Every finding on record at Life Care Center of Treasure Valley

Based on observation, record review, policy review, resident and staff interviews, it was determined the facility failed to ensure physician orders and professional standards of practice were followed. This was true for 4 of 24 residents (#1, #8, #58, and #88) reviewed for quality of care and 1 of 4 residents (Resident #82) whose medications administration was observed. This deficient practice placed residents at risk for unmet care needs, potential decline in conditions and the potential for adverse drug reactions or ineffective treatment. Findings include: 1a.Resident #88 was admitted to the facility on [DATE] with multiple diagnoses, including cognitive communication deficit, muscle weakness, Parkinson's disease (a slow brain disorder that makes it hard to move), and diabetes. A physician order dated 4/22/26 documented: prevalon boot(s) to bilateral heels while in bed; remove and check skin integrity every shift. Resident #88 was observed in bed without prevalon boots on for the following dates and times: -8/4/26 at 8:24 AM -8/5/26 at 8:51 AM -8/6/26 at 11:50 AM During an interview on 8/6/26 at 12:01 PM, RN #5 reviewed Resident #88's physician order and confirmed Resident #88 was to wear prevalon boots while in bed. RN #5 accompanied the surveyor to Resident #88's room and confirmed Resident #88 was not wearing his prevalon boots and should have been wearing the prevalon boots. b. Resident #58 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction (stroke) affecting the left dominant side, difficulty in walking, and cognitive communication deficit. The care plan initiated 2/9/24 documented, Resident #58 had the potential for skin breakdown with interventions to apply Prevalon boots to both feet while in bed and check skin integrity every shift, float heels while in bed, and notify the nurse of any refusals. A physician's order dated 5/13/26, documented staff to apply Prevalon boots to bilateral feet while in bed and check skin integrity every shift. The August 2026 MAR and TAR documented, the ordered Prevalon boots were being applied for the following dates, including day and night shifts; - 8/1/26 - 8/2/26 - 8/3/26 - 8/4/26 - 8/5/26 - 8/6/26 Observations were made of Resident #58 in bed without the Prevalon boots on both feet or heels floating on the following dates and times. The Prevalon boots were also observed to the right of the bed on top of the clothing hamper; - 8/3/26 at 1:54 PM - 8/4/26 at 8:46 AM - 8/4/26 at 3:34 PM - 8/6/26 at 10:11 AM On 8/6/26 at 10:11 AM, Resident #58 stated she made a deal with one of the nurses that she would not have to wear the boots if she had a pillow under her feet. Resident #58 stated she did not think the nurse wrote down the deal because they always forget. She further stated that there was no pillow under her feet at that moment because she and the staff forgot about it. On 8/6/26 at 11:57 AM, RN #3 reviewed Resident #58's medical record and stated the order for Prevalon boots instructed the boots to be on both feet while in bed and to check the integrity of the skin. RN #3 stated Resident #58 spends most of the time in bed so the Prevalon boots should always be on, however, Resident #58 often will refuse the boots. RN #3 stated that she was not sure if the refusals have been communicated with the provider. RN #3 stated it should be documented when Resident #58 refuses but the aides are so busy that they often forget to let her know or make a note. On 8/6/26 at 12:31 PM, the ADON reviewed the August 2026 MAR/TAR for Resident #58 and stated that the documentation showed Prevalon boots were applied for all shifts. The ADON stated most of the time Resident #58 will refuse or kick them off and when that happens staff should be documenting a refusal. The ADON stated the order was not being followed if Resident #58 refused the boots and it was not documented. 2. The facility's PRN Physician Standing Orders policy, revised on 12/17/19, documented the following medications should be given for Bowel Care Protocol Standing Orders: To be listed PRN MARs: 1. Bisacodyl 5 mg, give 2 tablets to equal 10 mg PO on the [NAME] shift if no BM x3-days prn/bowel care; 2. Dulcolax suppository PR (per rectum) on the evening shift if no results from Bisacodyl/Bowel Care; 3. Fleets enema PR on night shift if no results from Dulcolax, and notify MD for further bowel care needs, (contact physician prior to administering fleets enema if resident has a diagnosis of Inflammatory Bowel disorder. a. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including orthostatic hypotension (a sudden drop in blood pressure while standing up from sitting or lying down), muscle weakness, cognitive communication deficit, adult failure to thrive, diabetes, and major depression. Resident #1's physician's orders documented: Bisacodyl EC (enteric coated) Tablet Delayed Release 5 MG (laxative), give 2 tablet by mouth as needed for 3 days without bowel movement, give on day shift, initiated 12/16/24. Resident #1's care plan, initiated on 12/4/25, directed staff to provide bowel medication per current MD/NP orders. A review of Resident #1's medical record documented that he did not have a bowel movement on the following dates in July 2026: - 7/15-7/18 (4 days); - 7/29 - 8/1 (4 days). A review of Resident #1's July 2026 MAR, did not document any medication administration on the dates listed above. On 8/6/26 at 2:05 PM, the DON stated Resident #1's medical record did not document he was provided bowel medication as ordered. b. Resident #88 was admitted to the facility on [DATE] with multiple diagnoses, including cognitive communication deficit, muscle weakness, Parkinson's disease (a slow brain disorder that makes it hard to move), and diabetes. A review of Resident #88's care plan, revised 5/7/26, directed staff to administer bowel medication per current MD/NP orders. A physician's order dated 4/22/26 documented Resident #88 was to receive Miralax oral packet 17 grams (Polyethylene glycol 3350) give 1 scoop enterally as needed for bowel care; for no bowel movement (BM) in 2 days. A review of Resident #88's bowel movement log from 7/8/26-8/6/26 documented no bowel movement for the following dates: -7/23/26 -7/24/26 -7/25/26 -7/26/26 -7/27/26 -7/28/26 A review of Resident #88's July 2026 MAR documented Resident #88 received Miralax on 7/26/26 and 7/27/26. On 8/6/26 at 1:56 PM, the DON confirmed the physician order for Miralax was not followed and Resident #88 should have received Miralax on 7/25/26. 