Every finding on record at Life Care Center of Post Falls

Based on observations, record review, interviews, and policy review, the facility failed to ensure medication was not left at bedside unless a medication administration assessment was conducted for one of one resident (Resident (R) 97) reviewed for medications at bedside of 25 sample residents. This failure had the potential to result in residents consuming excess medications. Findings include: Review of the admission Record located under the Profile tab of the electronic medical record (EMR) revealed R97 was admitted on [DATE] with diagnosis which included muscle weakness. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of the EMR revealed there was no self-administration assessment completed for R97. Review of the Order Summary Report located under the Orders tab of the EMR, revealed an order, dated 08/08/25, for Tums Oral Tablet Chewable 500 mg (milligram). Give one tablet by mouth two times a day for indigestion. The Rolaids were not listed. During an observation and interview on 08/11/25 at 9:53 AM, R97 had a bottle of Tums, a small plastic medication cup with two Tums, and a container of menthol rub located on the resident's bedside table. R97 stated she took the Tums before her other medications, sometimes. She stated she had not taken it recently because her stomach was better. She confirmed the Tums, and the menthol rub were located on her bedside table. During an observation and interview on 08/12/25 at 4:08 PM, the resident had a half full bottle of Rolaids, and a container of menthol rub located on the bedside table. The resident was currently out of the room. When observed with Licensed Practical Nurse (LPN) 3, she stated they were not supposed to be there. LPN3 stated they confiscated medications on admission. LPN3 confirmed it should not have been here at bedside. She reviewed the resident's chart and stated the resident did not have a self-administration order. During an interview on 08/13/25 at 10:17 AM, the Director of Nursing (DON) stated there was an assessment form available in the EMR. The DON stated no medications were allowed at bedside without a self-administration assessment completed. Review of the facility's policy titled, Self-Administration of Medication, reviewed 09/16/24, revealed The facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications.

Based on record review, interviews, review of the facility's policies, the facility failed to ensure the code status of one resident of 25 sample residents (Resident (R) 99) was updated in the electronic medical record (EMR) to match the code status ordered. The deficient practice could result in a resident receiving cardiopulmonary resuscitation that did not want to be resuscitated.Findings included:A review of R99's ''Profile'' screen located under the ''Profile'' tab and the ''Physician's Orders'' located under the ''Orders'' tab of the EMR on 08/11/25 at 4:33 PM revealed ''Full Code.'' The Profile screen of the EMR revealed R99 was her own responsible party.A review of R99's ''Idaho Physician's Orders for Scope of Treatment (POST)'' located under the ''MISC'' tab of the EMR, dated 08/11/25, had an ''X'' marked next to ''Do not resuscitate'' and was signed by both R99 and the physician. Review of R99's ''Brief Interview for Mental Status (BIMS)'' located under the ''Assessments'' tab of the EMR revealed a BIMS score of 8 out of 15 which indicated the resident had moderate cognitive impairment. Review of R99's care plan dated 08/11/25 revealed the resident's code status was ''Do not resuscitate.''Review of R99's EMR on 08/12/25 at 3:44 PM, still showed a code status of ''Full code'' and the ''POST'' was still marked ''Do Not Resuscitate [DNR].'' During an interview on 08/12/25 at 4:11 PM, Certified Nursing Assistant (CNA) 4 stated, ''[R99's] code status is Full code,'' while looking in the EMR.During an interview on 08/12/25 at 4:18 PM, Licensed Practical Nurse Unit Care Coordinator (LPNUCC) 2 stated ''We looked in POST binder - she is DNR,'' while looking in the POST binder.During an interview on 08/12/25 at 4:22 PM, Licensed Practical Nurse (LPN) 1 stated ''[R99] is a full code'' while looking in the EMR. Then LPN1 stated, ''We also look in the POST binder. Here she is DNR. The POST binder is the most accurate. Normally, the code status in the computer is updated by the resident care manager [RCM (LPNUCC2)]. It definitely needs to be updated. I will find the RCM to update.'' LPN1 then proceeded to locate the RCM in LPNUCC1's office. During an interview on 08/12/25 at 4:30 PM, LPNUCC1 stated, ''Normally social services would pass the code change to RCM to update order in computer since social services does not have the ability to update orders.'' Both RCMs (LPNUCC1 and LPNUCC2) were in the office updating the code status orders in the computer.During an interview on 08/12/25 at 4:33 PM, the Social Services Director (SSD) stated, ''We get the POST signed by the doctor, scan it in, and we email all of the nurse managers regarding the change. The email regarding [R99] was sent on 08/11/25 at 3:01 PM and the DON responded, 'thank you' at 3:13 PM.Review of the email revealed the Social Services Assistant (SSA) sent an email on 08/11/25 at 3:01 PM that stated ''[R99] has changed her status to DNR w/ [with] comfort measures. The provider here today has the POST and will get it signed.'' The DON responded at 3:11 PM ''Thank you [SSA].''A review of the ''Physicians Orders'' located under the ''Orders'' tab of the EMR revealed the order for ''DNR'' was entered on 8/12/25 at 4:27 PM.During an interview on 08/13/25 at 11:28 AM, the SSA stated, ''[R99's Power of attorney (POA)] came into the office on Monday, 08/11/25, and stated [R99] was requesting her code status to be changed to DNR. I consulted with [R99] regarding the change in code status as [R99] is her own responsible party.''During an interview on 08/13/25 at 11:49 AM, the Director of Nursing (DON) stated, ''We have to get a new POST signed by the physician. We now have a binder with POSTs, face sheets, and inventory sheets updated. If a POST isn't signed by physician, the order gets changed in [the EMR] at the time the POST is signed by the physician. If post has not yet been signed by the physician and something happens, then we would verify verbally with physician. We were notified by social services that [R99's] POST was updated. It was uploaded by social services on 8/11/25 on the day of the change. It should have been changed in [the EMR] on same day. Staff have been educated to verify code status in the POST book as the book is most accurate. Social services emails the change in the POST to the management team. When the email is sent regarding POST changes, we are not always at our email, so it should also be verbally communicated. Nurse on the cart or any manager could change the order in [the EMR]. I didn't see the email until the next day. Any manager should have changed the order. The manager should have responded to the email saying the order was updated and completed.'' The DON reviewed her emails and stated, ''The email was sent at 3:01 PM on 8/11 and I responded at 3:13 PM. One of the RCM's should have updated the order and responded. I should have followed up to ensure it was changed and updated in the computer. The RCM on the 200 hall is brand new so he may not have known what to do.''Review of the facility's policy titled, ''Advance Directives and Advance Care Planning'' revised 08/02/22, included ''Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive. Residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, an immediate notation is made on the care plan, and an immediate entry is made in the medical record.''

Based on observations, record review, policy review and interviews, the facility failed to ensure competencies were completed for Registered Nurse (RN) 2 to administer ordered medications to residents for one of five nurses reviewed. The deficient practice resulted in one resident not receiving ordered insulin medication.Findings included:Review of R101's physician's orders, located under the EMR ''Orders'' tab, revealed an order dated 08/06/25 for ''Humalog injection solution, Inject as per sliding scale: . 211 - 240 = 4; 241 - 270 = 5; 271 - 300 = 6; 301 - 330 = 7; 331+ = 8, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications.Review of R101's August 2025 ''Medication Administration Record'' located in the EMR ''Orders'' tab revealed, R101's blood sugar on 08/09/25 at 3:48 PM was 229 and required Humalog sliding scale insulin of 4 units to be administered which was not administered. On 08/09/25 at 8:05 PM, R101's blood sugar was 317 and 7 units of Humalog insulin was administered in accordance with physician order. Review of R101's progress note dated 08/09/25 at 3:47 PM, Registered Nurse (RN) 2 documented ''Humalog not in facility.''During an interview on 08/14/25 at 1:58 PM, RN2 stated, ''I checked his [R101's] blood sugar at dinner time and his blood sugar was about 200. Fast acting insulin at 4:00 PM was not given because I didn't know that we had emergency stock insulin at the time. Another nurse on the floor just told me to just mark that it could not be given because it was not available. When I checked his blood sugar at 9:00 PM, it was higher about 300 and then a different nurse told me there was emergency stock, so I got the emergency stock insulin and gave him the dose according to the sliding scale. I hired on about a month ago and this was my first shift off orientation. I was not aware of any emergency stock medications available before to the 9:00 PM dose that was given.''During an interview on 08/14/25 at 2:59 PM, the Director of Nursing (DON) stated, ''The expectation is if the resident's insulin pen is not available, the medication is to be pulled from the emergency stock. Nurses should be oriented to emergency stock medications during orientation on the floor but I'm not sure if it's actually on the checklist. If not, it needs to be added.'' The DON obtained and reviewed [RN2's] nursing orientation checklist. The Nursing Orientation Checklist was signed by RN2, dated 08/14/25. The top rows of the Nursing Orientation Checklist had a date of ''07/25'' and the RN2's initials with arrows drawn down the columns including rows that did not have skills to be checked off. The checklist was not signed by any ''Trainers'' or the ''Orientation Coordinator.'' The ''Competency/Skills Checklist'' had a date completed of ''08/01/25,'' however, all spaces on the checklist were blank including ''Documentation - medication/PRN Med Sheets.'' Emergency stock medications was not included on the checklists.During an interview on 08/14/25 at 4:27 PM, RN2 stated, ''During orientation I was put with good nurses. The emergency medications never came up and so that was never discussed. There was an orientation checklist, but I did not see it. The nurse training me told me just to sign off that we went over it. There were some things that I was specifically oriented to but don't remember what specific things.''During an interview on 08/14/25 at 4:47 PM, the DON stated, ''I'm not able to confirm if [RN2] had completed any items on the competency checklist. No nurse had signed off the orientation checklist as completed. Only [RN2] signed the checklist. I reviewed the orientation checklist and that the checklist contained items such as ventilators and implanted ports that are not areas that our facility cares for. Items such as emergency medication access was not included on the checklist and I want it added to the checklist.''Review of the facility's policy titled, ''Competent Staff,'' dated 09/13/22, included ''The facility will have sufficient nursing staff with the appropriate competencies and skills needed to provide nursing and related services to assure resident safety and maintain the highest level of care. The facility will evaluate educational needs to achieve competency throughout the clinical orientation period utilizing the competency skills checklists . Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: . Medication management. The Staff Development Coordinator/designee will be responsible for maintaining training records.''

Based on record review, interviews, and facility policy review, the facility failed to ensure one of three residents reviewed for insulin of 25 sampled residents was free from significant medication errors when Resident (R) 101 did not receive Humalog (insulin medicine) on one occasion. This failure resulted in elevated blood sugar for R101.Findings include:Review of the facility's ''Administration of Medication'' policy, dated 02/13/23, revealed ''The facility will ensure medications are administered safely and appropriately per physician Order to address residents' diagnoses and signs and symptoms . Significant medication error -This means one which causes the resident discomfort or jeopardizes his or her health and safety.''Review of R101's physician's orders, located under the EMR ''Orders'' tab, revealed an order dated 08/06/25 for ''Humalog injection solution, Inject as per sliding scale: if 0 - 120 = 0; 121 - 150 = 1; 151 - 180 = 2; 181 - 210 = 3; 211 - 240 = 4; 241 - 270 = 5; 271 - 300 = 6; 301 - 330 = 7; 331+ = 8, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications.Review of R101's August 2025 ''Medication Administration Record'' located in the EMR ''Orders'' tab revealed, R101's blood sugar on 08/09/25 at 3:48 PM was 229 and required Humalog sliding scale insulin of 4 units to be administered which was not administered. On 08/09/25 at 8:05 PM, R101's blood sugar was 317 and 7 units of Humalog insulin was administered in accordance with physician order. Review of R101's progress note dated 08/09/25 at 3:47 PM, Registered Nurse (RN) 2 documented ''Humalog not in facility.''During an interview on 08/14/25 1:05 PM, Licensed Practical Nurse (LPN) 7 verified in the medication cart that R101's Humalog insulin pen was available. Observation of R101's Humalog insulin pen revealed an open date of 08/10/25. LPN7 stated, ''[R101] has had insulin available since he has been on the 200 hall. Humalog is available in the emergency stock in the medication room if the resident's insulin pen is not available.'' Observation of the emergency stock kit revealed four vials of Humalog insulin in the clear locked box.Review of R101's resident census revealed the resident was transferred from the 300 hall to the 200 hall on 08/08/25.During an interview on 08/14/25 at 1:16 PM, the Director of Nursing (DON) stated, ''The pharmacy restocks emergency medications monthly. I am not aware of any resident being out of insulin and not having emergency stock insulin available. If insulin is removed from the emergency stock, it would be signed out on the sign out sheet.'' Observation of the emergency stock sign-out sheet on the 200 hall did not list R101 as having emergency stock insulin removed. During an interview on 08/14/25 at 1:58 PM, RN2 stated, ''If insulin was available, then I would pull from emergency stock. [R101] did not have his fast-acting insulin in stock. I went to the 300 hall to get Humalog insulin from emergency stock about 9:00 PM. I checked his blood sugar at dinner time, and his blood sugar was about 200. Fast acting insulin at 4:00 PM was not given because I didn't know that we had emergency stock insulin at the time. Another nurse on the floor just told me to just mark that it could not be given because it was not available. When I checked his blood sugar at 9:00 PM, it was higher about 300 and then a different nurse told me there was emergency stock, so I got the emergency stock insulin and gave him the dose according to the sliding scale. I hired on about a month ago and this was my first shift off orientation. I was not aware of any emergency stock medications available before to the 9:00 PM dose that was given.'' During an interview on 08/14/25 at 2:59 PM, the DON stated, ''The expectation is if the resident's insulin pen is not available, the medication is to be pulled from the emergency stock. Not administering insulin as ordered is considered a significant medication error.''

Based on observations, interviews, and policy review, the facility failed to ensure medications were labeled with open and discard dates and expired medications were disposed of and not made available on the medication cart for one of three medication carts and two of two medication storage rooms reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications.Findings include:The following observations were made during the review of medication carts and medication storage rooms throughout the facility.During a review of the medication cart on the 100 hall on 08/13/25 at 2:56 PM with Certified Medication Aide (CMA) 1, a tube of ''Skin Protectant Cream'' was found in the bottom drawer with other tubes of cream. The tube had a resident name written on it but did not have an open or discard date. The date stamped from the manufacturer on the tube stated ''Exp [DATE].'' CMA1 confirmed the date and stated ''The cream is expired and needs to be discarded.'' When asked where creams were stored, CMA1 stated ''They are kept in the central supply room.''During a review of the central supply room on 08/13/25 at 3:13 PM with Central Supply, the skin protectant cream was not found and Central Supply stated ''skin protectant cream is out of stock. It would normally be here (pointing to the spot on the shelf).'' A box of ''Pepto Bismol Tablets'' were found on the shelf with a date stamped on the box ''Exp [DATE].'' Central Supply verified the date and stated ''yes, those are expired!'' and through them in the trash. During a review of the medication storage room on the 200 hall on 08/13/25 at 3:42 PM with Licensed Practical Nurse (LPN) 6, a vial of tuberculin was found opened and not dated. LPN6 verified the vial was opened and not dated and stated, ''The vial needs to be discarded since there is no open date, and we do not know how long it has been opened. If I was opening a new vial, I would check the expiration date on the vial and write the opened date on the vial. The vial would be good for 30 days from opening. The Resident Care Managers (RCMs) are responsible for checking the medication carts and medication rooms for expiration dates.''During an interview on 08/13/25 at 4:17 PM, the Administrator deferred to the Director of Nursing (DON) regarding the labeling and expiration dates of medications including central supply. During an interview on 08/13/25 at 4:25 PM, the DON stated ''The skin protectant cream came from the hospital when the resident returned yesterday. The nurse did not verify the expiration date prior to placing the tube of cream in the medication cart. The weekend manager is responsible for reviewing all the carts every weekend, following the checklist, making sure everything is dated and verify there is nothing in the carts that shouldn't be there. During the state window [time period when facility is due for their annual survey by the state agency], I jump in and help verify carts as well. When vials are opened, the expectation is that the nurses date the vial. If the vial is not dated, the vial is discarded, and education is provided to the nurses. The Central Supply Director is responsible for central supply expiration dates.''Review of the facility's policy titled, ''Storage and Expiration Dating of Medications and Biologicals,'' with a revised date of 08/01/24 included ''Facility should ensure medications and biologicals that: have an expired date on the label; have been retained longer than recommended by manufacturer or supplier guidelines . are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.''

Based on policy review, review of the staffing record and staff interview, it was determined the facility failed to ensure an RN was on duty for eight consecutive hours per day. This failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all 64 residents living in the facility. Findings include: The facility's Staffing policy, documented The facility maintains adequate staff on each shift to meet residents' needs, posts daily staffing data and furnishes staffing information to the state as specified in the Federal regulations. The Posting of Licensed and Unlicensed Direct Care Staff, dated 1/1/24 through 6/30/24, documented there was no RN coverage on 1/27/24, 2/4/24, 2/10/24, and 3/3/24. On 7/4/24 at 1:23 PM, the DON reviewed the timecard information and stated there was no RN on duty during the 24-hour period on 1/27/24, 2/4/24, 2/10/24, and 3/3/24. On 7/4/24 at 1:30 PM, the Administrator stated there were significant issues at the beginning of the year for RN coverage on every 24-hour period. The Administrator stated there were no RN scheduled to work on 1/27/24, 2/4/24, 2/10/24, and 3/3/24. The Administrator stated there should be an RN in the building on those days.

Based on observation, record review, and staff interview, it was determined the facility failed to develop and implement a care plan that is comprehensive and resident specific to include measurable objectives, interventions, and time frames for how staff will meet residents' needs. This was true for 1 of 16 residents (Resident #210) whose care plans were reviewed. This failure created the potential for the resident to receive inappropriate care. Finding include: Resident #210 was admitted to the facility on [DATE], with multiple diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), muscle weakness, difficulty walking, and systemic sclerosis (a connective tissue disease impacting skin, internal organs, cartilage, bones, tendons, ligaments). An Admission MDS, dated [DATE], documented Resident #210 required extensive assistance of 2 staff for bed mobility, transfers, dressing, and toileting. The MDS also documented Resident #210 had a pressure relieving mattress. Resident #210's care plan documented, The resident will improve current level of function in (SPECIFY ADLS) through the review date. Resident will be able to (SPECIFY). The care plan did not specify goals for ADL self-care performance. Resident #210's care plan documented, Eating: the resident is able to (SPECIFY) . Personal Hygiene/Oral care: The resident is able to (SPECIFY) . Skin inspection: The resident requires SKIN inspection (SPECIFY FREQ) . Toilet use: The resident requires (SPECIFY assistance) by (X) staff for toileting . Transfer: The resident requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as needed. The care plan interventions did not specify the amount of assistance, number of staff needed, or frequency for the ADLs. On 3/21/23 at 9:19 AM, Resident #210 was observed lying on an air mattress. Resident #210's care plan did not specify the need or appropriate settings for the air mattress. On 3/23/23 at 5:03 PM, the DON was interviewed and Resident #210's care plan was reviewed in her presence. The DON stated the care plan was not resident specific. The facility failed to ensure Resident #210's care plan was comprehensive and resident specific for her ADLs.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident's care plan was revised and updated as the resident's needs changed. This was true for 1 of 2 residents (Resident #58) whose records were reviewed for significant changes. This deficient practice placed residents with significant changes at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plan. Findings include: The facility's Comprehensive Care Plans and Revisions policy, revised 8/17/22, stated when changes in the resident condition occur, the facility should review and update the plan of care to reflect the changes to care delivery. This policy was not followed. Resident #58 was initially admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including acute respiratory failure and metabolic encephalopathy (a condition in which an illness or an improperly functioning organ causes a chemical imbalance in the blood resulting in problems with brain function). Resident #58 passed away on 12/26/22. An Annual MDS Assessment, dated 11/12/22, documented Resident #58 was severely cognitively impaired. Resident #58 was transferred from a hospital to the facility on [DATE]. Hospital Transfer Orders, dated 12/19/22, documented consultations for palliative care or hospice were ordered for Resident #58. Resident #58's record included a physician's visit summary, dated 12/20/22. Her physician documented Resident #58's Power of Attorney chose to begin comfort measures for her during her hospital stay. Resident #58's record included a physician's order, dated 12/20/22, for comfort measures to be implemented. Resident #58's record did not include documentation her care plan was updated to include interventions to address her comfort measures. On 3/23/23 at 2:15 PM, the DON was interviewed and Resident #58's record was reviewed in her presence. The DON stated Resident #58's care plan was not updated to include her comfort measures. She stated it should have been updated when the physician's order was received. The facility failed to ensure Resident #58's care plan was revised and updated to address her comfort measures.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 2 of 15 residents (#26 and #49) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of foot care. Findings include: The facility's Nail Care policy, reviewed 8/22/22, directed staff to ensure residents' toenails were clean and trimmed to avoid injury and infection. This policy was not followed. 1. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body tissue), pneumonitis (inflammation of the lung tissue due to non-infectious causes) due to inhalation of food, vomiting, and stroke. On 3/20/23 at 2:20 PM, Resident #26's toenails were observed with the DON. Resident #26's toenails on her right second, third and fifth toes were long, thick, and whitish in color. The DON stated Resident #26 was not diabetic and CNAs should have provided her with nail care at least once a week during her showers. The DON stated if she was the nurse on duty she would prefer to attend to Resident #26's toenails herself because of the condition of the toenails. 2. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including dementia, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and depression. On 3/23/23 at 3:09 PM, Resident #49's toenails were observed with the DON. Resident #49's toenails on his right first, second, third, and fourth toes were long, thick, and whitish in color. The DON stated Resident #49 was not diabetic and CNAs should have provided him with nail care at least once a week during his showers. The DON stated she would cut Resident #49's toenails herself. The facility failed to ensure Resident #26 and Resident #49 received care of their toenails.

Based on review of facility staffing records and staff interview, it was determined the facility failed to ensure an RN was on duty at least 8 hours a day, 7 days a week. This was true for 2 of 21 days reviewed. The failure created the potential for harm if routine and/or emergency nursing needs went unmet, and had the potential to affect all residents living in the facility. Findings include: The facility provided the nursing schedule for 2/26/23 to 3/18/23. The nursing schedule documented there was no RN coverage on 3/5/23. The time punches for 3/5/23 did not include documentation an RN was on duty. Additionally, the time punches on 3/12/23 documented an RN was on duty for 7.18 hours, less than the required 8 hours per day. On 3/24/23 at 12:54 PM, the facility's Regional [NAME] President was interviewed, and the time punches were reviewed in her presence. She stated the facility was unable to provide consistent RN coverage, 8 hours per day, 7 days a week, due to an RN leaving employment in February. She stated the RN position was not filled at the time of the survey and interviews with RN candidates were being performed. The facility failed to ensure an RN was on duty at least 8 hours a day, 7 days a week.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment during perineal care. This was true for 1 of 1 resident (Resident #49) whose perineal care was observed. This failure created the potential for negative outcomes by exposing a resident to the risk of infection and cross-contamination. Findings include: The CDC website, last reviewed on 1/30/20, and accessed on 3/27/23, included a topic on Hand Hygiene Recommendations, which documented hand hygiene should be performed when moving from a contaminated-body site to a clean-body site during patient care. The facility's Hand Hygiene policy, revised 7/15/22, documented It is important to make sure that hand hygiene is performed at the appropriate times before and after touching a resident, between residents and frequently during care. This policy and guidance were not followed. On 3/21/23 at 10:43 AM, CNA #1 and CNA #2 were observed providing perineal care to Resident #49. CNA #1 was wearing gloves and wiped feces from Resident #49's buttocks several times and then removed the soiled incontinence brief. CNA #1 then placed a clean incontinence brief next to Resident #49 and tucked it in under Resident #55. CNA #1 did not change her gloves or perform hand hygiene after cleaning Resident #49 and before she grabbed a clean brief. CNA #1 then flattened the incontinence brief by running her gloved hands over the brief, the same gloves she used when she wiped feces from Resident #49's buttocks. CNA #1 then placed her gloved left hand on Resident #49's left upper thigh and her gloved right hand on Resident #49's upper shoulder, and together with CNA #2 they assisted Resident #49 to turn onto his back and fastened his incontinence brief. On 3/21/23 at 10:59 AM, CNA #1 stated she did not change her gloves after she cleaned Resident #49's buttocks. CNA #1 stated she should have removed her gloves, performed hand hygiene and donned new gloves before applying the clean incontinence brief and touching Resident #49's skin. The facility failed to ensure staff performed hand hygiene during perineal care for Resident #49.

Based on policy review and staff interview, it was determined the facility failed to ensure testing was conducted in a manner consistent with current standards of practice for conducting COVID-19 tests. This was true for 1 of 1 staff (LPN #1) who self-tested in the facility. This failure created the potential for the development and transmission of COVID-19 in the facility. Findings include: The facility's COVID-19 (SARS-CoV-2) Healthcare Personnel Testing policy, revised 3/13/23, documented testing was conducted according to nationally recognized guidelines, outlined by the CDC. The CDC website, updated 3/29/21, and accessed on 3/27/23, included a topic on Performing Broad-Based Testing for COVID-19 in Congregate Settings, which documented, For indoor specimen collection activities, designate separate spaces for each specimen collection testing station, either rooms with doors that close fully or protected spaces removed from other stations by distance and physical barriers, such as privacy curtains and plexiglass. It also stated to prevent inducing coughing/sneezing in an environment where multiple people were present and could be exposed, avoid collecting specimens in open-style housing spaces with current residents or in multi-use areas where other activities are occurring. This policy and guidance were not followed. On 3/23/23 at 3:54 PM, LPN #1 placed a COVID-19 test card with the swab inside it on the counter inside the nurse's station and wrote her name on it. When asked where she performed the test, LPN #1 stated she tested herself in the nurse's station. Another test card was observed on the counter on the other side of the nurse's station. An unopened COVID-19 test kit was also observed on the counter. The RCM, who was also in the nurse's station, stated LPN #1 should not have performed her COVID-19 test in the nurse's station. The RCM stated staff should perform their COVID-19 test in the copy room. The RCM then took the unopened COVID-19 test kit away. The facility failed to ensure testing was conducted in a manner that was consistent with CDC guidance for conducting COVID-19 tests.

Based on policy review, grievance review, and resident and staff interview, it was determined the facility failed to ensure resident grievances were responded to and resolved in a prompt manner. This was true for 1 of 3 residents (Resident #41) reviewed for grievances related to missing clothing. This failure created the potential for psychosocial harm when a resident's grievances were not acted upon in a timely manner. Findings include: The facility's policy, Grievance Program, revised 6/15/22, stated, The resident has the right to, and the facility must make, prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. The Definitions section of the policy stated, 'Prompt efforts to resolve' include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The policy was not followed: 1. The facility's grievances, dated April 2022 - September 2022, were reviewed. The facility's grievance policy was not followed for 2 grievances which documented missing clothing, as follows: a. A resident grievance, dated 6/30/22, documented Resident #41 reported she was missing 1 gray pair of capri pants, 1 blue pair of capri pants, and 1 black pair of capri pants. The facility documented staff searched for the clothing, but the items could not be found. The Facility Investigation and Response form, documented, Capris were not found. The Concerned Party's Response to the Action Plan/Outcome section, documented, [Resident #41] showed her frustration on her missing items and we have set up an approach to laundry (only) picking up her laundry. The grievance did not include documentation of how the facility was addressing the replacement of the missing clothing. b. A resident grievance, dated 9/3/22, documented Resident #41 reported she was missing 3 pairs of capri pants and a t-shirt with the comment, Please reimburse me. The Facility Investigation and Response form, documented, Laundry personnel unable to locate missing items. The Actions Taken to Resolve/Respond to Concern section, documented the resident purchased clothing items to replace those which were missing and the facility reimbursed her. On 9/21/22 at 3:21 PM, Resident #41 stated her last grievance [dated 9/3/22] was for a t-shirt that was recently missing and the capri pants were reported missing before [6/30/22], but the facility had not replaced them. She stated since the issue was not resolved for the capris, she put them on a new grievance. Resident #41 stated the facility told her she had to buy the clothing, give the facility the receipt, and then the facility would reimburse her for the missing items. Resident #41 stated she did not have enough money to buy new clothing to replace the items from the June grievance and that is why the facility did not reimburse her until September. Additionally, Resident #41 stated she did not trust the laundry staff with her belongings and worried more of her belongings would disappear that she couldn't afford to buy. On 9/22/22 at 8:27 AM, the Social Services staff stated she was not aware of Resident #41's grievance form, dated 6/30/22. She stated the previous Executive Director kept the grievance book in his office and instructed housekeeping to deliver grievances to the Executive Director's office. The Social Services staff stated the resolution for the 9/3/22 grievance included the items that were reported missing on 6/30/22. She stated the 6/30/22 grievance was not completed in a timely manner, per the facility's grievance policy. On 9/22/22 at 9:27 AM, the acting Administrator/Regional [NAME] President stated she was made aware that grievances were being kept in the previous Administrator's office the week of the survey. She stated Resident #41's 6/30/22 grievance was not resolved in a timely manner and facility policy was not followed. The facility failed to ensure grievances were responded to in a timely manner for Resident #41.

Based on policy review, record review, staff interview, it was determined the facility failed to ensure a resident's care plan was revised and updated as the resident's needs changed. This was true for 1 of 13 residents (Resident #28) whose care plans were reviewed. This deficient practice placed Resident #28 at risk of undetected or recurrent urinary tract infections due to a lack of information in the care plan related to a history of urinary tract infections. Findings include: The facility's policy, Comprehensive Care Plans and Revisions, dated 3/2/22, stated the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered care plan. When resident condition changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, including additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal, and interventions to address a time-limited condition. This policy was not followed: Resident #28 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note, dated 7/18/22 at 5:01 PM, documented Resident #28 complained of dysuria (painful or difficult urination) and itching during urination. Resident #28's physician was notified. A physician order, dated 7/19/22, documented Resident #28 was to receive [MEDICATION(S)] (an antibiotic) 100 mg, 1 capsule by mouth, 2 times a day to be for a urinary tract infection. A progress note, dated 7/21/22 at 12:49 AM, documented the physician was notified of Resident #28's urinalysis results indicating colonies of gram-negative rods (bacteria resistant to multiple drugs and increasingly resistant to most available antibiotics) forming. A progress note, dated 7/22/22 at 1:50 PM, documented Resident #28 was confirmed with colonies of ESBL E. Coli (bacteria that produces a small enzyme which can make the bacteria resistant to certain commonly used antibiotics). The physician changed the antibiotic from [MEDICATION(S)] to [MEDICATION(S)] to treat the urinary tract infection. Resident #28's care plan was updated, including a urinary tract infection care plan, initiated on 7/22/22 and discontinued on 8/4/22. Resident #28's care plan did not included interventions after 8/4/22 related to her urinary tract infection risk. The National Library of Medicine website for Urinary Tract Infection, accessed on 10/5/22, stated, The majority of women with a [CONDITION(S)] [urinary tract infection] have an excellent outcome. Following treatment with an antibiotic, the duration of symptoms is 2-4 days. Unfortunately, nearly 30% of women will have a recurrence of the infection. Morbidity is usually seen in older debilitated patients . The website included the following nursing management interventions: - Assess the symptoms of [CONDITION(S)]. - Encourage patient to drink fluids. - Encourage patient to void frequently. - Educate patient on proper wiping (from front to the back). - Educate patient on drinking acidic juices which help deter growth of bacteria. On 9/22/22 at 9:37 AM, the IP said there was no active urinary tract infection risk care plan in place for Resident #28, and there should be care plan interventions after the active urinary tract infection care plan was resolved. The facility failed to ensure Resident #28's care plan was revised and updated to include her risk of urinary tract infections.

