATE] and reviewed on [DATE], documented the resident was at risk for falls due to a history of falls, cognitive deficits, a [DIAGNOSES REDACTED]. Approaches included: *"Motion alarms to bed and chair...anti roll back bars on (wheelchair)." *"At nurse's discretion, may implement (every) ,[DATE] minute checks, 1:1, line of sight." Resident #1's CP for ADL assistance, initiated [DATE] with an updated target date of [DATE], documented the resident had an alteration in ADL's related to kidney disease, catheter use, Parkinson's disease with muscle weakness and decline in mobility, diabetes, and the use of high risk medications. Approaches documented, "Uses (wheelchair) for assisted mobility on/off unit. Able to propel self for short distances." Resident #1's ADL MFRs for locomotion off the unit on day shift documented: *[DATE]. Extensive assistance of one person 14 of 30 days, did not occur 7 of 30 days, and the resident was independent with the activity 9 of30 days. *[DATE]. Extensive assistance of one person 14 of 31 days, did not occur 6 of 31 days, supervision after set-up 3 of 31 days, and the resident was independent with the activity 8 of 31 days. Resident #1's CAAs for the annual MDS dated [DATE] documented: *Falls analysis of findings, "(Resident #1) hasn't had any (sic) recent falls but he is at risk for falls and injury - fall assessment with a score of 14, (diagnosis) of Parkinson's, impaired mobility and balance, needs staff assist with transfers and mobility. Able to propel (sic) (wheelchair) but staff usually assist. Has antiroll back brakes (sic) on (wheelchair). Alarms as he has a (history) of attempting to self-transfer. Proceed to care plan." *Cognitive Loss supporting documentation, "BIMS score is 9 showing moderate cognitive issues. Resident has confusion and is very forgetful." *Activities of Daily Living supporting documentation and analysis of findings, "(Resident #1) needs staff assist with his needs daily, has impaired mobility, Parkinson's...poor balance and needs staff assist or sit to stand lift depending on how he is feeling...has had some decline in his care needs, he needs assist with all ADLs and is now needing sit to stand at times...recent addition of pain patch...will proceed to care plan to assist with cares as he is at risk for needs not being met." Resident #1's ADL MFR for locomotion off the unit on day shift between [DATE] and [DATE] documented the resident required: *Extensive assistance of 1 for 9 of 15 days, including [DATE]; *The acitivity did not occur 1 of 15 days; and *The resident was independent 5 of 15 days. On [DATE] at 12:00 noon, a facility I/A documented, "Resident went out front doors into parking lot, rolled down drive way in his wheelchair hitting curb at flagpole that flipped wheelchair over throwing (sic) resident to the ground. Left hip struck curb while upper torso landed in the rocks..." The resident's mental status both before and after the incident was documented as, "Alert/confused." An attached FSI, under the area, "What did the resident say they were trying to do just prior to they fell ?" documented, "They were talking to another resident's family member." On [DATE] at 3:54 PM, Resident #1's PNs documented, "At approximately 12 noon, overhead page for assistance to front was sounded. When this nurse arrived at front doors I noted this resident laying in the middle of the parking lot with his left hip on the cement curb and upper torso in the rocks of the flower bed. Multiple staff were at resident's side. We did not move this resident (due to) increase in pain of left hip and possible fracture. Resident was (complaining of) left hip pain at this time. CNA called 911..." On [DATE], Resident #1's H&P from the acute care hospital documented he was diagnosed with [REDACTED]. On [DATE], unknown time, a handwritten statement from a facility LN, included as a witness statement in the facility's investigation of the incident, documented, "In regard to (Resident #1) a little over 3 (weeks) ago after supper, I asked the CNA where (Resident #1) was because at times they had been leaving him in the dining room alone after meals (and at times when he move (sic) about in wandering fashion (with) his hand on his head for a very long time and often went to A wing.) After a few minutes I came back down that portion of the wing (and Resident #1) was sitting in the middle of the hall (no) other issues noted. He was in good humor. The next day (staff) said you know (Resident #1) was outside yesterday we saw him and brought him back. Was almost down near the flag. No further issues noted when he was brought back to wing. (After) meals he liked to go right to bed. I thought mistakenly that this was an isolated issue." On [DATE], the facility faxed investigation results from the incident to the Bureau of Facility Standards. The report documented, in part, "...(Resident #1) went outside to enjoy the sunshine and when he attempted to find his room, he started to propel down the slight slope at the entrance and could not stop...(Resident #1) does enjoy going outside but does not do it very often. The last time was approximately 3 weeks ago and he sat out in front of the building visiting with families...(Resident #1) told the Executive director when he went to see him at the hospital, that he went outside in the sun and then decided to go back to his room, and at that point exactly what occurred is unsure. (Resident #1) said he pulled out to turn around and go back to his room and the next thing he knew he was going down the slope...he stated, "I started to roll and was not able to stop the chair..." On [DATE] at 8:55 AM, the DNS was asked about Resident #1's fall. The DNS stated: *The resident had a history of [REDACTED]. Because the resident had been able to find his way about the facility, i.e., his room, the dining room, etc., and had stated at the time of the fall he was trying to turn his wheelchair around to come back into the building when the wheel caught on the slope of the driveway, the facility had not considered his exit from the building an elopement. *The resident had been observed just minutes prior to the event in the lobby of the building, but was not observed to exit the building. *The DNS was asked, considering the risk factors for this resident, including weakness, variable confusion, and high fall risk, if it was acceptable for the resident to be outside unsupervised. The DNS stated since there had never been a problem with the resident going outside that she was aware of, the facility did not feel the need to address this issue in the resident's care plan. *When asked about the statement from the nurse indicating the resident had been outside the facility and retrieved by staff approximately 3 weeks prior to the fall, the DNS stated, "A nurse who did not normally work with the resident saw him outside and didn't know if it was OK, so she sent a CNA out to get him. The CNA went out, asked him if he was ready to come in, and he said yes. The nurse just saw a resident outside and didn't know if it was OK. He was perfectly fine." "He never goes anywhere. He just sits out there and looks at the flowers then comes back in. The fact that he got carried down that slope is a fluke. It was completely unforeseen," and "We recognize (the risk) now. There had never been an incident before. I think he was trying to turn around and the wheel of the chair just dropped off the edge, and he was gone. There is no way we could have foreseen the slope would be a problem." NOTE: The LN's statement from [DATE] documented the resident had been found outside near the flags. See description of the fall scene below. *When asked whether the resident had ever been educated as to the presence of the slope at the end of the drive way, or evaluated for his ability to recognize or recover from the slope safely, the DNS stated, "No. There was never any need. He had been out many times, and had gotten back into the facility." However, the DNS was unable to describe how often the resident had been in that area unsupervised, versus with a visitor, and whether or not the facility had re-evaluated this situation after the resident had been found outside near the flags. *The DNS was asked if the driveway contained any visual cues, such as a sign or contrasting paint on the slopes from the driveway, to alert residents to the presence and severity of the slope. The DNS stated, "No." *The DNS was asked if the slope from the driveway on the side the resident lost control of his wheelchair was more pronounced than the other side, the DNS stated, "Yes, much. Significantl