3. Review of the facility's policy titled, Physician Orders dated 2/11/26 documented, medications, diets, therapy, and any treatment may not be administered to the resident without a written order from the attending physician. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included Pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus), difficulty in walking, and Rheumatoid Arthritis (a long-term autoimmune disease where the immune system attacks the lining of the joints). On 8/3/26 at 10:13 AM, Resident #8 was observed to be in her room sitting in a recliner wearing a black knee brace on the right leg. On 8/5/26 at 1:36 PM, Resident #8 was observed returning to her room in wheelchair wearing a black knee brace on the right leg. The order summary showed no documentation of an order for a knee brace to be applied on the right knee of Resident #8. The care plan revised 7/13/26 showed no documentation of Resident #8's use of a knee brace. On 8/5/26 at 2:27 PM, Resident #8 was observed to be sitting in a recliner in her room wearing a black knee brace on the right leg. Resident #8 stated she used the brace to assist with the pain she experiences. She stated she went out and bought the knee brace herself because her insurance would not cover it. Resident #8 stated staff must assist her in placing the brace because she cannot put it on herself. On 8/6/26 at 7:52 AM, a staff member was observed assisting Resident #8 with applying a black knee brace to the right leg. On 8/6/26 at 10:28 AM, RN #3 stated if a resident wanted to start wearing a brace, she would need to get a provider order for one and further stated almost everything needs an order. RN #3 stated they would need to get an order for a brace because the staff would need to check the integrity of the skin and make sure the application of the brace was appropriate. RN #3 stated Resident #8 uses a knee brace to help her get in and out of her chair and stated that the CNAs usually help her apply it. RN #3 reviewed Resident #8's orders and confirmed there is no order for a knee brace and that the ADON would know more about it. On 8/6/26 at 10:34 AM, the ADON stated that she was not aware of Resident #8 wearing a knee brace and stated that Resident #8 does not have a current order for one as she came into the facility for Pneumonia. The ADON stated if she was aware of Resident #8 using a knee brace without a physician's order, she would have to contact the provider for an order. The ADON stated that staff are expected to report on any new treatments that are not ordered to ensure resident safety. 4.The facility's Medication Management policy revised 9/9/25 documented that the facility will ensure medications were administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. The policy also documented that staff were responsible for medication administration medication would adhere to the 10 rights of Medication Administration namely: a. Right Drug b. Right Resident c. Right Dose d. Right Route e. Right Time and Frequency f. Right Documentation g. Right Assessment h. Right to Refuse i. Right Evaluation / Response j. Right Education and Information. Resident #82 was admitted to the facility on [DATE], with multiple diagnoses including difficulty walking, muscle weakness and diabetes. A physician's order dated 7/15/26, directed staff to apply Lidocaine External Cream 4%, to Resident #82's left knee two times a day for pain. Review of Resident #82's August 2026 MAR documented Lidocaine External Cream 4% (Lidocaine). Apply to L [left] knee topically two times a day for pain. On 8/6/26 at 8:41 AM, RN #1 was observed to apply Lidocaine 5% anorectal cream to Resident #82's left knee. On 8/6/26 at 10:50 AM, RN #1 showed the Lidocaine 5% anorectal cream to the Surveyor and stated he applied the cream to Resident #82's left knee. On 8/6/26 at 11:32 AM, the DON was informed of the Lidocaine 5% anorectal cream was applied to Resident #82's left knee. The DON then reviewed Resident #82's physician's order and stated the physician's order was not followed.

Based on observations, staff interviews, policy review, and review of the Food and Drug Administration (FDA) Food Code 2022, it was determined the facility failed to ensure the resident food refrigerators were being used appropriately, dry storage foods were stored properly, and walk-in refrigerator fans and cooking equipment were clean. These deficiencies had the potential to affect the 100 residents, 7 of which were residents who received enteral tube feedings, who consumed food, prepared, and stored by the facility. This deficiency had the potential to place residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:The FDA Food Code (2022) Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.The FDA Food Code (2022) Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. Review of the facility policy titled, Food from Outside Sources, dated 5/22/26 documented that, food stored in designated refrigerators/freezers should be labeled with the resident's name and room number, date received and use by date according to established guidelines for food safety.Review of the facility policy titled, Food Safety, dated 5/26/26 documented that food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth.On 8/7/26 at 1:55 PM, during a kitchen walkthrough and interview with the Dietary Manager (DM), the following was observed:- In the dry storage room, one 5-gallon clear container with a teal lid containing green split peas, with no dates or labels;The DM stated the split green pea container should have been labeled and dated. - In the walk-in refrigerator, the two ventilation fans located on the back wall had a grey fluffy coating on the fans with the same grey fluffy coating scattered on the ceiling nearby;The DM stated, the fans get serviced and cleaned every three months and that it must be close to that cleaning time again.On 8/7/26 at 2:18 PM, during the A-Wing resident refrigerator/freezer walkthrough with the DM, the following was observed:- One clear resealable plastic bag with 2 pink soft gel ice packs with a room number written on the bag, no names or dates;- Two light blue ice packs with black straps;- All food items in the refrigerator were observed to only have a room number written on the item, no dates or names.On 8/7/26 at 2:25 PM, during the D-Wing resident refrigerator/freezer walkthrough with the DM, the following was observed:- One blue ice pack used for therapyThe DM stated she did not know where the therapy ice packs should be stored and further stated she would talk with the Unit Managers.