Based on policy review, record review, resident and staff interview, it was determined the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed Resident #28 at risk for [CONDITION(S)] (high blood sugar) or [CONDITION(S)] (low blood sugar) when her insulin was not administered as ordered. 1. The facility's policy, Administration of Medications, revised 5/6/22, stated staff responsible for medication administration would adhere to the ten rights of medication administration, including the Right Time and Frequency and The Right Documentation. The policy further stated the Right Documentation included correctly writing the time and any remarks on the chart. This policy was not followed. The Drugs.com website, accessed 9/28/22, stated: - [MEDICATION(S)] is a long-acting insulin. It can be administered by subcutaneous injection once or twice daily. When administered twice a day give the evening dose with the evening meal, at bedtime, or 12 hours after the morning dose. - [MEDICATION(S)] and [MEDICATION(S)] are fast-acting insulins. They worked by lowering blood sugar level about 15 minutes after injection, peaked in about 1 hour, and kept working for 2 to 4 hours. After injection, a meal should be eaten within 5 to 10 minutes. Resident #28 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/22 at 12:10 PM, Resident #28 stated she was insulin-dependent, and the evening nurse sometimes gave her insulin and [CONDITION(S)] medication late. She stated she usually received her evening medication around 8:00 PM to 9:00 PM and would go to bed on time after taking the medications. Resident #28 stated sometimes she received her evening medication as late as 11:00 PM to 12:00 AM, which interrupted her routine sleeping schedule because she would need to take some extra late-night snacks with her insulin and would wake up late the next day. Resident #28's record documented she received her insulin injection late. Examples include: a. A physician order, dated 5/24/22, documented to administer [MEDICATION(S)] 17 units subcutaneously to Resident #28 at bedtime for diabetes. Resident #28's July 2022 MAR, documented her [MEDICATION(S)] was scheduled to be given at 9:30 PM. Resident #28's [MEDICATION(S)] was administered at 11:37 PM on 7/25/22, 2 hours and 7 minutes after the scheduled time. b. A physician order, dated 8/12/22 at 9:45 PM, documented to administer [MEDICATION(S)] 10 units intramuscularly right now to Resident #28 due to a blood sugar of 569 mg/dL. Resident #28's [MEDICATION(S)] was administered at 1:42 AM on 8/13/22, 3 hours and 58 minutes after the ordered time. c. A physician order, dated 8/19/22, documented to administer [MEDICATION(S)], per sliding scale, 3 times a day and before bedtime as follows: Blood Sugar Range Administer 0 - 149 0 units 150 - 200 2 units 201 - 250 4 units 251 - 300 6 units 301 - 350 8 units 351 - 400 10 units 401+ 12 units Resident #28's August and September 2022 MAR, documented her bedtime dose of [MEDICATION(S)] was scheduled to be administered at 9:00 PM. Resident #28's bedtime [MEDICATION(S)] was administered late as follows: - On 8/31/22, Resident #28's bedtime [MEDICATION(S)] was administered at 10:22 PM, 1 hour and 22 minutes after the scheduled time. - On 9/5/22, Resident #28's bedtime [MEDICATION(S)] was administered at 10:23 PM, 1 hour and 23 minutes after the scheduled time. - On 9/6/22, Resident #28's bedtime [MEDICATION(S)] was administered at 12:09 AM on 9/7/22, 3 hours and 9 minutes after the scheduled time. - On 9/9/22, Resident #28's bedtime [MEDICATION(S)] was administered at 10:25 PM, 1 hour and 25 minutes after the scheduled time. On 9/22/22 at 11:08 AM, the Regional Director of Clinical Services stated medications should be given one hour before or after the scheduled time. The Regional Director of Clinical Services reviewed Resident #28's MAR and stated Resident #28's insulin was administered late. She stated if Resident #28's insulin was scheduled to be administered at 9:00 PM, administering it after 10:00 PM was considered late administration. The facility failed to ensure Resident #28's insulin was administered as ordered by her physician.

Based on observation and staff interview, it was determined the facility failed to ensure medications available for patients were labeled and dated. This was true for 1 of 2 medication carts inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy. Findings include: On 9/22/22 at 2:11 PM, 1 opened bottle of [NAME] Eye Drops and 1 opened bottle of Top Care Eye Drops were found inside the top drawer of the 200 Hall Medication Cart #1. The 2 bottles were not dated or labeled. When asked, LPN #1 stated the 2 eye drop bottles were already in the medication cart when she started to work that morning and she did not know which residents they belong to. On 9/22/22 at 2:37 PM, RCM #1 stated the eye drops should have been dated when opened and labeled with the resident's name. RCM #1 stated unlabeled medications should not be inside the medication cart. The facility failed to ensure medications were labeled and dated.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. The facility's Cleaning and Disinfection of Non-Critical Patient Care Equipment, revised 3/13/20, directed staff to clean and disinfect equipment prior to storage. On 7/22/20 at 10:24 AM, CNA #1 pushed the Hoyer lift (a mobility lift device used for transfers) out of Resident #12's room. CNA #1 then left the Hoyer lift outside Resident #12's room and went to the soiled utility room. On 7/22/20 at 10:36 AM, NA #1 pushed the Hoyer lift to a vacant room where the other two Hoyer lifts were stored. NA #1 did not clean or disinfect the Hoyer lift before placing it in the storage room. On 7/22/20 at 11:42 AM, CNA #1 said she did not disinfect or clean the Hoyer lift after she used it to help transfer Resident #12 to her wheelchair. On 7/22/20 at 3:00 PM, the ICP said the Hoyer lift should have been cleaned after each use. 2. The facility's Cleaning and Disinfection of the Glucometer (a portable machine used to measure the blood glucose level) policy and procedure, revised 4/7/20, directed staff to do the following: *Clean and disinfect the glucometer prior to leaving the resident's room with commercially available Environmental Protection Agency (EPA) registered disinfectant wipes. *Wipe the entirety of the glucometer using the disinfectant wipe. *Wrap the glucometer with a clean wipe. *Place the glucometer in a disposable cup, to ensure the glucometer remained wet for the duration of time required according to the manufacturer recommendation. A plastic container of Sani-Cloth wipes, with a red top, included directions for disinfection. The directions stated a three-minute contact time (the total amount of time that it takes to inactivate all the microorganisms listed on the product label) was required. On 7/22/20 at 11:17 AM, RN #1, while wearing gloves, took a wipe from the Sani-Cloth container and wiped the glucometer outside Resident #11's room. RN #1 then placed the glucometer on top of the PPE cart located outside Resident #11's room. There was no barrier between the glucometer and the PPE cart. RN #1 removed her gloves and performed hand hygiene. RN #1 then picked up the glucometer and walked toward the medication cart. RN #1 placed the glucometer on top of the medication cart. There was no barrier between the glucometer and the medication cart. RN #1 then took another wipe and wiped the glucometer and placed the glucometer back on the top of the medication cart with no barrier between the glucometer and the medication cart. RN #1 then opened the medication cart and placed the glucometer in the top drawer of the medication cart. On 7/22/20 at 12:15 PM, RN #1 said she did not put a barrier between the glucometer and the PPE cart, and the glucometer and medication cart after she used a Sani-Cloth wipe. RN #1 said she was not sure what kind of barrier she was going to use. RN #1 said the facility had both Sani-Cloth wipes with a purple top and a red top and she was not sure which one she used to wipe the glucometer. RN #1 said she knew the red top Sani-Cloth had a three-minute contact time. RN #1 said she placed the glucometer back in the medication cart and she did not think she followed the three-minute contact time when she wiped the glucometer with a Sani-Cloth wipe. On 7/22/20 at 3:00 PM, the ICP said there should be a barrier when staff put the glucometer on any surfaces. The ICP said the barrier could be a paper towel or an empty cup. The ICP also said she expected the staff to follow the Sani-Cloth manufacturer's recommendations for the contact time in cleaning the equipment. 3. The facility's Hand Hygiene for Residents policy, dated 4/16/20, directed staff to encourage and assist residents to perform hand hygiene prior to eating or drinking. This policy was not followed. On 7/22/20 from 11:45 AM to 12:34 PM, lunch trays in the 100 and 200 hallways were being served to residents. a. The following was observed in the 100 hall: - At 11:45 AM, RNA #1 delivered and set up Resident #1's meal for him on his tray table in his room. RNA #1 did not offer hand hygiene to Resident #1 prior to eating his lunch. - At 11:58 AM, NA #2 delivered and set up Resident #2's meal for her on her tray table in her room. NA #2 did not offer hand hygiene to Resident #2 prior to eating her lunch. - At 12:10 PM, NA #2 delivered and set up Resident #3's meal for him on his tray table in his room. NA #2 did not offer hand hygiene to Resident #3 prior to eating his lunch. - At 12:16 PM, RN #2 delivered and set up Resident #4's meal for her on her tray table in her room. RN #2 did not offer hand hygiene to Resident #4 prior to eating her lunch. - At 12:19 PM, NA #2 delivered and set up Resident #5's meal for her on her tray table in her room. NA #2 did not offer hand hygiene to Resident #5 prior to eating her lunch. - At 12:22 PM, NA #2 delivered and set up Resident #6's meal for her on her tray table in her room. NA #2 did not offer hand hygiene to Resident #6 prior to eating her lunch. At 12:24 PM, the DON delivered and set up Resident #7's meal for her on her tray table in her room. The DON did not offer hand hygiene to Resident #7 prior to eating her lunch. On 7/22/20 at 11:50 AM, Resident #1 said he was blind in one eye, had difficulty seeing with his other eye and needed assistance from staff to set up his meals. Resident #1 said staff did not offer to assist him with hand hygiene before his meals. On 7/22/20 at 12:07 PM, Resident #2 said staff did not always offer her hand hygiene before meals. On 7/22/20 at 12:30 PM, Resident #3 said staff did not offer him to hand hygiene before meals. He said he would like the staff to offer him the chance to perform hand hygiene before eating. On 7/22/20 at 12:35 PM, Resident #6 said staff did not offer her hand hygiene before her lunch was served. On 7/22/20 at 12:38 PM, NA #2 said she had not offered residents hand hygiene when she delivered their meal trays. On 7/22/20 at 2:00 PM, RNA #1 said she did not offer Resident #1 hand hygiene prior to his lunch. She said she had not been offering residents hand hygiene for over a month because residents' trays no longer came with hand sanitizing wipes on them. RNA #1 said she thought the wipes were supplied by the dietary department. On 7/22/20 at 3:00 PM, the DON said she did not offer Resident #7 hand hygiene prior to her lunch and said she should have. On 7/22/20 at 3:00 PM, the ICP said she expected staff to offer residents hand hygiene before every meal. b. The following was observed in the 200 hall: - On 7/22/20 at 12:28 PM, CNA #2 delivered Resident #8's food tray. CNA #2 removed the hot plate cover and set up the tray for Resident #8. CNA #2 then asked Resident #8 if there was anything else she needed, Resident #8 said no. CNA #2 then left Resident #8's room. CNA #2 did not offer Resident #8 hand hygiene before eating her meal. - On 7/22/20 at 12:30 PM, CNA #2 delivered Resident #9's food tray and placed it on Resident #9's overbed table and left the room. CNA #2 did not offer Resident #9 hand hygiene before eating his meal. On 7/22/20 at 12:42 PM, CNA #2 said she did not offer Resident #8 and Resident #9 hand hygiene before eating their meals. CNA #2 said she usually offered residents hand hygiene after she assisted them to use the restroom or when their hands were soiled. On 7/22/20 at 12:34 PM, the DON delivered Resident #10's food tray. The DON removed the hot plate cover and set up the tray for Resident #10. The DON then asked Resident #10 if there was anything she needed, Resident #10 said she was okay. The DON then left Resident #10's room. The DON did not offer Resident #10 hand hygiene before eating her meal. On 7/22/20 at 2:35 PM, Resident #8 said she was not offered hand hygiene before eating her meals. On 7/22/20 at 3:00 PM, the DON said she did not offer Resident #10 hand hygiene before eating her meal. The DON said hand hygiene should be offered to the residents before and after eating their meals.

Based on observation, record review, policy review, review of grievances, review of the Facility Assessment, review of I&A Reports, review of staffing schedules, and interviews with residents, family, and staff, it was determined the facility failed to ensure there were sufficient numbers of competent staff to meet supervision, ADL needs, medication administration, and answer call lights in a timely manner for residents. This was true for 27 of 97 residents (#4, #7, #8, #13, #14, #17, #19, #20, #23, #24, #25, #32, #35, #46, #49, #53, #59, #61, #62, #65, #72, #130, #131, #180, #333, #380, and #480) reviewed for staffing concerns, and had the potential to affect all residents in the facility. These systemic deficient practices placed the 97 residents residing in the facility at imminent risk of serious harm, impairment, or death, from delayed call light response times, elopement, falls, or other adverse events due to lack of staff monitoring, and medication errors. The lack of sufficient staff also placed residents at risk of skin breakdown and embarrassment due to lack of bathing/showers. Findings include: The facility's policy for Staffing, dated 4/24/19, stated the facility maintained adequate staff on each shift to meet residents' needs and utilized the Facility Assessment to determine staffing levels needed to ensure residents' needs were met. This policy was not followed. Facility staffing was insufficient to meet the care and needs of the residents and to respond to resident concerns. Examples include: a. Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #8's care plan identified her exit seeking, or elopement, and included interventions to redirect her if she was heading towards the doors and if wearing a coat or [NAME]et to reassure her she was in the right place, allow her to express her desire to go home, and assist with calling her son if that was she was exit seeking, initiated on 1/19/19. Resident #8's record included a progress note, dated 6/15/19 at 6:15 PM, which stated she had exited the facility and set off a door alarm near the 300 hall. Resident #8 was followed out to the parking lot by a CNA and she told the CNA her son was waiting for her in the car, which he was not. The CNA used a cell phone to contact other staff regarding the elopement. The facility had 1:1 supervision for Resident #8 for the 2:00 PM to 10:00 PM shift, and for the night shift it changed to 15 minute safety checks. Resident #8's record included an Elopement Risk Evaluation, dated 6/15/19, which documented she was at risk for elopement due to dementia and hallucinations. On 10/29/19 at 11:21 AM, Resident #8 was observed with her coat and a set of keys in her hands. Resident #8 stated to RN #4 she needed to get her car. RN #4 redirected Resident #8 and instructed other staff members to watch her. At 11:30 AM, Resident #8 was observed sitting on the seat of her wheeled walker, down the 200 hall, near the exit door without staff in view. Resident #8's room was also in the same area, two rooms away from the exit door. On 10/30/19 at 2:25 AM, LPN #5 stated Resident #8 was outside of the facility after dark. LPN #5 stated she saw Resident #8 walk by the nurses' station about 8:15 PM with her coat on. LPN #5 said she was unaware Resident #8 had left the facility. She stated a staff person from the 100 hall, returned with Resident #8 about 8:45 PM. The staff person stated Resident #8 was knocking on the side door. The weather was cold, and it was dark outside. LPN #5 stated there was one LPN and one CNA on the 200 unit to care for 42 residents. On 10/30/19 at 2:00 AM, there was one CNA and one LPN on the 200 hall to care for 42 residents. One LPN and two CNAs were on the 100 hall to care for 43 residents. E.D. #1 was in the facility standing outside of Resident #130's room providing 1:1 supervision. At 2:42 AM, CNA #4 said she had not yet seen all of her assigned residents. At 2:55 AM, CNA #4 said Resident #8's door was closed per Resident #8's request. CNA #5 said Resident #8 was to be checked every 15 minutes. She said the checks were not being done because the corporate person who was doing the checks left. The facility did not provide adequate ordered supervision and interventions to prevent Resident #8 from elopement which placed her in Immediate Jeopardy of serious harm, impairment, or death. b. Residents were interviewed and stated the facility did not have sufficient staff to meet their needs. - On 10/27/18 at 11:51 AM, resident #53 said the facility was short of staff. - On 10/27/19 at 3:05 PM, Resident #25 said she was tired of waiting for assistance, and sometimes it took 30 minutes to an hour to get assistance. Resident #25 also said there was not enough help in the dining room. - On 10/28/19 at 9:07 AM, Resident #59 said the facility was short on help, so the residents tried to do more for themselves. - On 10/27/19 at 11:45 AM, Resident #49 was asked if she felt there was sufficient staff to take care of her and the other residents, the resident emphatically stated, No, and added that staffing was worse on the day and evening shifts. Resident #49 stated she has had to wait 20 to 30 minutes for the staff to provide her with pain medication. The resident stated she has talked to Social Services about the short staffing, but that staffing has worsened, the past two months. - On 10/27/19 at 11:55 AM, Resident #4 was asked if there were enough staff to take care of her and the other residents' needs, the resident gestured with a closed fist up and down and emphatically stated, No, no, no, and then began to cry and put her head in her left hand. When asked if anything negative had occurred with her care due to insufficient staffing, the resident stated, No. The resident continued to cry but was unable to vocalize what if any negative event(s)/outcome(s) she had experienced due to short staffing. - On 10/27/19 at 2:16 PM, Resident #7 stated staff made her feel degraded and had made me cry in the last month, the last time was about two weeks ago. She said staff talked down to her and acted like she was out of bounds with them. Resident #7 was asked if she could recall any staff member or names and Resident #7 stated It's all the CNAs, on every shift. Resident #7 was asked if she had reported these incidents to the Executive Director and she stated no, she wanted to remain anonymous because she was afraid of retaliation from staff after the survey team left. Resident #7 requested the team lead and this surveyor's business card, just in case. When asked why, Resident #7 added just in case the staff does something to me after you leave. - On 10/27/19 at 3:00 PM, Resident #480 reported CNA #13 yelled at him to hurry up, we have 16 people and there is only two of us. Resident #480 stated he felt the staff member was getting angry with him. Due to this interaction Resident #480 said he avoided going to the dining room when CNA #13 was there and went to another dining/public area. Resident #480 stated he also kept his door closed, so he knew whenever someone entered his room. - On 10/27/19 at 3:08 PM, Resident #23 was asked if there were enough staff to take care of her and the other residents' needs, the resident stated that meals were not always served on time, her pain medication and other medications were not administered on time, and that scheduled showers were not routinely provided. - On 10/27/19 at 3:17 PM, Resident #180 said he asked for assistance to urinate, and by the time staff came to help him it was too late. Resident #180 said staff were often working double shifts. - On 10/28/19 at 9:25 AM, Resident #65 said there was not enough staff. Resident #65 said the staff would get rushing around, it could take 45 minutes to an hour to get assistance, and it was worse at mealtimes. - On 10/28/19 at 12:00 PM, a family member reported overhearing an unnamed staff member tell Resident #35 If you don't eat, you are not going to [MEDICAL TREATMENT]. Per the family member they wished to remain anonymous because they were afraid of what would happen if someone found out they said anything and that their family member would not receive care if the staff knew they reported it. The incident was reported to E.D. #1 and the Director of Clinical Services to investigate. - On 10/30/19 at 12:30 PM, Resident #333 stated she was afraid to say anything to the staff, because she did not trust them. Resident #333 stated a CNA threatened to turn her water off, so she could not shower without facility knowledge which made her feel like a child. Resident #333 stated a CNA failed to follow through when she made a request, and she was told you can just leave in a nasty tone by the CN[NAME] When asked who the staff member was, Resident #333 refused to say any more about the incident. c. Staff were interviewed and stated there was not sufficient staff to provide the cares required and to meet the needs of the residents. - On 10/27/19 at 11:25 AM, CNA #12 stated she has worked at the facility for two years and was transferred to work in Activities for the past six months. CNA #12 stated that today was not her normal shift; she was held over due to short staffing. CNA #12 stated the facility has been short of staff for a while now. When asked about how this staff shortage affected resident care, CNA #12 stated, You'd have to ask management about that. When asked how it affected her ability provide care for her residents, CNA #12 stated, You'll have to talk with management about any staffing issues. - On 10/27/19 at 11:45 AM, RN #1 and LPN #1 stated the residents who were scheduled for a shower did not receive one because there was not a shower aide scheduled. They stated to be fully staffed for the day and evening shift was 1 RN, 1 LPN, 4 CNAs, 1:1 supervision for Resident #130, and 1 shower aide for the day shift. - On 10/28/19 at 2:53 PM, CNA #3 said a lot of staff recently quit, resulting in use of agency staff who were unfamiliar with the residents. CNA #3 said E.D. #1 was notified of the staffing concerns, and he did not want to hear it. CNA #3 said during the previous night there were 2 CNAs working on her hall until 5:30 AM, and when both aides were assisting a resident at the same time there was nobody to watch the floor. CNA #3 also said at times there was only 1 CNA on the 300 hall. CNA #3 said she brought her concerns to the DON and was told to work short with a smile. CNA #3 said resident care suffered due to lack of staff. - On 10/28/19 at 4:11 PM, the scheduler said she did not like the facility staffing, and 3 CNAs for 46 residents was not okay. - On 10/29/19 at 4:52 PM, the DON said the facility had some struggles with staffing. - On 10/30/19 at 2:10 AM, CNA #2 said staffing was not good, and there was only 1 CNA on the 200 hall at that time. - On 10/30/19 at 2:15 AM, LPN #5 said staffing was pretty rough. LPN #5 said there were a lot of residents who required 2-person assistance on her hall, and from 2:00 until 10:00 PM there was supposed to be 4 CNAs but there were only 3 CNAs working at that time. - On 10/30/19 at 3:50 PM, E.D. #1 said the facility was facing a staffing crunch. E.D. #1 said at times a shower aide was pulled from giving showers to work on the floor, but now they were catching up on showers. E.D. #1 said the facility needed CNAs and had not been successful in finding more CNAs. He said evening shift was difficult to cover, so they used agency staff. On 10/31/19 at 8:47 AM, E.D. #1 said the residents were concerned with the amount of agency staff, and residents felt the facility's regular staff knew them better. - On 10/30/19 at 2:10 AM, CNA #11 stated she was assigned to work at the facility the past month. CNA #11 stated the facility did not provide her with any training related to its policies and procedures, or where certain items, like the automatic external defibrillators, were located or with instructions on how to use the overhead paging system. - On 10/30/19 at 2:30 AM, CNA #9 stated she was hired by the facility four to five months ago, and that the first night she worked, I was thrown to the floor because an agency CNA did not show up for work. CNA #9 stated that she then had three to five days training with two of the facility's experienced CNAs before working her shift independently. - On 11/1/19 at 2:58 PM, LPN #4 said on that day there was 1 NA and 2 CNAs for 100 hall, and during the previous evening there was 1 CNA and 1 NA (Nursing Assistant) for the 100 hall. d. The Resident Council expressed concerns regarding lengthy call light response times, assistance with meals which were not addressed by the facility. The Concern & Comment Forms, known as the blue cards, were organized by month in two binders for the year 2019. Five facility blue cards, dated 2/14/19 (2 on this date), 6/19/19, 7/17/19 and 8/14/19, documented the Resident Council filed grievances regarding call light wait times on each date. - The blue card, dated 2/14/19, documented per Resident Council, Resident #7 was told staff was sent home early due to low census - she is upset because she feels it causes her a longer wait time in getting her call light answered. The facility documented on the back the investigation findings were: staffing was adjusted to resident acuity and census. Facility continued to monitor staffing levels and call light audits. Actions taken to resolve/respond to the concern was: continue to monitor through QAPI. The date the findings/action plan were shared with the concerned party was 2/26/19, 12 days after complaint was filed, and the concerned party's reaction was checked as cautious but optimistic. - The blue card, dated 2/14/19, written per Resident Council, documented Resident #32 agreed that call lights were not being answered in a very timely manner. The facility documented investigation findings on the back side as: continue to work with QAPI plan and conduct call light audits and daily Angel Rounds (manager makes rounds to talk with residents). - The blue card, dated 6/19/19, documented the grievance was filed on behalf of the Resident Council, and described the concern as residents feel call lights are getting to be slower lately, and they reported the concern to a staff member. The facility documented the person designated to investigate/follow-up with the concern was the MDS Coordinator, and investigation findings were: Have received multiple C/O (complaints) call light wait times; will address in QAPI 7/9/19. Actions taken were documented as: Audit completed, we are addressing the call light response time, Angel Rounds (implemented - The blue card, dated 7/17/19, documented the grievance was filed on behalf of the Resident Council, and described the concern as: (Resident Council) would like us to do our audits at off times, like during meals and after meals when residents want to lay down, to show us just how long they really have to wait for help. It was documented the complaint was reported to a staff member. The facility documented the person designated to investigate/follow-up with the concern was the MDS Coordinator, and investigation findings were: Talked with department heads about doing call light audit with PM Manager. - The blue card, dated 8/14/19, documented the grievance was filed on behalf of the Resident Council, provided resident name as 100 and 200 Hall, and described the concern as: call lights are still slow to answer, and that the concern was reported to a staff member. The facility documented the person designated to investigate/follow-up with the concern was the MDS Coordinator. The blue card did not document a date/time of initial contact with the concerned party (Resident Council President) and the investigation findings were: Work in progress, this needs to be all team members, See QAPI. Actions taken were documented as: Off hour call light audits continuing with PM Managers. The facility failed provide sufficient staff to meet resident needs when identify by the Resident Council and through the complaint/grievance process. e. Residents were not able to voice grievances about care and services without fear of reprisal and the facility did not respond to grievances, investigate them, and take prompt corrective action to resolve them. i. Resident #61 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #61's quarterly MDS assessment, dated 9/28/19, documented she was cognitively intact. On 10/29/19 at 10:33 AM, Resident #61 said on 10/2/19 the staff took 2 hours to answer her call light from 6:45 PM to 8:40 PM, she called the facility and the phone rang 25 times with no answer and she hung up. Resident #61 became teary eyed and upset and said that she loves it here, but not right now - it keeps getting worse and I am tired of hearing it will get better when in fact it gets worse every day. She said the worst time was the evening shift 2:00 -10:00 PM, especially after dinner, it's a ghost town out in the hallway, you can't find anyone to help you. Two Comment and Concern blue cards, dated 10/2/19, were completed by Resident #61 regarding lack of staff assistance. On one she wrote: I have never been treated so poorly. The last two nights I had my call light on for more than two hours without any assistance. I went out to the (200 hall) nurse's station and no one could be found. Is anyone even working here anymore? I even called the facility and the phone rang 25 times and no answer. She wrote on the blue card that she reported the concerns to two nurses on the 200 Hall. On Resident #61's second blue card, dated 10/2/19, she wrote: We are constantly denied a shower. It has been a week this time and has been as many as 12-14 days. Hygiene is just as important to my healthcare. I am disappointed in the overall care I have gotten during my stay this time. I have always requested Post Falls Life Care. She wrote she reported the concern to two nurses on the 200 Hall. There was no facility response included on the card copy. On 11/7/19 at 1:38 PM, regarding the grievance procedure, Resident #61 said people were now reluctant to complete a blue card - residents were turning in blue cards but when nothing happened, no action was taken, they quit filing them. Resident #61 said she filed two grievances on 10/2/19 regarding her inability to get a response when she sought assistance and lengthy delays between showers. Resident #61 said E.D. #1 fired staff who expressed concerns, he just wanted it to be happy. ii. Resident #7 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #7's quarterly MDS assessment, dated 7/19/19, documented she was cognitively intact. A Comment & Concern blue card, dated 8/24/19, documented by LPN #4 on behalf of Resident #7, said I think it is totally ridiculous that my scheduled Friday shower - she (shower aide) couldn't do it because she was pulled to the floor. The card documented Resident #7 said the shower aide told her she would do the shower on Saturday and she was pulled to the floor again, so she did not receive a shower on Saturday. The card documented Why don't they have enough staff? I shouldn't have to miss my shower. What about agency working? Never see them on days, only evenings. On 11/5/19 at 11:17 AM, the P.[NAME] said in (MONTH) 2019 the E.D. separated from the facility and things got worse. The P.[NAME] said the new E.D. (E.D. #1) requested only positive attitudes from staff and would fire those who complained. f. The facility did not provide 1:1 supervision for residents as ordered by their provider. Examples include: i. Resident #130 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. An IDT investigation note, dated 9/3/19, documented new interventions for Resident #130 included having 1:1 supervision and his care plan was revised. The care plan was revised on 9/5/19, and stated 1:1 as ordered, after family departs for the day, have 1:1 in place with resident 1 hour prior to family departure. A Care Plan Conference Note, dated 10/14/19, documented family, RCM #2, a therapy representative, the Director of Social Services, and LSW #1 were in attendance. The note documented Resident #130 needed 24/7 diligence for safety. Resident #130 did not have 1:1 supervision as follows: * On 10/1/19, no 1:1 supervision assignment from 6:00 AM to 8:00 AM and 2:00 PM to 3:00 PM * On 10/2/19, no 1:1 supervision assignment from 6:00 AM to 7:00 AM * On 10/3/19, no 1:1 supervision assignment from 9:00 AM to 10:00 AM * On 10/4/19, no 1:1 supervision for assignment for day shift, evening shift, and night shift * On 10/8/19, the aide assigned for 1:1 supervision was at clinical * On 10/12/19, no 1:1 supervision assignment for day shift, evening shift, and night shift * On 10/13/19, no 1:1 supervision assignment for night shift * On 10/15/19, no 1:1 supervision assignment from 6:00 AM to 7:00 AM * On 10/15/19, no 1:1 supervision assignment from 6:00 AM to 7:00 AM * On 10/16/19, no 1:1 supervision assignment from 6:00 AM to 8:00 AM * On 10/22/19, no 1:1 supervision assignment for night shift * On 10/24/19, no 1:1 supervision assignment on evening shift * On 10/25/19, no 1:1 supervision assignment for day shift or night shift * On 10/27/19, no 1:1 supervision assignment for the day and evening shift On 10/27/19 at 12:30 PM, LPN #1 stated Resident #130 was not assigned to 1:1 supervision for 22 day, until after the survey team entered the facility. Resident #130 was sitting in the dayroom with the Activity Director assisting him with an activity. LPN #1 stated Resident #130 was required to have 1:1 supervision 24/7 due to his impulsiveness, wandering, poor safety awareness, and impaired gait. LPN #1 stated Resident #130 was more often without 1:1 supervision than he was with one for the past month. On 10/27/19 at 2:30 PM, Resident #130 was observed in bed resting without 1:1 supervision. On 10/27/19 at 2:45 PM, E.D. #1 was standing outside of Resident #130's room. E.D. #1 stated he was Resident #130's 1:1 supervision. On 10/28/19 at 2:20 PM, CNA #2, the facility's nursing scheduler, was reclined in Resident #130's recliner looking at her phone, while he was sleeping. CNA #2 stated she assigned herself as the 1:1 supervision for Resident #130 because she was unable to fill the position with anyone else. CNA #2 stated she had to be around Resident #130 because he was a high fall risk. On 10/28/19 at 3:17 PM, LPN #1 stated Resident #130 required 1:1 supervision due to wandering into other resident rooms, but most of the time Resident #130 was not assigned 1:1 supervision. LPN #1 stated Resident #130 did not have 1:1 supervision assigned to him currently and she was responsible to keep an eye on him while she was passing medications to other residents. LPN #1 stated it was impossible to keep Resident #130 safe without being with him at all times. On 10/28/19 at 3:25 PM, Resident #130's spouse stated when she visited the staff member assigned to Resident #130's 1:1 supervision would leave the room and she assisted him. Resident #130's spouse also stated if she was unable to provide personal care for Resident #130, she asked for assistance from the staff. The spouse stated Resident #130 needed 1:1 supervision 24/7 due to his impulsiveness and wandering. On 10/30/19 at 2:05 AM, E.D. #1 was standing outside of Resident #130's doorway and Resident #130 was sleeping in bed. E.D. #1 stated he was assigned as Resident #130's 1:1 supervision for the night shift from 10:00 PM to 6:00 AM. E.D. #1 stated he was not a CN[NAME] E.D. #1 stated he notified the CNA assigned to the hall to assist Resident #130 with personal cares. E.D. #1 stated he was there to assure Resident #130 did not wander into another resident's room. There was one CNA and one LPN assigned to 42 residents on the 200 hall for the night shift. On 10/30/19 at 3:05 AM, the BOM relieved E.D. #1 as Resident #130's 1:1 supervision. The BOM stated she was a CNA and was able to provide assistance for Resident #130. Resident #130 was in bed sleeping and the BOM was sitting in a chair close to the doorway. On 10/30/19 at 3:15 AM, E.D. #1 was standing outside Resident #130's doorway and stated he was back to provide 1:1 supervision for Resident #130. On 11/1/19 at 10:00 AM, the new scheduler stated he transferred from one of the sister facilities and was working on filling the holes in the schedule for Resident #130's 1:1 supervision for the evening shift. The 200 Hall Daily Assignment Sheet documented, Need Help!!! on the evening shift. On 11/2/19 at 7:20 PM, CNA #4 was sitting outside Resident #130's room assigned as his 1:1 supervision. CNA #4 stated she was instructed to assure Resident #130 did not fall or wander into other residents' rooms. Resident #130 was in bed sleeping. On 11/2/19 at 7:30 PM, CNA #4 was observed assisting Resident #130 to the bathroom. On 11/2/19 at 7:50 PM, CNA #4 was sitting next to Resident #130 on the side of his bed. Resident #130 was talking to CNA #4. On 11/3/19 at 10:30 AM, Sitter #1 was observed sitting outside of Resident #130's room while he was in bed sleeping. Sitter #1 stated she was not a CN[NAME] Resident #130 was awake and attempting to get out of bed and Sitter #1 did not see him getting up. Sitter #1 was told Resident #130 was getting out of bed. Sitter #1 assisted him walking by holding his left hand with her right hand with their fingers interlocked and her left hand was holding his left bicep. Resident #130 had an unsteady gait and Sitter #1 was leading him to walk forward, while his right foot was shuffling. Resident #130 stated he needed to use the bathroom. Sitter #1 led him to his bathroom and asked another sitter to find a CNA to provide cares for Resident #130. Sitter #1 stated she was unable to provide personal cares and did not know if Resident #130's bathroom had a call light to activate. Resident #130's bathroom did have a call light in his bathroom. On 11/5/19 at 9:32 AM, the DON stated Resident #130's trial of not having 1:1 supervision failed in less than a day. She said Resident #130 had an unsteady gait and wandered into other residents' rooms and he needed 24/7 supervision. On 11/5/19 at 11:05 AM, the P.[NAME] stated Resident #130 should not have been trialed without 1:1 supervision. The P.[NAME] stated she was instructed to discontinue the 1:1 supervision by E.D. #1, he told her the facility did not have enough staff to provide 1:1 supervision for Resident #130 and he instructed the P.[NAME] to discontinue the 1:1 supervision. The P.[NAME] stated Resident #130 required 1:1 supervision due to having an unsteady gait, he was at risk for falls, and he had been wandering in and out of other residents' rooms. The P.[NAME] stated after Resident #130 wandered into the female's bathroom while she was in there, she reinstated the 1:1 supervision and E.D. #1 was not happy. The P.[NAME] stated her priority was to keep all residents safe and she knew discontinuing the 1:1 supervision was a bad idea. On 11/5/19 at 2:08 PM, the P.[NAME] stated the 1:1 supervision needed to be a CNA to provide personal cares and assist with transfers and they needed to be within arm's reach of Resident #130. The facility did not provide ordered supervision and interventions to prevent Resident #130 from falling and wandering into other residents' rooms. ii. Resident #72 was admitted on [DATE], with [DIAGNOSES REDACTED]. A Fax Order Request/Notification form, dated 10/17/19, documented the physician ordered 1:1 supervision as needed for Resident #72. On 10/27/19 between 11:30 AM and 12:10 PM, Resident #72 was observed in a tilt back wheelchair in the dayroom on the 200 hall without 1:1 staff. Resident #72 was observed repositioning the leg rests and moving his legs over the side of the wheelchair. On 10/27/19 at 11:20 AM, LPN #1 said Resident #72 was supposed to have 1:1 supervision. At 11:30 AM, RN #4 also said Resident #72 was supposed to have 1:1 supervision. Both verified no one was assigned for 1:1 supervision as evidenced by the daily assignment sheet. RN #4 stated the facility used the tilt back wheelchair to attempt to prevent Resident #72 from falls or give staff enough time to get to him before he fell . LPN #1 and RN #4 said they were unaware of what monitor per protocol meant. The nurses also verified the order for 1:1 as needed had no parameters. On 10/27/19 at 3:30 PM, CNA #1 said there was not enough staff for 1:1 supervision. On 10/27/19 at 3:40 PM and 3:50 PM, CNA #2 and CNA #3 respectively, confirmed there was not enough staff for 1:1 supervision. A Nurse's Progress Note, dated 10/27/19, documented Resident #72 propelled himself to the 100 unit via his manual wheelchair. The note documented Resident #72 entered the private room of another resident and attempted to self-transfer. The progress note further documented Resident #72 fell out of his wheelchair due to his inability to bear weight. Resident #72's physician order [REDACTED]. On 10/28/19 at 9:00 AM, RN #4 verified Resident #72 fell at 5:50 PM on 10/27/19 on another unit, in another resident's room. On 10/28/19 at 9:30 AM, Resident #72 was in a tilt back wheelchair in the 200 hall dayroom without staff present in the room. At 9:40 AM, a staff member pushed Resident #72 to a table in the dayroom and gave him a cup of coffee then left the room. At 9:43 AM, Resident #72 told a visitor he needed to go to the bathroom. The visitor informed a CNA, who stated she would be back. Resident #72 again told the visitor and another resident he needed to go to the bathroom. At 9:55 AM, another CNA came into the dayroom and removed him. The CNA returned Resident #72 to the dayroom in the tilt back wheelchair at 10:00 AM and left. There was no 1:1 staff with him. Resident #72 was moving the wheelchair around the dayroom from 10:00 AM to 10:40 AM with his legs hanging over the side of the wheelchair and dangling under the leg rests. At 10:40 AM, a CNA entered the dayroom and repositioned Resident #72 in the wheelchair. Resident #72 was observed continuously in the dayroom from 9:30 AM to 10:50 AM without 1:1 supervision by staff as ordered by the physician. A Nurse's Progress Note, dated 10/28/19 at 1:05 PM, documented Resident #72 was sitting at a table in the dayroom eating lunch when he pushed his wheelchair back and stood up. Resident #72 then sat himself on the edge of wheelchair cushion and slid off the cushion and onto the floor in between the footrests of his wheelchair. The note documented Resident #72 was assessed by the nurse and he denied pain, but there were two small reddened areas observed, one on his lower back and one on his left thigh. The note documented his physician was notified. On 10/30/19 at 3:14 PM, the Medical Director said the order for 1:1 as needed was not a definitive order. He