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure residents received the appropriate care and services, including adequate supervision, to prevent both injury- and non-injury falls. This was true for 2 of 4 sampled residents (#s 8 and 9) reviewed for falls. Resident #8 was lowered to the floor when a CNA failed to lock the resident's wheelchair brakes prior to transferring the resident. Resident #9 was injured when she fell on her newly acquired leg stump and the incision site dehisced. This failed practice had the potential for harm if either resident sustained [REDACTED]. 1. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses, including above the knee amputation, generalized pain, Peripheral Vascular Disease (PVD), and Coronary Atherosclerosis. The resident's most recent MDS, dated [DATE], documented the resident required extensive assist of two people for bed mobility, transfers, and toileting. The resident's Fall care plan documented the following interventions: * "6/27/14 - Hi/Lo bed in lowest position when in use with mats on floor at bedside. At nurses discretion, may start 1:1, Q (every) 15-30 minute checks, direct line of sight, etc. * 7/21/14 - One assist with wheelchair mobility. * 8/2/14 - q (every) 30 minute checks. * 8/4/14 - Alarm to BR (bathroom door). * 8/27/14 - Offer to toilet before or after meals, (and) HS (hour of sleep) * 9/10/14 - Brakes must be engaged (locked) with all transfers." An Incident/Accident Data Entry Questionnaire dated 9/10/14 documented: * "When new CNA was assisting resident to the toilet she put the gait belt on and was going to lock the brakes and resident said she didn't have to and when she (CNA) started to transfer her (resident) the w/c (wheelchair) moved and she (CNA) had to lower her (resident) to the floor." * Witness Interview/Statement Form: "Resident told me (CNA) that the wheels did not need to be locked (on the wheelchair) and so I did as she requested. I helped her stand up and she sat in the chair, but was sitting on the corner so we tried to lift her up. The chair came out from underneath her and I didn't know what to do so I slowly lowered her to the floor." * "CNA educated the brakes are always to be locked when transferring a resident." * "Remind resident that with all transfers the w/c breaks must be locked before any transfer can be done, cna also educated." On 9/23/14, the DNS stated the CNA was doing what the resident wanted per the resident's rights. The DNS agreed the facility is responsible to keep residents safe and wheelchair brakes should be locked prior to any transfer. 2. Resident #9 had multiple admissions to the facility. The two most recent admission occurred on 8/18/14 and 8/28/14. The resident was admitted with multiple diagnoses, including below the knee amputation, [DIAGNOSES REDACTED], and mononeuritis. The resident's Quarterly MDS, dated [DATE], coded the resident required set-up supervision for bed mobility, transfers, and toileting. The resident had no impairment to her upper or lower extremities. The resident's Fall care plan, dated 7/21/14, documented the following interventions: * Bed against wall to increase living space. * Bedside commode next to bed at night. On 7/25/14, "hourly checks for safety" was handwritten on the care plan. The resident's Progress Notes, dated 8/11/14, documented the following: "I entered res' (sic) room and found res. lying on back with head about 1 ft. under the bed and rest of body facing out toward tv (television). Res. was unable to explain what caused her to be on the floor. Res. was involuntary (sic) shaking and I asked res if she was cold and she shook her head yes...Res eyes not focusing. Res. not able to answer simple questions and body continued to experience involuntary coarse tremors... Resident was transported to the hospital and admitted with possible sepsis. The Idaho Department of Health & Welfare, Bureau of Facility Standards Informational letter #2014-04, dated 5/23/14, documented the following: "All investigations must be signed by the Administrator within five (5) working days of the allegation/incident. This signature indicates the administrator has reviewed the investigation, approves it as complete, and has ensured that appropriated measures have been taken. If the Administrator is out of the facility, his/her designee may sign the investigations." The Incident Follow-up and Recommendation form, dated 8/11/14, was not signed by the Administrator until 8/29/14 or 14 working days after the incident occurred. An Incident form, dated 8/11/14, documented the following: * "Resident attempted to self transfer to bathroom (and) was found on floor, upon assessment res(ident) was noted (with) increased confusion and abnormal (vital signs). Seen 30 min(utes) prior (and) denied need to toilet. * Interventions in place at the time of incident, "blue gripper socks, call don't fall reminder, and bed alarm." * Interventions in place after the fall, "bed alarm." NOTE: The Nurse's Progress Note and the Summary of Investigative Facts documented two different statements for the cause of the resident's fall. Additionally, the interventions listed on the Incident Follow-up form did not correspond with the current interventions listed on the resident's Fall care plan. The resident's Fall care plan documented the following: * "8/18/14 - D/C (Discontinue) Bedside commode next to bed at night. D/C bed alarm while in bed. * 8/19/14 - W/C (wheelchair) at bedside at night. Encourage call light use at night, wait for help with transfers. Wear blue gripper socks. Wake x 1 at night to toilet. Q (every) hour checks for safety." On 8/25/14, Resident #9 was admitted to the hospital for a below the knee amputation of her right leg and was re-admitted to the facility on [DATE]. The resident's Fall care plan, dated 8/28/14, documented the following: * D/C Q hr (every hour) checks for safety. * Mobility alarms to bed and wheelchair. The resident's Significant Change MDS, dated [DATE], documented the resident was a two person extensive assist with bed mobility, transfers, and toileting. The resident had impairment to a lower extremity. The resident's Progress Notes, dated 9/2/14, documented, "...CNA reports went to resident's room and found her sitting on the floor leaning against bed. Bed was in low position, non skin (sic) sock worn to L(eft) foot, stump brace (protector) worn to RLE. When asked what happened stated, 'I was trying to reach something on my night stand and I slowly slid off the side of the bed.' She also added that she did not hit her buttocks hard on the floor because she gradually slid off. Call bell was in reach and was not on during the fall." Similar findings were documented in the resident's Incident Follow-Up form dated 9/2/14. Additionally, the Incident Follow-Up form documented the following: * Has Hi/Low bed (with) mats. * Bed not in low position. * Has bolsters that were not in place. * Bed alarm not sounding. Bed alarm changed out. * Will initiate lipped mattress to bed. D/C bolsters when available. NOTE: The hourly checks were discontinued on 8/28/14 after the resident was readmitted to the facility with a right below the knee amputation. On 9/2/14, four days after the hourly checks were discontinued Resident #9 fell . The Fall care plan was updated on 9/3/14 to include: * Lipped mattress to bed DC bolsters when mattress available. * OT to assess environment and set up for improved functioning. NOTE: The resident's Fall care plan did not document the facility had considered or implemented increased supervision, before or after this fall. The Incident Follow-up and Recommendation form, dated 9/17/14, was required to have been signed by the Administrator or designee on or by 9/23/14. The area for signatures on the form was blank. The resident's Incident Follow-Up & Recommendation Form, dated 9/17/14, documented the following: * "Resident found sitting on floor, leaning against recliner. blood (sic) on stump dressing - (sic) states she was trying to get more (incontinent briefs) from closet shelf (and) slid out of wc - (sic) pulled (herself and), crawled to recliner... Assessed for injuries - (sic) noted dehiscence of Rt (right) stump incision and abrasion to mid(dle) spine. First aide (sic) provided." The resident's Progress Note, dated 9/18/14, documented: * "5:15 PM, LE (Late Entry) for 9/17/14 eve(ning). LN came to resident's room at 5:15 PM to ask resident's consent for Bathroom (sic) alarm due to her multiple self transfers, explained the purpose, the risk and benefits, resident did not give consent stating that, 'it's getting so restrictive now.' * 5:30 PM, I saw the resident's call light on, head (sic) to her room to response, (sic) found resident sitting on the floor leading (sic) against the recliner opposite to the close. (sic)... R(ight) stump was bleeding, pressured (sic) and found a 3 x 1 x 0.1 cm skin tear to mid spine area. Resident stated she could not remember if he (sic) hit his (sic) head of (sic) not. Incision to RBKA was dehisce (sic) 3 x 0.2, pressure applied." The resident's Progress Notes documented the following: * On 9/20/14 at 1:06 AM, the resident was on 15 minute checks for fall precautions. * On 9/20/14 at 3:43 AM, the resident was on 1 hour checks. NOTE: It could not be determined which intervention was implemented after the fall. The resident's Fall care plan did not document fifteen minute checks or hourly checks as an intervention. On 9/23/14 at 5:45 PM, the DNS and Regional Nurse Consultant (RNC) were interviewed. The DNS was asked how the facility determined that adding more alarms to a resident who already had alarms would decrease the resident's risk of falls. The DNS stated, "When an alarm goes off it alerts staff that a resident is trying to transfer himself/herself and the staff goes to the resident's room and assists the resident." The RNC stated alarms did not always prevent falls, but alarms could alert the resident to wait for assistance. When the surveyor asked whether the alarms helped prevent Resident #9 from falling. The DNS stated the facility had implemented every intervention they had to decrease the resident's risk for falls and the resident was placed on fifteen minute checks on 9/17/14 after her fall with injury. No additional information was provided to resolve this concern.