Based on record review, policy review, review of the American Nurses Association (ANA), and staff interviews, it was determined the facility failed to provide residents with the opportunity to make informed treatment decisions related to the risks and benefits of treatment. This was true for 2 of 6 residents (#1 and #12) whose records were reviewed for informed consent. This deficient practice created the potential for harm if Resident #1 was not provided with psychotropic medication education prior to starting the medications, and the potential for psychosocial harm when Resident #12 was not offered an opportunity to discuss the placement of a bathroom door alarm. Findings include: 1. The facility's Medication Management policy, revised 5/6/22, documented nursing should provide the right education and information to provide enough knowledge to the residents of what drug he/she would be taking and what the expected therapeutic and side effects are. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including orthostatic hypotension (a sudden drop in blood pressure while standing up from sitting or lying down), muscle weakness, cognitive communication deficit, adult failure to thrive, diabetes, and major depression.Resident #1 had the following medications ordered:- Quetiapine Fumarate Oral Tablet 100 (atypical antipsychotic), give 1.5 tablet by mouth at bedtime for major depressive disorder related to major depressive disorder, recurrent, initiated, 12/16/24.- Lorazepam (benzodiazepine/anti-anxiety) Oral Tablet 0.5 mg, 1 tablet by mouth three times a day for anxiety related to anxiety disorder, give with 2 mg to 2.5 mg per dose, initiated 3/21/25.- Lorazepam Oral Tablet 2 mg, 1 tablet by mouth three times a day for anxiety related to anxiety disorder, give with 0.5 mg dose to equal 2.5 mg per dose, initiated 3/21/25.Resident #1's medical record did not include medication consents for quetiapine fumarate or lorazepam.On 8/7/26 at 4:17 PM, the DON stated via email there were no medication consents for quetiapine or lorazepam for Resident #1 prior to 8/7/26.2. The American Nurses Association (ANA) standards, accessed on 8/13/26, documented patient education is a critical component of nursing practice, ensuring residents are informed about their care, including the use of assistive devices. The ANA highlights the necessity for nurses to provide comprehensive information to residents about the purpose, benefits, and potentials risks of assistive devices, allowing residents to make informed decisions about their care. Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia, difficulty walking, muscle weakness, and cognitive communication deficit.On 8/3/26 at 3:10 PM, Resident #12 stated she had fallen multiple times in the bathroom as she did not like to wait for staff to help her as it was uncomfortable to wet herself. She stated she did not have a choice about the bathroom alarm door and did not recall being asked if there was any other way to alert staff when she needed to use the restroom.A review of Resident #12's record documented she had multiple falls in her bathroom on the following dates: 5/11/25 and 5/23/26.An Interdisciplinary Team progress note, dated 5/26/26, documented Resident #12 was to have a bathroom door alarm placed to alert staff when she was going into the bathroom.A review of Resident #12's record did not include an assessment or conversation with Resident #12 or her representative related to the bathroom door alarm prior to its placement.On 8/7/26 at 2:56 PM, the DON stated via email there was no documentation associated with assessing and discussing the bathroom dorm alarm with Resident #12.