Based on record review, review of the facility's Abuse Policy, review of facility grievances, family and resident interview, and staff interview, it was determined the facility failed to ensure residents were free from staff intimidation when reporting verbal abuse for 8 of 97 residents (#4, #7, #32, #35, #61, #62, #333 and #480) reviewed for abuse and neglect. This failure resulted in immediate jeopardy related to the psychosocial harm of residents due to fear and intimidation of retaliation by the facility in reporting abuse and neglect by staff. Findings include: The facility's policy Protection of Residents: Reducing the Threat of Abuse and Neglect, revised 1/21/19, included the definition of mental abuse which stated Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The policy stated the facility must provide residents and representatives with information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. The facility policy also stated residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported. This policy was not followed. a. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/27/19 at 11:55 AM, Resident #4 was interviewed. Resident #4 was alert and oriented to person and place. When asked if she had any concerns with the staff or care provided, Resident #4 exclaimed Yes. When asked if anything negative had occurred with her care or if anyone had ever been abusive to her, Resident #4 stated no and cried with tears rolling down her cheeks. She was unable to vocalize what if any negative outcomes had occurred. b. On 10/27/19 at 2:16 PM, Resident #7 stated staff made her feel degraded and had made me cry in the last month, the last time was about two weeks ago. She said staff talked down to her and acted like she was out of bounds with them. Resident #7 was asked if she could recall any particular staff member or names and Resident #7 stated It's all the CNAs, on every shift. Resident #7 was asked if she had reported these incidents to the E.D. and she stated no, she wanted to remain anonymous because she was afraid of retaliation from staff after the survey team left. Resident #7 requested the team lead and this surveyor's business card, just in case. When asked why, Resident #7 added just in case the staff does something to me after you leave. c. On 10/27/19 at 3:00 PM, Resident #480 reported CNA #13 yelled at him to hurry up, we have 16 people and there is only two of us. Resident #480 stated he felt the staff member was getting angry with him. Due to this interaction Resident #480 said he avoided going to the dining room when CNA #13 was there and went to another dining/public area. Resident #480 stated he also kept his door closed, so he knew whenever someone entered his room. When asked if he had reported the incidents, Resident #480 stated that he thought he had but was unsure. The facility's grievance and incident logs from (MONTH) 2019 through (MONTH) 2019 did not include a grievance or incident filed for Resident #480. On 10/29/19 at 8:45 AM, with permission from Resident #7, E.D. #1 and the Director of Clinical Services were informed of the allegation of verbal abuse by staff towards Resident #7. d. On 10/28/19 at 12:00 PM, a family member reported overhearing an unnamed staff member tell Resident #35 If you don't eat, you are not going to [MEDICAL TREATMENT]. Per the family member they wished to remain anonymous because they were afraid of what would happen if someone found out they said anything and that their family member would not receive care if the staff knew they reported it. The incident was reported to E.D. #1 and the Director of Clinical Services to investigate. A Resident Council meeting was conducted on 10/29/19 at 10:16 AM, with a sample of the facility residents. The residents were asked collectively if the staff treated them with respect and dignity. Residents #4, #32, #61, and #62 responded no and stated they were made to feel like an imposition, being shuffled around like we are furniture. When the residents were asked if they had reported this to the facility, they stated they were very apprehensive about reporting staff incidents. The residents in attendance stated they did not feel anyone would do anything, and they did not trust and/or were afraid of the agency staff because they did not know them. Residents #4, #32, #61, and #62 added the staff were demeaning and disrespectful towards residents. On 10/30/19 at 12:30 PM, Resident #333 stated she was afraid to say anything to the staff, because she did not trust them. Resident #333 stated a CNA threatened to turn her water off, so she could not shower without facility knowledge which made her feel like a child. Resident #333 stated a CNA failed to follow through when she made a request, and she was told you can just leave in a nasty tone by the CN[NAME] When asked who the staff member was, Resident #333 refused to say any more about the incident. On 11/7/19 at 9:30 AM, during a telephone interview, CNA #13 was asked if she remembered yelling at Resident #480 and telling him to hurry up, that she had 16 people and there was only two of us. CNA #13 responded she did not recall the incident. CNA #13 added she had a loud voice, but that she would not even speak to residents that way. On 11/8/19 at 9:00 AM, the DON was questioned about the outcome of the investigations for Resident #7, Resident #35, and Resident #480. The DON stated for Resident #35 LPN #7 was placed on leave until the investigation was completed and LPN #7 was provided with customer service, abuse, and neglect training. Related to Resident #480, CNA #13 was suspended and received customer service, abuse, and neglect training. Related to Resident #7, the remaining staff was provided with customer service, abuse, and neglect training. E.D. #1 was informed on 10/31/19 at 4:00 PM, there was an Immediate Jeopardy related to resident abuse. The Immediate Jeopardy was not removed at the time of survey exit on 11/8/19.

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to prevent the development or worsening of pressure ulcers in the facility. This was true for 4 of 10 residents (#13, #36, #131, and #134) reviewed for pressure ulcers. Resident #131's health and safety was placed in Immediate Jeopardy when his sacral pressure ulcer worsened and required surgical intervention. Resident #13 was harmed when she developed a pressure ulcer to her left antecubital (crease of elbow) and a Stage II pressure ulcer to her left heel. Resident #36 was harmed when she developed an unstageable pressure ulcer to her to left heel. Resident #134 had a potential for harm when he was admitted to the facility with a pressure ulcer to his sacrum and no interventions or treatments were initiated. Findings include: The National Pressure Ulcer Advisory Panel (2016), defines pressure ulcers as follows: Stage 2 - Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury Unstageable - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. Deep tissue pressure injury - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The facility's Wound/Skin Management policy and procedure, dated 2/6/19, documented, Upon admission, a full-body skin assessment is conducted. If there is an abnormal skin condition, a Licensed Nurse must visualize and document, describing the skin conditions and update the Care Plan/Kardex. The physician and resident representative would be notified and treatment was obtained immediately following identification of a wound. The policy documented the facility would complete weekly skin assessments and document on the Weekly Skin Integrity Data Collection, the facility established a wound care team comprised of the DON or designated RN, dietary representative, a therapy representative, and additional team members could be added as needed. It is encouraged that the RN on the wound team have advanced training in wound assessment and care, such as wound care competency, Wound Care Nurse training through (the facility's name) or actual certifications in wound care. The wound team completes weekly wound rounds and if the wound has not changed for two weeks or has deteriorated since the last assessment, the physician is notified for potential treatment changes. The facility failed to follow its policy. 1. Resident #131 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The admission skin collection tool, dated 8/20/19 at 11:26 AM, documented Resident #131 had a large necrotic area to his coccyx and sacral areas. There were no measurements documented. Resident #131's skin integrity care plan, dated 8/22/19, documented to place an air mattress to Resident #131's bed and a gel cushion on the seat of his wheelchair. Staff were to assist Resident #131 with repositioning every 2 hours, perform weekly skin checks, and weekly treatment documentation including measurements and changes of the wound. A Wound Observation Tool, dated 8/26/19, documented Resident #131 was admitted with an unstageable deep tissue injury to his sacrum. The tool assessment documented the visible tissue was 100 % necrotic tissue in the wound bed. There was a small amount of sanguineous (fresh red blood when injury first occurs) drainage and a foul odor. The sacrum wound measurements were 9.0 cm x 8.0 cm. The depth was not documented. The assessment was completed by RCM #2, who was an LPN. Resident #131's admission MDS assessment, dated 8/27/19, documented he was moderately cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS documented Resident #131 was at risk for pressure ulcers and had eight stage 2 pressure ulcers and two unstageable pressure ulcers that were suspected deep tissue injuries. Resident #131's physician orders, dated 8/22/19, documented to clean his wounds with normal saline and apply Allevyn (absorbent foam dressing) to his bilateral knees, bilateral shins, bilateral heels, left posterior lower leg, bilateral elbows, left posterior shoulder, and coccyx (tailbone). The order instructed licensed staff to change the dressing every 3 days on the night shift and as needed for soiling or saturation. The (MONTH) 2019 TAR documented all the dressings were changed on 8/22/19, 8/25/19, and 8/31/19. The TAR was left blank on 8/28/19. A physician's orders [REDACTED].#131's coccyx wound. A physician's orders [REDACTED].#131's coccyx wound. Another physician's orders [REDACTED].#131 was to have the soonest general surgery appointment to evaluate Resident #131 for a surgical debridement of his coccyx wound. A Wound Observation Tool, dated 9/12/19, documented Resident #131 was admitted with an unstageable deep tissue pressure ulcer to his sacrum. The visible tissue was improving with slough and necrotic tissue to 85% of the wound bed. There was no drainage and there was a foul odor. The measurements were 9.4 cm x 7.9 cm and the depth was not documented. The wound had tunneling at the 6:00 o'clock position with a 0.4 cm depth. The documentation to notify the physician was left blank. The assessment was completed by RCM #2, who was an LPN. A Wound Observation Tool, dated 9/26/19, documented Resident #131 was admitted with an unstageable deep tissue pressure ulcer to his sacrum. The visible tissue was improving with slough and necrotic tissue to 85% of the wound bed. There was no drainage and there was a foul odor. The measurements were 9.4 cm x 7.9 cm and the depth was not documented. The wound had tunneling at the 6:00 o'clock position with a 0.4 cm depth. The documentation to notify the physician was left blank. The Wound Observation Tool was completed by LPN #3. An Operative Consult Report, dated 9/30/19, documented Resident #131 had a Stage 3 necrotic sacral pressure ulcer. The procedure was a wide excisional debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of necrotic skin, subcutaneous (inside layer of the skin that helps keep the body's temperature stable) tissue and some fascia (lowest layer of skin in the body) of the sacral pressure ulcer measuring 8.0 cm x 7.0 cm x 5.0 cm and a wound VAC (a device for advanced wound healing therapy) was placed. This was 27 days after a wound clinic consultation was ordered by Resident #131's physician and the wound had a 5.0 cm increase in depth. A Wound Observation Tool, dated 10/3/19, documented Resident #131 was admitted with an unstageable deep tissue pressure ulcer to his sacrum. The visible tissue was improving with slough and necrotic tissue to 85% of the wound bed. There was no drainage and there was a foul odor. The measurements were 22.23 cm x 26.1 cm (a 14.23 cm x 19.1 cm difference from the 9/30/19 measurements 3 days ago) and the depth was not documented. The tool documented the wound was undermining at the 6 o'clock position with a 4.6 cm depth and at the 1:00 o'clock position with a 5.9 cm depth and the tunnel was 5.0 cm. The documentation to notify the physician was left blank. The assessment was completed by RCM #2. The Wound Observation Tool was completed 3 days after the surgical debridement was completed with significant changes to the wound and the surgeon was not notified. The Wound Observation Tools were not completed weekly with assessments, measurements and staging wounds and were without oversight from RNs or the DON with wound care competency per the facility's policy. A Fax Order Request/Notification Form, dated 10/7/19, sent to the surgeon, requested an order clarification for the frequency of the wound VAC changes for Resident #131. This was seven days after the original order date. The surgeon responded with an order, dated 10/7/19, which documented to change the wound VAC every Monday, Wednesday, and Friday to Resident #131's sacral pressure ulcer. Resident #131's (MONTH) 2019 MAR, initiated on 10/9/19, documented to change the wound VAC 3 times a week; Monday, Wednesday, and Friday for wound care. This was nine days after the original order date and two days after the clarification order date. A Postoperative Follow Up, dated 10/10/19, documented, Overall wound appears to be improving 10 days following excisional debridement and application of wound VAC to the sacral pressure ulcer. There is a moderate amount of slough remaining, too much to debride in the office, and I've recommended second debridement in the OR (Operating Room). The plan documented to continue with the wound VAC and schedule a second debridement for 10/16/19. A Fax Order Request/Notification Form, dated 10/10/19, to Resident #131's primary physician, documented Resident #131 was continuously removing the wound VAC and refused to have the wound VAC replaced or a dressing placed. A physician's orders [REDACTED].#131's refusals, apply wet to dry dressing changes, and documented collagen (promotes wound healing) may be used. A surgeon's physician order, dated 10/11/19, documented to cleanse the sacral wound with normal saline, cut to fit Alginate dressing (removes dead or damaged skin and helps stabilize blood flow), place collagen powder on Alginate dressing and place in wound bed, and cover with an Allevyn dressing daily. The (MONTH) 2019 TAR, dated 10/11/19, documented the Alginate dressing change was completed daily. The (MONTH) TAR was left blank on 10/31/19. A Preoperative Consult, dated 10/15/19, documented a nurse at the facility stated Resident #131 was removing the wound VAC 4-5 times a day and he was scheduled for a second debridement of the sacral wound on 10/16/19. The nurse's progress notes from 9/30/19 to 10/9/19 documented Resident #131's wound VAC to his sacrum was running continuously without concerns. There was no documentation in Resident #131's record he was continuously removing the wound VAC. A Postoperative consult report, dated 10/16/19, documented Resident #131 had a Stage 3 necrotic sacral pressure ulcer. The procedure was an excisional debridement of all the nonviable subcutaneous tissue and fascia of the sacral pressure ulcer measuring 3.0 cm x 3.0 cm x 5.0 cm and a wound VAC was placed in the recovery room. A nurse's progress note, dated 10/16/19 at 6:00 PM, documented Resident #131 had wound debridement from the surgeon that morning and the wound VAC was secured and running continuously without concerns. A nurse's progress note, dated 10/16/19 at 9:48 PM, documented Resident #131 removed his wound VAC and wanted to be left alone with no dressing placed on his sacral wound. A nurse's progress note, dated 10/17/19 at 12:12 AM, documented Resident #131 allowed the licensed nurse to apply the Alginate dressing and cover with an Allevyn dressing. There was no documentation in Resident #131's record the surgeon was notified Resident #131 removed the wound VAC on 10/16/19, after the second surgical debridement was performed. On 10/27/19 at 4:14 PM, RN #1 was observed changing the dressing to Resident #131's sacral wound. RN #1 removed Resident #131's incontinent brief. The incontinent brief was saturated with a copious (large) amount of serous (yellowish tan in color) drainage. There was no dressing on Resident #131's sacrum wound. RN #1 stated with the amount of drainage in Resident #131's incontinent brief, the dressing was not on for very long. RN #1 washed her hands and applied gloves to provide wound care, and tucked the saturated incontinent brief under Resident #131's buttocks with her gloved hands. RN #1 did not remove her gloves or perform hand hygiene after she tucked the saturated incontinent brief under Resident #131. She then cleansed the sacral wound with normal saline and stated Resident #131's wound was increased in size and appeared worse. There was no foul odor noted. The wound bed had granulating tissue with a small amount of slough in the middle of the wound. RN #1 stated the left side and the center of Resident #131's wound bed had tunneling that was not there a week ago. RN #1 then sprinkled the collagen powder to her left contaminated glove and sprinkled it over the wound bed. RN #1 removed her gloves and replaced them with a clean pair of gloves without washing her hands between removing her contaminated gloves and applying a clean pair of gloves. She then packed three 4 x 5 inch [MEDICATION NAME] AG dressings into the wound bed, applied skin prep to the peri-wound, and secured it with two Allevyn dressings. RN #1 removed her gloves and washed her hands. RN #1 stated [MEDICATION NAME] AG was the same as the Alginate dressing. On 10/27/19 at 4:50 PM, RN #1 stated she should have removed her gloves, washed her hands, and applied a clean pair of gloves after she tucked Resident #131's saturated incontinent brief under his buttocks, after she cleansed his wound with normal saline, and after she applied the collagen powder to Resident #131's wound bed. On 10/30/19 at 12:15 PM, RCM #2 stated the Wound Observation Tool assessments were completed by the three RCMs and the DON, weekly on Tuesdays. RCM #2 stated the Wound Observation Tool included assessments and measurements completed every Tuesday. RCM #2 stated the Wound Observation Tool assessments and measurements were not completed on 10/29/19 because the facility had state surveyors in the building. RCM #2 stated the last weekly Wound Observation Tool assessment was completed on 10/3/19. RCM #2 did not know why the Wound Observation Tool was completed on a Thursday and not on Tuesday and did not know why the 10/8/19 assessment was not completed. RCM #2 stated he was on vacation from 10/16/19 through 10/27/19 and did not complete the weekly Wound Observation Tool assessments and measurements. RCM #2 stated the DON was part of the weekly assessments and she had the binder with the documentation of the assessments for all the weekly rounds of residents with wounds. On 10/31/19 at 8:20 AM, the DON stated she was not part of the weekly Wound Observation assessments. The DON stated the three RCMs were completing the Wound Observation assessments every Tuesday. The DON stated she did not have a binder of all the residents wounds with assessments and measurements. The DON stated the weekly Wound Observation assessments and measurements were not completed weekly. The DON stated the Weekly Skin Integrity Data Collection were completed by the floor nurses weekly, but were not implemented for all the residents. The DON stated Resident #131's 10/3/19 Wound Observation Tool measurements were incorrect, and the physician should have been notified of the change of measurements from the debridement measurement on 9/30/19. The DON stated she expected floor nurses completed weekly skin assessments and notified the physician for skin impairments or if the wound worsened. The DON stated she expected the RCMs completed weekly Wound Observation Tool assessments and measurements every Tuesday and provided an update to the physician. The DON stated she was not aware of licensed staff members who were wound care certified. The DON stated the three RCMs and herself were not wound care certified. On 10/31/19 at 9:53 AM, RCM #1 stated the RCMs did not complete weekly Wound Observation Tool assessments and measurements for quite a while. A Postoperartive follow up Consult Report, dated 10/31/19, documented Resident #131's sacral wound measurements were 6.5 cm x 7.0, cm with undermining at 12:00 o'clock at 2.5 cm, 2:00 o'clock at 4.5 cm, and 9:00 and 11:00 o'clock at 2.5 cm. The surgeon scheduled a flap closure (tissue is removed or lifted from a donor site to cover the wound) on 11/20/19. Resident #131's sacral pressure ulcer had increased in size in 15 days. There was no assessments, measurements, or notification to Resident #131's surgeon or his primary physician the sacral pressure ulcer worsened in 15 days. On 11/5/19 at 11:30 AM, the P.[NAME] stated Resident #131's flap surgery could have been prevented if the nurses were following the surgeon's wound care orders for daily dressing changes and followed infection control precautions. There was no documentation the wound surgeon was consistently notified of the wound measurements and progression. Resident #131's record documented LPNs were assessing and staging wounds without oversight of the RNs or DON in the facility. Resident #131's record documented his sacral wound continued to worsen related to the lack of consistent treatments ordered by the physician. The documentation also stated Resident #131's the wound continued to worsen due to care which did not follow standard practice and guidelines for wound treatments and dressing changes for prevention of potential contamination and infection which encouraged healing. The facility did not provide adequate ordered treatment and interventions for Resident #131's sacral pressure ulcer which placed him in Immediate Jeopardy when his sacral pressure ulcer worsened and required surgical intervention. E.D. #2 was notified verbally and in writing of the Immediate Jeopardy on 11/4/19 at 5:25 PM. 2. Resident #134 was readmitted to the facility on [DATE] and discharged on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #134's hospital discharge orders, dated 9/4/19, documented therapy orders for pressure ulcer precautions. An Admission/Readmission Collection Tool, dated 9/5/19, documented Resident #134 had a 3 cm pressure ulcer on his coccyx and it was covered with an Allevyn dressing. Resident #134's baseline care plan, dated 9/4/19, documented he was at risk for skin breakdown. A Nutrition Data Collection Assessment, dated 9/9/19, documented Resident #134 had a pressure ulcer to his coccyx. The admission MDS assessment, dated 9/11/19, documented Resident #134 was moderately cognitively impaired and required extensive assistance of staff members for bed mobility, transfers, and dressing. The assessment documented he had one Stage 2 pressure ulcer present on admission. The nurse's progress notes, from 8/27/19 to 9/16/19, did not include documentation Resident #134 had a pressure ulcer to his coccyx. The (MONTH) 2019 MAR and TAR did not include wound care documentation to Resident #134's coccyx. On 11/7/19 at 5:11 PM, the dietitian stated she collected her initial assessment from the admission assessment and from the nursing staff. On 11/7/19 at 5:27 PM, RCM #2 stated the nurse who documented the pressure ulcer on the admission assessment should have notified the physician for wound care orders. RCM #2 stated Resident #134's record did not include weekly skin assessments or wound observation assessments. 3. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's skin breakdown care plan, dated 7/31/19, included interventions for weekly skin checks. Resident #13's weekly skin integrity data collection was completed 8/22/19 through 9/22/19. There was no documented skin integrity data collection on 9/29/19. A Braden Scale (tool used to assess a resident's risk for developing pressure ulcers) assessment, dated 9/5/19, documented Resident #13 was at high risk for developing a pressure ulcer, with additional risk factors including decreased bed mobility. Resident #13's annual MDS assessment, dated 10/14/19, documented she was severely cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS documented Resident #13 was at risk for pressure ulcers and had one Stage 2 pressure ulcer. a. Resident #13's Weekly Skin Checks, dated 8/22/19 through 9/22/19, did not include documentation of the pressure ulcer to Resident #13's left antecubital (elbow crease). Subsequent skin checks were as follows: - A Weekly Skin Integrity Data Collection, dated 10/7/19, documented Resident #13 had an open sore, red and draining to the left antecubital. There was no documentation of measurements or a description of the appearance of the open sore to the left antecubital. - A Weekly Skin Integrity Data Collection, dated 10/13/19, documented Resident #13 had a wound in the left antecubital with no measurements or description of the appearance of the wound. Allevyn (absorbent foam dressing) was in place and documentation noted the wound was warm, red and draining. - A Weekly Skin Integrity Data Collection, with no date or signature, documented Resident #13 had a wound to the left antecubital, red, warm and draining with an Allevyn dressing in place. The skin check documentation did not include appearance or measurements of the wound. A nurse progress note, dated 10/3/19 at 9:49 PM, documented a deep open wound in the crevice of the left elbow of Resident #13. The Wound Observation Tool, dated 10/4/19, documented Resident #13 had a deep open wound on the left arm, surrounded with pink skin, detailing the location as the left elbow crease. A physician's progress note, dated 10/4/19 at 9:30 AM, documented Resident #13 had a Stage 4 pressure ulcer to her left upper extremity antecubital, where the arm was contracting. The assessment and plan documented a pressure ulcer Stage 4 to Resident #13's left upper extremity antecubital due to contracture, apply Allevyn dressing with [MEDICATION NAME] (foam wound dressing with honey based wound care gel), change the dressing daily, and wound care team was to consult on 10/8/19. A physician's progress note, dated 10/14/19 at 8:00 AM, documented to continue with Resident # 13's wound care. The (MONTH) TAR for Resident #13 documented the following: * Resident #13's (MONTH) 2019 TAR, dated 10/4/19 through 10/15/19, documented an order for [REDACTED]. * Resident #13's (MONTH) TAR, dated 10/15/19 through 10/25/19, documented an order for [REDACTED]. The documentation included the order was not clear and needed clarification. On 10/30/19 at 12:15 PM, RCM #2 was asked what the above physician's orders [REDACTED].#2 stated he was on vacation during that time and was unable to answer the question. * Resident #13's (MONTH) TAR included documentation treatments were completed on 10/18/19, 10/21/19, and was left blank on 10/24/19. On 10/30/19 at 12:18 PM, RCM #2 stated, when the TAR is left blank the task was not completed. * Resident #13's (MONTH) 2019 TAR, dated 10/25/19, documented the Allevyn dressing to her left antecubital was to be changed every 3 days and in the evening. Resident #13's record did not include documentation a wound care team consult occurred. On 10/27/19 at 3:22 PM, RN #1 stated Resident #13's left antecubital open area was caused by a contracture, and there were two pressure ulcers, one resolved after treatment, and the other was open and draining. On 10/30/19 at 1:00 PM, RCM #2 stated wound care was not completed from 10/27/19 through 10/30/19 since the state surveyors were at the facility. On 10/30/19 at 1:30 PM, the DON stated RCM #1, RCM #2, and RCM #3 completed weekly wound care assessments and obtained measurements. The DON was unsure if anyone was wound care certified. The DON stated she expected wound care was completed as ordered, including when state surveyors were present. On 10/30/19 at 4:15 PM, the P.[NAME] stated she wrote the orders for Resident #13 and they were never processed by RCM #2. The P.[NAME] stated E.D. #1 and the DON were notified of orders not being processed in a timely manner. On 11/1/19 at 12:08 PM, the Medical Director evaluated Resident #13's wounds. After removing a dressing dated 10/29/19, he stated the wound bed was granulating (beefy, red), open, had discharge from the distal (farthest from the head) area, and the size was 1 cm. He also stated the RCMs should have continued with the weekly skin assessments and measurements and he wanted to have a wound clinic come into the facility to observe weekly and communicate with RCMs. The Medical Director stated the facility needed continuity of care and not a different nurse each day doing something differently or who does not have time to do the wound care. He said residents do not get the care they deserve. The Medical Director stated he talked to the DON and E.D. #1 on several occasions, as well as during QA (quality assurance) meetings to stop admissions until more staff was available to provide wound care, and suggested an in house wound team to manage the wounds in the facility. He stated he has not received a response. b. On 10/27/19 at 3:22 PM, RN #1 stated Resident #13's left heel was boggy upon admission, and then opened with drainage. Resident #13's Wound Observation Tool, dated 8/23/19, documented upon admission she had a stage 2 pressure ulcer to her left heel, with granulation tissue (beefy red), serosanguineous (pale red) drainage, measuring 2.1 cm x 1.3 cm x 0.0 cm. Further Wound Observation Tools documented the following: * 8/30/19: The overall impression of Resident #13's left heel was the wound was healed and resolved and there was no drainage. No measurements were taken by RCM #2. * 9/15/19: There was a stage 2 pressure ulcer with dimensions of 1.5 cm x 1.2 cm x 0.0 cm. An Allevyn dressing was applied to Resident #13's heel by RN #1. * 9/22/19: There was a stage 2 pressure ulcer with measurements of 2.5 cm x 3.0 cm x 0.0 cm, An Allevyn dressing was applied by RN #1 to Resident #13's heel, with a kerlix (gauze roll bandage). An air mattress and foot cradle (lifts bedding away from the legs to relieve pressure and friction from blankets) were also utilized. An order summary report of active orders, dated 11/1/19, documented an order on 8/1/19 for wound care to Resident #13's left heel, daily in the evening, and an order on 10/14/19 for weekly skin checks, and in the morning every Sunday. Resident #13's (MONTH) 2019 TAR, did not include documentation wound care was provided to Resident #13's left heel. Resident #13's (MONTH) 2019 TAR, documented wound care to her left heel daily in the evening. There was no documentation wound care was completed on 10/3/19. Resident #13's weekly skin integrity data collection, dated from 8/22/19 through 8/25/19, documented a stage 2 pressure ulcer to her left heel. Further skin checks for Resident #13's foot were documented as follows: * On 9/1/19, the dressing was changed. * On 9/8/19, the ulcer was scabbed over. * On 9/15/19, an Allevyn dressing to the heel in was in place, and the heel was improving. * On 9/22/19, the blister was resolved and there were pressure prevention measures in place. * On 9/29/19, there were unopened areas, and the heel was pink and boggy. The 9/22/19 wound observation tool documented Resident #13 had a stage 2 pressure ulcer with wound measurements of 2.5 cm x 3.0 cm x 0.0 cm. The weekly skin integrity data collection report also dated 9/22/19, documented the wound was resolved. On 10/28/19 at 2:01 PM, Resident #13's left heel was observed with no dressing in place and the wound was open with drainage. On 11/1/19 at 12:08 PM, the Medical Director was examining Resident #13's left heel and stated it was an open wound with drainage, at least 1 cm long. The Medical Director stated he would issue new orders for dressings to be applied to the left heel. On 11/1/19 at 3:41 PM, Resident #13 was observed positioned on her right side facing the window, with a Keen lift (device to keep heels from the mattress surface), with no dressing in place. 4. The facility's Skin Integrity & Pressure Ulcer/Injury Prevention and Management policy, dated 10/3/19, documented, A resident's risk (for pressure ulcer development) may increase due to an acute illness or condition change . and may require additional evaluation. The frequency of assessment should be based upon each resident's specific needs . Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: a) reposition at least every 2-4 hours . as consistent with overall patient goal and medical condition; b) utilize positioning devices to keep bony prominence's from direct contact; . d) heel protection/suspension should be implemented while the patient is in bed. Resident #36 was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #36's quarterly MDS, dated [DATE], documented she had moderately impaired cognitive skills for daily decision making, required limited assistance of one staff person for bed mobility and transfers, extensive assistance of one staff member for toilet use, and did not walk. The assessment documented the resident was frequently incontinent of bowel. The assessment documented Resident #36 had no pressure ulcers or other skin conditions present. Resident #36's care plan, initiated on 3/26/19, documented she had a potential for pressure ulcer development related to immobility, urinary incontinence, and