Based on observation, resident and staff interview, and record review it was determined the facility failed to evaluate residents' conditions and risk factors, or to implement, monitor, and revise interventions necessary to prevent pressure ulcer development. This was true for 4 of 7 residents sampled for pressure ulcers (#s 4, 5, 7, and 13). Resident #13 was harmed when he developed a Stage III pressure ulcer to the coccyx/sacrum. Resident #4 was harmed when she developed multiple Stage II pressure ulcers to her coccyx and buttocks. Residents #5 and #7 also developed Stage II pressure ulcers at the facility, which had a potential for harm related to possible complications of infection or pain due to pressure sores. Findings included: 1. Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 6/1/12 Annual MDS assessment coded: * Cognitively intact * Extensive assistance by 2 or more staff required for bed mobility and bathing * Dependent on assistance by 2 or more staff for transfers and toileting * Extensive assistance by 1 staff for dressing * Did not walk in room or corridor * At risk for pressure ulcers, none present * Active and Passive Range of Motion exercises provided 4 of the prior 7 days The 3/22/12 Care Plan documented that effective 7/10/09 the resident was, "At risk for alteration in skin. Related to impaired mobility, risk for friction/shearing, use of pads/briefs, use of cardiac, diuretic and anticoagulant meds, (history) of [MEDICAL CONDITION], bilateral [DIAGNOSES REDACTED]." The goal was, "Resident will have no (avoidable) ulcers in next 90 days." The target date was 6/30/12. Approaches included: * Apply lotion to groin and perianal area after cleaning as ordered. * Pressure reducing mattress to bed and chair. * Encourage resident to spend time out of bed. * Weekly skin assessment. * Use draw sheet to assist with repositioning resident when in bed (every) 2 hours. * Resident at Risk (review) per facility protocol. - Added on 4/23/12: "Trial wedge to relive pressure off coccyx." NOTE: There was no documentation of whether or not the "trial" was effective and/or continued. - Discontinued on 6/2/12: Pressure reducing mattress to bed and chair. - Added on 6/2/12: Air mattress with full side rails and bolsters, and air cushion to wheelchair. - Added on 6/4/12: "Actual breakdown to coccyx Stage II open ulcer." NOTE: The ulcer was documented as Stage III on the 6/2/12 Pressure Ulcer Status Record. - Added on 6/4/12: "Encourage resident to turn (and) reposition (every) 2 hours. Resident does refuse." NOTE: Repositioning frequency was not increased from that provided prior to the pressure ulcer development. - Undated, handwritten entries documented: "Resident refuses to reposition; known to say no thanks to lotion (offer from staff to apply)." NOTE: The Care Plan did not document any interventions related to the resident's refusal to reposition and decline lotion. A 6/4/12 addendum to the Care Plan documented the problem, "Wound to coccyx, Stage 3 (sic)." Approaches included: * Wound nurse consult as needed; treatment per wound nurse order * Assist resident to keep off area when in bed or wheelchair, every 2 hours NOTE: Repositioning frequency was not increased from that provided prior to the pressure ulcer development. * Pressure reducing mattress to bed, cushion to wheelchair * Resident at Risk (review team) to follow * Encourage adequate nutritional intake * Labs and multivitamin with minerals per physician order During the initial tour of the facility, RCM #1 was interviewed about this and other residents who had acquired pressure ulcers at the facility. Resident #13 was reported to have developed a pressure ulcer, "in house." Braden Scales for Predicting Pressure Sore Risk documented the resident was "at risk" with scores of 15 on 9/7/11, 12/19/ 11, and 3/31/12. The resident was at "moderate risk" with a score of 12 on 6/4/12 - after a pressure ulcer developed on 6/2/12. The resident's Pressure Ulcer Status Records and Weekly Skin Assessments documented: * 5/19/11 - Blanchable Stage II area on coccyx, which measured 0.8 x 0.4 x 0.1 centimeters (cm). This was documented as "Resolved" on 5/22/11. NOTE: Although the above pressure ulcer occurred prior to the facility's alleged date of compliance, it is included here as evidence that the resident had a prior pressure ulcer on the coccyx. * 5/23/11 - 6/1/12 - no pressure ulcers * 6/2/12 - Stage III pressure ulcer on the coccyx/sacrum, which measured 1.2 x 0.7 x 0.3 cm. * 6/8/12 - "Beefy red wound bed (decreased) in size... improved" with measurements of 1.8 x 0.5 x 0.2 cm. * 6/14/12 - "(Macerated) edge... (increased) size" with measurements of 2.2 x 0.4 x 0.3 cm. Nutritional Progress Notes documented: * 3/5/12 - "No new skin issues at this time. New (order for multivitamin with minerals)." * 4/30/12 - "Recently had thoracentesis and had fluids removed. Likely (weight) loss is (related to) this... (no changes) needed." * 5/3/12 - "(No changes) needed." * 5/18/12 - "Noted that team started... fortified food (every) meal and med pass (supplement)... (no) skin breakdown... (no changes) needed now." * 6/14/12 - "Per nurse, (resident) now has a wound to coccyx... will ensure more protein to aid healing. (Recommend multivitamin with mineral every day and large protein portions with meals.)" NOTE: Multivitamin with minerals was previously ordered 3/5/12. The resident's Weight History documented that he gained weight (222 pounds on 12/20/11, 245 pounds on 3/20/12) and then lost weight (215 pounds on 6/12/12). NOTE: The resident had a thoracentesis procedure in which an unspecified amount of fluid was removed, which may have contributed to the weight loss; on 6/21/12, the DON was asked to provide the date the procedure was done and documentation related to how much fluid was removed, but this was not provided. Refer to F325 for further information related to weight changes. Physician's Progress Notes documented: * 5/23/12 - "Weight loss of undetermined cause.. skin (without) breakdown." * 6/4/12 - "LN reports new wound observed ... appeared spontaneously... on (pressure-relieving) mattress and (pressure-relieving, wheelchair) cushion in place since 6/3/12." * 6/19/12 - "LN reports sacral wound healing without problems. Routine Visit Records for Wound Care, written by the facility's wound nurse practitioner, documented: * 6/4/12 - Stage III, 1.2 x 0.7 x 0.3 cm * 6/18/12 - Stage III, 1.1 x 0.4 x 0.2 cm A 6/8/12 Nurse's Note documented: "Weekly skin team assessment completed to area of concern to wound on coccyx... Will continue current (plan of care) as is working... Will monitor via skin team weekly until resolved... Resident tolerated exam well, however is reluctant to turn side to side. Requires much encouragement. Risks (and) benefits reinforced as to offload to this area." A 6/14/12 Care Plan Conference Record documented: "RCM reinforced him eating (and) him being repositioned in chair (and) bed." Monthly Summaries documented the resident had no pressure ulcers between July 2011 and 5/8/12. The resident's medical record did not contain a Monthly Summary for June 2012. On 6/21/12 at 2:00 PM, the DON was asked to provide the June 2012 Monthly Summary. She responded by stating, "we didn't find one." No further information related to Resident #13's pressure ulcer was provided by the facility. The resident refused to allow surveyors to observe the wound, on 6/21/12 and 6/22/12. INVESTIGATIVE GUIDELINES at F314 instruct: "Review... documents... regarding the assessment of the resident's overall condition, risk factors... to determine if the facility identified the resident at risk and evaluated the factors placing the resident at risk... history of impaired nutrition; and history of previous pressure ulcers... and the facility's efforts... to remove, modify, or stabilize the risk factors and underlying causal factors." Resident #13 was harmed when he developed a Stage III pressure ulcer at the facility. He had been previously identified as "at risk" for pressure ulcer development, had a history of [REDACTED]. The Care Plan did not include interventions for resident refusals, even though the resident was documented to require, "much encouragement." After a new pressure ulcer developed on the resident's coccyx/sacrum, the repositioning frequency was not increased. Increased protein was not added to the resident's dietary plan until after the pressure ulcer developed. The Administrator, DON, and Regional Vice President were informed of the findings on 6/21/12 at 6:35 PM. No further information was received from the facility related to Resident #13's pressure ulcer. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 4/11/12 Significant Change MDS assessment, completed when the resident was placed on hospice, coded: * Cognitively intact * Extensive assistance by 2 or more staff for bed mobility * Extensive assistance by 1 staff for transfers, dressing, hygiene, and bathing * Did not walk in room or corridor; wheelchair used for mobility * No pressure ulcers The resident's 4/7/12 Hospice Care Plan documented: * Risk for skin breakdown due to immobility. Skin to remain intact over bony prominences. Frequent repositioning, skin care, toileting. The resident's 4/11/12 facility Care Plan documented: * Alteration in self care related to impaired mobility... pain, weakness with poor activity intolerance. * Resident has chosen to receive hospice care... coordinate care with hospice team - notify of medical changes. * Skin at risk... pressure reducing mattress to bed, cushion in wheelchair. Provide incontinence care every 2 hours and as needed, barrier cream as needed. Weekly skin checks. Educate resident on relieving pressure. Hand written entries on the Skin page of the Care Plan documented: * Turn and reposition every 2 hours - 4/11/12 * Open areas to buttocks, Stage II - air mattress - 6/6/12 *Wheelchair cushion placed in recliner and wheelchair - 6/11/12 * Known to refuse supine - wants head of bed elevated - prefers to not lay side to side - prefers to not change position and stay in bed - including for mealtime; encourage side lying and out of bed 3 times a day - undated. NOTE: RCM stated on 6/21/12 at 12:22 PM that the undated notes related to positioning refusals were implemented "at the same time" as the 6/11/12 addition of wheelchair cushion in recliner and wheelchair. The facility had a Hospice Agreement with the resident's hospice provider, effective 9/29/09. Services to be provided by hospice included: * "The Hospice Plan of Care will be updated by the Interdisciplinary Group bi-weekly or more often as necessary. Hospice will consult and coordinate with Facility." * "The Hospice Plan of Care must identify the care and services that are needed and specify which provider is responsible for performing the respective functions." The resident's 3/26/12 admission nursing assessment documented there were no wounds or skin problems on the resident's coccyx, sacrum, or buttocks. The resident fell and sustained a neck fracture on 4/14/12. During the Initial Tour of the facility on 6/18/12, RCM #1 stated that Resident #4 had developed a pressure ulcer, "in house." Braden Scales for Predicting Pressure Sore Risk documented the resident was not at risk to develop pressure ulcers, as follows. The scale documented that a score of less than or equal to 9 indicated very high risk, 10-12 indicated high risk, 13-14 indicated moderate risk, and 15-18 indicated at risk. The assessment was, "To be completed upon admission, then for an additional 3 weeks; quarterly and PRN (as needed)." NOTE: The first 4 assessments were completed, but there was no additional Braden Scale assessment after the resident developed multiple Stage II pressure ulcers in May and June 2012. * 3/26/12 - Score 24 * 4/2/12 - Score 20 * 4/9/12 - Score 19 * 4/16/12 - Score 19 Weekly Care Management Reviews documented no pressure ulcer concerns on 3/27/12 and 4/5/12. Hospice Aide Notes documented: * 5/8/12 - "Complaining of bottom being sore from position she must lay. Breakdown. Notified RN at facility." Hospice Aide Supervisory Visit (nursing) notes documented: * 5/9/12 - "Open blisters to buttocks bilaterally. Redness to coccyx - blanchable at this time... Her buttocks are 'extremely sore, afraid to draw a deep breath because they hurt'... applied two foam... dressings to open areas of buttocks to try and protect and prevent any further breakdown... repositioned (resident) in bed (with) left hip on a pillow to float buttock... states she is comfortable at this time but her buttocks still hurt." * 5/11/12 - "Redness to coccyx, bilateral open blisters to buttocks... states buttocks have been less tender but still painful... encourage staff to reposition (resident) frequently. (Resident) states she is up to her recliner every afternoon but it still puts pressure on her buttocks." * 5/18/12 - "(Two) small blood blisters... 1 small open... in the coccyx fold... staff visualized pressure sores to buttocks. Encouraged staff to turn/reposition (every 2 hours) PRN (as needed)... The open blisters on buttocks are dried, closed with no open areas, overall redness and open areas are improved from Tuesday." * 5/29/12, 6/1/12, 6/4/12 - Mention of 2 open areas as above * 6/8/12 - "Small open blister, scant amount of drainage." * 6/12/12 - "Blister... closed (new), 2 small open blisters." * 6/15/12 - "Blister to coccyx... wound not visualized." Monthly Summaries documented the resident's skin was "dry and fragile" without any open areas or pressure ulcers on 5/13/12 and 5/14/12. NOTE: Separate Monthly Summaries were completed by 2 LNs on 2 consecutive days in May 2012. Although the resident was documented to have "bilateral open blisters bilaterally" by hospice staff, these were not reflected in the facility's nursing documentation. Pressure Ulcer Status Records documented: * 5/18/12 - Stage II to right buttock, blood blister, resolved 5/22/12 - body diagram indicated approximately 8-9 o'clock position on the resident's right buttock. * 5/18/12 - Stage II to right buttock, blood blister, resolved 5/22/12 - body diagram indicated approximately 7-8 o'clock position on the resident's right buttock. * 6/5/12 - Stage II to right sacral, "improved" 6/14/12 - body diagram indicated midline at the top of the crease between the resident's buttocks. Non-Pressure Skin Condition Records documented: * 5/18/12 - Abrasion to left inner buttock, resolved 6/3/12. * 6/5/12 - Open Sore to right buttock, "improved" on 6/17/12 - body diagram indicated the center of the resident's right buttock. NOTE: This wound was also documented on a 6/5/12 Weekly Skin Integrity Sheet. Progress Notes by nursing staff documented: * No mention of pressure sores or other areas of concern to the resident's buttocks, coccyx, or sacrum prior to 5/18/12. * 5/18/12 - "Previous shift reports (resident) with blister to right buttock. Staff (turns)/repositions (resident) every two hours. (Resident) is also able to make minor position changes for comfort... Previous shift has reported informing hospice of blister." * 5/19/12 - "Apparent blister to (right) buttocks with skin intact." * 5/19/12 - "Monitored for blister noted on right buttock... is able to turn herself and staff also turn/reposition." * 6/5/12 - "Noted to have open area to right buttock." * 6/6/12 - "Monitored for open sore to right buttock... Staff encourages (resident) to turn off of right side/buttock." NOTE: Similar entries related to cueing the resident to reposition frequently, and the resident's compliance with the requests, 6/7-6/19/12. With each mention, the resident was documented to comply at least briefly with staff requests. One example, dated 6/14/12, is: "Resident reluctant to turn side to side in bed but will allow small position changes with a small pillow under her hips and side occasionally. Turning highly encouraged." A 6/11/12 Nurse's Note documented an "area of concern to right sacral area, Stage II." During a Resident Interview on 6/19/12 at 9:00 AM, Resident #4 stated, "After I came here I was laying still all the time. They are taking care of (my pressure ulcers) very well. Twice a week they change the bandages." On 6/21/12 at 9:30 AM the DON and Administrator were interviewed and asked for documents related to Resident #4's pressure ulcers, and documents previously provided were reviewed. Specifically, the surveyor requested: * A Care Plan outline of which cares were to be provided by hospice and which by the facility staff. * A time line of what interventions for pressure ulcers were initiated, in relation to the resident's complaints of a sore bottom due to positioning on 5/8/12 and the development of pressure ulcers on 5/8/12 ("breakdown"), 5/9/12, 5/18/12, 6/8/12, and 6/12/12. * Any documented communication with hospice staff related to pressure ulcers, since there were pressure ulcers documented as present by hospice staff during the same time period in which facility staff documented there were no pressure ulcers. * Any Braden Scale assessments after 4/16/12. The DON stated that the Braden Scale was "due" in July 2012. None of the requested documents were provided. Resident #4 experienced a change of condition when she sustained a neck fracture in a fall on 4/14/12. Pain and discomfort increased her risk of pressure ulcers, and the resident complained of a sore bottom due to positioning on 5/8/12. The resident developed multiple Stage II pressure ulcers on her buttocks, coccyx, and sacrum between 5/8/12 and 6/12/12. The resident was well documented to be compliant with staff repositioning requests and assistance, and the MDS assessment coded the resident required assistance by 2 staff for bed mobility - yet turning frequency was never increased from "every 2 hours," which was in place prior to her fracture and/or development of pressure ulcers. Additionally, Braden Scale assessments were not completed after changes in condition. The facility failed to increase preventive measures, which contributed to the development of the first pressure ulcer on 5/8/12. The facility then failed to modify interventions to prevent further pressure ulcers from developing, and the resident ultimately developed a total of 5 Stage II pressure ulcers. The resident reported pain related to the pressure ulcers. Refer to F514 as it is related to the facility's inaccurate documentation related to pressure ulcers. The Administrator, DON, and Regional Vice President were informed of the findings on 6/21/12 at 6:35 PM. No further information was received from the facility related to Resident #4's pressure ulcers. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 5/12/12 "Initial Data collection Tool/Nursing Service (Nursing Admission Assessment)" documented under the General Skin Condition section, "one Pressure Sores and Red Non-blan(chable)." The resident's Pressure Ulcer Status Record documented, "5/12/12, Stage I, Sacral coccygeal, non blanchable, & redness." Size 15.0 centimeters (cm) in length, 8.0 cm in width, and no depth. The Record also documented the area resolved on 6/8/12. The resident's "Braden Scale for Predicting Pressure Sore Risk" documented, in part: -5/12/12 score of 14, moderate risk. -6/1/12 score of 17, at risk. The resident's 5/19/12 admission MDS assessment coded, in Section M0210, that the resident did not have one or more unhealed pressure ulcers(s) at Stage I or higher. Note: Please refer to F278 as it related to MDS accuracy. The resident's undated Care Plan identified the problem of at risk for alteration in skin related to decreased mobility. One of the problem approaches was, "Resident refuses to turn side to side." The resident's Nurses Notes, dated 5/14/12 and 5/29/12, documented that the resident was non-compliant with off loading (repositioning to prevent skin breakdown) to the sacral coccyx area. The Notes also documented staff educated the resident regarding risks and benefits to the resident's skin. The resident's 6//1/12 physician's orders [REDACTED]. -5/12/12, Weekly Skin Assessment Review of the resident's 5/2012 and 6/2012 Treatment Administration Record and Treatment Orders sheet (TARs) revealed: * The weekly skin assessment was not completed on 5/24/12 and on 6/14/12. *In addition, the TAR directed staff to "monitor coccyx - Stage I every shift, date was 5/13/12." The TAR provided evidence that the resident's coccyx was not monitored on the evening shifts on 5/24, 5/28, & 5/29. On 6/20/12 at 9:45 a.m., the surveyor informed the Resident Care Manager (RCM) that in May and June 2012 the weekly skin assessments were not consistently completed and in May 2012 the resident's coccyx was not consistently monitored every shift. The RCM stated, "We were treating the resident for a Stage I when he was admitted . Monitoring a resident's coccyx is something we do as part of our skin program. According to the Pressure Ulcer Status Record (PUSR), the nurse evaluated his skin on 5/21/12. We consider that a weekly skin assessment for 5/24/12." The RCM acknowledged that the record did not provide evidence that on 6/14/12 the weekly skin assessment was completed. On 6/21/12 at 4:35 p.m., a surveyor observed the resident's coccygeal area. The area was not open and was blanchable. On 6/22/12 at 10:30 a.m., the Regional Vice President, the DON, and the Administrator were informed that treating an identified skin area and documenting the PUSR for that treatment did not provide evidence that the resident's weekly skin assessments were completed as ordered. 4. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's CP for alteration in skin related to pressure ulcers included in the "Approaches" section that the wound nurse practitioner (WNP) was to see the resident weekly. Resident #5's medical record documented on the "Routine Visit Record: Wound Care" that the WNP had not seen the resident for the following weeks: February - 2/12/12, 2/22/12 April - 4/2/12, 4/16/12, 4/30/12 May - 5/15/12,5/28/12 June - 6/11/12 On 6/21/12 at 10:15 a.m. RCM #1 stated the CP was incorrect as there was no order from the physician to see the resident weekly. RCM #1 revised the CP at that time.

Based on record review, staff interview, and family interview, it was determined the facility failed to ensure residents received adequate treatment and supervision to avoid falls and/or intentional self harm. This was true for 1 of 5 residents (#9) sampled for falls and/or fractures. Resident #9 was harmed when eight days after telling a nurse that she would throw herself to the ground as a way of getting staff at the facility into trouble, the resident propelled herself onto the floor and sustained a fractured femur that required surgical repair. Findings include: Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 3/10/11, documented the following: * Moderately impaired cognitive skills for daily decision making * Extensive assistance of one staff member required for ambulating on the unit * Limited assistance of one staff member required for moving between locations on the unit * Set-up and supervision only required for eating * Extensive assistance of one staff member required for personal hygiene and toileting * Physical assistance of one staff member required for bathing * No functional limitations in range-of-motion for the lower extremity - hip, knee, ankle, and foot Resident #9's most recent significant change MDS assessment, dated 4/28/11, documented the following: * Severely impaired cognitive skills for daily decision making * Resident did not ambulate on the unit during the preceding seven days * Extensive assistance of one staff member required for moving between locations on the unit * Limited assistance of one staff member required for eating * Extensive assistance of at least two staff members required for personal hygiene and toileting * Physical assistance of at least two staff members required for bathing * Impairment on one side to the lower extremity - hip, knee, ankle, and foot Resident #9's Cognitive Loss/Dementia RAP, dated 9/24/10, documented, "She is alert to self and family members, some noted ST (short term) memory loss at a mild level of impairment." The resident's Mood State RAP, dated 9/24/10, documented, "This resident continues with Dx (diagnosis) of depressive disorder, anxiety state, and dementia with behaviros (sic) being treated per MD order and behaviors are being monitored. She continues with repetitive non health complaints, and has a history of paranoia, and accusatory statements." Resident #9's Falls RAP, dated 9/19/10, documented, "High fall risk at this time." A Physical Restraint Informed Consent, dated 3/5/10, documented the resident had alarms to her bed and wheelchair "(at) all times)," as well as a low positioned bed, due to "poor safety awareness ... and impulsive behavior." Fall Risk Assessments, dated 3/7/10, 7/9/10, (illegible date), 9/7/10, 12/13/10, 2/6/11, and 4/16/11 documented respective scores of 30, 24, 24, 24, 22, 24, 26, and 28; resident with scores of 10 or more were to be considered "at risk" of falls. NOTE: Physician Telephone Orders documented the resident's Seroquel antipsychotic medication dosage and/or time of administration was adjusted on several occasions in 2010. A Physician Telephone Order, dated 12/23/10, documented, "Start Aricept 5 mg (milligrams) PO (orally) daily (for) 4 wk's (weeks) then (increase) to 10 mg PO daily," however that medication was discontinued on 12/28/10 following a FAX'd communication from the facility to the physician, dated 12/27/10, that documented, "Family concerned about resident's increased confusion and difficult behaviors the past few days. Has changes since starting the med(ication) Aricept ... Family not happy (with) new med." A urinalysis completed in December 2010 for Resident #9 cultured negative for infection. Recapitulated physician orders, dated 3/30/11, documented the following psychotropic medications and start dates for Resident #9: * "Alprazolam 0.5 mg tablet; give 1 tablet orally daily at bedtime." Start date: 2/1/11. * "Cymbalta 30 mg capsule: Give 1 capsule (with) 60 mg (to) 90 mg orally once a day (Depressive Disorder)." Start date: 3/15/10. * "Cymbalta 60 mg capsule: Give 1 capsule (with) 30 mg (to) 90 mg orally once a day (Depressive Disorder)." Start date 3/15/10. * "Seroquel 50 mg tablet: Give 1 tablet orally at 3 PM for dementia with delusions (and) disturbed behaviors." Start date: 2/15/11. NOTE: A FAX'd communication from the facility to the resident's physician, dated 4/4/11, documented, "FYI (For Your Information): (Resident #9's) behaviors have been escalating. Fri(day) night called 911. Sat(urday) evening called (family member). We have 2 staff members caring for her at all times. She will have a pharmacological review done." A return Physician Telephone Order to the facility, dated 4/4/11, documented, "Change Seroquel to 50 mg PO BID (orally twice daily)." Resident #9's Falls Care Plan, dated 2/1/11, documented the following: * "Problem Onset: 10/13/09. Problem/Need: Resident at risk for fall related to hx (history) of falls, poor balance, unsteady gait, impaired vision. Uses a w/c (wheelchair), requires assistance with transfers and mobility. Use of antianxiety, cardiac, and diuretic meds. Compulsive r/t (related to) answering her cell phone." * "Goal (and) Target Date: Resident will have no serious injuries from falls in next 90 days. 6/30/11." * "Approaches (included): At nurses discretion she/he may initiate q (every) 15 or 30 minute checks, 1:1 (one-to-one supervision), direct line of sight, etc." The resident's Behaviors Care Plan, dated 2/1/11, documented the following: * "Problem Onset: (line drawn through 3/15/10) 4/2/11. Problem/Need: Resident with accusatory statements towards staff, mental function varies." * "Goal (and) Target Date: Resident behaviors will not interfere with cares. 