Based on observation, record review, policy review, review of the ANA website, review of the Lippincott Manual, staff and resident interviews, it was determined the facility failed to ensure position change alarms and bolster mattresses were appropriately assessed as a potential restraint. This was true for 2 of 3 residents (#4 and #72) whose records were reviewed for potential physical restraints. This failure created the potential for Resident's #4 and #72 freedom of movement to be restricted and dignity to be inhibited. Findings include: Review of the facility's policy, Position Change Alarm Use, revised 9/3/25 documented, The facility should also take steps to identify issues that place the resident at risk for falls and implement approaches to address those risks in a manner that enables the resident to achieve or maintain his or her highest practicable physical, mental, and psychosocial wellbeing. The Position Change Alarm Use policy further documented, The facility should evaluate the position change alarm to determine if the use of the device meets the definition of a physical restraint and refer to the Physical Restraint Policy for additional guidance. 1. Resident #72 was admitted to the facility on [DATE], with multiple diagnoses that included polyneuropathy (numbness, tingling, and weakness usually starting symmetrically in the feet and hands), difficulty in walking, and a history of falls. The care plan initiated 7/1/25 documented Resident #72 was at risk for falls with interventions to place bed alarm per family request. A Physical Restraint Informed Consent form dated 9/29/25 documented the type of restraining device used was a bed alarm, the frequency and duration of the device was for when in bed, and the medical reasons for the restraining device was family request. The Informed Consent was signed by Resident #72's family member. A physician's order documented a start date 9/29/25 at 4:23 PM for a bed alarm per family request. An Annual MDS assessment dated [DATE] documented Resident #72 to be assessed as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. On 8/3/26 at 8:52 AM an observation was made of a Change Pad Indictor alarm dangling underneath Resident #72's bed. On 8/4/26 at 1:41 PM Resident #72 stated the staff put an alarm on his bed because the staff were afraid he was going to try to leave the building. Resident #72 stated he has asked multiple times for the alarm to be removed because every time he moves the alarm goes off. Resident #72 stated he is often met with no response from the staff when he requests the alarm to be removed. He further stated the alarm bothers him because he feels as though he cannot move around in his bed without staff running into his room appearing like they need to tackle him for moving. On 8/4/26 at 4:50 PM, the DON stated a bed alarm could be used if a resident has had multiple falls and the facility has exhausted all fall prevention interventions. The DON stated an evaluation, consent, and provider order needed to be done to be able to use a bed alarm. The DON reviewed the Physical Restraint Consent form in Resident #72's medical record and stated that under the medical reason for the restraint was written, per family request and the consent was signed by Resident #72's Durable Power of Attorney for Healthcare (DPOA). The DON stated that a DPOA would go into effect when a resident is cognitively impaired and it would depend on the needs of the resident. The DON stated Resident #72 had a recent BIMS of 15. The DON stated at the time the consent was signed, Resident #72 was moderately cognitively impaired. The DON further reviewed the order summary for Resident #72 and stated the provider order bed alarm per family request does not have an appropriate medical indication. The DON stated that there may be evaluations for the bed alarm in his paper chart as she could not find any in the record. On 8/5/26 at 2:42 PM, Resident #72 stated the alarm on his bed goes beep, beep, beep, beep every time he tries to move and further stated he is trapped in his bed and staff refuse to take the alarm off when he asks them to. 2. The ANA, accessed 8/14/26, emphasized the need for individualized assessments and the use of the least restrictive interventions to ensure resident safety and autonomy. When considering the use of a bolstered mattress for a paraplegic resident, it is essential to evaluate whether the device serves as a supportive aid or if it functions as a restraint. The Lippincott Nursing Manual provided guidelines for assessing the appropriateness of assistive devices and modification, stressing the importance of evaluating their impact on resident mobility and independence. Any device, including a bolstered mattress, should be assessed for its potential to restrict movement or be perceived as a restraint. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia, muscle weakness, and diabetes. On 8/4/26 at 8:35 AM, Resident #4 was observed laying in his bed on a bolstered mattress. A review of Resident #4's medical record did not document a specific assessment for safety or restraint related to the use of a bolstered mattress. Resident #4's care plan, initiated on 3/31/26 documented and adjustable hi/low bed with bolsters to mattress. On 8/5/26 at 3:18 PM, the DON stated Resident #4 did not require an assessment for safety or restraint since Resident #4 had paraplegia and a bolstered mattress would not be considered a restraint.

Based on record review, policy review, and staff interviews, it was determined the facility failed to physician's orders. This was true for 1 of 5 residents (Resident #25) reviewed for unnecessary medication. This deficient practice created the potential for harm if Resident #25 medication administration was not followed as ordered. Findings include: The facility's Physician's Orders policy, revised 2/11/26, documented the facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including dementia, diabetes, anxiety, adjustment disorder, and depression, muscle weakness, cognitive communication deficit, and history of falling.Resident #12's physician order, initiated 9/26/25, documented Haloperidol Oral Tablet 2 MG (antipsychotic), give 2 tablets by mouth every 8 hours related to dementia. Resident #12 was observed on the following dates and times: -On 8/3/26 at 8:56 AM, Resident #25 was sleeping in his wheelchair, leaning to the right side. He did not wake up when the Surveyor knocked on the door to speak with him. -On 8/3/26 at 12:12 PM, during lunch observation, Resident #25 was observed sleeping in his wheelchair in the Restorative Dining Room. CNA #1 attempted to wake him up saying, [Resident #25] are you going to eat? Resident #25 did not respond. The IP stated if he is like that [sleeping] it's difficult for us to wake him up. -On 8/3/26 at 12:15 PM, CNA #1 sat next to Resident #25 and asked, Do you want mashed potato? Resident #25 did not respond. The IP asked a staff member to bring Resident #25 to his room. -On 8/4/26 at 8:45 AM, Resident #25 was observed in his room sleeping in his wheelchair, leaning to the left side with hands closed in a fist resting on his chest. -On 8/5/26 at 9:39 AM, Resident #25 was located in the Activities Room, sleeping in his wheelchair with his head leaning to the left side. -On 8/5/26 at 10:41 AM, Resident #25 was observed still sleeping in his wheelchair in the Activities Room. -On 8/6/26 at 9:45 AM, Resident #25 was sleeping in his wheelchair in the Activity Room. A review of Resident #25's MAR documented, Haloperidol was not administered from May through August 5, 2026: -10 of 31 opportunities in May, coded 9 (sleeping)-14 of 30 opportunities in June, coded 9 (sleeping)-16 of 31 opportunities in July, coded 9 (sleeping)-3 of 5 opportunities in August, coded 9 (sleeping)There was no documentation in Resident #25's medical record the physician was notified of the missed doses of Haloperidol in the morning. On 8/7/26 at 10:27 AM, the DON stated if Resident #25 is sleeping, he does not receive the Haloperidol as it is a not an as needed (PRN) medication. However, as the medication order is written, it cannot be PRN. When asked if the physician was notified about Resident #25 sleeping through the morning and not taking the Haloperidol, the DON stated, We have not observed an increase in his sleeping. On 8/7/26 at 10:38 AM, when asked when the provider was notified about the need for the morning dose of Haloperidol medication, the DON stated there was no documentation related to notifying the physician, but she did find documentation related to Resident #25 sleeping in the morning and sleeping through his meals.