Based on observation, record review, and family, and staff interview, the facility failed to ensure residents received adequate supervision to prevent hazards, risks, accidents, and injuries to residents. This was true for 5 of 10 residents (#8, #36, #72, #130, and #231) reviewed for supervision. These failures resulted in immediate jeopardy to Resident #8 who eloped from the facility without the awareness of staff. This placed the other residents at risk for serious impairment, harm or death when Resident #72 fell out of his wheelchair, Resident #130 wandered and exhibited aggressive behavior toward residents and staff, Resident #36 fell and fractured her right ankle, and Resident #231 fell resulting in a subdural hematoma. Findings include: 1. Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #8's care plan identified her exit seeking, or elopement, and included interventions to redirect her if she was heading towards the doors and if wearing a coat or [NAME]et to reassure her she was in the right place, allow her to express her desire to go home, and assist with calling her son if that was she was exit seeking, initiated on 1/19/19. Resident #8's record included a progress note, dated 6/15/19 at 6:15 PM, which stated she had exited the facility and set off a door alarm near the 300 hall. Resident #8 was followed out to the parking lot by a CNA and she told the CNA her son was waiting for her in the car, which he was not. The CNA used a cell phone to contact other staff regarding the elopement. The facility had 1:1 supervision for Resident #8 for the 2:00 PM to 10:00 PM shift, and for the night shift it changed to 15 minute safety checks. Resident #8's record included an Elopement Risk Evaluation, dated 6/15/19,which documented she was at risk for elopement due to dementia and hallucinations. On 10/29/19 at 11:21 AM, Resident #8 was observed with her coat and a set of keys in her hands. Resident #8 stated to RN #4 she needed to get her car. RN #4 redirected Resident #8 and instructed other staff members to watch her. At 11:30 AM, Resident #8 was observed sitting on the seat of her wheeled walker, down the 200 hall, near the exit door without staff in view. Resident #8's room was also in the same area, two rooms away from the exit door. On 10/30/19 at 2:25 AM, LPN #5 stated Resident #8 was outside of the facility after dark. LPN #5 stated she saw Resident #8 walk by the nurses' station about 8:15 PM with her coat on. LPN #5 said she was unaware Resident #8 had left the facility. She stated a staff person from the 100 hall, returned with Resident #8 about 8:45 PM. The staff person stated Resident #8 was knocking on the side door. The weather was cold, and it was dark outside. LPN #5 stated there was one LPN and one CNA on the 200 unit with 42 residents. On 10/30/19 at 2:00 AM, there was one CNA and one LPN on the 200 hall to care for 42 residents. One LPN and two CNAs were on the 100 hall to care for 43 residents. E.D. #1 was in the facility standing outside of Resident #130's room providing 1:1 supervision. At 2:42 AM, CNA #4 said she had not yet seen all of her assigned residents. At 2:55 AM, CNA #4 said Resident #8's door was closed per Resident #8's request. CNA #5 said Resident #8 was to be checked every 15 minutes. She said the checks were not being done because the corporate person who was doing them left. The facility did not provide adequate ordered supervision and interventions to prevent Resident #8 from elopement which placed her in Immediate Jeopardy of serious harm, impairment, or death. E.D. #1 was notified verbally and in writing of the Immediate Jeopardy on 10/30/19 at 7:10 PM. 2. Resident #231 was initially admitted on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #231's admission MDS assessment, dated 7/31/19, documented he required supervision of one person with physical assistance for transfers, walking in his room and corridor. The assessment also documented Resident #231 was cognitively intact. Resident #231's record did not include an admission MDS assessment for his readmission on 9/20/19. A Physical Therapy and Plan of Treatment note, dated 9/20/19, documented Resident #231's functional mobility assessment for transfers and level surfaces as contact guard assist (one or two hand contact to help steady the other person's body and help with balance) while using a two-wheeled walker. Nurse's Progress Notes, dated 9/21/19 and 9/22/19, documented Resident #231 required SBA (stand by assist) for transfers and ambulation and he used a four-wheeled walker. A Physical Therapy Discharge Summary, dated 9/23/19, for dates of service 9/20/19 to 9/23/19, documented Resident #231's functional skills assessment for mobility was SBA for transfers and on level surfaces. Resident #231's care plan documented he was at risk for falls, had an unsteady gait related to disease process, and directed staff to assist with mobility and ADLs as needed. The care plan also documented staff were to orient Resident #231 to his room, and he required one-person assistance for toileting and transfers, initiated 9/23/19. On 11/6/19 at 3:21 PM, Physical Therapist #1 said SBA means close enough to grab a resident by the gait belt if needed. He said the expectation was a resident had a gait belt on and staff were close enough to grab it if needed. A Progress Note, dated 9/23/19 at 12:40 PM, documented Resident #231 was found on the floor in a room other than his own and appeared to be having a [MEDICAL CONDITION]. An order received from the P.[NAME] said to send Resident #231 to the Emergency Department (ED). The note stated Resident #231 was not responding appropriately, he vomited, had facial drooping on his right side, and was unable to grasp on his right side. He was transported to the hospital at 1:00 PM, and his wife was contacted. There were no documented witnesses of the event. An Incident and Accident Report, dated 9/23/19, documented Resident #231 was found on the floor at 12:40 PM and was responsive only to vigorous stimulation. His eyes were open, but he was not responding to questions. A Witness Statement, dated 9/23/19, written by the Maintenance Director, documented he heard Resident #231 fall in room [ROOM NUMBER]. Resident #231 was found lying on his left side and back with his walker out in front and the walker was leaning over his right side. Resident #231 was not responsive. He pulled Resident #231's walker off him and got nursing assistance. A Witness Statement, dated 9/23/19, written by RN #7, documented she interacted with Resident #231 several times prior to the incident and he exhibited normal behavior. He came to the dining room at 11:15 AM and he ate lunch with no problems. She wrote she observed him leave the dining room and no odd behaviors or concerns regarding his cognition were noted. RN #7 documented he was alert and oriented to person, place, time, and situation during her shift. RN #7 said she was called to assist with Resident #231 by the Maintenance Director, and Resident #231 was found on his back and it appeared he was having a [MEDICAL CONDITION]. Staff stayed with Resident #231 and RN #7 documented she called 911. A Staff Interview, dated 9/23/19, with PT #2, documented Resident #231 looked the best I have seen during therapy the day of the event, and had no noted concerns about his gait or balance. Resident #231 was at appropriate oxygen levels, was able to determine his resting periods while walking with his walker and was compliant with walker use during his therapy session. There were no noted concerns of confusion/change in level of consciousness during the therapy session. An ED note, dated 9/23/19, documented Resident #231 presented to the ED at 1:22 PM via Emergency Medical Services (EMS). Resident #231's family said the resident fell and they found him lying on the ground, he had [MEDICAL CONDITION] type activity, and EMS was able to stand Resident #231 up, assist him to his chair, and he was able to initially converse with EMS. EMS reported Resident #231 had right sided weakness and drift (diminishing strength) and was dragging his right foot. Resident #231's Glasgow Coma Scale (the scoring system used to describe the level of consciousness in a person following a [MEDICAL CONDITION]), started to decline and EMS decided to intubate him (insert a tube into the throat for breathing). The family denied Resident #231 had a history of [REDACTED]. A subsequent ED note, dated 9/23/19, documented by the ED physician, stated Resident #231 arrived via ambulance with rapidly declining mental status after an unwitnessed fall and he was intubated in the field. Resident #231 was sent to CT (a computerized x-ray scan) from the ambulance where a large subdural hematoma (bleeding and increased pressure on the brain usually caused by severe head injuries which can be life-threatening) with midline shift (a shift of the brain past the midline) was found. It was determined the family members agreed with Resident #231's previous stated wishes for DNR/DNI (Do Not Resuscitate/Do Not Intubate) and the breathing tube was removed and he was monitored further in the ED. Resident #231 was discharged with the expectation of imminent demise. The facility did not provide supervision and interventions to prevent Resident #231 from having an unwitnessed fall with injury. 3. Resident #130 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #130's admission MDS assessment, dated 9/3/19, documented Resident #130 was severely cognitively impaired and required extensive assistance with two staff members for bed mobility and transfers. The assessment documented Resident #130 required extensive assistance with one staff member for ambulation. Resident #130's care plan, dated 8/27/19, documented Resident #130 was at risk for falls. The interventions were for staff to provide assistance with ADLs as needed, orient resident to his room, and have the call light within reach. An Incident and Accident Report, dated 8/27/19 at 11:55 PM, documented Resident #130 was sitting on his bed when he attempted to stand and lost his balance, and was lowered to the floor by the CN[NAME] There were no injuries noted. The CNA's witness statement documented Resident #130 was restless and kept pulling on his PEG tube (a flexible tube placed through the abdominal wall and into the stomach that allows nutrition, fluids and/or medications to be put directly in the stomach) and the CNA was attempting to redirect him. The interventions were to move Resident #130 closer to the nurse's station. An Incident and Accident Report, dated 8/28/19 at 5:26 AM, documented the CNAs heard a loud bump and found Resident #130 on the floor beside his bed with feces on his hands and bedside table. The report documented Resident #130 was being checked every 15 minutes all night, a second fall was expected. An Incident and Accident Report, dated 8/28/19 at 10:53 PM, documented Resident #130 was found lying on the floor with the bedside table tipped over and items from the bedside table were scattered on the floor next to his bed. The report documented Resident #130 was resistant of the nurse assessing him for injury and did not allow his vital signs to be checked. The report documented Resident #130 was moved to the 200 hall. Resident #130's care plan, dated 8/29/19, documented Resident #130 was to ambulate with therapy staff only, he required assistance with bed mobility and transfers with one staff member, and staff were to toilet Resident #130 every 2 hours. An Interdisciplinary Team (IDT) investigation note, dated 9/3/19, documented Resident #130 was moved into a different room closer to the nurse's station and he was encouraged to ask for assistance when transferring. The note documented fall mats were placed next to his bed as a new intervention. An Incident and Accident Report, dated 8/29/19 at 7:30 AM, documented Resident #130 was lying on the floor with a cut above his right eye. The immediate action taken was Resident #130 was placed on 1:1 supervision. An IDT investigation note, dated 9/3/19, documented new interventions for Resident #130 included having 1:1 supervision and his care plan was revised. The care plan was revised on 9/5/19, and stated 1:1 as ordered, after family departs for the day, have 1:1 in place with resident 1 hour prior to family departure. A Physical Therapy Discharge Summary Report, dated 10/10/19 at 2:31 PM, documented to continue Resident #130's 1:1 supervision for all mobility to decrease his risk for falls. A Physical Therapy Daily Summary Note, dated 10/10/19 at 4:25 PM, documented Resident #130 was impulsive, staff were to never leave him unattended, he attempted to stand and walk by himself, and he required 1:1 supervision 24 hours a day. A Care Plan Conference Note, dated 10/14/19, documented family, RCM #2, a therapy representative, the Director of Social Services, and LSW #1 were in attendance. The note documented Resident #130 needed 24/7 diligence for safety. A Nurse's Progress Note, dated 10/16/19 at 9:46 PM, documented Resident #130 required 1:1 supervision due to impulsive behaviors. A Fax Order Request/Notification Form for Resident #130, dated 10/17/19, documented it was okay to trial discontinuing 1:1 supervision and was signed by the P.[NAME] on 10/17/19. A Nurse's Progress Note, dated 10/19/19 at 8:44 PM, documented Resident #130 required 1:1 supervision due to frequent wandering and impaired gait. A Nurse's Progress Note, dated 10/20/19 at 8:53 PM, documented Resident #130 required 1:1 supervision due to frequent wandering and impaired gait. A Nurse's Progress Note, dated 10/21/19 at 9:56 PM, documented Resident #130 was agitated when family left the facility for the evening and became verbally and physically aggressive. The note documented Resident #130 was attempting to enter other residents' rooms and safety checks were initiated every 15 minutes. An Incident and Accident Report, dated 10/22/19 at 12:00 PM, documented Resident #130 wandered without assistance into a female resident's bathroom, while she was receiving toileting assistance by a CN[NAME] The report documented the CNA escorted Resident #130 to the dayroom. The physician was notified, and orders were received to resume 1:1 supervision. A Nurse's Progress Note, dated 10/22/19 at 12:04 PM, documented New orders noted to resume one on one sitter; discontinuation failed. The note documented the DON was notified of Resident #130 requiring 1:1 supervision. A Nurse's Progress Note, dated 10/22/19 at 12:55 PM, documented Resident #130 was usually a 1:1, but has been trialed to be independent with walking around facility. (Resident #130) inadvertently walked into another resident's room and opened bathroom door while resident was in there. The note documented E.D. #1 and the DON were aware of the event. A Nurse's Progress Note, dated 10/22/19 at 6:43 PM, documented Resident #130 had 1:1 supervision during the evening shift to prevent wandering into other residents' rooms, prevent falls, and he required one-person assistance with ambulation due to impaired gait. The 200 Hall Daily Assignment Schedule documented there were times and shifts when there was no 1:1 supervision assigned to Resident #130 as ordered by his provider. Examples include: * On 10/1/19, no 1:1 supervision assignment from 6:00 AM to 8:00 AM and 2:00 PM to 3:00 PM * On 10/2/19, no 1:1 supervision assignment from 6:00 AM to 7:00 AM * On 10/3/19, no 1:1 supervision assignment from 9:00 AM to 10:00 AM * On 10/4/19, no 1:1 supervision for assignment for day shift, evening shift, and night shift * On 10/8/19, the aide assigned for 1:1 supervision was at clinical * On 10/12/19, no 1:1 supervision assignment for day shift, evening shift, and night shift * On 10/13/19, no 1:1 supervision assignment for night shift * On 10/15/19, no 1:1 supervision assignment from 6:00 AM to 7:00 AM * On 10/15/19, no 1:1 supervision assignment from 6:00 AM to 7:00 AM * On 10/16/19, no 1:1 supervision assignment from 6:00 AM to 8:00 AM * On 10/22/19, no 1:1 supervision assignment for night shift * On 10/24/19, no 1:1 supervision assignment on evening shift * On 10/25/19, no 1:1 supervision assignment for day shift or night shift * On 10/27/19, no 1:1 supervision assignment for the day and evening shift On 10/27/19 at 12:30 PM, LPN #1 stated Resident #130 was not assigned to 1:1 supervision until after the survey team entered the facility. Resident #130 was sitting in the dayroom with the Activity Director assisting him with an activity. LPN #1 stated Resident #130 was required to have1:1 supervision 24/7 due to his impulsiveness, wandering, poor safety awareness, and impaired gait. LPN #1 stated Resident #130 was more often without 1:1 supervision than he was with one for the past month. On 10/27/19 at 2:30 PM, Resident #130 was observed in bed resting without 1:1 supervision. On 10/27/19 at 2:45 PM, E.D. #1 was standing outside of Resident #130's room. E.D. #1 stated he was Resident #130's 1:1 supervision. On 10/28/19 at 2:20 PM, CNA #2, the facility's nursing scheduler, was reclined in Resident #130's recliner looking at her phone, while he was sleeping. CNA #2 stated she assigned herself as the 1:1 supervision for Resident #130 because she was unable to fill the position with anyone else. CNA #2 stated she had to be in the area of Resident #130 because he was a high fall risk. On 10/28/19 at 3:17 PM, LPN #1 stated Resident #130 required 1:1 supervision due to wandering into other resident rooms, but most of the time Resident #130 was not assigned 1:1 supervision. LPN #1 stated Resident #130 did not have 1:1 supervision assigned to him currently and she was responsible to keep an eye on him while she was passing medications to other residents. LPN #1 stated it was impossible to keep Resident #130 safe without being with him at all times. On 10/28/19 at 3:25 PM, Resident #130's spouse stated when she visited the staff member assigned to Resident #130's 1:1 supervision would leave the room and she assisted him. Resident #130's spouse also stated if she was unable to provide personal care for Resident #130, she asked for assistance from the staff. The spouse stated Resident #130 needed 1:1 supervision 24/7 due to his impulsiveness and wandering. On 10/30/19 at 2:05 AM, E.D. #1 was standing outside of Resident #130's doorway and Resident #130 was sleeping in bed. E.D. #1 stated he was assigned as Resident #130's 1:1 supervision for the night shift from 10:00 PM to 6:00 AM. E.D. #1 stated he was not a CN[NAME] E.D. #1 stated he notified the CNA assigned to the hall to assist Resident #130 with personal cares. E.D. #1 stated he was there to assure Resident #130 did not wander into another resident's room. There was one CNA and one LPN assigned to 42 residents on the 200 hall for the night shift. On 10/30/19 at 3:05 AM, the BOM relieved E.D. #1 as Resident #130's 1:1 supervision. The BOM stated she was a CNA and was able to provide assistance for Resident #130. Resident #130 was in bed sleeping and the BOM was sitting in a chair close to the doorway. On 10/30/19 at 3:15 AM, E.D. #1 was standing outside Resident #130's doorway and stated he was back to provide 1:1 supervision for Resident #130. On 11/1/19 at 10:00 AM, the new scheduler stated he transferred from one of the sister facilities and was working on filling the holes in the schedule for Resident #130's 1:1 supervision for the evening shift. The 200 Hall Daily Assignment Sheet documented, Need Help!!! on the evening shift. On 11/2/19 at 7:20 PM, CNA #4 was sitting outside Resident #130's room assigned as his 1:1 supervision. CNA #4 stated she was instructed to assure Resident #130 did not fall or wander into other residents' rooms. Resident #130 was in bed sleeping. On 11/2/19 at 7:30 PM, CNA #4 was observed assisting Resident #130 to the bathroom. On 11/2/19 at 7:50 PM, CNA #4 was sitting next to Resident #130 on the side of his bed. Resident #130 was talking to CNA #4. On 11/3/19 at 10:30 AM, Sitter #1 was observed sitting outside of Resident #130's room while he was in bed sleeping. Sitter #1 stated she was not a CN[NAME] Resident #130 was awake and attempting to get out of bed and Sitter #1 did not see him getting up. Sitter #1 was told Resident #130 was getting out of bed. Sitter #1 assisted him walking by holding his left hand with her right hand with their fingers interlocked and her left hand was holding his left bicep. Resident #130 had an unsteady gait and Sitter #1 was leading him to walk forward, while his right foot was shuffling. Resident #130 stated he needed to use the bathroom. Sitter #1 led him to his bathroom and asked another sitter to find a CNA to provide cares for Resident #130. Sitter #1 stated she was unable to provide personal cares and did not know if Resident #130's bathroom had a call light to activate. Resident #130's bathroom did have a call light in his bathroom. On 11/5/19 at 9:32 AM, the DON stated Resident #130's trial of not having 1:1 supervision failed in less than a day. She said Resident #130 had an unsteady gait and wandered into other residents' rooms and he needed 24/7 supervision. On 11/5/19 at 11:05 AM, the P.[NAME] stated Resident #130 should not have been trialed without 1:1 supervision. The P.[NAME] stated she was instructed to discontinue the 1:1 supervision by E.D. #1, he told her the facility did not have enough staff to provide 1:1 supervision for Resident #130 and he instructed the P.[NAME] to discontinue the 1:1 supervision. The P.[NAME] stated Resident #130 required 1:1 supervision due to having an unsteady gait, he was at risk for falls, and he had been wandering in and out of other residents' rooms. The P.[NAME] stated after Resident #130 wandered into the female's bathroom while she was in there, she reinstated the 1:1 supervision and E.D. #1 was not happy. The P.[NAME] stated her priority was to keep all residents safe and she knew discontinuing the 1:1 supervision was a bad idea. On 11/5/19 at 2:08 PM, the P.[NAME] stated the 1:1 supervision needed to be a CNA to provide personal cares and assist with transfers and they needed to be within arm's reach of Resident #130. The facility did not provide ordered supervision and interventions to prevent Resident #130 from falling and wandering into other residents' rooms. 4. Resident #36 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #36's quarterly MDS assessment, dated 12/16/19, documented she had moderately impaired cognitive skills for daily decision making, required limited assistance of one staff person for bed mobility and transfers, extensive assistance of one staff member for toilet use, and did not walk. The MDS assessment stated Resident #36 had no falls since her prior MDS assessment. Resident #36's Fall Risk Evaluation forms completed from 12/27/18 through 9/3/19, documented a score of 10 or above was considered a high-risk for falls. Resident #36's was assessed as a high risk for falls as follows: - 12/27/18, score of 21 - 2/10/19, score of 16 - 5/10/19, score of 16 - 5/14/19, score of 13 - 5/28/19, score of 13 - 8/28/19, score of 13 - 9/3/19, score of 22 Resident #36's Order Summary Report, dated 11/7/19, included an order to check her every thirty minutes for safety, anticipate her needs such as toileting, call light within reach, and to keep her bed in a low position six times a day for fall risk. Resident #36's care plan documented she had a history of [REDACTED]. The care plan documented Resident #36 had a fall with injury on 5/28/19, resulting in a right ankle fracture and a fall resulting in a hematoma (blood filled bruise) on 9/2/19. The interventions for Resident #36 on the care plan included the following: * Fall risk assessment quarterly and after events * Wheelchair to be used for mobility, do not leave at beside * Referral for Physical Therapy/Occupational Therapy screen and treatment as needed * Provide frequent reminders to wait for assistance to transfer * Anti-roll back brakes on wheelchair * Check with resident in the morning to assist with morning ADLs and encourage resident to not attempt to do ADLs herself * Provide increased monitoring for falls during times of illness 2/10/19 * Re-educated (Resident #36) to call for help and wait for assistance prior to transferring for her safety 2/18/19 * Reminded (Resident #36) to wear non-skid footwear for transferring 2/28/19 * Ensure slippers are in reach as well as wheelchair to avoid her having to reach for them * If awake during the night, offer to toilet * Place (Resident #36) on one-hour safety checks, anticipate her needs such as toileting, drink/food, getting out of bed, and take her to meals * Call light within reach, bed in low position Resident #36's orders, care plan interventions, and the interventions listed on her Visual/Bedside Kardex Report, included the following discrepancies: * There were orders for frequent safety checks every 30 minutes, another intervention instructed CNAs to make one-hour safety checks, for care needs such as toileting, drink/food, getting out of bed, and taking Resident #36 to meals. * The interventions on the Kardex for bowel/bladder included offering and assisting Resident #36 with toileting before meals, after meals, at bedtime, and as needed. The care plan interventions stated to offer assistance to Resident #36 with toileting every two hours while awake (revised on 9/6/19), and if awake during the night, offering to assist her with toileting (revised on 9/4/19). Resident #36's progress notes documented she had 4 falls between 2/10/19 and 9/2/19, as follows: * A Nurse's Progress Note, dated 2/10/19 at 4:34 PM, documented Resident #36 was found in the bathroom laying on the floor next to the toilet and her wheelchair in a soiled brief. Resident #36 attempted to self-transfer to the toilet and lost her balance. Resident #36 complained of tenderness to her right hip. An assessment documented there were no abnormalities in voluntary movement/strength of either lower extremity, or abnormal findings. The nurse notified the physician and received orders to monitor and report back if Resident #36 had worsening pain to her right hip. The two interventions added to the care plan on 2/10/19, were to re-educate Resident #36, who has dementia, to call for help, wait for assistance prior to transferring, and remind Resident #36 to wear non-skid footwear for transferring. * A Nurse's Progress Note, dated 5/14/19 at 2:59 AM, documented Resident #36 was found on the floor laying on her back, parallel to her bed with her head at the head of the bed. Her wheelchair was pushed away to the side next to her. Resident #36 stated she rolled out of bed and denied trying to go to the bathroom. The progress note stated Resident #36 did not hurt herself. An assessment documented no injuries, and staff assisted Resident #36 back into bed. Neurological assessments were started, and the physician was notified. Resident #36's wheelchair was at her bedside, her care plan interventions were not followed. No changes or additions were made to Resident #36's care plan to prevent further falls. * A Nurse's Progress Note, dated 5/28/19 at 1:43 AM, documented staff were performing walking rounds at the end of the shift and were standing by Resident #36's room and heard her call out. The documentation stated upon investigation, Resident #36 was found sitting on her knees at the head of her bed up against her night stand. Her right arm was twisted behind her on the bed rail. The documentation stated staff slowly raised Resident #36 up to untwist her arm. An assessment of Resident #36's right arm documented normal range of motion (ROM) and Resident #36 denied having pain. A further physical assessment documented there were no problems found, all of Resident #36's joints had normal ROM, and she denied pain. The assessment also documented Resident #36 was then taken to the bathroom, and when she was assisted to bed and took off her shoes and socks, it was noted her right ankle was swollen and bent at a weird angle. At the time of the fall, it was noted Resident #36's call light was within reach and not turned on and she had shoes and socks on her feet. A Nurse's Progress Note, dated 5/28/19 at 3:18 PM, documented Resident #36 had a right ankle fracture, a soft cast was on the ankle, and it was elevated with ice applied. There were no new interventions added to the fall prevention care plan until 6/3/19. The interventions included placing Resident #36 on the Falling Leaves Program with no specific fall prevention measures documented. The plan also documented Resident #36 was placed on one-hour safety checks, and staff were to anticipate her needs such as toileting, drink/food, getting out of bed, and staff were to take her to meals. The plan also stated to keep Resident #36's call light within reach and keep her bed in low position. * A Nurse's Progress Note, dated 9/2/19 at 12:17 AM, documented she was called to Resident #36's room where she found her on the floor between her bed and her roommate's bed, laying on her right side. The nurse documented Resident #36 was able to move all extremities and denied pain. Staff assisted Resident #36 back to bed, and she asked for a bedpan. The nurse documented Resident #36 had a quarter-size hematoma/bruise to her right shoulder bone, and a small bump on her head. The nurse documented Resident #36 stated she did not remember hitting her head. Neurological assessments were initiated. The care plan intervention added on 9/6/19, instructed staff to toilet Resident #36 every two hours while awake, offer her a bedpan, and to educate staff to anticipate her needs. The interventions were not new or changed from the previous interventions. On 11/1/19 from 10:30 AM to 11:30 AM, Resident #36 was observed lying in bed on her back. The two CNAs on the unit conducting resident rounds did not enter Resident #36's room or check on her needs every 30 minutes as ordered. On 11/7/19 at 1:30 PM, RCM #1 stated Resident #36 fell in her room and sustained a fracture to her right ankle on 5/28/19. RCM #1 stated for residents who were high-risk for falls, she expected staff to check on the resident frequently for supervision and to anticipate and assist with their care needs. The RCM #1 stated Resident #36 had every 30-minute checks and then every one-hour checks ordered after her fall, but both the 30-minute and one-hour checks were discontinued. On 11/8/19 at 9:35 AM, the DON stated after each fall staff should reassess residents to determine the root cause of the fall and have a therapy evaluation for rehabilitation or for the Restorative Nurse Aide (RNA) program, and for other resident-specific interventions appropriate to help prevent future falls. The facility did not follow care plan interventions, physician orders, or implement new interventions to prevent Resident #36 from falling. 5. Resident #72 was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS admission assessment, dated 10/9/19(TRUNCATED)