6/30/11." * "Approaches: Monitor for delusions, delusional statements. All staff to interact with res(ident) in room with 2 person present - always have a witness. Staff to report immediately any accusatory situations and write statements prior to ending shift. (Change) antipsychotic - 4/4/11. Referral to Soc. Serv (Social Services) - 4/5/11." NOTE: Behavior/Intervention Monthly Flow Records were reviewed for February through April 2011. Those documents provided areas for staff to record "signs/symptoms of delusions, sad/worried expression/verbalization of depressive statements, (change) in appetite, (change) in usual behavior, (complaints of) anxiety, unfounded accusations/allegations towards others/caregivers, verbal/physical abuse of caregivers/others," and side effects of the resident's psychotropic medications. Resident #9's Mobility Care Plan, dated 2/1/11, documented the following: * "Problem Onset: 10/13/09. Problem/Need: Alteration in mobility related to lower ext(remity) weakness. DX (Diagnosis): Degenerative disk disease, knee pain from recent fall, Parkinson's." * "Approaches (included): Extensive assist with use of wheelchair for mobility. W/c for locomotion, able to self propell (sic) and staff assist. Pt easily distracted and impulsive. Give consistent cues for safe mobility technique and to stay on task. 2 STAFF PRESENT AT ALL TIMES WHEN INTERACTING WITH PT." The resident's Psychotropic Medication Care Plan, dated 2/1/11, documented the following: * "Problem Onset: 12/30/1899 (sic). Problem/Need: Resident takes medication for [DIAGNOSES REDACTED]. Medications include Xanax, Cymbalta, and Seroquel. Res(ident) takes medication for dx of delusions." * "Goal (and) Target Date: (Resident #9) will adjust to SNF (Skilled Nursing Facility) setting with minimal behavior issues - 6/30/11. (Resident #9) will meet with Senior Counseling group on a regular basis - 6/30/11." * "Approaches (include): Staff to monitor for increased behaviors i.e. (such as) complaints of roommate or other residents. Approach resident in a calm and friendly manner and explain tasks that will be done. Review with behavior management team on a regular basis. Monitor behaviors for delusional statements. Establish and maintain boundaries. Resident can be accusatory at times. Do not argue with resident. If conflict arises, refer (the resident) to (name) with Senior Counseling. Admin(ister) antipsychotic per MDO (physician's orders [REDACTED]. Monitor for side effects for use of Seroquel q shift and report to MD." NOTE: Senior Counseling Group Progress Notes were reviewed. Those Progress Notes documented that the resident participated in the Senior Counseling Group on 2/2/11, 2/10/11, 2/16/11, 2/24/11, 3/7/11, 3/16/11, 3/23/11, 3/30/11, 4/6/11, and 4/15/11. physician progress notes [REDACTED]. * 3/18/10: "Pt (Patient) started on Seroquel (antipsychotic) ... (secondary) to severe depression as well as (increased) Cymbalta (antidepressant). Pt was intermittantly (sic) suicidal. Pt combative at times. Short term memory worse." * 4/14/10: "Mood/agitation better (with) addition of Cymbalta and Seroquel. Hallucinations have resolved now. Depression/Dementia better on high dose Cymbalta and Seroquel. * 10/19/10: "Has complained a lot of daily HA's (headaches) in the last 2 (weeks) or so. Some more bizarre behaviors seem to be worse at night. More agitated, cranky (with) everyone. New onset HA's a bit concerning along with other things like (changes) in behavior." NOTE: Resident #9's physician documented on an Office Visit Communication Form under the heading, "Results of Visit: (Summary): will (check) MRI (Magnetic Resonance Imaging) of head." The form was dated 10/19/10. A hospital MRI report, dated 10/26/10, documented, "No evidence of acute intracranial abnormality." Nurse's Notes for Resident #9 documented the following: * 10/11/10 - 2:00 a.m.: "(The resident) became very upset (with) CNA. States, 'If you can't read my mind you should know what I need.' She would not tell this nurse or CNA what she wanted. A second CNA came on - (the resident) became verb(ally) abusive to both aids. This nurse enc(ouraged) res(ident) to please try to cooperate (with) staff concerning cares. Res(ident) became angry (and) stated, 'I'll get you all fired.'" * 10/11/10 - 2:30 a.m.: "NOC (Night) super(visor) from A-wing called (and) advised by this time res(ident) had called her (family member) requesting she come get her. Res(ident) attempted to get OOB (out of bed) - was helped by second CNA. Dressed (and) taken to A-wing (per request) to speak (with) NOC super(visor)." * 10/11/10 - 3:00 a.m.: "(Resident's family member) arrived. Made aware of situation by this nurse (and) NOC super. Res(ident) returned to room - returned to bed - stating, 'No ones (sic) been in her to help me all night long.' Again res(ident) encouraged to try to cooperate (with) staff concerning cares." * 10/11/10 - 4:00 a.m.: "Res(ident) requested 3rd CNA to come change her. CNA responded (and) took res(ident) to bathroom (and) returned her to bed. Res(ident) stated to 3rd CNA, 'No one takes care of me.' Became upset when CNA stated, 'We've all been in here several times.'" * 10/31/10 - 10:00 pm.: "Resident very argumentative - making threats of 'getting everyone into trouble before she leaves' - used 2 staff (with) cares - Very unpleasant t/o (throughout) shift." NOTE: A Psychotropic/Behavior Management Summary, dated 10/6/10, documented the resident exhibited signs or symptoms of delusions on three occasions, had 16 "unfounded accusations/allegations towards others/caregivers," and 17 incidents of "verb(al)/physical abuse of caregivers/others." * 12/11/10 - 10:00 p.m.: "Resident is accusing sister of kicking her in the knee. 2 witnesses said it never happened. (No signs or symptoms) of injury." * 12/12/10 - 10:00 p.m.: "Resident ... frequently makes accusations towards others." * 12/19/10 - 11:00 p.m.: "(County Emergency Medical Services) 911 notified us that resident called saying, 'They're out to get me.' Called (family member), called 911 again. Resident accused staff of lying - stealing -trying to hurt her. Eventually took meds (and) went to bed (without) further incident." NOTE: A Psychotropic/Behavior Management Summary, dated 12/29/10, documented the resident exhibited no signs or symptoms of delusions, but had 15 incidents of "unfounded accusations/allegations towards others/caregivers." * 2/6/11 - 10:00 p.m.: "Numerous attention seeking behaviors noted t/o shift - refused supper, calling staff (and) residents, nurses, accusing staff of being 'crazy.' Refused (bedtime) meds (after) multiple attempts." * 2/9/11 - 11:00 p.m.: "Attention seeking, argumentative, trying to stir up problems t/o shift. Made multiple accusations r/t (related to) staff." * 2/17/11 - 9:00 p.m.: "At beginning of shift ((2:00 p.m.)) resident was observed in room, (illegible) (and) throwing stuff on the floor and calling staff names." * 2/20/11 - 3:10 p.m.: "Resident states confusion r/t behaviors on previous evening/NOC shift, stating, 'I feel like I just lose my mind and it's a scary thought.' This same statement was mentioned in front of (family member) during visit two days prior of confusion r/t evening before behaviors." * 2/20/11 - 3:15 p.m.: "Resident does remain in room for today, common behavior noticed (with) resident's yelling/calling out from room to meet needs, yelling specific staff names, common to hear accusations from room of 'uncaring staff' r/t meeting needs." * 3/7/11 - 10:00 p.m.: "Forgetful at times. Behaviors have shown some improvements but at times will accuse people of taking things or laughing/talking about 'her.' Occasional c/o (complaints of) headache or joint pain ...High risk for falls due to poor safety awareness." * 3/12/11 - 11:05 a.m.: "Late entry for 3/11/11, evening shift. Resident was in pleasant mood (and) cooperative (with) caregivers until approximately (7:00 p.m.) when resident became agitated and verbally abusive towards staff. Starting to call out, 'Take me out there, I need to get on the bus.' Tried to explain that 'no buses were running at this time' but refused to listen. Self propelled w/c (wheelchair) out to D-wing nurses station then accused other staff members of 'taking my purse.' CNA assisted resident back to room ... then started to get someone on cell phone. No one was on the phone, but resident started saying, 'They are holding me here and beating me.'" * 3/16/11 - 11:00 p.m.: "Resident making accusations (and) threats t/o shift - refused multiple attempts to give (bedtime) Xanax (antianxiety) ..." * 3/18/11 - 4:00 p.m.: "(Increased signs and symptoms) anxiety/agitation. Attempting to leave unit." * 3/19/11 - 10:00 p.m.: "Making accusations of staff trying to kill her. Made statements that she was going to have me killed." * 3/20/11 - 10:00 p.m.: "Continues to make statements that cause stress (and) anxiety in other residents (and) staff." NOTE: A Psychotropic/Behavior Management Summary, dated 4/6/11, documented the resident exhibited signs or symptoms of delusions on one occasion, made two "unfounded accusations," and had no incidents of "verbal/physical abuse of staff." An undated and unsigned note on the summary documented, "(Increase) in behaviors - Doctor appt (appointment) tomorrow. Pharmacological Review pending." * 4/1/11 - 10:00 p.m.: "Multiple behaviors, accusations, threats t/o shift. Called 911, res(ident's) phone in med cart. Refused (bedtime) meds ... Kicked this writer in the shin." * 4/2/11 - 11:00 p.m.: Resident exhibited multiple attention seeking, agitation, accusing, threatening, violent behaviors. Plus attacked this writer physically, hitting, slapping, spitting. The resident also accused this writer of throwing her on the floor, ripping her clothing - all untrue. Talked (at) length to her (family member) - he is supportive of us, stated he knows there was no abuse. He want us to keep her (and) all involved safe (and) happy." * 4/3/11 - 1:30 p.m.: C/o to staff about night people are after her. Wants to call a lawyer and claim a lottery winning ticket - ticket dated 2010. Wants to know who can take her home to live." * 4/3/11 - 11:00 p.m.: "Resident made multiple false statements, made threats towards this writer. Refused medication at (4:00 p.m.), but demanded all her pills (at) (6:00 p.m.). Res(ident) refused supper (and) was assisted to bed (at 7:00 p.m.)." * 4/4/11 - 9:30 a.m.: "Res(ident) in door of room, overheard activities (staff) talk about Thursday's outing. Res(ident) then started telling anyone close enough to hear (that) she is going to go wherever she wants, no one is stopping her. Reminded by this nurse (that) she needs someone to take her such as activities (staff) or family out of facility. She then began saying she can go alone and that absolutely no one is trustworthy. Continued to tell that this nurse has been telling her and everyone inappropriate names all night. At this time resident has (illegible) accusations." * 4/6/11 - 9:30 p.m.: "Around (5:40 p.m.) (the resident) came and sat by nurses station, making a few negative statements towards another resident and anyone in sight. Following this episode, resident started making accusation (and) threats toward staff, asking, 'Where's my gun, I'm going to kill you,' and accusing staff of 'having sex together,' which was stated numerous times throughout the shift. Was very hard to redirect, started striking out at CNA (and) (LPN), hitting faces, arms, kicking legs (and) scratching arms (and) face. Refused to take (8:00 p.m.) medications, spit out into own hand (and) refused to give back to this LN. Kept in hand until this LN was able to retrieve the Xanax when it was dropped into lap. A few times, started to grab at other residents' arms, walkers or w/c while passing this resident in the hallway. Other residents were able to walk or wheel away (without) problems. Most accusations (and) threats were towards staff members and at one time was calling another resident names like 'You're stupid' or 'ugly.'" * 4/8/11 - 1:30 p.m.: "Resident attempted to self transfer to nurses station. When asked by this nurse (if) she needed assist, she began accusing that this nurse stole her cell phone (and) lies, began calling this nurse 'lier, lier, lier (sic)' over (and) over again. Began calling out to others within site (sic) of the lies, this nurse stole her phone. Res(ident) was attempted (with) redirection by another nurse (and) CNA on 2 (occasions), both unsuccessful. Resident in hall in front of her room (and) when this nurse walked by she put foot out attempting to trip this nurse. (Illegible) to accuse, blame, threaten (and) call profane names (and) use profanity (regarding) this nurse." * 4/8/11 - 10:00 p.m.: "Had a few outbursts directed towards this writer (and) other residents, multiple accusations (regarding) her phone were made. Tried to self transfer x2 (twice) when I explained that she needs to have someone to assist (with) transfers. She said, 'I'll show you - one of these days I'll throw myself on the floor and you will pay.'" * 4/9/11 - 1:30 p.m.: Res(ident) took meds (and) accepted patch, then started stating (that) this nurse is a 'lier (sic), thief, (and) took her phone and she will pray to God you loose my job. Res(ident) in hall in AM telling anyone that walks by (that) this place is full of liers (sic). Res(ident) attended group act(ility). When by reception (area) started making delusional accusations. 2 nurses (and) CNA searched room for phone (without) result." * 4/9/11 - 10:00 p.m.: "Called both staff (and) other residents names, made accusations, called us liers (sic) (and) was just plain grumpy." * 4/10/11 - 1:00 p.m.: "Short tempered (with) CNA (and) cares. Verbally aggressive to CNA (and) cares. Verbally aggressive to CNA. Treatment nurse offered (and) gave meds. This nurse monitored from a-far (sic) since she accuses this nurse of taking her phone (and) lying to her (and) everyone." * 4/11/11 - 9:30 p.m.: "Around (6:00 p.m.) came out of room, sat by doorway, then saw another resident and started calling that resident some names, like 'big butt.'" * 4/13/11 - 10:15 a.m.: (Resident #9) came to see me in my office. c/o no one will agree to take her across street to where she'll meet her (family member). Became upset when it was explained her safety was in question (and) recommendation to have (family member) meet her in facility (with) response of, 'My (family member)'s too busy to come here. She does come all the time but too busy now.'" * 4/13/11 - 11:30 a.m.: "Res(ident) went across street (with) staff, began verbalizing vulgarities in public area (with) public people in hearing range. Escorted back to facility (with) staff - stating she had a 'great time.'" * 4/13/11 - 10:30 p.m.: "Pt very argumentative, accusatory, disruptive this shift, kicked at CNA, goes from resident to resident (with) accusation about staff being dishonest, uncaring. Redirected by RN several times ..." * 4/14/11 - 1:30 p.m.: "Res(ident) making delusional accusations to staff. Threatening (with) profanity to have staff fired. Then talking about winning a race last night and her prize was one of the CNAs and now her servant. Res(ident) accepted meds (and) ADLs, threw breakfast tray on floor, yelling out for assistance - not using call light." * 4/16/11 - 11:00 p.m.: "Resident was verbally abusive, disruptive of cares, told other resident to 'Don't take those pills, the nurse is trying to poison you.' Calling staff (and) residents names, physically abusive. Kicked me multiple times, slapped me x2 - tried to trip me multiple times - Refused multiple attempts to give medications - threw water on me - made the statement, 'I pray for a knife so I can kill the nurse.' At (9:30 p.m.) resident was out (at) D-wing nurses station accusing staff of stealing her money. I was asked to return to her room. Resident planted her feet preventing me from pushing her wheelchair, while slapping me (and) screaming for help, saying, 'He is trying to kill me.' I walked backwards wheeling her towards her room. Resident stated, 'I'm going to throw myself on the floor - you'll be sorry when your (sic) in jail.' Resident slid herself forward to the edge of the chair. I stopped the chair, resident used her hands on the arms to push herself to the floor, landing on her buttox (sic). Resident screamed, refusing assessment, slapping, kicking, spitting. Unable to keep her still or quiet (and) CNA (and) myself assisted her to her feet, sat her in her wheelchair. 