Based on record review, policy review, and staff interviews, it was determined the facility failed to ensure required health information was transmitted to the receiving provider upon transfer and failed to notify the Ombudsman advocate of resident transfers or discharges. This was true for 3 of 6 residents (#2, #20, and #106) whose records were reviewed for discharge documentation. This failure created the potential for harm if required health information was not provided to the receiving provider and the Ombudsman was not made aware a resident may require an advocate while out of the facility. Findings include:Review of the facility's policy, Transfers and Discharges reviewed 8/29/25 documented, The specific information which must be conveyed depends upon whether the resident is transferred (expected to return) or is discharged (not expected to return). If the resident is being transferred, and return is expected, the following information should be conveyed to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative infomation, including contact information; c. Advance directive information; d. Infection status, including but not limited to; presence of targeted organisms, symptoms, and the type of transmission-based precautions in use. This should be communicated through the use of the Transfer Form for Infection Control and Prevention UDA, unless the facility is located in a state where a mandated communication tool is required. e. The residents' comprehensive care plan goals; f. All other information necessary to meet the residents' needs through the use of a standardized communication method (e.g., eINTERACT Transfer Fonn), which includes, but may not be limited to: g. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; h. Diagnoses and allergies; i. Medications (including when last received); j. Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; k. Treatments and devices (oxygen, implants, IVs, tubes/catheters); l. Most recent relevant labs, other diagnostic tests, and recent immunizations. m. Additional information, if any, outlined in the transfer agreement with the acute care provider. 1. Resident #106 was admitted to the facility on [DATE], with multiple diagnoses including non-ST elevation myocardial infarction (a type of heart attack), atrial fibrillation (a common heart problem where the upper parts of the heart beat fast in an uneven way), and adult failure to thrive. a. A Progress Note dated 7/1/26 at 9:00 AM documented, Resident #106 was transferred to the hospital. An INTERACT Nursing Home to Hospital Transfer Form dated 7/1/26 did not include the following: -Contact information for the resident representative; -Current medication administration record (MAR). On 8/7/26 at 3:08 PM, when asked what documentation was sent when resident #106 transferred to the hospital, the DON stated the record did not specifically say what was sent when the resident transferred to the hospital. b. Resident #106's medical record documented he went to the hospital on 6/30/26 and 7/1/26 for stroke-like symptoms. A review of Resident #106's medical record did not include documentation the Ombudsman was notified of his transfers to the hospital. c. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes, muscle weakness, dementia, bipolar disorder, depression, and Alzheimer's. A review of Resident #2's medical record documented, he was admitted to the hospital on [DATE]. Resident #2's medical record did not show notification to the Ombudsman relating to his hospital transfer. On 8/5/26 at 11:58 AM, the Ombudsman stated they had not been notified of any transfers or discharges from the facility since October 2025. The Ombudsman stated they provided instructions to medical records on how to submit notifications. On 8/5/26 at 2:00 PM, the facility's Director of Medical Records (DMR) stated they had not been notifying the Ombudsman of discharges or transfers. 2. Resident #20 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included secondary Parkinsonism, difficulty in walking, and muscle weakness. An Alert Note dated 3/18/26 at 6:53 PM, documented Resident #20 had a low-grade fever of 99.5 degrees, and the on-call provider was made aware. The Alert Note documented to send Resident #20 to the emergency room if a fever starts or if Creatine Kinase/Kinase labs are too high. The Alert Note documented that Resident #20 was sent out to the hospital, family and management were made aware, and a verbal Bed Hold was received. Resident #20's medical record did not include documentation the required health information was sent with Resident #20 when she went to the hospital on 3/18/26. On 8/6/26 at 12:20 PM, the ADON stated when an unplanned transfer occurs staff must obtain a provider order, complete an E-Interact Transfer form and an Infection Control Transfer form, get a Bed Hold, call the receiving hospital, and make a progress note indicating what was sent with the resident and that the provider, family, and ombudsman was notified. On 8/6/26 at 12:24 PM, the ADON reviewed Resident #20's transfer documents. The ADON stated the nurse that handled the transfer only input a progress note and a Bed Hold. The ADON further stated the transfer was not completed properly.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure the minimum data set (MDS) accurately reflected a resident's status at the time of the assessment. This was true for 1 of 7 residents (Resident #72) whose MDS Assessment was reviewed for accuracy. This failure created the potential for Resident #72 to not receive appropriate person-centered care. Findings include:Review of the facility's policy titled Certification of Accuracy of the MDS dated [DATE] documented, the assessment must represent an accurate picture of the resident's status during the observation period of the MDS. The Observation Period (also known as the Look-back period) is the time frame over which the resident's condition or status is captured by the MDS assessment and ends at 11:59 p.m. on the day of the Assessment Reference Date (ARD). Be aware that different items on the MDS have different Observation Periods.1. Resident #72 was admitted to the facility on [DATE] with multiple diagnoses that included polyneuropathy, difficulty in walking, and a history of falls. A physician's order documented a start date 9/29/25 at 4:23 PM for a bed alarm per family request. Quarterly MDS Assessments under Section P - Restraints and Alarms, documented no bed alarm being used for the following assessment dates: -10/1/25-12/8/25 -3/2/26 An Annual MDS assessment dated [DATE] documented under Section P - Restraints and Alarms, documented no bed alarm being used.On 8/4/26 at 5:03 PM, the MDS Nurse stated she reviews and uses the data from the entire health record to ensure accurate information is being coded on the MDS. The MDS Nurse stated the accuracy of the assessment is important because the resident's health record must be accurate to ensure that they get proper care. On 8/4/26 at 5:09 PM, the MDS Nurse reviewed Resident #72's order summary and stated there was an active physician's order for a bed alarm per family request for a start date of 9/29/25. The MDS Nurse then reviewed the MDS Assessments dated 10/1/25, 12/8/25, 3/2/26, and 5/28/26 and stated that the bed alarm was not coded in the MDS when it should have been.