Based on observation, policy review, review of grievances, and interviews with residents and staff, it was determined the facility failed to provide services that maintained residents' highest practicable level of well-being for 40 out of 40 residents (#4, #7, #8, #13, #14, #17, #18, #19, #20, #23, #24, #25, #28, #31, #32, #35, #36, #38, #46, #49, #53, #54, #57, #59, #61, #62, #65, #72, #75, #130, #131, #134, #180, #231, #333, #380, #430, #4311, #480, and #481) who were reviewed, and affected the other 57 residents in the facility. The administration failed to act when they had knowledge of issues and concerns pertaining to the receipt of appropriate care and services and lack of sufficient staff. Findings include: The facility's policy for Administrative Responsibility, dated [DATE], stated the E.D. was responsible for supervision and overall implementation of facility policies, with input from consultants, medical staff, and department staff. The policy also stated The Executive Director will be responsible for all implications of the facility operation as it effects the residents, staff, families, and community. The responsibilities and duties of the E.D. included: - Managing the ongoing functions within the facility. - Assuring the public information describing the facility's services was accurate and fully descriptive. - Ensuring each resident's right to fair and equal treatment, self-determination, individuality, privacy, property and civil rights, including the right to file a complaint, was strictly enforced. - Implementing established policies and procedures to remain in compliance with required laws, regulations, and guidelines. - Evaluating and implementing recommendation from committees within the facility. This policy was not followed. Administration was aware of the issues and concerns with resident care and did not act to ensure residents attained and/or maintained physical, mental, and psychosocial well-being. Examples include: 1. On [DATE] at 3:50 PM, E.D. #1 said the facility was facing a staffing crunch. E.D. #1 said at times a shower aide was pulled from giving showers to work on the floor, but now they were catching up on showers. E.D. #1 said the facility needed CNAs and had not been successful in finding more CNAs. E.D. #1 said evening shift was difficult to cover, so they used agency staff. He said there were issues with the facility's staffing coordinator, so a new staffing coordinator was being brought on. E.D. #1 said overall the residents' care needed to be better, and other issues he was aware of included falls and wounds. E.D. #1 said the facility did not have a wound team or wound nurse at that time. E.D. #1 said call light response times and showers were also a concern, but the facility was not able to get more help due to a nationwide shortage of medical staff. E.D. #1 said when he received grievance cards, he gave a copy to the department head and they were to address the grievance and return the grievance card back to him. E.D. #1 said the RCMs were to come up with effective interventions regarding falls and accidents. E.D. #1 said he was aware of an RN working in the facility who was not licensed in Idaho, and she was kept from working on the floor until her license was good, but the decision was made outside of his knowledge to let her work on the floor one shift without an appropriate license. On [DATE] at 8:47 AM, E.D. #1 said the residents were concerned with the amount of agency staff in the facility, and residents felt the regular staff knew them better. On [DATE] at 12:08 PM, the Medical Director stated the facility needed continuity of care and not a different nurse each day doing something differently or who does not have time to do the wound care. He said residents do not get the care they deserve. The Medical Director stated he talked to the DON and E.D. #1 on several occasions, as well as during QA (Quality Assurance) meetings to stop admissions until more staff was available to provide wound care and suggested an in house wound team to manage the wounds in the facility. He stated he has not received a response. On [DATE] at 4:15 PM, the P.[NAME] stated she notified E.D. #1 and the DON provider orders were not being processed in a timely manner. On [DATE] at 11:17 AM, the P.[NAME] said in (MONTH) 2019 the E.D. separated from the facility and things got worse. The P.[NAME] said the new E.D. (E.D. #1) requested only positive attitudes from staff and would fire those who complained. Staff were interviewed and stated there was not sufficient staff to provide the cares required and to meet the needs of the residents. - On [DATE] at 11:25 AM, CNA #12 stated she had worked at the facility for two years and was transferred to work in Activities for the past six months. CNA #12 stated that today was not her normal shift; she was held over due to short staffing. CNA #12 stated the facility was short of staff for a while now. When asked about how this staff shortage affected resident care, CNA #12 stated, You'd have to ask management about that. When asked how it affected her ability provide care for her residents, CNA #12 stated, You'll have to talk with management about any staffing issues. - On [DATE] at 2:53 PM, CNA #3 said a lot of staff recently quit, resulting in use of agency staff who were unfamiliar with the residents. CNA #3 said E.D. #1 was notified of the staffing concerns, and he did not want to hear it. CNA #3 said during the previous night there were 2 CNAs working on her hall until 5:30 AM, and when both aides were assisting a resident at the same time there was nobody to watch the floor. CNA #3 also said at times there was only 1 CNA on the 300 hall. CNA #3 said she brought her concerns to the DON and was told to work short with a smile. CNA #3 said resident care suffered due to lack of staff. - On [DATE] at 4:52 PM, the DON said the facility had some struggles with staffing. - On [DATE] at 2:10 AM, CNA #11 stated she was assigned to work at the facility the past month. CNA #11 stated the facility did not provide her with any training related to its policies and procedures, or where certain items, like the automatic external defibrillators, were located or with instructions on how to use the overhead paging system. - On [DATE] at 2:30 AM, CNA #9 stated she was hired by the facility four to five months ago, and that the first night she worked, I was thrown to the floor because an agency CNA did not show up for work. CNA #9 stated that she then had three to five days training with two of the facility's experienced CNAs before working her shift independently. - On [DATE] at 1:15 PM, RN #4 stated the facility had not provided CPR or code training since the departure of the previous E.D. in (MONTH) 2019. RN #4 added that the facility did not provide agency staff orientation training specific to the building and residents. RN #4 stated There is a book at each nurses' station that includes information on the agency staffs' responsibilities, but that's all. During an observation on [DATE] at 2:05 AM, E.D. #1 was standing outside of Resident #130's doorway and Resident #130 was sleeping in bed. E.D. #1 stated he was assigned as Resident #130's 1:1 supervision for the night shift from 10:00 PM to 6:00 AM. E.D. #1 stated he was not a CN[NAME] E.D. #1 stated he notified the CNA assigned to the hall to assist Resident #130 with personal cares. E.D. #1 stated he was there to assure Resident #130 did not wander into another resident's room. There was one CNA and one LPN assigned to 42 residents on the 200 hall for the night shift. 2. The facility's Grievance Procedures and Concern and Comment Program, effective date [DATE], documented the policies and procedures, including: * The Social Services staff and/or the E.D. was responsible for the following: - Maintaining a recordkeeping system of all complaints reported via Concern & Comment Program or any other means of reporting that included the steps taken to investigate the grievance and a statement as to whether the grievance was confirmed or not confirmed. * Administrative staff were responsible for the following: - The appointed manager would contact the concerned party within 24 hours, to share the status of the investigation and resolution. * E.D. and/or Designee were responsible for the following: - Ensuring that all grievances and Concern & Comment Reports were reviewed and addressed in a timely and appropriate manner and that concerned individuals felt that some type of resolution had been communicated, achieved and maintained. - Collaborating with the interdisciplinary team to identify and address repeated concerns from residents and families. The completed Concern & Comment Forms, known as the blue cards, stated, A facility manager will contact you as soon as possible to discuss the concern, and any subsequent investigation and measures to resolve the concern. The back side of the card with the facility response included space to write the name of the person designated to investigate and follow-up with the concern, the date/time the concerned party was initially contacted, investigation findings, actions taken to resolve/respond to the concern, the date/time the findings/action plan was shared with the concerned party, and the concerned party's response to the action outcome, and space for the E.D.'s signature and date. The Resident Council filed grievances regarding call light wait times as follows: - The blue card, dated [DATE], documented the grievance was filed on behalf of the Resident Council, and described the concern as residents feel call lights are getting to be slower lately, and they reported the concern to a staff member. The facility documented the person designated to investigate/follow-up with the concern was the MDS Coordinator, and investigation findings were: Have received multiple C/O (complaints) call light wait times; will address in QAPI [DATE]. Actions taken were documented as: Audit completed, we are addressing the call light response time, Angel Rounds (implemented). Date findings/action plan shared with the concerned party was documented as: next Resident Council meeting. The document was signed by E.D. #1 on [DATE]. - The blue card, dated [DATE], documented the grievance was filed on behalf of the Resident Council, and described the concern as: (Resident Council) would like us to do our audits at off times, like during meals and after meals when residents want to lay down, to show us just how long they really have to wait for help. It was documented the complaint was reported to a staff member. The facility documented the person designated to investigate/follow-up with the concern was the MDS Coordinator, and investigation findings were: Talked with department heads about doing call light audit with PM Manager. Actions Taken: See above. Date findings/action plan was shared with concerned party documented as the next Resident Council meeting. The document was signed by E.D. #1 on [DATE]. - The blue card, dated [DATE], documented the grievance was filed on behalf of the Resident Council, provided resident name as 100 and 200 Hall, and described the concern as: call lights are still slow to answer, and that the concern was reported to a staff member. The facility documented the person designated to investigate/follow-up with the concern was the MDS Coordinator. The blue card did not document a date/time of initial contact with the concerned party (Resident Council President) and the investigation findings were: Work in progress, this needs to be all team members, See QAPI. Actions taken were documented as: Off hour call light audits continuing with PM Managers. The date the action was shared with the concerned parties and their response was not documented. The document was signed by E.D. #1 without a date. Two Comment and Concern blue cards, dated [DATE], were completed by Resident #61 regarding lack of staff assistance. On one she wrote: I have never been treated so poorly. The last two nights I had my call light on for more than two hours without any assistance. I went out to the (200 hall) nurse's station and no one could be found. Is anyone even working here anymore? I even called the facility and the phone rang 25 times and no answer. She wrote on the blue card that she reported the concerns to two nurses on the 200 Hall. There was no facility response included on the card copy. On Resident #61's second blue card, dated [DATE], she wrote: We are constantly denied a shower. It has been a week this time and has been as many as ,[DATE] days. Hygiene is just as important to my healthcare. I am disappointed in the overall care I have gotten during my stay this time. I have always requested Post Falls Life Care. She wrote she reported the concern to two nurses on the 200 Hall. There was no facility response included on the card copy. On [DATE] at 10:16 AM, the Resident Council meeting attendees had these comments regarding grievances: Resident #32 said They do not respond to the blue cards. Resident #61 said she gave (blue cards) to the CFO on [DATE]. I had not heard back. There is no response if the administration doesn't respond. Resident #333 said I was never made aware of where to file my concerns/complaints. On [DATE] at 1:38 PM, regarding the grievance procedure, Resident #61 said people were now reluctant to complete a blue card - residents were turning in blue cards but when nothing happened, no action was taken, they quit filing them. Resident #61 said she filed two grievances on [DATE] regarding her inability to get a response when she sought assistance and lengthy delays between showers. Resident #61 said she completed two blue cards, received no answers, and no explanation was provided to her. Resident #61 said E.D. #1 fired staff who expressed concerns, he just wanted it to be happy. 3. Please refer to F725 as it related to lack of sufficient staff to meet residents' needs, placing residents in immediate jeopardy. 4. Please refer to F600 as it related to failure to ensure residents are free from abuse, placing residents in immediate jeopardy. 5. Please refer to F686 as it related to failure to provide treatment and services to prevent and heal pressure ulcers, placing residents in immediate jeopardy. 6. Please refer to F689 as it related to failure to provide 1:1 supervision, resulting in falls with injury, wandering into other residents' rooms, and elopement, placing residents in immediate jeopardy. 7. Please refer to F677 as it related to failure to provide bathing and showers to meet the residents' needs. 8. Please refer to F684 as it related to failure to provide care and services in a manner which enhanced and promoted each resident's highest practicable physical, mental, and psychosocial health and well-being.

Based on observation, record review, policy review, review of grievances, review of I&A Reports, review of staffing schedules, review of Quality Assessment and Performance Improvement (QAPI) meeting minutes, and interviews with residents and staff, it was determined the facility failed to ensure the QAPI program was effectively implemented. This failure directly impacted 40 out of 40 residents (#4, #7, #8, #13, #14, #17, #18, #19, #20, #23, #24, #25, #28, #31, #32, #35, #36, #38, #46, #49, #53, #54, #57, #59, #61, #62, #65, #72, #75, #130, #131, #134, #180, #231, #333, #380, #430, #4311, #480, and #481) who were reviewed, and affected the other 57 residents in the facility. As a result, the facility failed to implement improvement actions to resolve identified patient care concerns necessary to ensure each resident's well-being and safety were maintained. Findings include: The facility's QAPI Plan, dated 11/15/17, stated The decision making within the facility will be driven by quality assurance performance improvement principles. These decisions will assist in promoting quality of care and quality of life of residents. The QAPI Plan was signed by a previous E.D. The facility's QAPI Meeting Minutes from 2/21/19 through 10/4/19 were reviewed. The meeting minutes identified concerns with an increase in grievances, call light issues, skin assessments, increase in incident reports, and facility staffing, without documented corrective action being taken to resolve the issues, as follows: 1. The facility's QAPI Plan, dated 11/15/17, stated The QAPI program focuses on safety while striving to achieve successful clinical interventions and outcomes. The QAPI Meeting Minutes, dated 2/21/19, documented an increase in reportable incidents. There was no action plan to address the reportable incidents. The QAPI Meeting Minutes, dated 3/13/19, documented there was a significant increase in incident reports and state reportable incidents. It was documented the facility received previous citations related to abuse/neglect and thorough investigations. There was no action plan to address the increase in incident reports and state reportable incidents The QAPI Meeting Minutes, dated 7/9/19 and 10/4/19 did not include information related to resident abuse, neglect or reportable incidents. Please refer to F600 where an Immediate Jeopardy was identified as it relates to the facility's failure to ensure 8 residents (Residents #4, #7, #32, #35, #61, #62, #333 and #480) were free from verbal abuse and staff intimidation when reporting verbal abuse. 2. The facility's QAPI Plan, dated 11/15/17, documented the QAPI committee had the responsibility of planning, designing, implementing, and coordinating care and services for residents. The QAPI Meeting Minutes, dated 2/21/19, documented an increase in skin issues. There was no action plan to address the increase in skin issues. The QAPI Meeting Minutes, dated 3/13/19, documented it continued to be necessary to provide frequent reminders to perform skin assessments. There was no action plan to address the need to remind staff to perform skin assessments. The QAPI Meeting Minutes, dated 7/9/19 and 10/4/19, did not include information related to skin issues. Please refer to F686 where an Immediate Jeopardy was identified as it relates to the facility's failure to ensure 4 residents (#13, #36, #131, and #134) received treatment and services to prevent and heal pressure ulcers. 3. The facility's QAPI Plan, dated 11/15/17, documented the QAPI committee chose associates to .participate in performance improvement projects. The committee will follow the progress, provide any necessary input and will ensure that the staff members have the appropriate resources. The QAPI Meeting Minutes, dated 2/21/19, documented the facility continued to struggle with 24-hour RN coverage for night shift. Agency staff were utilized due to the facility's difficulty in meeting staffing needs. There was an increase in grievances, and call lights were noted as an issue. The facility continued to rely on agency staff in an attempt to meet staffing needs. There was no documented action plan to address the facility's staffing needs, the residents' grievances, and concerns regarding call lights. The QAPI Meeting Minutes, dated 3/13/19, documented there were 24 grievances for the month, and the greatest trend was care complaints related to call light response times. It was documented the facility received a previous citation related to RN coverage, and state requirements included 24-hour RN coverage for a census of 90 or greater. There was no action plan to address the residents' complaints, call light response times, or the facility's staffing needs. The QAPI Meeting Minutes, dated 7/9/19, documented Resident Council trends/needs included call lights. There was no action plan to address the Resident Council issues regarding call light response times or staffing needs. The QAPI Meeting Minutes, dated 10/4/19, documented staff missed lunches, causing overtime. There was no action plan to address the facility's staffing needs. Please refer to F725 where an Immediate Jeopardy was identified as it relates to the facility's failure to ensure there was sufficient staff to prevent adverse outcomes including supervision, ADL needs, medication administration, and answer call lights in a timely manner for residents, for 26 residents (#4, #7, #13, #14, #17, #19, #20, #23, #24, #25, #32, #35, #46, #49, #53, #59, #61, #62, #65, #72, #130, #131, #180, #333, #380, and #480). 4. The facility's QAPI Plan, dated 11/15/17, documented the QAPI program focused on safety while aiming to achieve successful clinical interventions and outcomes. The QAPI Meeting Minutes from 2/21/19 to 10/4/19 did not document discussion of 1:1 supervision, falls, wandering, or elopement. There was no action plan to address resident safety. Please refer to F689 where an Immediate Jeopardy was identified as it relates to the facility's failure to provide 1:1 supervision, resulting in falls with injury, wandering into other residents' rooms, and elopement, for 5 residents (#8, #36, #130, #172, and #231). On 10/30/19 at 3:50 PM, E.D. #1 said the facility was facing a staffing crunch. E.D. #1 said at times a shower aide was pulled from giving showers to work on the floor, but now they were catching up on showers. E.D. #1 said the facility needed CNAs and had not been successful in finding more CNAs. E.D. #1 said evening shift was difficult to cover, so they used agency staff. He said there were issues with the facility's staffing coordinator, so a new staffing coordinator was being brought on. E.D. #1 said overall the care needed to be better, and other issues he was aware of included falls and wounds. E.D. #1 said the facility did not have a wound team or wound nurse at that time. E.D. #1 said call light response times and showers were also a concern, but the facility was not able to get more help due to a nationwide shortage of medical staff. He said when he received grievance cards, he gave a copy to the department head and they were to address the grievance and return the grievance back to him. E.D. #1 said the RCMs were to come up with effective interventions regarding falls and accidents. He said he was aware of an RN who did not have a license for Idaho, and she was kept from working on the floor until her license was good, but the decision was made outside of his knowledge to let her work on the floor one shift without an appropriate license. On 11/8/19 at 9:13 AM, E.D. #2 said the latest QAPI meeting was in October, and she was guessing there were previous issues that were not worked through QAPI because there were still problems identified during the current survey. E.D. #2 said the facility was aware of areas that needed improvement, including accidents, medications, skin issues, comments and concerns, abuse, and grievances. E.D. #2 said the QAPI meeting notes documented staffing was addressed in October, and there were activities addressing resident council concerns, [MEDICAL CONDITION] medication management, and infection control. On 11/14/19 at 2:30 PM, E.D. #2 said there was no additional information for the QAPI Meeting Minutes from 2/21/19 through 10/4/19. The facility failed to ensure an effective QAPI program was implemented and maintained to address identified priorities. The facility failed to identify issues and concerns which were likely to cause serious harm, impairment, or death through its QAPI program.

Based on observation, resident and staff interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were provided care and services in a manner which enhanced and promoted each resident's highest practicable physical, mental, and psychosocial health and well-being for 6 of 32 residents (Residents #18, #61, #65, #131 #430, and #431) reviewed for quality of care. Specifically: * Resident #431, with a known history of cardiovascular disease, was harmed when the facility failed to ensure her care plan included interventions related to her cardiac instability and conduct a thorough physical assessment during cardiovascular events. Resident #431 subsequently underwent unsuccessful CPR. * Resident #430 was harmed when the facility failed to ensure the administration of oxygen as ordered, and he subsequently underwent unsuccessful CPR. * Resident #61 was at risk of harm when the facility failed ensure insulin was administered as ordered, wound treatments were performed as ordered, and accurate wound assessments were completed. * Resident #131 was at risk of harm when the facility failed to perform wound dressing changes as ordered, and erroneously discontinued his a peripherally inserted central catheter (PICC) intravenous access device. * Resident #65 was at risk of harm when wound dressing changes were not completed as ordered and per accepted standards of practice. * Resident #18 was at risk of harm when the facility failed to administer medications per accepted standards of practice for Resident #18. Findings include: 1. Resident #431 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The admission MDS assessment, dated [DATE], documented Resident #431 was cognitively intact and required extensive assistance of 1 to 2 or more staff members for her ADLs except for eating. She received oxygen prior to admission and while a resident of the facility. Resident #431's undated comprehensive care plan failed to include information and interventions related to her [DIAGNOSES REDACTED]. The care plan did not include emergency assessments and interventions for acute cardiac events, or the parameters for notifying the physician in the event of acute chest pain or other symptoms of an acute cardiac event. Resident #431's Progress Notes from [DATE] through [DATE] documented the following: - On [DATE] at 2:28 PM, RCM #2 documented, the administration of, [MEDICATION NAME] Tablet Sublingual (a medication that dilates the arteries of the heart to improve blood flow and oxygen to the heart muscle) 0.4 mg .1 tablet sublingually (under the tongue) every 5 minutes as needed for Chest Pain x 3 doses. If no relief, call MD. - On [DATE] at 3:55 PM, RCM #2 documented Resident #431 coded (term used when a person's the heart and/or breathing stops) at approximately 3:00 PM and CPR was initiated. The note also documented no shock (electrical impulse method to restart the heart) was advised during entire episode, and EMS was called at approximately 3:02 PM. RCM #2 also documented she notified the DON and E.D. #1 and left them messages. The Nurse Manager was notified at 3:45 PM. - On [DATE] at 5:38 PM, RCM #2 documented the administration of, [MEDICATION NAME] Tablet Sublingual 0.4 mg .1 tablet sublingually every 5 minutes as needed for Chest Pain x 3 doses. If no relief, call MD. PRN (as needed). The medication was documented as: Effective. - On [DATE] at 6:20 PM, LPN #9 documented, At approximately 3 pm resident's family came to the nurses (sic) station and stated that she had stopped breathing. We had been putting a packet together to send her to the ER, so this writer and CNA .went down to the room and started CPR. On our way down, I directed a CNA to call 911 and a second to obtain the crash cart (a supply cart with emergency and lifesaving medications and supplies). CPR was started .AED (automated external defibrillator - a device that delivers an electric shock through the chest to the heart) was placed, and no shock was advised during the session. CPR was not stopped until Ambulance staff and EMT's took over. EMT's preformed (sic) CPR for another 30 minutes or so. Resident was intubated (breathing tube placed) and .IV was started. (Two) bags of fluid and 5 rounds of [MEDICATION NAME] (a cardiac medication) were administered. See next note for continued information. - On [DATE] at 4:01 AM, LPN #9 documented, At (4:05 PM), by family and EMT/ER MD, it was decided that further CPR would not bring about a positive result. CPR was stopped. - On [DATE] at 12:59 PM, RCM #2 documented a late entry note for [DATE], which stated, Around 0930 (9:30 AM) this LN (Licensed Nurse) was alerted by CNA that resident (was) turning grey, upon entering room resident was not turning grey encouraged to breath (sic) through nose instead of mouth, auscultated lungs found clear bilateral throughout. Continued to monitor throughout day. (At) Approx. (2:15 PM) (the resident's) husband approached this LN about resident having mid lower sternum (chest area) upper mid abd (abdominal) pain, administered nitro ([MEDICATION NAME]) at (2:28 PM - 13 minutes after the notification of the resident's complaint of chest pain), (at) (2:35 PM) reevaluated resident asked resident directly if still in pain, denies pain at that time. (At) Approx. (2:50 PM) husband requested for resident be transported to (the) ER, inquired on what he saw different, stated resident just is not being herself. Around (2:55 PM) started paperwork for transfer to ER. Around (3:00 PM) family approached and stated resident not breathing. (LPN #9) stated she would take a look, seconds later heard her state to bring (the) Crash Cart. This LN instructed (CNA #15) to call 911 and this LN took crash cart to resident room where CPR was already initiated. This LN and (LPN #9) started to use Ambu-bag (a device used to assist breathing) since unable to tilt head d/t (due to) spinal fusion and that jaw was extremely still that required more force for a jaw thrust. AED was attached and resident analyzed to find no shock advised, CPR continued .until EMS arrived who took over. The facility's policy titled, Changes in Resident's Condition or Status, with a review date of [DATE], stated, This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status .In a long-term care setting, it's important to identify and address any change in a resident's status from baseline .Upon recognition of a potentially life-threatening condition or significant change in status, you must communicate with other health care providers to meet the resident's needs .Chronic diseases and conditions can lead to potentially life-threatening conditions. It's your responsibility to be informed of the resident's status and to monitor for changes .At a minimum, you should assess the resident by: · reviewing the medical record · asking how the resident feels and what symptoms are present · obtaining vital signs · observing the resident's overall condition, including function and cognition · exploring complaints. (You are) responsible for communicating a resident's change in status, including the assessment findings, to the practitioner. Most cases of cardiopulmonary arrest are preceded by clinical signs of deterioration that the practitioner could recognize and treat quickly. During an interview on [DATE] at 2:50 PM, RCM #2 stated he was told by the CNA that Resident #431 was turning grey. RCM #2 stated, I asked the CNA to obtain the resident's vital signs and I checked her pulse ox (oxygen level) and it was normal. I checked her lung sounds and asked if she was having pain, and she stated no pain. She did not have a grey cast to her skin. RCM #2 stated he did not notify the physician of the event but continued to monitor the resident. RCM #2 stated he did not know the results of Resident #431's vital signs taken by the CN[NAME] RCM #2 stated that he performed additional assessments of Resident #431 that morning but did not document the assessments. He stated Resident #431 had no nausea or vomiting and was not sweating. RCM #2 stated, At 2:15 PM, the resident's husband came to the desk and said the resident was complaining of 'sternal pain.' I went down to the room and asked her about the pain, and she said she didn't have any pain. At 2:50 PM, the family wanted her sent to the ER, so I started getting the paperwork ready. (LPN #9) then checked on the resident and she was unresponsive. A code was called, but she couldn't be revived. I was in the process of notifying the doctor to send her out to the ER for evaluation. She had an extensive cardiac history. During an interview on [DATE] at 9:35 AM, the DON stated that Resident #431's cardiac condition should have been included in her care plan, and that she would have expected the nurse to conduct a comprehensive physical assessment when the resident reported symptoms. The DON also stated if an assessment was positive for acute symptoms, the nurse should notify the physician for treatment orders. 2. Resident #430 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #430's Physician order [REDACTED]. The admission MDS assessment, dated [DATE], documented Resident #430 was moderately cognitively impaired and required extensive assistance of 2 or more staff members for bed mobility and transfers, and received oxygen prior to admission and while a resident at the facility. Resident #430's undated comprehensive care plan, failed to include information and interventions related to his [DIAGNOSES REDACTED]. An SNF Initial Physician Evaluation completed by the P.[NAME] on [DATE] at 1:15 PM, stated Resident #430 denied, .cp (chest pain), sob (shortness of breath), (or) n/v (nausea/vomiting) The P.[NAME] also documented Resident #430's lung assessment as, .no dyspnea (difficulty breathing) .good air movement .decreased breath sounds and his cardiovascular assessment as, RRR (regular rate and rhythm) .pulses .normal throughout. The P.[NAME] documented Resident #430 had oxygen on at 2 liters per minute. Resident #430's physician order [REDACTED]. A Mayo Clinic website article, dated [DATE], accessed on [DATE], documented: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Resident #430's Progress Notes for [DATE] through [DATE], documented on [DATE] at 10:36 PM, Resident #430 stated he fell and had a [MEDICAL CONDITION]. Resident #430's oxygen tubing was off to the side of the bed. His oxygen saturation level registered 78%. After five minutes on oxygen, (Resident #430) denied chest pain and waived away questions so that he could return to sleep. Resident with a pattern of tossing off his nasal cannula and was checked on frequently for the remainder of the evening. Resident #430's Progress Notes documented he had 2 more falls, 1 on [DATE] (documented as a Late Entry note) with no injuries, and the other on [DATE] at 12:13 PM, after which, he experienced severe back pain. The nurse documented Resident #430's oxygen saturation level was 75% with a respiratory rate of 24 breaths per minute. The oxygen flow rate was not documented. However, Resident #430's oxygen was, increased to 4L/min and his oxygen saturation level increased to 95%. A Cleveland Clinic website article, last reviewed on [DATE], accessed on [DATE], documented: The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. None of the Progress Notes reviewed, other than on [DATE] at 10:36 PM, documented evidence Resident #430 tossed off his oxygen tubing. The Progress Notes continued until [DATE] at 4:17 PM, when the RN documented the administration of an intravenous antibiotic. The next Progress Note, dated [DATE] at 1:55 PM, stated Resident #430 had passed away. The medical record failed to reflect the events leading up to the staffs' discovery of Resident #430 on the floor in his room without a pulse, and with no oxygen worn. A Facility Reported Incident concerning Resident #430, dated [DATE], stated Resident #430 . was found on the floor, face down with no vital signs. CPR was initiated but resident was not (able to be) resuscitated. The report stated night shift CNA #9 reported that while performing the last rounds of her shift, she checked on Resident #430 at 5:05 AM and found him on the floor next to the bed with no pulse. CNA #9 summoned and received assistance from staff that included fell ow night shift CNA #10 and the oncoming day shift nurse RN #4. Staff performed CPR while a call to 911 was placed with EMS responding. Resident #430 was pronounced dead at 5:40 AM. During an interview with CNA #9 on [DATE] at 2:30 AM, the CNA stated Resident #430 was his usual self during the night shift ([DATE] to [DATE]). CNA #9 stated she checked on him at 4:30 AM, and he wanted his remote control, his covers adjusted, and the door closed to his room. CNA #9 stated around 5:05 AM, during her final rounds for that night, she found Resident #430 face down on the floor beside his bed. The CNA stated she shook Resident #430's shoulder and called his name with no response. She then checked for a pulse and found none. CNA #9 stated she went to the nurses' station for the charge nurse, LPN #8, and to get CNA #10. They went to Resident #430's room, but LPN #8 did not stay and start CPR. LPN #8 went back to the nurses' station to call the Code overhead but did not know how to use the overhead paging system. Another nurse from a different hallway came to Resident #430's room and started CPR with CNA #10. CNA #9 stated she went after the crash cart. When EMS arrived, they took over the code, but were not able to bring back Resident #430. After completion of the code and Resident #430 was pronounced deceased , she and CNA #10 did the post-mortem (after death) care for Resident #430. It was during this time that CNA #10 noted and told her that Resident #430's oxygen flowmeter was turned off at the wall. CNA #9 stated she did not check Resident #430's oxygen saturation level during her shift. CNA #9 stated the facility later provided oxygen administration training to her and other staff. During an interview on [DATE] at 1:15 PM, RN #4 stated when she entered Resident #430's room during CPR, she saw the resident's oxygen tubing was, .coiled around the oxygen flow meter on the wall and the O2 flow meter was turned off. RN #4 stated the agency nurse responsible for Resident #430's care the previous night, LPN #8, did not address the code situation and death of Resident #430 during the shift-to-shift report that morning. RN #4 stated the facility had not provided CPR or code training since the departure of the previous E.D. in (MONTH) 2019. RN #4 added that the facility did not provide agency staff orientation training specific to the building and residents. RN #4 stated There is a book at each nurses' station that includes information on the agency staffs' responsibilities, but that's all. During an interview on [DATE] at 10:30 AM, CNA #10 stated she worked her night shift on the hall with CNA #9, the same hall with Resident #430's room. CNA #10 stated that CNA #9 came up to her and told her that Resident #430 was on the floor in his room face down and he had no pulse. CNA #10 stated when she entered Resident #430's room, he did not have his oxygen tubing on. She and a nurse started CPR. EMS took over the code when they arrived but were unable to revive Resident #430. After the code and Resident #430 was pronounced dead, she and CNA #9 performed the resident's post-mortem care. CNA #10 stated this was when she noticed that Resident #430's oxygen flow meter on the wall was turned off. CNA #10 stated that no one in the room during or after the code touched the flow meter to turn off the oxygen, It was already off. During an interview on [DATE] at 9:35 AM, the DON stated that Resident #430's oxygen use should have been on his care plan with interventions clearly stated. 3. According to Potter-Perry, Stockert-Hall Fundamentals of Nursing, Eighth Edition (2013): Administering medications to patients requires knowledge and a set of skills that are unique to a nurse. You must first assess that the medication ordered is the correct medication. Do not assume that all medications that are in the patient's 'drawer' or pillbox are to be given to him or her. Resident #18's Admission Record documented she was admitted on [DATE]. Her [DIAGNOSES REDACTED]. bladder control) , chronic pain, adult failure to thrive, diabetes, [MEDICAL CONDITION] and [MEDICAL CONDITION] ([MEDICAL CONDITION] is paralysis of one side of the body; [MEDICAL CONDITION] is a slight paralysis or weakness on one side of the body) , depression and hypertension. On [DATE], at 10:15 AM, RN #3 was observed outside of Resident #18's room in the hallway at the medication cart. RN #3 opened the top drawer of the medication cart and there was a plastic medicine cup with eight medications. At the time of the observation, RN #3 showed she had dispensed the eight medications, and then realized Resident #18 was in the bathroom. RN #3 placed the medications in the medication cart. She stated the medications were for Resident #18. RN #3 identified the medications as: [MEDICATION NAME] 20mg, Aspirin 81mg, [MEDICATION NAME] ER 500mg, [MEDICATION NAME] 1000mg, Meloxican 7.5mg, [MEDICATION NAME] 25mg, multivitamin and D-Menose Powder in water. RN #1 approached the medicine cart and stated she would administer the medications since RN #3 was visibly upset. RN #3 left the area and RN #1 began dispensing the remainder of Resident #18's medication into the plastic medication cup with the eight medications that she had not dispensed. She began preparing additional medications into the same medication cup RN #3 had been using. RN #1 added Omega 3 1 gram 2 tabs, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 100 mg 3 caps, potassium chloride 20meq, [MEDICATION NAME], vitamin B 5000, [MEDICATION NAME] ER 150 mg and UTI Stat 30 ml was added to the D-Menose that RN #3 stated she had mixed in water. During an interview with RN #1 on [DATE] at 11:03 AM, she verified she gave medications to Resident #18 that were dispensed by RN #3. A policy was requested, and on [DATE] at 10:00 AM, the DON said there was no medication policy specific to this deficient practice. 4. Resident #61 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #61's records from the hospital, dated [DATE], documented Resident #61 underwent a partial fifth MTP (toe joint) resection (surgically removing part or all of a tissue, structure, or organ) and a cuboid resection (outer side of the foot) with closure to her right foot. Resident #61's right foot wound drainage was positive for corynebacterium striatum and [MEDICATION NAME] faecium (bacterial infections) and she continued on IV antibiotics for a wound infection. A quarterly MDS assessment, dated [DATE], documented Resident #61 was cognitively intact. The MDS assessment documented she required extensive assistance of 2 staff members with bed mobility and transfers. The MDS assessment documented Resident #61 had a surgical wound. Resident #61's care plan, dated [DATE], documented she was non-weight bearing to her right foot related to a [MEDICAL CONDITION] post debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) and resection of the cuboid bone and fifth metatarsal (long bones that link your ankle to your toes). The care plan documented staff were to complete weekly skin checks and provide treatment as ordered. a. Resident #61's admission orders [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. Resident #61 was to receive the first dose of the [MEDICATION NAME] IV at 6:00 PM. The (MONTH) MAR indicated [REDACTED]. The admission progress note, dated [DATE], documented LPN #2 verified the physician orders [REDACTED]. The progress note documented the pharmacy would fill the medication order and deliver the medication to the facility that tonight. The admission progress note also documented the physician was notified the medications were going to be started later on [DATE]. A Fax Order Request/Notification Form, dated [DATE] at 6:40 PM, documented Resident #61 was admitted on [DATE] at 4:00 PM and the pharmacy would not be able to deliver her medications until later that night. The request form was signed by the physician on [DATE]. A physician's progress note, dated [DATE], documented Resident #61 expressed significant concern and displeasure that she has not had any IV abx (antibiotics) for 4 days. The progress note documented Resident #61 had not received IV antibiotics since her admission on [DATE] and the Infectious Disease physician recommended IV [MEDICATION NAME] and [MEDICATION NAME] in place of the IV [MEDICATION NAME]-Sulbactam antibiotics. A physician's orders [REDACTED]. The nurse's progress notes from [DATE] through [DATE] did not include documentation the physician was notified or the pharmacy was notified that Resident #61 did not receive the IV antibiotic medication for 20 doses of the medication for her right foot surgical incision infection. A physician's progress note written by the infectious disease physician, dated [DATE], documented Resident #61 did not receive the IV antibiotic for 72 hours due to a shortage of the [MEDICATION NAME]-Sulbactam. Resident #61 did not receive the IV [MEDICATION NAME]-Sulbactam from [DATE] to [DATE]. On [DATE] at 10:30 AM, Resident #61 stated when she was readmitted to the facility on [DATE], the facility was delayed in treating her infection to her right foot with IV antibiotics. On [DATE] at 12:05 PM, the Medical Director stated he was not notified the pharmacy was unable to provide the IV [MEDICATION NAME]-Sulbactam due to a shortage of the antibiotics for Resident #61 until 4 days later. The Medical Director stated he was on-call ,[DATE] or one of his colleagues and the pharmacy was on-call ,[DATE] to notify them of the shortage of the [MEDICATION NAME]-Sulbactam. The Medical Director stated the antibiotic could have been changed to a different one. The Medical Director stated there should not have been a delay in treatment for [REDACTED]. On [DATE] at 11:31 AM, LPN #1 provided an inventory list of medications stocked in the emergency kit in the facility. The inventory list, dated [DATE], documented [MEDICATION NAME]-Sulbactam 3 grams vial 1 each was one of the normally stocked medications. The inventory list documented the emergency kit did not have the [MEDICATION NAME]-Sulbactam available at that time. On [DATE] at 11:41 AM, the DON stated the pharmacy delivered medications to the facility Monday through Friday at 5:00 PM and 12:30 AM, Saturdays at 5:00 PM, and no delivery on Sundays. The DON stated if there was a new medication ordered on the weekends the facility used a back up pharmacy that was local. The DON stated the pharmacy consultant came to the facility on ce a month to restock the emergency kit. The DON was unable to provide an inventory list of medications prior to [DATE]. The DON stated the nurses should have notified the physician by phone on [DATE] and not by writing a fax notification form that the physician responded on [DATE] to change the IV antibiotics for Resident #61. The DON stated the pharmacy should have notified the facility right away when there was a shortage of the IV antibiotics and the pharmacy was unable to fill the prescription order. b. The facility's Wound/Skin Management policy and procedure, dated [DATE], documented, Upon admission, a full-body skin assessment is conducted. If there is an abnormal skin condition, a Licensed Nurse must visualize and document, describing the skin conditions and update the Care Plan/Kardex. The physician and resident representative would be notified and treatment was obtained immediately following identification of a wound. The policy documented the facility would complete weekly skin assessments and document on the Weekly Skin Integrity Data Collection, the facility established a wound care team comprised of the Director of Nursing/designated RN, dietary representative, a therapy representative, and additional team members could be added as needed. The policy stated It is encouraged that the RN on the wound team have advanced training in wound assessment and care, such as wound care competency, Wound Care Nurse training through (the facility's name) or actual certifications in wound care. The policy documented the wound team completed weekly wound rounds and if the wound had not changed for two weeks or had deteriorated since the last assessment, the physician was notified for potential treatment changes. The facility failed to follow its policy. The facility used an Admission Skin Assessment form. The form included a section for Skin Condition, which included check boxes staff were to mark if the resident had skin integrity problems, such as surgical incisions, or open areas/wounds. The form also included a diagram of a body. Licensed staff were to mark the area of the body which corresponded to the area of the resident's body and then write a description of the skin problem associated with that area. An Admission/Readmission Progress Note, dated [DATE], documented Resident #61 stated she did not want the skin assessment performed until after dinner in the evening. LPN #2 documented she received a verbal report from the hospital nurse that Resident #61 had a generalized rash on her abdomen and legs, [MEDICAL CONDITION] blisters on her lower legs, and a surgical wound to her foot. The documentation did not include the description of the surgical wound or which foot. The Admission Skin Assessment, dated [DATE], documented Resident #61 had a surgical incision. The narrative at the bottom of the skin section documented Resident #61 had a surgical debridement to her right foot ulcer. The narrative did not clarify whether the surgical incision was the same as the surgical debridement. The narrative did not include information regarding the location of the wound on Resident #61's right foot or description of the wound and surrounding area including length, width, depth, color, drainage, and healing status. Resident #61's admission physician orders, dated [DATE], did not include wound care orders for Resident #61's right foot wound. The nurse's progress notes, from [DATE] through [DATE], did not include documentation of a description of Resident #61's right foot wound. A Fax Order Request/Notification Form, dated [DATE] at 1:15 AM, documented Resident #61 had a surgical incision wound with sutures to her left lateral foot. The requested action documented to cleanse with normal saline, clean with [MEDICATION NAME] around the edges of the surgical wound, apply Alginate in wound bed, cover with ABD (absorbent/gauze) pad to left foot. The physician signed the request order on [DATE]. Resident #61's [DATE] Admission Skin Assessment documented the wound was on her right foot, not the left. A nurse's progress note, dated [DATE] at 4:04 AM, documented Resident #61 was admitted to the facility on [DATE], following debridement and resection on her left foot and sutures were in place with no signs or symptoms of infection. The progress note documented wound care dressing change orders for Resident #61's left foot had been requested. The (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The (MONTH) MAR from [DATE] to [DATE], and [DATE] were left blank. Resident #61's admission record documented she had a surgical wound to her right foot. On [DATE] at 11:32 AM, RN #6 stated Resident #61 had only the one wound and it was on her right foot. RN #6 stated the LPN that documented Resident #61's wound was on the left foot did so in error. A Weekly Skin Integrity Data Assessment, dated [DATE], documented Resident #61's skin had an open area/wound. The body diagram was left blank. The narrative at the bottom of the skin section documented Resident #61 had wounds to her lower extremities. The narrative documented Resident #61's wound care was completed at the physician's office. The documentation did not include where the wound was located on Resident #61's body. An infectious disease physician progress notes [REDACTED].#61's right foot ulcer at the wound base had 100% slough (non-viable yellow, tan, gray, green, or brown tissue) with a tunnel (channels that extend from a wound into and through the tissue and/or muscle below) of 2.3 cm. The wound measurements were 7.4 cm x 3.0 cm x 1.6 cm. The progress note documented the physician was concerned Resident #61 may need a below the knee [MEDICAL CONDITION] of the right lower extremity due to limb threatening infection and a high risk of antibiotic usage. A physician's orders [REDACTED].#61's right foot wound with ,[DATE] inch plain gauze. A Fax Order Request/Notification Form, dated [DATE] at 1:25 PM, documented Resident #61 was seen by the surgeon and the surgeon requested to change the wound care orders to: cleanse with normal saline, apply [MEDICATION NAME] to the periwound (skin/tissue surrounding a wound), apply Alginate to the wound bed, apply ,[DATE] inch gauze packing, cover with an ABD pad, and secure the dressing with kerlix (gauze roll) every day. The primary physician signed the order on [DATE]. The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) MAR from [DATE] - [DATE] was left blank, without documentation the wound care and dressing changes were completed for Resident #61. The (MONTH) MAR indicated [REDACTED]. A wound description for Resident #61's right foot, dated [DATE] and signed by the surgeon, documented Resident #61's right foot had eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) tissue and was debrided. The measurements were 6.5 cm x 2.5 cm x 2.5 cm. A wound VAC (vacuum assisted closure machine) was placed on Resident #61's right foot at