30 min(utes) later resident said, 'I'm in pain. I want to go to the hospital.' When asked where she hurt resident said, 'I want a lawyer.' Refusing assessment, kicking legs, moving arms. I attempt to call (family member) (no) answer. (Another family member) contacted, notified her of self fall and later that resident was being transported to (a nearby hospital) ER (emergency room ) for evaluation." An Incident Follow-up & Recommendation Form, dated 4/19/11, documented the following: * "On 4/16/11 (at 9:30 p.m.) res(ident) was in w/c trying to open a locked soiled utility room door when one staff member observed another staff member approach (Resident #9) to re- direct her to her unit. The staff member was also observed to use a kind demeanor while re-directing. (Resident #9) was wheeled in her w/c backwards as she may plant her feet solidly on the ground. Staff member placed his (left) hand on her (left) shoulder (and) his (right) hand on w/c to propel backwards. Resident slid her buttocks towards edge of w/c. Staff called for asst (assistance). Resident stated, 'I'm going to throw myself on the floor (and) you are going to jail.' Staff responded: 'Please don't.' Next, the resident made physical contact (with) her hands to staff member's face 3 times, staff member then leaned back to avoid another slap. She then lurched forward - pushing off the w/c armrests (and) landed on the floor, in a sitting position. Staff observed this while another 2 staff members simultaneously approaching observed this. They also overheard that she stated she was going to throw herself on the floor, but did not get to her (before) she was able to follow through. (Resident #9) swore verbally to staff (and) kicked while in sitting position. She did not c/o pain but would not allow an assessment by staff member. She refused a set of v.s. (vital signs) to be obtained, refused to lay still. She stated: 'Get me back in my damn w/c.' (Two) asst (person assistance) back into her w/c. MAEW (Moves all extremities well). Thirty minutes went by when (Resident #9) stated: 'I hurt.' Staff attempted a pain assessment to gather data when she said, 'Talk to my lawyer.' Staff were unable to perform a more detailed assessment other than statement, 'I hurt all over.' MD was immediately called (with) n/o (new order) received to send for evaluation. ... (Resident #9 was) admitted (to the hospital with a fracture). During as well as prior to incident, careplan was followed by staff." A hospital History and Physical, dated 4/17/11, documented, "X-rays revealed a femoral neck fracture ... She reports severe pain with any motion of the right leg. She has been unable to walk. Surgery will be performed this morning, April 17, 2011." A hospital physician's consultation report, dated 4/20/11, documented the following: * "Chief Complaint: 'Have you talked to that boy that hurt me?' (Apparent quote of resident). * "History of Present Illness: ... early dementia. The patient has been noted by family members to have become increasingly paranoid over the last several months. She will report others are out to harm her when, in fact, there is no evidence of that. As a result, she has often struck out at nursing home staff. She has been placed on low-dose Seroquel to address some (of) these symptoms although symptoms have only progressed. According to the (family member), even the patient's recent fall may have been in part due to her psychotic symptoms and poor coping. According to the (family member), the patient was unrealistically fearful about the individual who was helping her and, per the daughter's impression, the patient even dove out of the way by herself and without being pushed or mishandled. At the time of this interview, the patient focused on fears that a nursing home attendant was 'out to get her.' She reported no other acute stressors and the family reported no other acute stressors." * "Past Psychiatric History: The patient does have a history of treatment of [REDACTED]. Over the last several months she has been prescribed Cymbalta to address symptoms of depression and anxiety, although there has been limited evidence of much positive effect on the Cymbalta." * "Review of Symptoms: She appeared somewhat sedated from her recent round of pain medications. She reported that her hip was painful." * "Initial Mental Status Examination: The patient is perhaps slightly confused. Her thought processes are somewhat tangential and circumstantial, but generally focuses on belief that somebody in her nursing home tried to hurt her. She definitely shows signs of paranoid delusions. Judgement and insight are impaired." * "Assessment of Strengths and Limitations: She appears to be struggling with the combined issues of a psychotic mood disorder as well as early dementia." * "Treatment Recommendations: The patient should remain on antipsychotic agent. It appears that her benefits of the medication should outweigh the risks. If Seroquel needs to be increased, we will need to monitor her for any orthostatic symptoms. Currently she is on a does of Seroquel that will not adequately treat psychosis or mood instability. Some consideration may be given to reducing her dose of Cymbalta and perhaps even discontinuing it. If her primary symptom s depression and anxiety, we may want to continue at least low-dose Cymbalta. If her primary symptom (is) that of mood instability and psychosis, she may be best to eventually get off the Cymbalta and optimize the antipsychotic mood stabilizing agent." Nurse's Notes following Resident #9's readmission to the facility on [DATE] documented the following: * 4/21/11 - "Family able to make needs known. Medicated for (right) hip pain. Res(ident) stated, 'I had been all day babysitting ...' After that is asking, 'Did you hear what I said?' Refused to get up for dinner. Needs (two-person assistance with) ADLs, transfers, toileting. WBAT (Weight bearing as tolerated) to RLE (right lower extremity), however res(ident) doesn't bear wt (weight)." * 4/22/11 - "Pain noted in hip." * 4/22/11 - "... still talking about that man who raced her down the hall in her w/c ... * 4/23/11 - "Resident c/o pain and asked to be put back to bed ... beginning to make comments that she is misinterpreting such as, 'Il be with you in a moment,' to 'what's the matter, don't you want to help anymore?'" * 4/24/11 - " ... stated to one CNA that she wasn't going to believe anything because she had (illegible) eyes when she told her that she was changing her because she was wet - 2 CNAs (with) all cares. Also stated that she was thrown into bed and she didn't want those CNAs to help her again. Also said CNA (name) was in and put her into bed, but all he did was answer her call light ..." * 4/26/11 - "Will have care conf(erence) this AM to discuss re-applying mobility alarms (with) expectation of function to (increase) post surgery (with) (illegible)." * 4/26/11 - "Family notified (that) resident often talking to self." * 4/27/11 - "Discussed (with) (family member) in care conf(erence) 4/26/11 ... A behaviorial (sic) unit where (after) focus of hip resolving is done the focus can be on her psych(iatric) issues (with) possible outcome of ... peace (with)in her." * 4/27/11 - "FAXED psych consult report to PCP (primary care physician) (with) inquiry if any med(s) to be done." A FAX'd communication from the facility to the resident's physician, dated 4/25/11, documented, "Requesting routine pain med at this time due to recent (right) hip fracture to make her more comfortable." A Physician's Telephone Order, dated 4/26/11, documented the resident was ordered "Norco 7.5/325 (two tablets by mouth twice daily)." Resident #9's Social Services Progress Notes were reviewed and documented the following: * 4/25/11 - "Resident had a fall on 4/16/11 (with) injury to hip. She returned to us on 4/21/11. Pain is keeping her from staying up in w/c for very long. Cont(inues) to voice concerns about 'that man.' Needs x2 CNA (with) all cares." * 4/26/11 - "Had a care conference (with family member) today. We discussed moving (Resident #9) to a behaviorial (sic) unit." On 4/26/11, at 7:50 a.m., Resident #9 was interviewed. The resident said that staff and other residents were "jealous" of her and that people in the facility "want to get rid of me." When asked to tell the surveyor where she was, the resident stated, "I don't know." On 4/27/11, at 2:40 p.m., the resident's family member was interviewed in the resident's room with Resident #9 present. When asked about the 4/16/11 fall and consequent injury, the resident's family member stated, "It frustrates me that they had this long issue and nothing was ever done. In the end, if she intentionally lurched herself out of the wheelchair ... she's not a fast mover. Anyone who's worked with her knows it's a slow process. I do think there's some fault there (with the facility's care of the resident). (The relationship between the resident and caregiver at the time of the 4/16/11 fall) had escalated and maybe got so personal." When asked whether the facility's efforts to locate behaviorial (sic) unit that may be better equipped to provide care for the resident, Resident #9's family member stated, "I don't think that's fair actually. It can't be out of the area because then she would have no visitors and that would be a death sentence for her; I'm absolutely opposed to that." On 4/28/11, at 8:45 a.m., the DON and Registered Nurse Consultant were interviewed. When asked why the facility didn't seek an alternative placement for the resident prior to the 4/16/11 fracture, t