Based on record review, policy review, and staff interview, it was determined the facility failed to develop and implement residents' comprehensive person-centered care plan that addressed the specific needs, triggers and interventions related to a diagnosis of Post Traumatic Stress Disorder (PTSD). This was true for 1 of 24 residents (Resident #11) whose care plan was reviewed. This deficient practice placed Resident #11 at risk for emotional distress, re-traumatization and unmanaged behavioral symptoms. Findings include: The facility's policy titled, Comprehensive Care Plans and Conferences, revised 8/29/25, documented, The facility will ensure the timelines of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care.Resident #11 was admitted to the facility on [DATE] and re-admitted [DATE], with multiple diagnoses including PTSD (a mental health condition that can develop after you experience or witness a terrifying, life-threatening or traumatic event. It causes lasting symptoms like flashbacks, nightmares, severe anxiety, and emotional numbness that disrupt your daily life), depression, and chronic pain syndrome. On 8/5/26, a review of Resident #11's comprehensive care plan did not include the specific needs, triggers, and interventions related to her diagnosis of PTSD. On 8/5/26 at 3:50 PM, the DON stated, a resident with a PTSD diagnosis should have it care planned.

Based on record review, policy review, and staff interviews, it was determined the facility failed to provide quarterly care conferences for residents, and to provide care plan revisions. This was true for 4 of 24 residents (#2, #6, #12, and #25) whose care plans were reviewed. This deficient practice created the potential for harm if the care conferences for Residents #2 and #25 were not completed in a timely manner, and when Resident #6 and #12's care plan were not revised. Findings include:1. The facility's Care Panning - Baseline, Comprehensive, and Routine Updates, reviewed 12/4/25, documented the care plan must be updated with each MDS assessment and periodically. a. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including tracheostomy (a surgical opening made through the front of the neck into the windpipe), hemiplegia and hemiparesis (weakness on one side of the body due to a brain or spinal cord injury), muscle weakness, congestive heart failure (a chronic condition where the heart muscle cannot pump blood well), and depression.A physician's order, dated 3/20/26, documented the following:-Clean around stoma daily, apply skin prep around edges of stoma, allow to dry and apply round adhesive housing make sure flush against skin, then apply the Accufit Speakfree HME valve. (There is a brush to use in his room to clean inside the voice prosthesis). If he refuses this, please make a note everyday shift and as needed.Resident #6's care plan documented the following:- Resident has trach stoma, resident performs own trach care with staff ensuring daily that supplies are provided, initiated: 8/22/19;- Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. The resident's comfort will be maintained through the review date, initiated: 11/24/25.On 8/7/26 at 4:17 PM, the DON via email identified Resident #6's care plan was not accurate as Resident #6 was no longer caring for his stoma.b. Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low level of oxygen), difficulty walking, muscle weakness, and cognitive communication deficit.On 8/3/26 at 4:33 PM, Resident #12's bed was observed in the middle of her room with bedroom space available on both sides of her bed.Resident #12's care plan, dated 3/16/22, documented Resident #12's bed was placed against the wall for aesthetics.On 8/6/26 at 8:19 AM, the DON stated Resident #12 moved to a bigger room on 5/5/26 and her care plan was not updated related to having her bed against the wall.2. The facility's Comprehensive Care Plans and Conference policy, reviewed 8/29/25, documented the facility should provide the resident and resident representative with advance notice of care planning conference to enable resident/resident representative participation when they are available to participate, and to help facility their participation in the care planning process. a. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes, muscle weakness, dementia, bipolar disorder, depression, and Alzheimer's. A review of Resident #2's record documented an initial care conference was held on 2/20/26. No additional care conferences were documented in the medical record. On 8/5/26 at 10:20 AM, the SSD #1 stated, care conferences are held quarterly and documented in the medical record. The SSD #1 further stated, if the documentation is not there, the conference did not happen.b. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, cognitive communication deficit, history of falling, dementia, diabetes, anxiety, adjustment disorder, and depression.On 8/3/26 at 4:10 PM, Resident #25's representative stated he was concerned the facility had not reached out to him for care conferences. He had to request each one. Resident #25's medical record documented, Resident #25 had a care conference in December 2025 at the Representatives request.On 8/5/26 at 10:18 AM SSD #1 stated, there was no documentation in Resident #25's medical record that he or his Representative was invited to attend a care conference in March or June 2026.