Based on record review and resident and staff interview, it was determined the facility failed to ensure a resident's physician was notified of significant changes in the resident's clinical condition in a timely manner. This was true for 2 of 3 (#61 and #180) residents reviewed for appropriate notification. This had the potential for harm when the facility failed to immediately notify Resident #61's physician of not receiving IV antibiotics and failed to immediately notify Resident #180's physician of his death. Findings include: The facility's policy for Changes in Resident's Condition or Status, reviewed [DATE], stated This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff . This policy was not followed. 1. Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #61's hospital discharge instructions dated [DATE] at 9:30 AM, documented a discharge prescription of [MEDICATION NAME] Sodium/Sulbactam 3 G, every 6 hours times 38 doses, for right foot infection, last dose on [DATE] at 6:00 PM. The [DATE] and [DATE] quarterly MDS assessment documented Resident #61 was receiving IV medications while a resident at the facility. Resident #61's care plan directed staff to administer antibiotic medications as ordered by the physician. Resident #61's nurse progress note, dated [DATE] at 5:51 PM, documented the IV antibiotic was not available and the physician was made aware and the pharmacy was notified. The note documented the medication would be delivered in the evening. Resident #61's (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Fax Request/Notification form, dated [DATE] at 6:40 PM, documented Resident #61 was admitted with an order for [REDACTED].[NAME] reviewed the form and signed and dated it on [DATE], 5 days later. Residents #61's nurse progress notes, dated [DATE] through [DATE], did not include further documentation of notification to the physician regarding the unavailability of the IV antibiotic. On [DATE] at 10:30 AM, Resident #61 said the facility told her the antibiotic was not available from the pharmacy and did not call the physician to get another antibiotic. On [DATE] at 12:05 PM, the Medical Director stated the facility did not notify him that the pharmacy was unable to provide the [MEDICATION NAME] Sulbactam IV antibiotic for Resident #61 until 4 days later. The Medical Director stated there was a shortage of [MEDICATION NAME] Sulbactam IV antibiotics and the pharmacy was unable to fill the order for Resident #61. The Medical Director stated he, or one of his colleagues, was on-call ,[DATE] and the pharmacy was also on-call ,[DATE] to fill orders for a different antibiotic. The Medical Director stated there should not have been a delay in treatment for [REDACTED]. On [DATE] at 11:05 AM, the P.[NAME] said she had not received a call about the IV antibiotic not being available for Resident #61. A Fax Request/Notification form, dated [DATE] at 6:30 PM, documented the [MEDICATION NAME] Sulbactam IV antibiotic was not received from pharmacy and requested the physician change the order since the antibiotic was not available. The form documented Resident #61 had been without the antibiotic since admission on [DATE]. A reply request box was checked on the form. The P.[NAME] reviewed the form and signed and dated the form on [DATE]. A physician's written order, dated [DATE], documented [MEDICATION NAME] (antibiotic) 1 GM IV every 12 hours with stop date [DATE], and [MEDICATION NAME] (antibiotic) 2 GM IV every 24 hours with stop date [DATE]. A physician progress notes [REDACTED].#61 had not received ordered antibiotics since admission on [DATE]. On [DATE] at 11:41 PM, the DON stated the nurses should have notified the physician by phone on [DATE] that the pharmacy could not provide the [MEDICATION NAME] Sulbactam IV antibiotic, instead of by sending a fax notification form. 2. Resident #180 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On [DATE] at 8:40 AM, RCM #1 said Resident #180 was actively dying and he was receiving hospice services. On [DATE] at 9:10 AM, Resident #180 was in bed with his eyes closed, was breathing heavily, and did not respond to verbal stimuli. Resident #180's family member said he received a call from the facility at approximately 9:30 PM or 10:00 PM the previous night he took a turn for the worse. Resident #180's hospice notes, dated [DATE], documented he was admitted to hospice services on [DATE] and passed away approximately 4 hours after being admitted . There was no documentation in Resident #180's record the facility notified his primary physician of his death. On [DATE] at 7:19 PM, LPN #9 said Resident #180 passed away at approximately 4:00 PM the previous day. On [DATE] at 9:46 AM, the DON said Resident #180 had passed away, and she became aware of it on [DATE]. On [DATE] at 2:13 PM, the P.[NAME] said she was not notified when Resident #180 died , the facility staff did not call her or the on-call physician, and she found out about his death that day ([DATE]). On [DATE] at 2:30 PM, RCM #1 said the nurse did not notify the physician when Resident #180 died . On [DATE] at 1:31 PM, the hospice nurse said after Resident #180 died , she notified RCM #1 and RCM #3, the CNAs who were caring for him, and the hospice Medical Director. On [DATE] at 3:45 PM, the facility's Medical Director said he was not sure when he was made aware Resident #180 died .

Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents received adequate services and monitoring to prevent a decrease in ROM (Range of Motion). This was true for 1 of 1 resident (Resident #13) reviewed for ROM and mobility. Resident #13 was harmed when she developed contractures to her upper extremities without receiving services or interventions to prevent the development of the contractures. Findings include: Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The admission MDS assessment, dated 8/6/19, documented Resident #13 was cognitively intact and required extensive assistance of two staff members for bed mobility, transfers, and dressing. The assessment documented Resident #13 had no ROM impairment to either upper or lower extremities. The quarterly MDS assessment, dated 10/14/19, documented Resident #13 was severely cognitively impaired and required extensive assistance of two staff members for bed mobility and dressing. The assessment documented she had no ROM impairment to either upper or lower extremities. Resident #13's care plan, dated 8/12/19, documented staff were to monitor and report to the physician complications related to arthritis: Joint pain and stiffness, decline in mobility, and contracture formation/joint shape changes. On 10/27/19 at 3:22 PM, Resident #13 was laying on her back in bed with both of her arms bent with no devices in place. RN #1 stated Resident #13 did not wear devices to prevent further contractures to her upper extremities and was not receiving therapy or restorative therapy. On 11/1/19 at 12:08 PM, the Medical Director stated he should have been notified of Resident #13's ROM decline. The Medical Director stated he would have referred Resident #13 to therapy to evaluate and provide treatment to prevent further contractures. On 11/05/19 at 2:42 PM, the MDS Coordinator stated Resident #13's quarterly assessment on 10/14/19, documented she had no ROM impairment to either her upper or lower extremities. The MDS Coordinator stated Resident #13's quarterly assessment was documented as an error. The MDS Coordinator stated Resident #13 did not have contractures to her upper extremities when she was admitted to the facility. On 11/05/19 at 4:33 PM, RN #6 stated Resident #13 developed contractures to her upper extremities in the facility. RN #6 was unable to provide documentation in Resident #13's record the physician was notified of the contractures for treatment and services to prevent further contractures.

Based on staff interview, I&A report review, and record review, it was determined the facility failed to ensure injuries caused by staff were recognized as abuse or neglect. This was true for 1 of 5 residents (Resident #93) who were reviewed for abuse/neglect. Resident #93 was harmed when the facility failed to provide two person toileting assistance per her care plan and care directive instructions. This failure created harm when Resident #93 had a fall that resulted in a head injury and required emergency transport and treatment at a local hospital. Findings include: Resident #93 was admitted to the facility on [DATE], with multiple diagnoses, including right sided [MEDICAL CONDITION] and [MEDICAL CONDITION] (weakness and [DIAGNOSES REDACTED]) following a cerebral infarction (stroke). She was readmitted on [DATE], following left sided carotid endarterectomy (surgical removal of thickened areas of the innermost coat of an artery). Resident #93's Physician order [REDACTED]. Both medications were ordered on [DATE]. Resident #93's care plan included the following: - Risk for abnormal bleeding or hemorrhage related to the use of anticoagulant medication, dated 10/23/17. Interventions included: administer medications, laboratory, and treatments as ordered; report to the physician any signs and/or symptoms of abnormal bleeding or hemorrhage. - Risk for fall related injury due to history of stroke and [MEDICAL CONDITION] and [MEDICAL CONDITION], dated 10/22/17. Interventions included: fall risk assessment quarterly and PRN; provide environmental adaptations such as low bed, call light within reach on left side of resident, adequate lighting, area free of clutter; referral for PT and OT; provide and observe the use of adaptive equipment (wheelchair). - ADL self-care deficit due to stroke, dated 10/22/17. Interventions included: provide the amount of assistance/supervision needed, to the right of this intervention handwritten with a date of 11/3/17 was documented 2 person assist (with) transfer disk in Br (bathroom). To the left of the intervention for assistance/supervision handwritten with a date of 11/15/17, One assist transfer disk transfer @ bedside - sling on for all transfers. Resident #93's record also included a Care Directive, dated 10/25/17 at 12:30 PM, which documented she required the assistance of 2 staff for transferring and toileting. Another Care Directive, dated 12/17/17 at 2:23 PM, documented she required the assistance of 2 staff members with a pivot disk and a sling for toileting. Resident #93's care plan and care directive were not followed. An I&A report, dated 12/16/17 at 7:30 PM, documented Resident #93 had a fall which resulted in a hematoma (a swelling of blood within the tissue), closed head injury, fracture, and lacerations (cut) to her face and arm. The report documented Resident #93 was sitting on the toilet and the aide saw her falling forward. The aide grabbed her right arm and the back of her brief causing Resident #93 to twist to her left side, and her head was struck on the right side by a grab bar. The report further documented Resident #93 was assessed, cold compresses were applied, and 911 was called. A Nursing Note, dated 12/17/17 at 5:09 AM, documented an LPN contacted the local hospital for an update on Resident #93. The note documented I was told that she was admitted w/ a huge bleed and her outlook was not good. A Nursing Note, dated 12/17/17 at 1:44 PM, signed by LPN #1 documented Evening shift for 12/16/17: At 19:30 (7:30 PM), I was at my med (medication) cart down the hall from (Resident #93's) room and had just finished talking to the residents (sic) husband when (CNA #3) came out to the hall yelling 'I need help in her.' Upon entering the resident's bathroom, Resident was sitting on the toilet bleeding from the right side of her forehead. A large hematoma noted. Pressure was applied and pupils were assessed with [REDACTED]. Skin tears were cleansed and steri-stripped (a tape to hold skin together). Was unable to do ROM to right arm due to stroke. Ice placed to forehead. Resident remained alert and able to answer questions shaking head yes or no. Resident was assist (sic) back to bed and 911 was notified due to being full code and on anticoagulation medication. EMTs (Emergency Medical Transport) were here to transport at 20:10 (8:10 PM). On 12/13/18 at 12:08 PM, LPN #1 said she recalled Resident #93 and the incident on 12/16/17. LPN #1 said CNA #3 was with Resident #93 in her bathroom at the time of the incident. LPN #1 said CNA #3 told her she had turned away from Resident #93 to put clothes in a bag when she heard a noise and turned enough to see Resident #93 hit her head on the grab bar, then fell forward, head first. LPN #1 said CNA #3 told her she intercepted the fall because Resident #93 was falling head first to the floor, and when CNA #3 grabbed Resident #93's right arm and the back of her brief, the momentum caused Resident #93 to twist and hit the safety bar with the right side of her head. LPN #1 reviewed her documentation from 12/17/17, and said what she documented was different than what CNA #3 had told her. LPN #1 said she never considered abuse or rough treatment because she knew CNA #3 and had worked with her for many years. LPN #1 said by the time she got to Resident #93's bathroom, there was blood on the safety bar, but none on the floor. She said Resident #93 had a cut on her right cheek and a huge lump on her head. LPN #1 said she checked Resident #93's neurological status, she was awake and alert, verbalized she was in pain, and she was able to move her head, and used her left arm to move her right arm. LPN #1 said CNA #3 and another CNA assisted Resident #93 from the bathroom to her bed. LPN #1 said Resident #93's spouse came in the room and she told him Resident #93 needed to go to the hospital. On 12/13/18 at 12:35 PM, LPN #1 accompanied the surveyor to where Resident #93 had resided in the facility. The bathroom was approximately 7 feet wide by 6 feet deep. The toilet was in the rear left corner and there was a safety bar behind the toilet and another safety bar was to the left of the toilet. Four feet in front of the toilet was a metal towel bar on the wall. The sink was 3 feet away and to the left of the toilet. The doorway was directly in front of the sink. LPN #1 demonstrated to the surveyor how CNA #3 explained to LPN #1 how she grabbed Resident #93's right arm and the back of her incontinence brief and it caused the resident to twist and hit her head on the safety bar on the left side of the toilet. LPN #1 said there was blood on the safety bar but none on the floor. She said there was a cut on Resident #93's cheek and a huge lump on her head. On 12/13/18 at 2:21 PM, LPN #1 said the transfer disc was by Resident #93's bed not in her bathroom when the incident happened on 12/16/17. On 12/13/18 at 4:50 PM, the DON reviewed Resident #93's care plan and said it documented 2 person assistance with transfers and 1 person extensive assistance with toileting. The DON said Resident #93's care directive documented 2 person assistance with toileting. The DON said she did not investigate how Resident #93 was transferred onto the toilet, because Resident #93 did not fall during the transfer, she was on the toilet and her left arm slid off the grab bar causing her to fall forward and hit her head. The DON said the facility notified her around 2:00 AM or 3:00 AM Resident #93 had an incident and she was sent to the hospital and did not think it was that severe. The DON said the facility called her again around 6:00 AM to inform her Resident #93 may not live. The DON said after investigating the incident with CNA #3, she ruled out abuse or neglect. On 12/14/18 at 10:22 AM, the DON reviewed Resident #93's care plan and compared it to Resident #93's care directive, she said the therapy instructions to have 2 person toileting assistance should have been followed. The DON said the comprehensive care plan was not updated regarding the need for assistance by 2 staff during toileting, and the staff did not follow the care plan for Resident #93. The facility staff failed to follow Resident #93's care plan and care directives which resulted in harm.

Based on staff interview, I&A report review, and record review, it was determined the facility failed to ensure a resident's fall was thoroughly investigated. This was true for 1 of 5 residents (Resident #93) who were reviewed for fall investigations. Resident #93 was harmed when she sustained a head injury and required emergency transport and treatment at a local hospital. Findings include: Resident #93 was admitted to the facility on [DATE], with multiple diagnoses, including right sided [MEDICAL CONDITION] and [MEDICAL CONDITION] (weakness and [DIAGNOSES REDACTED]) following a cerebral infarction (stroke). She was readmitted on [DATE], following left sided carotid endarterectomy (surgical removal of thickened areas of the innermost coat of an artery). Resident #93's care plan identified ADL self-care deficit due to stroke, dated 10/22/17. Interventions included: provide the amount of assistance/supervision needed, to the right of this intervention handwritten with a date of 11/3/17 was documented 2 person assist (with) transfer disk in Br (bathroom). To the left of the intervention for assistance/supervision handwritten with a date of 11/15/17, One assist transfer disk transfer @ bedside - sling on for all transfers. An I&A report, dated 12/16/17 at 7:30 PM, documented Resident #93 had a fall which resulted in a hematoma (a swelling of blood within the tissue), closed head injury, fracture, and lacerations (cut) to her face and arm. The report documented Resident #93 was sitting on the toilet and the aide saw her falling forward. The aide grabbed her right arm and the back of her brief causing Resident #93 to twist to her left side, and her head was struck on the right side by a grab bar. The report further documented Resident #93 was assessed, cold compresses were applied, and 911 was called. An Incident Follow-Up & Recommendation Form signed by the DON on 12/20/17, documented a summary of the investigation. The summary documented CNA #3 was assisting Resident #93 to get ready for bed. CNA #3 was at the sink in the bathroom with Resident #93, who was sitting on the toilet, when Resident #93 began to fall forward. The summary documented CNA #3 saw Resident #93 falling out of the corner of her eye and CNA #3 grabbed Resident #93's right forearm and the back of her brief attempting to pull her back onto the toilet. The summary stated Resident #93 had her left arm sitting on the grab bar prior to the fall and it was unclear if her arm slipped or if she lost balance and then her left arm slipped off the grab bar. The summary documented when CNA #3 grabbed Resident #93's forearm it caused her to turn to the left and caused her upper body to go forward, striking the right side of her head on a grab bar. The summary documented CNA #3 stated she ensured Resident #93 was seated safely and she yelled out for help. The summary documented LPN #1 and another CNA responded to the call for help, 911 was called and Resident #93 was sent to a local hospital for treatment. The Incident Follow-Up & Recommendation Form, signed by the DON on 12/20/17, documented the root cause of the incident was Resident #93 lost her balance while sitting on the toilet and fell forward, CNA #3 attempted to stop Resident #93 from falling, and Resident #93 hit her head on a grab bar. The summary report documented Full investigation completed. The care plan was being followed as patient is supervised at all times in the bathroom. The report did not include the care plan or care directives which documented Resident #93 required 2 person assistance with transfer disk in the bathroom. On 12/13/18 at 5:20 PM, the DON demonstrated how CNA #3 demonstrated to her what occurred in the bathroom with Resident #93 on 12/16/17. The DON said CNA #3 was standing on Resident #93's right side and grabbed her right arm and her brief at the waist level to move Resident #93 back onto the toilet from leaning forward. When asked why Resident #93's brief was pulled up while she was supposed to be using the bathroom, the DON stated it was a good question and that doesn't make sense. When asked who and how was Resident #93 transferred to the toilet, the DON said she did not investigate that part, she only investigated from when Resident #93 fell forward from the toilet and hit her head. The facility investigation was not thorough for Resident #93.

Based on observation, staff interview, policy review, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 5 residents (#7, and #64) reviewed for pressure ulcers. Resident #7 was harmed when he developed a stage III pressure ulcer to the back of his right calf. Resident #64 was harmed when she developed unstageable pressure ulcers to her feet. Findings include: The facility's policy for Pressure Ulcer/Injury Prevention and Management, dated 11/27/18, documented: * A comprehensive skin assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. * A risk assessment tool, Braden Scale, determines the patient's risk for pressure ulcer development. * A skin assessment should be performed weekly by a licensed nurse. * Measures to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care: - skin inspections with attention to bony prominences; - minimize injury due to shear and friction through proper positioning, transfers, and turning schedules; - measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction and shear; - reposition at least every 2-4 hours; - utilize positioning devices to keep bony prominences from direct contact; - ensure proper body alignment when side-lying; - when skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient 1. Resident #7 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. An Initial Data Collection Tool/Nursing Service, dated 7/17/18, documented Resident #7 had no pressure ulcers to his right lower leg and pedal pulses were present. A Braden Scale for predicting pressure score risk, dated 7/17/18, documented Resident #7 was at risk for pressure related to predisposing medical conditions including [MEDICAL CONDITION], decreased or impaired bed/chair mobility, and pain affecting movement. A Braden Scale for predicting pressure score risk, dated 9/1/18, documented Resident #7 was at risk for developing a pressure ulcer. The predisposing medical conditions and risk factors were blank. A significant change MDS assessment, dated 9/9/18, documented Resident #7 was cognitively intact with occasional mild pain with 2 Stage II pressure ulcers. Resident #7's care plan, dated 11/13/18, documented staff were to encourage resident to stay off of his right side, implement a bariatric air mattress with bolsters, assess and measure wound, and administer wound treatments as ordered, treat pain prior to treatment/turning, and weekly treatment documentation to include measurements of each area of skin breakdown. The (MONTH) (YEAR) weekly skin check documentation for Resident #7 were completed on 9/7/18, 9/14/18, and 9/21/18. The weekly skin check on 9/28/18 was left blank. A nurse's progress note, dated 9/29/18, documented Resident #7 had an open area to his posterior RLE (right lower extremity) measuring 2.5 cm x 1.5 cm x 0.2 cm with minimal drainage. The physician was notified and an adhesive dressing was applied. The progress note also documented pillows were in place under RLE to offload pressure to calf and ankle, and frequent checks and rotations were implemented every 2 hours and PRN. A physician's orders [REDACTED]. A pressure ulcer status record, dated 9/29/18, documented Resident #7 had a stage II pressure ulcer to his right posterior RLE measuring 2.5 cm x 1.5 cm x 0.2 cm with 30% granulation and no necrotic tissue. A nurse's progress note, dated 10/5/18 for a late entry 10/2/18, documented Resident #7's RLE wound was not improving with measurements of 2.3 cm x 1.4 cm x 0.2 cm. The wound bed had 90% slough with pink edges and scant amount of serosanguinous drainage. The physician was notified with new wound care orders. A nurse's progress note, dated 10/13/18 at 11:23 PM, documented Resident #7's right calf ulcer continued to have slough, possibly due to in state of evolution. A Nursing Wound Observation Tool, dated 11/13/18, documented Resident #7's right posterior calf wound was acquired in the facility on 11/14/18. The measurements were 3.6 cm x 2.5 cm x 0.3 cm and a stage IV pressure ulcer with 60% slough, 40% necrotic tissue and the overall impression of visible tissue was worsening. The wound observation tool documented Resident #7 had an additional open area to his right posterior calf with measurements 1.0 cm x 2.1 cm x 0.1 cm and had 70% slough with 30% necrotic tissue and small amount of serosanguineous drainage. On 12/11/18 at 2:30 PM, UM #2 stated Resident #7 acquired the first pressure ulcer on 9/29/18 and acquired the second pressure ulcer on 11/13/18. UM #2 stated the Nursing Wound Observation Tool was documented as an error. A physician's orders [REDACTED].#7 to PT for wound care treatment. A PT note, dated 11/14/18, documented Resident #7 was provided CPI (Cell Proliferation Induction) wound treatment for [REDACTED]. PT documented Resident #7 had 2-3 small wound clusters within the overall perimeter to right posterior leg with eschar/necrosis. A PT note, dated 11/16/18, documented Resident #7 had a total of 3 wounds: * Wound #1: Measured 4.0 cm x 3.6 cm x 0.3 cm with 90% yellow eschar; * Wound #2: Measured 2.0 cm x 1.5 cm with black eschar at center; * Wound #3: Measured 1.5 cm x 0.5 cm mainly pink wound bed with 15% eschar. The wounds had a mild foul odor with minimal yellow/brown drainage. PT documented the wounds were debrided. PT services continued on 11/19/18, 11/20/18, 11/21/18, and 11/26/18. PT documented on 11/27/18, treatments were discontinued related to little benefit to the wounds. A Nursing Wound Observation Tool, dated 11/27/18, documented Resident #7's right posterior calf was unstageable with measurements of 7.1 cm x 5.0 cm x 0.1 cm with 60% slough tissue and 40% necrotic tissue in the wound bed with small amount of serosanguinous drainage. Resident #7 was referred to the wound clinic. The second wound on the right posterior calf documented it was unstageable with measurements 2.4 cm x 3.0 cm x 0.2 cm with 80% slough in the wound bed and a small amount of serosanguineous drainage. The tool documented Resident #7 was experiencing pain with wound care treatments and [MEDICATION NAME] was effective when given prior to wound care. A wound clinic progress note, dated 11/29/18, documented Resident #7's wound started from pressure and was worsening due to poor circulation, [MEDICAL CONDITION], and inability to tolerate being in one position due to chronic back pain. The Physician Assistant (PA) documented Resident #7 had weak pedal pulses and would set up a vascular surgeon consult for a second opinion. The PA documented, This is a difficult wound to heal, does have risk for [MEDICAL CONDITION]/amputation. There was no vascular studies in Resident #7's record. Resident #7's care plan, revised 12/7/18, documented Resident #7 developed a stage III pressure ulcer to his right posterior calf related to diabetes and immobility. On 12/12/18 at 9:40 AM, UM #2 stated Resident #7's pressure ulcer was caused by him sitting in a recliner where the open space of the recliner caused pressure to his right posterior leg. UM #2 stated the facility did not identify the pressure ulcer until the wound was open. On 12/12/18 at 9:45 AM, UM #2 and UM #3 were observed providing wound care to Resident #7's right posterior calf. UM #2 stated the lower open area to the right calf measured 5 cm x 1.5 cm x 0.4 cm with 80% slough and 20% red maceration. UM #2 stated the upper area of the wound measured 3.0 cm x 6.5 x 0.4 cm. UM #2 stated the third open area was located on the back of the right leg just below the knee and was caused due to vascular status, not pressure. UM #2 stated the open area was dark red/black in color and measured 3.0 cm x 1.5 cm x 0.4 cm with 90% eschar and was unstageable. On 12/12/18 at 3:45 PM, UM #2 stated there were no weekly skin assessments completed in (MONTH) (YEAR). UM #2 stated Resident #7's pressure ulcer was facility acquired and should have been prevented with repositioning and padding the recliner with pillows. UM #2 stated the wound began as a pressure ulcer and now we are having a hard time healing because of poor circulation. 2. Resident #64 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #64's quarterly MDS assessment, dated 8/16/18, documented she understood others and they understood her; she needed limited 1 person physical assistance with dressing and 1 person supervision with personal hygiene; and, she did not have any skin ulcers. A 9/20/18 fax order request/notification form documented, Resident #64 had an open area measuring 0.6 cm x 0.6 cm, superficial to her left medial foot caused from shoes with slight swelling & redness to surrounding area and blanching. It also documented the other red areas were all intact and there was blanching to both feet due to shoes. On 9/21/18, the physician ordered skin prep to the red areas on both feet twice a day and to apply a foam dressing to the open area on the left medial foot and red areas every 3 days and PRN until resolved; and, encourage her to not wear her leather shoes. Resident #64's care plan documented on 11/6/18 she had potential/actual skin impairment of the left and right medial foot related to tight fitting shoes. Interventions created 11/6/18 included instructions for staff to: * assess the location, size, and treatment of [REDACTED].>* report abnormalities, failure to heal, and signs and symptoms of infection or maceration to the physician; * follow facility protocols for treatment; and, * document weekly treatment, including measurements (width, length, depth) of each area of skin breakdown, tissue type, exudate, and any other notable changes or observations. A 11/6/18 fax order request/notification form documented a New 0.4 cm x 0.4 cm scab on her right medial foot. An order, also dated 11/6/18, documented skin prep was to be applied to the area twice a day until resolved and to monitor for signs and symptoms of complications every day for 1 week. Resident #64's 11/16/18 quarterly MDS assessment documented she had 2 unhealed and unstageable pressure ulcers. Resident #64's Order Recap Report, dated 8/1/18 to 12/31/18, documented a 10/14/18 order for a foam dressing to the open area on her left medial foot and red areas every 3 days and PRN until resolved. On 11/16/18, the order was changed from a night time treatment to a day time treatment. On 12/12/18 at 10:10 AM and 5:04 PM, Resident #64 was observed self propelling in her wheelchair in the hallways and near the main dining. She was wearing moccasin type slippers and during both observations a border dressing was partially visible at the medial aspect (arch) on both of her feet with redness along the top and upper sides of the dressings. The redness was greater on the left foot than the right foot. On 12/11/18 at 3:06 PM, LPN #2 stated that Resident #64 did not have pressure ulcers. On 12/13/18 at 9:11 AM, RN #2 said she planned to change Resident #64's bilateral foot dressings in an hour. On 12/13/18 at 10:13 AM, RN #2 RN stated she had pre-medicated Resident #64 with Tylenol 30 minutes earlier. Resident #64 agreed to the bilateral foot dressing changes and for the surveyor to observe. RN #2 washed her hands and applied gloves, then she knelt down and removed Resident #64's left slipper, thigh high stocking, and a 2x2 border dressing. A scant amount of red-brown drainage was on the dressing. The entire area where the dressing had been was bright red and moist, and where the dressing's adhesive border had been was bright pink. Resident #64 said, Oh, that's tender, as she pointed at the open ulcer on her left foot. The ulcer was circular and about 0.5 cm in diameter with approximately 80% to 90% pale yellow slough in the wound bed. RN #2 changed her gloves and swabbed the area surrounding the ulcer with Skin prep, fanned it dry, then applied a new 2x2 border dressing over the left foot wound. She then reapplied the left stocking and slipper. RN #2 changed her gloves, removed the right slipper, stocking, and 2x2 border dressing. The dressing was dry and RN #2 said the right foot ulcer looked much better. There was a tiny (#2 pencil dot size) scabbed area at the upper aspect of the arch of her right foot. There was no redness or swelling in the area. RN #2 changed her gloves and applied Skin prep over area, fanned it dry, applied a new 2x2 border dressing, then reapplied her right stocking and slipper. Resident #64'2 TARs for (MONTH) through the day shift on (MONTH) 14, (YEAR) documented: * Weekly skin assessments were done in (MONTH) (YEAR). Weekly skin assessments were not included in the TARs or the MARs, for (MONTH) through (MONTH) (YEAR). * Skin prep to the red areas on both feet was applied twice a day from 9/20/18 to 9/30/18, and 10/23/18 through the day shift on 12/14/18. An X was typed in each space for documentation from 10/1/18 to 10/22/18, * A foam dressing to the left medial foot open area and red areas was applied every 3 days, and PRN, from 9/20/18 to 9/29/18, then from 10/26/18 to 11/1/18, 11/7/18 to 11/13/18, twice on 11/16/18, and from 11/19/18 to 12/13/18. An X was typed in each space for documentation from 10/1/18 to 10/22/18. In addition, the spaces for documentation on 10/23/18 and 11/4/18 were blank. * Skin prep was applied topically to the right medial foot scab every shift from 12/1/8 through the day shift on 12/14/18. These instructions for skin prep were dated 11/6/18; however, they were not included in the (MONTH) (YEAR) TAR or MAR. Resident #64's Progress Notes, dated 9/18/18 through 12/13/18 at 11:19 AM documented: * 9/20/18 at 4:01 PM - An LN notified the nurse Resident #64 had an area to her left foot and it had not been not assessed due to Resident #64 being in activities and dining on 9/19/18, the afternooon of the notification. The nurse and DON went in to see resident once resident returned to the unit on the afternoon of 9/20/18 at 1:20 PM. The progress note documented an open area on left medial foot, measuring 0.6 cm x 0.6 cm with a slightly moist scab. Other red areas were noted, and all areas of the toes on the right foot were blanching. Further documented was redness and slight swelling to an open area on left foot, and the red area was fully blanching, tender to touch, and shoes directly matched the red and open areas as the cause. Resident #64 was educated and agreed to not wear her leather shoes until the open area resolved. The nurse and DON left to get supplies and when they returned, Resident #64 was wearing the leather shoes. She did not recall the education or the ulcer on her foot. The leather shoes were removed and non-skid socks were applied. The leather shoes were put in the closet. An addendum at 4:11 PM documented Resident #64's representative was contacted and agreed to provide new looser fitting shoes and to remove the leather shoes from the room. * 10/4/18 at 3:33 PM - A scab to left medial foot measuring 0.6 cm x 0.6 cm, (unable to assess depth) due to scab and calloused edges. The documentation said other areas of redness continue to blanch and Resident #64 had been wearing her new shoes with no new areas of concern. The note documented monitoring would continue for areas of rubbing during weekly wound rounds. * 10/16/18 at 2:34 PM - Trace [MEDICAL CONDITION] noted to feet, varies. * 11/6/18 at 8:26 AM - Wound rounds for Resident #64 noted scab to right medial foot measured 0.4 cm x 0.4 cm, red peri-wound blanching, and resident denied pain. Resident #64 continued to wear some of her tight shoes versus new loose shoes and an inability to redirect, and at times, resident was willing to change shoes. Scab matched area to other foot, shoe caused friction/abrasion likely the the cause to right foot as well. The tight shoes were moved out of reach. Skin prep applied to scab and left open to air. * 11/15/18 at 10:56 AM - Resident #64 was encouraged to wear loose fitting non skid footwear and weekly skin checks were recommended. On 12/14/18 at 9:03 AM, UM #1 said Resident #64 insisted on wearing leather shoes that were tight. The UM said the resident had scant [MEDICAL CONDITION] in her feet at the time and a blister developed on the medial aspect of her left foot on 9/20/18. The UM said she removed the leather shoes and the family took them home. She said she evaluated Resident #64's other shoes and the family brought in a different pair of black shoes. The UM said the black shoes were not tight initially but a blister developed on the medial aspect of Resident #64's right foot on 11/6/18. UM #1 said she initiated foot assessments every shift after the left foot blister was found but she did not find documented evidence her feet were assessed every shift. The UM said RN #2 informed her on 12/13/18 that Resident #64's left foot ulcer was angry and tender. On 12/14/18 at 12:45 PM, UM #1 said she sent a request to the physician that morning for a treatment change to Resident #64's left foot ulcer. The UM said she had not seen the ulcer herself but that RN #2 had described it to her as angry on 12/13/18. The UM stated that RN #2 did not document the status of the left or the right foot ulcers after she provided the wound care and dressing changes on 12/13/18. The UM provided Wound Observation Tools and said it was all she could find. One set of Wound Observation Tools documented the left foot wound characteristics and measurements on 10/17/18, 10/25/18, 11/1/18, and 11/6/18. All of Tools documented it was a stage 2 facility acquired pressure ulcer with a scab and the depth could not be determined. Another set of Wound Observation Tools contained documentation for the left and right foot wound characteristics and measurements combined on 11/13/18, 11/21/18, 11/30/18, and 12/6/18. All of them documented the facility acquired wound location as the left medial foot and the right medial foot, and the wound type as Other. The 11/30/18 Wound Observation Tool documented Resident #64 reported the left wound hurt more than the right wound and it felt better after the dressing was applied. The 12/6/18 Wound Observation Tool documented no wound related pain. UM #2 said she combined the assessments for the left and right wounds because the Wound Observation Tools were lengthy. UM #2 said they did not consistently monitor Resident #64's feet for impairment and they could do better regarding identifying, assessing, and monitoring her bilateral foot pressure ulcers.