Based on observations, policy review, record review, staff and resident interviews, it was determined the facility failed to ensure that respiratory care and services were provided consistent with professional standards of practice and physician orders. This was true of 2 of 7 residents (#7 and #29) evaluated for oxygen therapy. This deficient practice created the potential for Residents #7 and #29 to experience respiratory difficulties and/or impaired breathing. Findings include: The facility policy titled, Physician Orders, revised 2/11/26, documented, A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. 1. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive lung disease (COPD- a long-term disease that blocks airflow and makes it hard to breathe), pneumonitis (inflammation of the lung tissue, usually triggered by breathing in irritants), and difficulty walking. Resident #29's physician orders included the following: -Oxygen at 2 liters per minute continuously per nasal cannula, dated 7/21/26. A Skilled Nursing note dated 8/2/26 documented, Resident alert and oriented, able to make needs known, uses call light appropriately. On 8/4/26 at 9:37 AM, Resident #29 was observed not wearing oxygen in her room while sitting in a chair. The oxygen concentrator was off and without tubing. When Resident #29 asked about the use of the oxygen, she stated she does not use oxygen. On 8/5/26 at 3:10 PM, Resident #29 was observed in her room sitting in a chair, not wearing oxygen. The oxygen concentrator in Resident #29's room was off and without tubing. RN #1 came down to Resident #29's room and confirmed Resident #29 was not wearing oxygen and did not have tubing on the oxygen concentrator. RN #1 stated Resident #29 had not used the oxygen for two weeks and that it had been discontinued. RN#1 was asked to check the oxygen administration record, and RN #1 confirmed he had signed it off as given on day shift 8/5/26 for the day shift. RN #1 confirmed oxygen had been signed as given as ordered everyday since 7/21/26. RN #1 stated, I made a mistake. On 8/5/26 at 3:10 PM, Resident #29's medical record was reviewed. The record did not show documentation Resident #29's oxygen had been discontinued. On 8/5/26 at 3:28 PM, the DON stated, oxygen should be taken off the oxygen administration record as soon as it has been discontinued. The DON stated she could not find a discontinuation order for Resident #29's oxygen. The DON stated she would look for a discontinuation order for Resident #29's oxygen. 2. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia, COPD, history of traumatic brain injury (TBI-happens when a sudden hit, blow, or jolt to the head damages the brain and changes how it works), and adult failure to thrive. A physician order dated 12/3/25 documented: -Oxygen at 1 liters/minute (LPM) via nasal cannula to keep saturation greater than 90% as needed for chronic respiratory failure with hypoxia. On 8/3/26 at 10:26 AM and 8/6/26 at 2:53 PM, Resident #7 was observed in her bed with a nasal cannula in both nares with the oxygen concentrator set at 2 LPM. On 8/6/26 at 4:09 PM, RN #4 accompanied the surveyor to Resident #7's room and confirmed the oxygen concentrator was set at 2 LPM. On 8/6/26 at 4:11 PM, RN #4 reviewed the Physician's order dated 12/3/25 and confirmed the order was written for 1 LPM. When asked if Resident #7's oxygen concentrator was set per the Physician's order, RN #4 stated no and confirmed the oxygen concentrator should have been set at 1 LPM.

Based on observation, record review, policy review, drugs.com website review, and staff interview, it was determined the facility failed to ensure medications were stored securely on the medication cart. This was true of 1 of 1 residents (Resident #29) whose medication was found unsecured at the bedside. This deficient practice created the potential for undetected use and/or side effects of medications. Findings include: The facility policy titled, Storage and Expiration Dating of Medications and Biologicals, revised 6/30/26, documented, Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room Drug.com, accessed 8/14/26, list side effects of Opcon A eye drops commonly cause mild burning, stinging, temporary blurred vision, dilated pupils and light sensitivity. Overuse past 72 hours can lead to rebound redness. Serious risks include eye pain, vision changes, or severe allergic reactions. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including COPD, pneumonitis, and difficulty walking. On 8/4/26 at 9:37 AM, Resident #29 was observed in her room sitting in a chair, next to Resident #29, on the table was Opcon A (an over-the-counter eye drop that combines an antihistamine and a redness reliever, to provide temporary relief from itchy, red eyes caused by allergens). When asked what Resident #29 used the eye drops for, Resident #29 stated she uses them for allergies as needed. On 8/5/26 at 3:10 PM, RN #1 came down to Resident #29's room and confirmed she had Opcon A on the room table. When asked RN #1 if there was an order for the Opcon A , RN #1 stated there was no order and the medication needs an order. RN #1 further stated that the Opcon A should be on the medication cart. On 8/5/26 at 3:38 PM, the DON stated over the counter medications should have a physician's order and be placed on the medication cart for administration.