Based on staff interview, hospital records, and record review it was determined the facility failed to provide adequate supervision and assistance for 1 of 5 residents (Resident #93) reviewed for falls and accident hazards. Resident #93 was harmed when the facility failed to provide two person toileting assistance as instructed by PT and OT, and per her care plan and care directive instructions. The fall resulted in a head injury and required emergency transport to a hospital for treatment. Findings include: Resident #93 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. She was readmitted on [DATE] following a left side carotid endarterectomy (surgical removal of thickened areas of the innermost coat of an artery). Resident #93's admission MDS assessment, dated [DATE], documented she did not speak but she understood others and they usually understood her; she had modified independence in cognitive skills for daily decision making with some difficulty in new situations only; she required extensive 1 person assistance with transfers, dressing, toilet use, and personal hygiene; she was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position and moving on and off the toilet; and the direct care staff believed she was capable of increased independence in at least some ADLs. Resident #93's (MONTH) (YEAR) Physician order [REDACTED]. Resident #93's (MONTH) (YEAR) MAR indicated [REDACTED]. Her comprehensive care plan documented the following: * Risk for abnormal bleeding or hemorrhage related to the anticoagulant medication, dated [DATE]. * Risk for physical injury related to falls, dated [DATE]. Interventions included resident/family teaching regarding safety measures to reduce her fall risk; referral to PT/OT for screening/treatment as needed; environmental adaptations included low bed; provide and observe the use of adaptive equipment (wheelchair); remind and reinforce safety awareness; and, offer toileting upon rising, before/after meals, at bedtime, and PRN. A new intervention was added on [DATE], which directed staff to lead to the left. * ADL self-care deficit, dated [DATE]. Interventions included to provide the amount of assistance/supervision Resident #93 needed. Added on [DATE] - A 2 person assist with transfer disk was to be used in the bathroom; and, on [DATE], 1 assist transfer with disk transfer at bedside and a sling to be on for all transfers, was added. Two Care Directives were in Resident #93's clinical record. Resident #93's [DATE] Care Directive documented she needed assistance of 2 for transfers with a sling on during transfers; and assistance of 2 staff members with toileting. Resident #93's therapy records documented the following: * [DATE] at 4:30 PM by an OT - .CNA admits that transfer disc was not in room and she did not use it for transfers. Located transfer disc and education provided that disc necessary for all transfers to avoid twist and pain to her right lower extremity. * [DATE] at 3:22 PM by an OT - .Education to nurse .concern about transfer technique being followed .Re-education provided .transfer disc should be used for all transfers to avoid twisting of ankle. Nurse stating she will pass on information. And, .seen for toileting retraining. Completed with CNA .Used sling and grab bar as well as transfer disc for optimal positioning and safe transfer technique .One person provided .assist to maintain stand while 2nd person provided max assist . with clothing management and hygiene. Transfer completed with minimum assistance of 2 people. * [DATE] at 3:28 PM by a PTA - .needing to use bathroom during this session .2 person assist needed for personal hygiene and clothing management . * [DATE] at 12:49 PM by an OT - .seen for toileting retraining completing stand and transfer with min assist x 1 and grab bar with pivot disc while 2nd person completed hygiene and clothing mgmt (management) . * [DATE] at 1:32 PM by a PT - treat with OT during standing balance activity with functional toileting task with the transfer disc. * [DATE] at 1:34 PM by an OT - seen for toileting due to pt (patient) needing assist x 2 for safety. An I&A report, with the date [DATE] at the bottom, documented Resident #93 had an intercepted fall on [DATE] at 7:30 PM resulting in a hematoma (a swelling of blood within the tissue), closed head injury, fracture, and laceration (cut) to her face and arm. It documented, Resident #93 was sitting on the toilet. The aide saw her starting to fall forward and grabbed her right arm and the back of the brief and hip area. This caused Resident #93 to twist to the left, striking the right side of her forehead on the grab bar. The aide got the resident stable on the toilet and yelled for help. The I&A report documented Resident #93 was assessed, cold compresses were applied, 911 was called, and she was sent to a hospital at 8:10 PM. It documented at the time of the incident Resident #93 was on anticoagulant medication, her balance and/or gait was abnormal, she was leaning over, and no assistive devices were in use. The I&A report documented Resident #93 was alert, but forgetful and did not lose consciousness after the incident. It also documented she had expired. Hospital records documented Resident #93 was brought to the emergency department from the facility on [DATE] after a fall. She was assessed to have, Catastrophic right acute subdural with 3.4 cm midline shift that is not compatible with life, radiographic and clinical evidence of herniation, and platelet dysfunction due to [MEDICATION NAME] use. On [DATE] at 12:08 PM, LPN #1 said she recalled Resident #93 and the incident on [DATE]. LPN #1 said CNA #3 was with Resident #93 in her bathroom at the time of the incident. LPN #1 said CNA #3 told her she had turned away from Resident #93 to put clothes in a bag when she heard a noise and turned enough to see Resident #93 hit her head on the grab bar, then fell forward, head first. LPN #1 said CNA #3 told her she intercepted the fall because Resident #93 was falling head first to the floor, and when CNA #3 grabbed Resident #93's right arm and the back of her brief, the momentum caused Resident #93 to twist and hit the safety bar with the right side of her head. LPN #1 reviewed her documentation from [DATE], and said what she documented was different than what CNA #3 had told her. LPN #1 said she never considered abuse or rough treatment because she knew CNA #3 and had worked with her for many years. LPN #1 said by the time she got to Resident #93's bathroom, there was blood on the safety bar, but none on the floor. She said Resident #93 had a cut on her right cheek and a huge lump on her head. LPN #1 said she checked Resident #93's neurological status, she was awake and alert, verbalized she was in pain, and she was able to move her head, and used her left arm to move her right arm. LPN #1 said CNA #3 and another CNA assisted Resident #93 from the bathroom to her bed. LPN #1 said Resident #93's spouse came in the room and she told him Resident #93 needed to go to the hospital. On [DATE] at 12:35 PM, LPN #1 accompanied the surveyor to where Resident #93 had resided in the facility. The bathroom was approximately 7 feet wide by 6 feet deep. The toilet was in the rear left corner and there was a safety bar behind the toilet and another safety bar was to the left of the toilet. Four feet in front of the toilet was a metal towel bar on the wall. The sink was 3 feet away and to the left of the toilet. The doorway was directly in front of the sink. LPN #1 demonstrated to the surveyor how CNA #3 explained to LPN #1 how she grabbed Resident #93's right arm and the back of her incontinence brief and it caused the resident to twist and hit her head on the safety bar on the left side of the toilet. LPN #1 said there was blood on the safety bar but none on the floor. She said there was a cut on Resident #93's cheek and a huge lump on her head. On [DATE] at 2:21 PM, LPN #1 said the transfer disc was by Resident #93's bed not in her bathroom when the incident happened on [DATE]. On [DATE] at 4:50 PM, the DON reviewed Resident #93's care plan and said it documented 2 person assistance with transfers and 1 person extensive assistance with toileting. The DON said Resident #93's care directive documented 2 person assistance with toileting. The DON said she did not investigate how Resident #93 was transferred onto the toilet, because Resident #93 did not fall during the transfer, she was on the toilet and her left arm slid off the grab bar causing her to fall forward and hit her head. On [DATE] at 12:45 PM, Resident #93's spouse said the facility had 2 people help her in the bathroom until [DATE] when only 1 staff helped her. He said they had the disc thing and all but one staff member often neglected to use it and that made her have to work harder. He said he stepped out of the room when the CNA helped her to the bathroom and he returned to her room when he heard someone yelling for help. He said she was slumped over on the toilet bleeding profusely and there was a pool of blood on the floor, and a 1 inch cut on her right cheek and a huge lump on her head. On [DATE] at 2:21 PM, LPN #1 said the transfer disc was by Resident #93's bed, not in the bathroom, when the incident happened on [DATE]. On [DATE] at 9:52 AM, OT #1 reviewed resident's PT/OT documentation for (MONTH) (YEAR). The OT said 2 people were needed to assist Resident #93 with toileting and transfers and the therapy staff had instructed the nursing staff regarding her care. On [DATE] at 10:22 AM, the DON re-reviewed Resident #93's care plan and care directives, then she reviewed the therapy documentation and said that 2 person toileting assistance should have been followed. On [DATE] at 11:23 AM, the RDCS said she had two concerns regarding Resident #93's incident on [DATE]: the 1 person transfer and toileting; and the CNA left the resident alone in bathroom to get help after the incident. Resident #93 she experienced a fall resulting in a severe head injury when the facility failed to ensure two people provided assistance with toileting and used the necessary equipment for transfers as care planned and instructed by the therapy staff.

Based on observation, staff interview, facility policy review, and record review, it was determined the facility failed to ensure residents' pain level was assessed prior to wound care. This was true for 1 of 2 residents (Resident #7) reviewed for pain management. Resident #7 was harmed when he experienced increased pain during a dressing change and the facility did not identify and treat it. Findings include: The facility's Pain Management policy, dated 11/2016, expected staff to recognize when the resident was experiencing pain and identify circumstances when pain can be anticipated. An individualized pain management care plan was to be developed and initiated when pain indicators were identified upon admission, change in condition, and with any event. Staff were to implement a pain management system to help residents attain or maintain their highest practicable level of well-being by preventing or managing pain. Resident #7 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A significant change MDS assessment, dated 9/9/18, documented Resident #7 developed 2 Stage II pressure ulcers in the facility and experienced mild pain. A physician's orders [REDACTED].#7 was to receive [MEDICATION NAME] 5 mg every 6 hours (midnight, 6:00AM, noon and 6:00PM) for pain. Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. On 12/12/18 at 9:52 AM, Unit Manager #2 was observed providing wound care to Resident #7's open area to his right calf area. Resident #7 cried out in pain during the cleansing of the wound by Unit Manager #2 and she continued to provide wound care without assessing, offering pain medication, or stopping the procedure to relieve the pain. On 12/12/18 at 10:33 AM, Unit Manager #2 stated she should have assessed Resident #7's pain level prior to the dressing change and should have stopped when he yelled out in pain. Unit Manager #2 stated she should have completed the dressing change 30 minutes after he received his pain medication not 3 1/2 hours later. Resident #7 was harmed when the facility failed to stop the dressing change when he cried out in pain.

Based on record review, review of the facility's hospice agreement, and staff interview, it was determined the facility failed to ensure a resident did not experience a delay of treatment and received coordinated care between the facility and a hospice provider. This was true for 1 of 4 (#4) residents reviewed for hospice care. This failure harmed the resident when a lack of coordination between the facility and a hospice agency resulted in a delay of treatment, the resident experienced [DIAGNOSES REDACTED], and a physician-ordered PRN [MEDICAL CONDITION] medication was not given as ordered. Findings include: The facility's Hospice Agreement, dated 10/16/09, documented: * Initial Plan of Care - Hospice shall furnish Facility with a copy of the Hospice Plan of Care within 24 hours of: 1) its completion or 2) Hospice Patient's admission to Facility, whichever is later. * Coordination - 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 that (are) contained therein. Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of frontal lobe ([MEDICAL CONDITION]), convulsions, and [MEDICAL CONDITION] with hospice services in place. Resident #4's 2/10/16 discharge summary from a local inpatient hospice facility documented prescriptions were to be obtained by the hospice agency and delivered to the nursing facility. physician's orders [REDACTED]. Resident #4's temporary care plan documented the resident had end stage [MEDICAL CONDITION] and received hospice services related to [MEDICAL CONDITION]. Resident #4's clinical record did not contain a hospice plan of care or delineation of duties and services. Resident #4's 2/11/16 Hospice Visit Note documented, Please fax any new orders .so we can keep our MAR/chart current. Resident #4's 2/16/16 physician's orders [REDACTED]. Resident #4's 2/16/16 Nursing Notes documented: * 9:45 am - CNA called this nurse to room. Resident noted to be having [MEDICAL CONDITION] activity. Resident un-responsive to verbal/tactile stimulation. Resident was rolled onto left side and staff stayed with resident to monitor. Nurse notified (hospice provider) of [MEDICAL CONDITION] activity and PRN [MEDICATION NAME] 1 mg SL given at this time .Resident resting comfortably at this time . * 10:00 am - Nurse made round to check on resident and noted resident to be having [MEDICAL CONDITION] activity. Resident rolled onto side and staff stayed to monitor. Nurse notified hospice of again of (sic) [MEDICAL CONDITION] activity, hospice nurse stated that she would make round and bring [MEDICATION NAME] suppositories. *10:15 am - Resident continues to have [MEDICAL CONDITION] activity. Staff at bedside to monitor. Resident rolled onto left side to prevent aspiration. * 10:30 am - (Physician) notified of resident's [MEDICAL CONDITION] activity and need for IM [MEDICATION NAME] .Medication was pulled out of E-Kit and administered. Hospice nurse here and [MEDICATION NAME] suppository administered . *11:00 am - Resident #4 was transported to a local hospice facility. On 5/27/16 at 11:00 am, LN #1 reviewed her progress note and said Resident #4 had an initial [MEDICAL CONDITION] at 9:45 am on 2/16/16 and after a few minutes the [MEDICAL CONDITION] stopped. She said at 10:00 am the [MEDICAL CONDITION] returned and continued until the hospice nurse arrived to administer the [MEDICATION NAME] suppository at approximately 10:30 am. She said during this time RCM #1 left to look for the [MEDICATION NAME] suppository while LN #1 stayed with Resident #4. RCM #1 told LN #1 the medication could not be found in the facility or the E-Kit and the physician ordered Stat IM [MEDICATION NAME] for the [MEDICAL CONDITION]. On 5/27/16 at 11:45 am, the DON said she could not find Resident #4's care plan or delineation of duties in the clinical record, which would have indicated what care and treatment the facility and the hospice provided. She said although there was no delineation of duties in the chart, the hospice agency was responsible for providing Resident #4's medication and should have provided the facility with the [MEDICATION NAME] suppository. She said Resident #4 experienced a delay in treatment for [REDACTED]. She said the facility attempted to treat Resident #4 with the Stat IM [MEDICATION NAME] after discovering the suppository was unavailable. On 5/27/16 at 2:00 pm, with the DON present, RCM #1 said that on 2/16/16, after Resident #4 began to experience [MEDICAL CONDITION], the physician instructed her to administer the [MEDICATION NAME] suppository and after not finding the suppository in the facility or in the hospice E-Kit, the physician ordered the Stat IM [MEDICATION NAME]. She said once the suppository was not found and the hospice nurse was notified, the hospice nurse was at the facility within 20 minutes with the suppository. She said the facility should have checked the hospice E-Kit when Resident #4 was admitted to make sure the suppository was included.

Based on record review and staff interview, it was determined the facility failed to ensure medications were available for 1 of 4 (#4) residents reviewed for hospice care. This failure harmed Resident #4 when a Phenobarbital suppository was not available and was not administered as ordered when the resident experienced [DIAGNOSES REDACTED]. Findings included: Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of frontal lobe (brain cancer), convulsions, and epilepsy with hospice services in place. Resident #4's 2/10/16 discharge summary from a local inpatient hospice facility documented prescriptions were to be obtained by the hospice agency and delivered to the nursing facility. Resident #4's 2/10/16 physician's orders [REDACTED]. Resident #4's 2/16/16 Nursing Notes documented: * 9:45 am - CNA called this nurse to room. Resident noted to be having seizure like activity. Resident unresponsive to verbal/tactile stimulation. Resident was rolled onto left side and staff stayed with resident to monitor. Nurse notified (Hospice Provider) of seizure like activity and PRN Ativan 1 mg SL given at this time .Resident resting comfortably at this time . *10:00 am - Nurse made round to check on resident and noted resident to be having seizure like activity. Resident rolled onto side and staff stayed to monitor. Nurse notified hospice of again of (sic) seizure activity, hospice nurse stated that she would make round and bring Phenobarbital suppositories. *10:15 am - Resident continues to have seizure like activity . Staff at bedside to monitor. Resident rolled onto left side to prevent aspiration. *10:30 am - (Physician) notified of resident's seizure activity and need for IM Ativan .Medication was pulled out of E-Kit and administered. Hospice nurse here and Phenobarbital suppository administered . On 5/27/16 at 11:00 am, LN #1 reviewed her progress note and said Resident #4 had an initial seizure at 9:45 am on 2/16/16 and after a few minutes the seizure stopped. She said at 10:00 am, the seizures returned and continued until the hospice nurse arrived to administer the Phenobarbital suppository at about 10:30 am. She said during this time RCM #1 left to look for the Phenobarbital suppository, while LN #1 stayed with Resident #4. RCM #1 told LN #1 the medication was not in the facility or hospice E-Kit. On 5/27/16 at 11:45 am, the DON said the hospice agency was responsible for providing Resident #4's medication and should have provided the facility with the Phenobarbital suppository. She said Resident #4 experienced [DIAGNOSES REDACTED] due to not receiving the suppository after 5 minutes of seizure activity as the order specified. On 5/27/16 at 12:45 pm, the pharmacist said Phenobarbital was not a medication she stocked in the facility's E-Kit. She said each hospice provider supplied their own E-Kits and varied on what was supplied. On 5/27/16 at 2:00 pm, with the DON present, RCM #1 said that on 2/16/16, after Resident #4 began to experience seizures, the physician instructed her to administer the Phenobarbital suppository, but after not finding the suppository in the facility or in the hospice E-Kit, the physician ordered Stat IM Ativan. She said once the suppository was not found and the hospice nurse was notified, the hospice nurse was at the facility within 20 minutes with the suppository. She said the facility should have checked the hospice E-Kit when Resident #4 was admitted to ensure the suppository was included.

Based on record review and interview, it was determined the facility failed to provide care and services in accordance with professional standards for 1 of 4 (#11) residents sampled for diabetic management. The facility failed to measure blood glucose as ordered by the physician, failed to provide prompt interventions for critically low blood glucose levels, and failed to provide care according to facility policy and protocol regarding monitoring food intake and reporting abnormal blood glucose measurements. The facility administered injectable insulin to Resident #11 without physician orders. Resident #11 required hospitalization in response to an altered level of consciousness secondary to [DIAGNOSES REDACTED] and urinary tract infection. The facility failure to ensure and implement a coordinated system to monitor blood glucose, monitor food intake, administer medications as ordered by the physician, and provide appropriate and timely interventions for critically low blood glucose levels placed Resident #11 and 26 residents in the facility who required care for diabetes mellitus in immediate jeopardy and at risk of serious injury or death. On 10/10/14 at 11:20 AM, the Administrator, DNS, and Regional Nurse Consultant were notified of the Immediate Jeopardy involving the facility ' s three conflicting diabetic management policies, its lack of interventions for critically low blood glucose readings, and its practice of nurses writing orders outside their professional scope of practice for - and then administering insulin injections without prior physician order. The facility submitted an acceptable Abatement Plan to the Bureau of Facility Standards on 10/20/14 at 9:38 AM and included: The facility would not accept a new referral with a diabetic [DIAGNOSES REDACTED]. The abatement plan was verified by an on-site follow-up by surveyors on 10/27/14. The American Diabetes Association's (ADA) Standards of Medical Care in Diabetes, January 2010, defines [DIAGNOSES REDACTED] as a glucose level less than 70 mg/dl (milligrams per decaliter). The ADA (http://www.diabetes.org), which documented, "Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma, and death," described initial "treatment" for [DIAGNOSES REDACTED] to include: ? "Consume 15-20 grams of glucose or simple carbohydrates ? Recheck ... blood glucose after 15 minutes ? If [DIAGNOSES REDACTED] continues, repeat ? Once blood glucose returns to normal, eat a small snack if (the) next planned meal or snack is more than an hour or two away." Review of the history and physical showed Resident #11 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged to the hospital on [DATE], and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician Telephone Order, dated 9/6/14, documented, "Per family check FSBG (finger stick blood sugars) (at) AC/HS (before meals, and at bedtime)." The resident's blood glucose record, however, revealed staff did not measure the resident's BG level from admission on 9/5/14 until 9/7/14 at 5:30 PM. On 9/7/14 an electronic Physician order [REDACTED]." Prior to her 9/16/14 discharge to the hospital, Resident #11's Sliding Scale Insulin (SSI) flow sheet documented the following blood glucose (BG) levels: ? 9/11/14 - 40 mg/dl ? 9/12/14 - 46 mg/dl ? 9/13/14 - 48 mg/dl ? 9/14/14 - 37 mg/dl The Diabetic Treatment Administration Record, dated 9/11/14 through 9/14/14, documented the resident did not receive any intervention or monitoring for the identified low BG levels, except for 9/14/14, when she was given orange juice. The Nurse Progress Notes dated 9/11 through 9/13 did not document whether the resident exhibited signs and symptoms of [DIAGNOSES REDACTED], blood glucose values, interventions administered, resident response to interventions, or whether the physician/family had been notified. The SSI flow sheet, dated September 2014, however, documented the resident received HS (bedtime) insulin on 9/10, 9/11, 9/12, and 9/13. A telephone order, dated 9/12/14, documented, "Nursing to assure resident receives HS snack due to (decreased/low) AM BG." A telephone order dated 9/13/14 documented, "Offer 1 cookie (with) 2% milk for HS snack." The MAR indicated [REDACTED]. Additionally, the September 2014 Meal Monitor record documented the resident refused or was not offered dinner on 9/9, 9/10, 9/12, and 9/14; ate twenty five percent or less of dinner on 9/7 and 9/11; and refused or was not offered PM and HS snacks on 9/5 through 9/14. The facility's Guidelines for Nursing Care of a Resident with Diabetes Mellitus, documented the dietician, nurse, and physician would assess the resident's nutritional needs and determine food preferences. Additionally, the facility would provide appropriate diagnostic testing to determine nutritional status, identify dietary needs, complications, and risk factors. There was nothing documented in the resident's record to indicate the CNAs reported the resident's lack of food intake to the Licensed Nurse (LN) and the LN documented the resident received HS snacks daily from 9/12/14 through 9/15/14. A Nurse Progress Note, dated 9/14/14, documented, "Blood sugar was low this AM, orange juice given and resident had breakfast, came up adequately. Sliding scale (insulin) administered per MAR indicated [REDACTED] The 9/14/14 Nurse Note did not document whether the resident exhibited signs and/or symptoms of [DIAGNOSES REDACTED], BG level 15 minutes after the intervention, whether the intervention was repeated, or whether the physician and family had been notified. A SBAR (Situation, Background, Assessment, Request) Communication Form, dated 9/16/14 at 5:35 PM, documented a FSBS measurement of 148 mg/dl with the resident exhibiting body jerking, unfocused eyes, increased confusion, unfocused thoughts, and other signs of [MEDICAL CONDITION]. On 9/16/14, Resident #11 discharged to the hospital, where an emergency room Report documented a BG of 70 mg/dl. The resident was admitted with altered mental status related to [DIAGNOSES REDACTED] and urinary tract infection. The resident's Hospital Progress Note, dated 9/19/14, documented "Altered consciousness due to urinary tract infection and diabetes with [DIAGNOSES REDACTED] now off [MEDICATION NAME]." The resident's Hospital Discharge Medication Orders, which also served as the facility's admission orders [REDACTED] - "Insulin [MEDICATION NAME]: 0 units SUBCUTANEOUS Before Meals Per sliding scale And At Bedtime." - Discontinue [MEDICATION NAME] 250 mg twice daily. - Discontinue [MEDICATION NAME] 250mg twice daily. - Discontinue [MEDICATION NAME] 1200 mg at bedtime. - Discontinue [MEDICATION NAME] 5 mg by mouth every Monday and Thursday. The resident's Hospital Discharge Medication Orders, dated 9/20/14, did not include an order for [REDACTED]. On 9/20/14, facility nursing staff - without prior consultation with the resident's physician - wrote the following admission orders [REDACTED] - [MEDICATION NAME] 100 unit/mL subcutaneous solution: Subq (subcutaneous) before meals and at bedtime insulin sensitive sliding scale. - [MEDICATION NAME] 500 mg tablet, give 1/2 tablet (250 mg) by mouth twice daily. - [MEDICATION NAME] 50 mg tablet, give 1 tablet by mouth as needed - four times a day every 6 hrs as needed for pain 1-5. - [MEDICATION NAME] 600 mg tablet five 2 tabs (1200 mg) by mouth at bedtime. - [MEDICATION NAME] 5 mg 1 tablet by mouth two times per week. - Glimepiride 4 mg tablet twice daily. - [MEDICATION NAME] 0.625 mg one tablet by mouth daily. The Nursing Home admission orders [REDACTED]"Med(ication) clarifications. D/C glimepiride and [MEDICATION NAME]!!!" Review of the resident's morning blood glucose levels after her return to the facility revealed the following: ? 9/17/14 - 50 mg/dl ? 9/18/14 - 63 mg/dl ? 9/22/14 - 49 mg/dl ? 9/23/14 - 48 mg/dl ? 10/1/14 - 60 mg/dl ? 10/8/14 - 51 mg/dl The Diabetic Treatment Administration Record did not document the resident received any interventions for the identified low BG levels on 9/22/14, 9/23/14, or 10/8/14. Nurse Progress Notes documented the following: ? 9/22/14 - " Blood sugars have been 49 this am (morning) and 280 at 11 am. Covered per MAR ... " ? 9/23/14 - " Low blood sugars today. 48 at breakfast and 61 at lunch ... " ? 10/8/14 - " This morning her BG was 51, gave OJ. BG came up to WNL (within normal limits) quickly. " The Nurses Notes for these three days did not document whether the resident had signs or symptoms of [DIAGNOSES REDACTED], blood glucose level 15 minutes after the intervention, whether the intervention was repeated more than once, the resident ' s response to the intervention, or whether the physician and family had been notified. Three facility procedures and policies - the Hypoglycemic Reaction Policy (HRP), Hypoglycemic Protocol (HP), and the Insulin Sensitive Sliding Scale (ISSS) - instructed staff to document in the disciplinary notes and nurses notes all signs and/or symptoms, resident assessment, blood glucose values, attempts to give oral carbohydrates, [MEDICATION NAME] injection location, the resident's response, and notification of physician and family. The three procedures and policies, however, contained the following discrepencies: ? The HP was to be implemented when BG was less than 60 mg/dl. ? The HRP did not indicate a blood glucose level, but instead instructed nurses to use " good clinical judgment. " ? The ISSS instructed staff to refer to the HP when fasting blood sugar was less than 60 mg/dl. ? The HP directed staff to repeat interventions until BG was greater than 100 mg/dl. ? The HRP directed staff to give supplemental carbohydrates if the BG remained low, however there was no value provided for " low, " or when interventions were to be discontinued. ? The ISSS instructed staff to repeat interventions until BG was greater than 80 mg/dl. ? The HP and ISS instructed staff to notify the physician of BGs less than 60 mg/dl, while the HRP instructed staff to call the physician and family if the resident failed to respond to interventions. On 10/10/14 at 11:20 AM, the DNS confirmed the resident ' s 9/20/14 Hospital Discharge Orders did not include insulin and Glimepiride. The DNS stated the facility wrote a clarification order for Glimepiride on 9/20/14, however the insulin was not included. When asked why nursing staff wrote an order for [REDACTED]. When asked why nursing then wrote orders for Glimepiride, [MEDICATION NAME] at bedtime, [MEDICATION NAME], and [MEDICATION NAME], the DNS did not answer. When asked whether the Physician compared the discharge medication orders with the admission orders [REDACTED]. NOTE: The resident's physician/facility medical director was out of the state at the time of survey and despite attempts by facility staff to contact her, she could not be reached. On 10/10/14 at 7:55 AM, the DNS was asked why nursing staff did not follow the facility's hypoglycemic protocol and document, signs/symptoms of [DIAGNOSES REDACTED], blood glucose values, resident assessment, interventions administered, the resident's response, and notification of physician and family. The DNS stated she could not answer, but stated the staff must have given the resident something for her low blood glucose levels because the resident was able to go to breakfast and participate with therapy on the mornings her blood sugars were low. On 10/10/14 at 11:20 AM, the Executive Director (ED), DNS and Regional Nurse Consultant (RNC) were asked why the resident received sliding scale insulin at HS on nights that she did not eat or refused dinner, PM and/or HS snack. The DNS said she was not sure and could not answer because she was not there. The DNS said the LN providing cares at the time may not have been informed by the CNA that the resident did not eat. When asked why there were discrepancies on the Meal Monitor flow sheets and the MAR for the identified dates related to the HS snack, the ED, DNS, and RNC did not answer. The DNS was then asked how the facility identified that a cookie was an appropriate HS snack for a diabetic resident. The DNS said she was not sure who chose the cookie and it was probably not an appropriate HS snack because the resident's blood sugar would drop during the night. The DNS was asked at what point should nursing staff have discussed the HS insulin dose with the physician related to low AM blood sugars. The DNS stated, "Nursing failed to think critically and look at the big picture." Additional information received from the facility on 10/14/14, 10/15/14, and 10/16/14 did not resolve the identified concerns. The facility failed to follow its own diabetic management policy, failed to ensure a resident received meals and snacks before administering insulin, failed to notify the physician of critically low blood glucose levels, and nursing staff - without prior consultation with the resident's physician - wrote admission orders [REDACTED].

Based on review of resident records, Incident/Accident reports and staff interviews, it was determined the facility failed to ensure a resident received adequate supervision to prevent a fall with injury and to ensure siderails were assessed to be safe prior to use. This was true for 2 of 7 (#s 8 & 16) sampled residents. Resident #16 was harmed when she fell , sustained a femur fracture, and required surgical intervention. 1. Resident #16 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical, documented, the 8/28/14 hospital admission was related to an acute fracture of the left superior and inferior pubic rami. The physician documented the resident had significant injuries over the past year and a half, with right hip fracture in June 2013 requiring open reduction and internal fixation, and a non-surgical pelvic fracture on 6/19/14. The current Admission MDS, dated [DATE], coded the resident required extensive assist of two people for transfers and toileting. The resident's balance for seated to standing and moving on/off the toilet was coded as not steady and only able to stabilize with human assistance. The facility's Falling Leaf program, updated on 9/3/14, documented, a resident with a falling leaf on his/her doorway and/or wheelchair was at high risk for falls. "Please be aware of these residents and check on them frequently to assure that they are not ambulating or transferring independently. Remember, if you pass a doorway marked with an orange leaf, you must check on them each time you pass by. Be proactive, offer toileting, food/drinks, and assure needed items are within reach, including call light." The care plan, dated 9/8/14 and 9/16/14 (current care plan), identified Resident #16 was at risk for falls with injury related to a fall risk score of 14, a recent fall(s), history of fall(s) with injury, and non-compliance with safety instruction. Additionally, the 9/16/14 care plan identified the resident was legally blind in the left eye. Care plan interventions dated 9/8/14 and 9/16/14, documented assistance of one person for transfers/ toileting and glasses on (the resident) prior to getting (him/her) out of bed. Additionally, the 9/16/14 interventions included, education to resident/family on call light use. Interventions added on 9/30/14 documented, "Provide frequent checks for safety, cue (resident) to wait (and) call for help, and resident placed on the Falling Leaf program." The Fall Risk Evaluation, dated 9/8/14, 9/14/14, and 9/16/14 documented the resident's fall risk score was 10 or more and directed staff to promptly put interventions in place. The interventions included, "9/8 cue to wait for assistance, 9/14 non-compliant would not use call light, re-educated on call light use, send to ER for evaluation for increased pain. Call sinage (sic) placed in room, 9/16 re-educated to call light use. Encouraged to call when doing any transfers." The Occupational Therapy daily treatment notes on 9/6/14 documented, "Upon therapist arrival, patient attempting to clean self following incont(inent) of bowel episode. 'I couldn't get to toilet in time.' Patient admits she did not wait for assistance due to urgency. Educated patient on requesting assistance for safety." The Incident/Accident report and Nurse Progress note dated 9/14/14 documented, "Was summoned to (room number) observed resident sitting on buttocks. Left leg in L shape and right leg extended, ask (sic) what happened resident stated that she tried to grab to (sic) bars by the toilet, and lost her grip and fell backward. Resident refused to get out of bed and go to the bathroom last night, bed abd(omen) cloths (sic) were saturated with urine, CNA put the resident on toilet and asked her to use the call light when she was done." The CNA left the room to assist another resident and when she returned to Resident #16's bathroom the resident was on the floor. On 9/14/14, Resident #16 was transported to a local hospital where the Operative report documented the resident had a comminuted left intertrochanteric/sub-trochanteric hip fracture (left femur) which required surgical intervention with open reduction internal fixation. The Physical Therapy daily treatment notes on 9/17/14 documented, "Co(current) (treatment) with OT secondary to low activity tolerance due to pain and present need for 2 person assist with mobility and ADLs; " 9/21/14 - "(Resident) unable to perform L LE (left lower extremity) exercises today due to increase (sic) hip pain;" 10/5/14 - the PT transferred the resident from the wheelchair to the toilet and asked the resident to use the call light when she was ready. "I heard pt transfer. I asked pt why she didn't use call light. The (resident) said she knows she needs to use it and self transferring has caused her falls." The Occupational Therapy daily treatment notes documented, 9/18/14 - "Seen for OT/PT co(current) treatment due to moderate LLE pain and poor activity tolerance following a new L(eft) hip ORIF;" 9/30/14 - "Pt stated 'they are changing my room to put me closer to the nurses station, I don't know what all the fuss is about.' Pt education for using call light secondary to safety secondary to TTWB on left LE. Pt reluctantly agreed to use the call light." A Final X-ray Report dated 10/7/14, read, "S/P (status [REDACTED]." On 10/10/14 at 8:55 AM, RCM #5 confirmed she was aware the resident had a history of [REDACTED]. The RCM stated the Fall care plan, dated 9/8/14, did not include interventions and should have included frequent checks and/or the Falling Leaf program. The RCM was asked why the Fall care plan dated 9/16/14 did not include "provide frequent checks for safety and Falling Leaf program,"which were not implemented until 9/30/14, or 14 days after the resident readmitted with the femur fracture. The RCM stated the interventions should have been care planned when the resident re-admitted on [DATE]. On 10/13/14 at 9:20 AM, the ED and DNS were notified of the above concern. When asked why a resident who was at increased risk for falls and poor safety awareness was left unattended on the toilet, the DNS said the resident didn't need to have staff wait with her because she is alert, oriented, and knows how to use the call light. The DNS said the resident had received increased supervision based on the location of her room on the 300 hall. "This hall is the rehabilitation hall and staff are in and out of residents' rooms all time and therefore all residents on this hall receive increased supervision." The DNS was asked why the Admission MDS and the care plan did not document the same information related to the resident's transfer and toileting needs. The DNS said she did not know, but confirmed the MDS documented the resident was a two person extensive assist for transfers and toileting and the Care Plan documented the resident was a one person extensive assist. No further information was provided to resolve this concern. 2. Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's care plan for the focus of potential for falls, dated 7/20/14, documented an intervention "1/2 Side Assist Rail X (times) 2 to promote bed mobility." The record contained Initial and Quarterly Restraint Assessments dated 2/25/14, 5/9/14, 6/9/14 and 10/9/14, signed by LN #3. Although there was a place on each assessment to document (check) that the "device (siderails) had been assessed to be appropriate and safe for use by this resident," the box was not checked. There was no other evidence that the siderails were assessed to be appropriate and safe. The resident was observed in bed with 1/2 siderails X 2 on: 10/6/14 at 2:00 PM, 10/7/14 at 2:30 PM and 3:32 PM. On 10/9/14 at 12:15 PM, LN #3 was asked for a siderail safety assessment on Resident #8. None was provided. On 10/14/14 at 9:50 AM, the Administrator and DON were informed of the observation. No further documentation was received from the facility regarding this issue.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure that a resident who entered the facility without a pressure sore did not develop a pressure sore. This was true for 1 of 5 (#3) sampled residents reviewed for pressure sores. The facility failed to assess and monitor a stage II pressure sore on Resident #3's coccyx from 6/18/13 to 7/23/13. During that time, the stage II pressure sore developed into a stage III pressure sore, causing Resident #3 harm, and put the resident at further risk for pain and infection. Findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's 3/26/13 significant change MDS assessment, coded in part: -Long and short term memory ok -Independent for daily decision making -Usually understood -Understands others -Dependent of two persons for bed mobility and transfer -Locomotion on and off the unit did not occur -Extensive assistance of 1 person for eating and personal hygiene -Extensive assistance of 2 persons for dressing, toilet use, and bathing -Upper and lower extremity impairment on one side -Always incontinent of urinary and bowel -Wheelchair use -At risk for developing pressure ulcers -No healed or unhealed pressure ulcers -Moisture associated skin damage (MASD) Resident #3's 6/26/13 most recent quarterly MDS assessment differed from the significant change assessment as follows: -Sometimes understood -Dependent of two persons for dressing, and toilet use -Extensive assistance of one person, for locomotion on and off the unit -Extensive assistance of two person for personal hygiene -Had an unhealed pressure ulcer -Had one stage 2 pressure ulcer -Date of oldest stage 2 pressure ulcer, 6/18/13 Resident #3's 1/11/13 "Braden Scale For Predicting Pressure Sore Risk" assessment documented Resident #3 scored a 15, "At risk" for developing pressure sores. Resident #3's care plan identified the problem: "8/2/12: Resident is at risk for developing a pressure ulcer related to immobility, disease process/condition post stroke" Approaches included in part: -Assist PRN to reposition/shift weight to relieve pressure, -avoid prolonged periods of skin to skin contact, -complete Braden scale risk assessment quarterly PRN, -complete weekly skin assessment, -notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care, -position with pillows to maintain proper body alignment PRN, provide incontinence care after incontinence episodes. Apply barrier cream PRN, -provide pressure relieving or reduction device: pressure reduction mattress, chair cushion -report changes in skin status to physician -2/12/13 turning and repositioning program frequently -use lifting device, draw sheet to reduce friction Additional care plan identified problems for Resident #3 included in part: "Wound type/location - 6/18/13 Stage II open area coccyx, this area heals and re-opens, moisture related excoriation" Approaches included in part: -Complete Braden Scale Risk Assessment quarterly and PRN, -Complete Weekly Skin Assessment, -Educate resident' responsible party about skin condition, treatment, -Inspect skin during bathing, especially over bony prominences, -Observe for pain and medicate PRN per physicians's orders, -Observe for s/s (sign and symptoms) infection or delayed healing and report to physician PRN, redness/[DIAGNOSES REDACTED], drainage-purulent or bloody, -Report changes in skin status to physician, -Wound care as ordered (see current physician's orders [REDACTED]. "3/21/2013 Resident is diagnosed with [REDACTED]. [MEDICAL CONDITION] with mets (metastasis) to the brian (sic) Resident is at risk for unavoidable significant declines initiation (sic) of Palliative cares" Approaches included in part: -Allow resident to discuss feeling if able and -Notify physician for change in condition. The 7/1/13 "physician's orders [REDACTED]. -8/7/12-Span America Air Mattress, -8/31/12-Side to side positioning every 2 hours, -12/01/12-Weekly skin assessment every Saturday Evening shift, -3/01/13-LN to monitor function of air mattress daily. F314 regulations state: "With each dressing change or at least weekly (& more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed &: o Location & staging; o Size (perpendicular measurements of the greatest extent of length & width of the ulceration), depth; & the presence, location & extent of any undermining or tunneling/sinus tract; o Exudate, if present: type (such as purulent/serous), color, odor & approximate amount; o Pain, if present: nature & frequency (e.g., whether episodic or continuous); o Wound bed: Color & type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); & o Description of wound edges & surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate." Resident #3's "Weekly Skin Integrity Data Collection" tool read, "If Open Area, proceed to appropriate skin condition record" and documented in part: -3/1/13-Skin Intact, -3/16/13-Skin Condition: Old, on R buttock excoriation, -4/6/13 & 4/13/13-Skin intact, dry, redness coccyx, -4/20/13 & 4/24/13-Skin intact, dry, -5/4/13, 5/12/13, 5/18/13, & 5/19/13-Skin intact, dry, redness coccyx, -5/26/13-Skin intact, dry, redness, excoriated area on coccyx, open area, -(Not dated)-Skin intact, dry, excoriated area on coccyx healing, open area, Old, -6/8/13-Skin intact, dry, excoriated area on coccyx healing, -6/15/13-Skin intact, dry, excoriated area on coccyx, -6/22/13-Skin intact, dry, -6/29/13-Skin intact,dry, -7/23/13-Open area, Old, -7/27/13-Dry, Open area, Old. Note: The Care Plan quoted above identified that a stage II pressure ulcer was discovered on Resident #3's coccyx on 6/18/13. There was no description of the Stage II pressure ulcer from 6/29/13 to 7/23/13 on the "Weekly Skin Integrity Data Collection" tool. Resident #3's 6/1/13 TAR documented in part: "12/01/12 Weekly Skin assessment Every Saturday Evening Shift" "6/27/13-Cleanse open area on coccyx c (with) NS (normal saline) then apply Allevyn Gentle Q 3 days." Note: A physicians order for treatment to the wound was ordered on [DATE]. This was 9 days after the care plan had identified the wound. Resident #2's 7/1/13 TAR documented in part: "12/01/12 Weekly Skin Assessment Every Saturday Evening Shift" The TAR was initialed as completed on July 6 and 13. July 20 and July 27 were blank, and indicated no assessment was provided. Note: Although the "Weekly Skin Assessment" was initialed as completed on July 6 & 13, there was no documentation of the Stage II Pressure Ulcer, and there were no entries on the "Weekly Skin Integrity Data Collection" tool from June 29 to July 23, 2013. This did not meet the minimum requirement as directed by F314 regulation as mentioned above when evaluating and documenting pressure ulcers. The order to "Cleanse open area on coccyx (with) NS then apply Allevyn Gentle Q 3 days" was discontinued on 7/24/13. A new treatment was initiated on 7/24/13 that read: "Cleanse area on coccyx (with) NS apply iodosorb to wound bed. Cover (with) Allevyn Gentle (change) Q M-W-F (Monday-Wednesday-Friday) (and) PRN until resolved." Note: There was no evidence the Stage II Pressure Ulcer on Resident #3's coccyx was assessed, measured, or monitored from 6/18/13 to 7/23/13. There was no documentation the treatment the resident was receiving was effective or should have been changed. Then, on 7/23/13, the Stage II pressure ulcer had become a stage III pressure ulcer. Resident #3's 7/25/13 Progress Notes documented: "Late entry for 7/23/12. Skin team in to assess coccyx wound. Area measures 1x1.0.1cm. 100% superficial slough noted to wound bed. Periwound skin with blanchable [DIAGNOSES REDACTED]. No drainage or s/sx of infection noted. Continues with air mattress, Q 2 hr (every 2 hours) side to side turns. Remains on palliative care and comfort meds. Resident continues to refuse to eat. Takes liquids and health shakes only. Discussed with resident and spouse consequences of continued refusal to eat and likely outcome of continued or worsened skin breakdown. Resident and spouse continues to request no aggressive interventions and remain on palliative care. Spouse at facility daily and very involved in resident cares." On 7/31/13 at 10:00 am, RCM #2 was interviewed regarding Resident #3's coccyx pressure ulcer. RCM #2 said Resident #3 had excoriation to the coccyx that would come and go, but developed a Stage II pressure ulcer to the coccyx on 6/18/13. The Stage II pressure ulcer developed into a Stage III pressure ulcer which was covered in slough. The surveyor informed RCM #2 of the blanks in the documentation of Resident #3's July TAR, and the lack of documentation for June 29, 2013 to July 23, 2013 in the "Weekly Skin Integrity Data Collection" tool. The surveyor requested documentation of the monitoring of Resident #2's coccyx pressure ulcer. On 7/31/13 at 1:40 pm, the surveyor observed the wound treatment to Resident #3's coccyx. LPN #5 said, "I don't remember the area around the wound being that red" and measured the wound to be 2.2x3.0 cm. The wound was covered in what appeared to be white colored, soft, and moist slough. On 7/31/13 at 3:00 am, RCM #2 provided the "Pressure Ulcer Status Record" and explained the difference in the "Weekly Skin Assessment" versus the "Pressure Ulcer Status Record". RCM #2 said the nurse working the floor completes an overall body check of the resident's skin for the weekly skin assessment. If open areas are found, the wound team is notified and the findings are recorded on the "Pressure Ulcer Status Record". The wound team makes rounds for the residents with pressure wounds one time a week. The wound round team measures, stages, and assesses the wounds during these rounds and documents the findings on the "Pressure Ulcer Status Record". She said the nurse that initially discovered the Stage II pressure ulcer on Resident #3's coccyx on 6/18/13, did not notify the wound team of the pressure ulcer, and the wound team failed to monitor or assess the wound until 7/23/13. Resident #3's "Pressure Ulcer Status Record" documented: Risk Factors related to Healing: "Incontinence" Date First Observed: "6/18/13" Stage: "II" Location: "Coccyx" Surface area: "2x2 cm" Depth: "1 cm" Date: 6/18/13, Stage: II, Surface Area in cm: 2cmx2cm, Depth: 1cm, Drainage: none, Odor: 0, color: red, Tunneling: 0, Appearance of wound: (blank), Response to Treatment: No change, Is resident experiencing pain: Yes, Non-Verbal Signs: Moaning/Crying, Location of Pain: Coccyx Date: 7/23/13, Stage: III, Surface Area in cm: 1x1, Depth:0.1cm, Drainage: None, Odor: 0, Color: Yellow, Tunneling: 0, Appearance of wound: Slough 100%, Response to Treatment: Deteriorated, Is resident experiencing pain: No, Non-Verbal Signs: (blank), Location of Pain: (blank) Date: 7/30/13, Stage: 3, Surface Area in cm: 0.8x1.5, Depth: 0.2, Drainage: None, Odor: 0, Color: yellow, Tunneling: (blank), Appearance of wound: Slough 100%, Response to Treatment: Deteriorated, Is resident experiencing pain: No, Non-Verbal Signs: (blank), Location of Pain: (blank) Note: There was no evidence or documentation the Stage II Pressure Ulcer on Resident #3's coccyx was assessed, measured, or monitored from 6/18/13 to 7/23/13. There was no evidence or documentation the treatment the resident was receiving was effective or that the treatment should have been changed. On 7/23/13, the Stage II pressure ulcer was documented as a stage III pressure ulcer. On 8/1/13 at 12:30 pm, during an interview with the DON, the DON agreed that the nurse who documented the Stage II pressure ulcer did not follow through the facility's protocol. The nurse failed to notify the wound team so that the wound team was aware to assess and monitor the wound. The DON said the staging of pressure ulcers was performed by two nurses and Resident #3 had developed a Stage III pressure ulcer on her coccyx. On 8/1/13 at 1:30 pm, the Administrator was informed of the concern of the Stage III pressure ulcer on Resident #2's coccyx. No information or documentation was provided that resolved the issue.

Based on observation, family and staff interviews, and record review, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers (PUs). This was true for 2 of 4 sample residents (#1 and #2) reviewed for PUs. Specifically, Resident #1 was harmed when two stage II PUs developed on the resident's sacral area; and, Resident #2 was harmed when unstageable PUs developed on both of the residents big toes, the right 2nd toe, and the right heel. In addition, for 1 of the 4 sample residents (#7) reviewed for pressure ulcers, the Weekly Skin Integrity Data Collection forms were not comprehensive which placed Resident #7 at risk for development of additional pressure ulcers. Findings include: 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 9/21/11, the resident's family elected the hospice benefit for end stage dementia. Resident #1's significant change MDS assessment, dated 12/30/11, coded in part: * Short and long-term memory problems; * Severely impaired cognitive skills for daily decision making; * Acute change in mental status; * Extensive assistance of 2 people for bed mobility, transfers, and toilet use; * Extensive assistance of 1 person for dressing, personal hygiene, and bathing; * Wheelchair (w/c) use; * Frequent bowel and bladder incontinence; * At risk for PUs; * No healed or unhealed PUs; and * Pressure reducing device for chair and bed and turning/repositioning program. On 3/16/12, Resident #1's Care Plan identified the acute problem, "(P)ressure areas (bilateral) sacral area will resolve (with) tx (treatment) by 4/16/12." Approaches included treatment per the physician's orders [REDACTED]. A 3/26/12 care plan entry noted, "Problem areas resolved." Review of Nurse's Notes (NN), dated 12/11/11 through 4/9/12, revealed the following: * 3/16/12 - "(Changed) dressings to backside (left) sacral area measures .6 (by) .6 cm (centimeters). (Right) sacral area measured 1 (by) .6 cm. (D)ermagran-b applied (and) covered with Allevyn Gentle. Will continue to monitor. No s/sx (signs/symptoms) of infection..." Note: There were no entries about Resident #1's skin prior to the 3/16/12 entry. * 3/17, 3/19, 3/21, and 3/23 - Noted dressing changes and the absence of s/sx of infection; * 3/26/12 - "Spots to backside resolved..." Weekly Skin Integrity Data Collection (WSIDC) sheets documented Resident #1's skin was intact every week from 1/3/11 through 4/10/12, except on 3/20/12. The 3/20/12 WSIDC documented Resident's skin condition as, "Other: Wound nurse to keep measurements" and "Old" in the area to note if the open area was new or old. No other description areas (such as dry, bruises, rash, redness, skin tears, or blisters) were marked. Resident #1's Pressure Ulcer Status Records (PUSRs) revealed the following documentation: * 3/16/12 - A stage II PU on the left sacral area and a stage II PU on the right sacral area. The left PU measured 0.6 by 0.6 cm. The right PU measured 1 by 0.6 cm. Incontinence and immobility were noted as risk factors related to healing for both of the PUs; * 3/19/12 - Both of the stage II sacral PUs were improved; and * 3/26/12 - Both of the sacral PUs were resolved. On 4/11/12 at 11:25 a.m., Resident #1 was observed as CNA #6 and CNA #7 assisted her to toilet in her bathroom. Two round, intact, slightly red spots (each approximately 0.6 cm in diameter, or about the size of the head of an eraser) were noted on the resident's sacral area. One spot was on the left and one was on the right of the sacral area. On 4/11/12 at 2:30 p.m., when asked about Resident #1's stage II sacral PUs, the Wound Nurse (WN) stated, "If I remember correctly, they were discovered before they were brought to my attention." The WN reviewed the resident's clinical record then said she did not find any documentation about the sacral PUs before her own documentation on 3/16/12. The WN said she did not know who applied a dressing on the resident's backside before 3/16/12. The WN stated, "I think they (the sacral PUs) could have been avoidable. I think it was the bed alarm sitting on top of the mattress, that was the culprit." Resident #1 was harmed when she developed 2 stage II PU on her sacral area. During the end of day conference on 4/13/12 at 10:40 a.m., the Administrator, the DON, and the Regional Director of Clinical Services were informed of the concern for harm to Resident #1 related to PU. No other information was received from the facility. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 4/29/11 admission MDS assessment and the most recent quarterly MDS assessment, dated 1/12/12, documented no pressure ulcers were present. Resident #2's current undated Care Plan (CP) identified the problem of pressure areas to bilateral great toes, right heel and right 2nd toe. The CP was hand written and signed by the wound nurse on 3/7/12. The CP goal was to resolve the pressure areas with no signs or symptoms of infection. The CP approaches included Prevalon boots when in bed, alert charting, slippers when in room (document refusals) and treatments as ordered by the physician. The CP was revised on 3/21/12 to float the resident's heels when in bed. The prior CP for potential skin breakdown, dated 1/12/12 included weekly skin assessments, pressure reducing mattress for bed and chair, and to observe skin during cares and notify the LN of any red or open areas. The 1/12/12 CP did not address any interventions for the prevention of pressure ulcers to the feet. NOTE: CMS guidance at F314 includes that tissue closest to the bone (such as the heel) may be the first tissue to undergo necrosis (dying skin). Pressure Ulcer Risk Assessments completed on 12/11/11, 1/1/12 and 1/15/12 documented the resident was at risk to develop pressure ulcers, with scores of 17, 16 and 16 respectively. Weekly Skin Integrity Data Collection forms reviewed for 11/6/11 through 4/8/12 revealed the following: 11/6/11- Skin intact - dry 11/13/11 - No weekly skin assessment. 11/20/11- Skin intact - dry 11/27/11 - Skin intact - dry 12/4/11 - Skin intact - dry 12/11/11 - Skin intact - dry 12/18/11 - Skin intact - dry 1/25/11 -No assessment 1/1/12 -Skin intact - dry 1/8/12 - No assessment 1/15/12 - No information on form 1/29/12 - Skin intact - red/Red area on coccyx 2/8/12 - Picture had a circle on the buttocks but no other description 2/15/12 - No assessment 2/19/12 - Skin intact -redness bottom-old 2/26/12 - Skin intact-dry -redness (area of redness not identified) 3/4/12 - Skin intact-dry -redness (area of redness not identified) 3/11/12 - No assessment 3/18/12 - Skin intact - dry NOTE:The wound nurse Pressure Ulcer Status Record (PUSR) documented on 3/7/12 "Found areas of suspected deep tissue injury to bilateral great toes, right 2nd toe and right heel. 3/25/12 - No assessment 4/1/12 -Skin intact - dry 4/8/12 - Skin intact - dry PUSRs and nurse's notes completed by the wound nurse (WN) documented the following: Date - Surface - Drainage/odor - Appearance - Progress * Right heel - Not stageable due to suspected deep tissue injury 3/7/12 - 3 x 3 cm - - 100% necrotic - 3/14/12 - 1.7 x 2 cm none - blackened - 3/19/12 - 2.5 cm diameter none dark red/necrotic improved 3/21/12 - none blackened - 3/28/12 There was no information for 3/28/12 4/2/12 - 2 cm diameter none dark/necrotic improved 4/9/12 - 1 cm diameter none black/hard/necrotic - * Right 2nd toe - Not stageable due to suspected deep tissue injury 3/7/12 - 0.3 x 0.4 cm - 100% necrotic - 3/14/12 - 0.4 x 0.3 cm none blackened - 3/19/12 - 0.4 cm x 0.4 cm none red blister like deteriorated 3/21/12 - - none blackened - 3/28/12 - There was no information for 3/28/12 4/2/12 - 0.3 x 0.2 cm none red improved 4/9/12 - 0.3 cm x 0.3 cm none red blister like/hard no change * Right great toe - Not stageable due to suspected deep tissue injury 3/7/12 - 0.5 x 0.7 cm - 100% necrotic - 3/14/12 - 0.6 x 0.6 cm none blackened - 3/19/12 0.5 cm diameter none red blister no change 3/21/112 - - none blackened - 3/28/12 - There was no information for 3/28/12 4/2/12 - 0.7 x 0.7 cm none red blister no change 4/9/12 - 0.7 x 0.7 cm none red blister no change * Left great toe -Not stageable due to suspected deep tissue injury 3/7/12 - 0.4 x 0.1 cm - 100% necrotic - 3/14/12 - 1.2 x 1.1 cm none blackened - 3/19/12 - 0.5 x 1.3 cm none red blister deteriorated 3/21/12 - - none blackened - 3/28/12 - There was no information for 3/28/12 4/2/12 - 0.6 x 1.2 cm none red no change 4/9/12 - 0.7 x 0.9 cm none red hard blister improved On 4/11/12 at 2:10 p.m. the WN was asked the stage of the four pressure ulcers. The wound nurse stated they were unstageable as they were deep tissue injuries. When asked if Resident #2 had the pressure ulcers for some time prior to being referred to her care, she stated yes. When asked about the missing data, she stated she worked part time as the wound nurse and it was difficult to provide the care and documentation for each resident with pressure ulcers. When asked why the weekly skin sheets did not identify the 4 pressure ulcers, she referred me to the RCM. On 4/13/12 at 8:40 a.m. the RCM for the 200 hall stated the 3/4/12 and/or the 3/18/12 weekly skin assessments should have reflected the 4 pressure ulcers. The surveyor asked the RCM about the missing skin assessments. The RCM stated she would look for them. On 4/13/12 at 10:40 a.m. the DON provided skin assessments to the surveyor that had already been reviewed. The DON was informed the information had previously been reviewed, and was provided the dates there were missing skin assessments. The facility provided no further information. 3. Resident #7 was admitted to the facility on [DATE], and most recently re-admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 3/15/12 Physician admission orders Braden weekly x 4 weeks (evaluate skin weekly for 4 weeks)." The resident's Care Plan identified the 3/15/12 resident need of, "at risk for break in skin integrity." Relating to, "Pressure Ulcer (left) heel" and "Non-pressure Ulcer site: SDTI on (right) ischial." The resident's Initial Data Collection Tool/Nursing Service (Admission Assessment), signed by a LN on 3/15/12 at 3:00 p.m., documented: - 2 "pressure" areas, one on the left heel and another on the resident's sacral area - bruised upper posterior left and right arms - bruised right and left lower quadrants - bruised posterior left hand and left toe a. A RN signed the resident's 3/22/12 Braden Scale for Predicting Pressure Sore Risk. Numbers were entered adjacent to 6 different Risk Factor areas, however, the "Total Score" block was blank. The Total Score Key identified 15-18 as "At Risk." There was no score key higher than 18 on the form. By addition of the numbers, the resident's Total Score was "19." b. The resident's WSIDC form contained the following: - 3/25/12, 2 checkmarks. One next to, Skin Intact" and one next to, "Dry." - 4/7/12, 3 checkmarks. One next to, "Skin Intact," one next to "Dry," and one next to, "Old." Note: On the WSIDC form, there were no other entries related to the areas identified on the Admission Assessment although the form had spaces to identify additional skin areas. In addition, the body diagrams on the WSIDC form were blank. The Wound Nurse (WN) documented in Nurse's Notes, from 3/16/12 to 4/4/12, that the resident received treatments for the left heel and the right sacral buttocks area. On 4/10/12 at 9:30 a.m., the resident stated, "They (the nursing staff) have suggested numerous times that I quit trying to wear a cowboy boot on my left foot." On 4/12/12 at 11:55 a.m., the surveyor informed the Regional Director of Clinical Services (Regional RN) of the lack of information on the WSIDC forms. The surveyor also identified to the Regional RN the facility's WN documentation. The Regional RN stated, "Yes, the Weekly Skin (WSIDC) forms should have more accurate skin information. Having 2 pair of eyes look at a resident's skin is very important." On 4/13/12 at 10:45 a.m., the Administrator, the DON, and the Regional RN were informed of the finding. On 4/16/12 at 10:45 a.m., the Regional VP, the Regional RN, and the Administrator were informed of the finding. The facility did not provide any additional information.