Based on observations, record review, policy review, resident and staff interviews, it was determined the facility failed to ensure medical records were accurate and complete clinical records were maintained in accordance with professional standards of practice. This was true for 2 of 24 residents (#1 and #29) whose records were reviewed for accuracy. This deficient practice had the potential for Resident #1 and #29 to result in clinical errors, inappropriate medical management and fragmented care. Findings include: The facility policy titled, Nursing Documentation, reviewed 8/29/25, documented, This facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice. It further documented, The medical record shall reflect a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status when any positive or negative condition change occurs, at a periodic reassessment and during the annual comprehensive assessment. The medical record must also reflect the resident's condition and the care and services provided across all discipline to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.1. Resident #29 was admitted [DATE], with multiple diagnoses including COPD, pneumonitis, and difficulty walking. Resident #29's physician orders included the following: -Oxygen at 2 liters per minute continuously per nasal cannula, dated 7/21/26. A Skilled Nursing note dated 8/2/26, documented Resident alert and oriented, able to make needs known, uses the call light appropriately. On 8/4/26 at 9:37 AM, Resident #29 was observed not wearing oxygen in her room while sitting in a chair. The oxygen concentrator was off and without tubing. When Resident #29 was asked about the use of the oxygen, she stated she does not use oxygen. On 8/5/26 at 3:10 PM, Resident #29 was observed in her room sitting in a chair, not wearing oxygen. The oxygen concentrator in Resident #29's room was turned off and was without tubing. RN #1 went to Resident #29's room and confirmed Resident #29 was not wearing oxygen and did not have tubing on the oxygen concentrator. RN #1 stated Resident #29 had not used the oxygen for two weeks and that it had been discontinued. RN #1 was asked to check the oxygen administration record, and RN #1 confirmed he had signed it off as given on 8/5/26 for the day shift. RN #1 confirmed oxygen had been signed as given as ordered everyday for all shifts since 7/21/26 night shift. RN #1 stated, I made a mistake. On 8/5/26 at 3:28 PM, the DON stated, oxygen should be taken off the oxygen administration record as soon as it has been discontinued. The DON stated she could not find a discontinuation order for Resident #29's oxygen. The DON stated she would look for a discontinuation order for Resident #29's oxygen. Resident #29's medical records reviewed 8/6/26, documented oxygen was given continuously starting 7/21/26 night shift through 8/5/26 day shift. The medical records documented the oxygen was discontinued 8/5/26 starting on the night shift. 2. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including orthostatic hypotension, muscle weakness, cognitive communication deficit, adult failure to thrive, diabetes, and major depression. A review of Resident #1's medical record documented he had been diagnosed with Dementia on 12/18/25. However, his care plan did not include any interventions for Dementia treatment. On 8/7/26 at 10:43 AM, the SSD #1 was asked about Resident #1's diagnoses and treatment of Dementia. The SSD #1 replied, [Resident #1] does not have dementia, he has a TBI (Traumatic Brain Injury.) On 8/7/26 at 12:53 PM, during a telephonic interview with the facility's Psychiatric Physician's Assistant stated Resident #1's medical record incorrectly documented a Dementia diagnosis, and should have been TBI instead.

Based on observation, record review, review of the American Lung Association website, and staff interviews, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 7 residents (Resident #29) observed for infection control. This deficient practice put Resident #29 at risk for cross contamination and infection. Findings include: The American Lung Association's, 'Patient Care Articles,' updated 5/29/26, documented, In a skilled nursing facility, proper storage of a nebulizer following American Lung Association guidelines requires disassembling the device, allowing all washed reusable parts to completely air-dry on a clean surface in a cool, dry place, and storing them in a clean enclosed container or bag to prevent bacterial growth and contamination. Resident #29 was admitted to the facility 7/21/26, with multiple diagnoses including COPD, pneumonitis, and difficulty walking. Resident #29's physician orders included the following: -Albuterol Sulfate Inhalation Nebulization Solution 2.5 mg/0.5 ml (Albuterol Sulfate) 0.5 ml inhale orally via nebulizer three times a day related to pneumonitis due to inhalation of food and vomit, dilute contents of 1 ampule (0.5 ml) in 2.5 ml of saline and administer via nebulizer, dated 7/21/26. Resident #29's August 2026 MAR documented, Resident #29 received the nebulizer treatments three times a day as ordered. On 8/4/26 at 9:37 AM, the nebulizer mask was observed in Resident #29's room, laying directly on the bedside stand, without a bag or clean covered container on it. On 8/5/26 at 9:30 AM, the nebulizer mask was observed on a stand, without a bag or clean covered container on it. On 8/5/26 at 3:10 PM, RN #1 while in Resident #29's room confirmed the nebulizer mask was on a stand without a bag or clean covered container. When asked how it should be stored, RN #1 stated in a bag or on a stand. On 8/5/26 at 3:28 PM, the DON stated a nebulizer mask should always be stored in a bag.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 5 of 19 residents (#4, #30, #34, #45, and #52) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with a readmission on [DATE], with multiple diagnoses including congestive heart failure (heart does not pump blood as well as it should) and major depressive disorder. On 11/11/24, Resident #4's PASRR level I documented she had diagnoses of depressive disorders, bipolar disorder, and anxiety disorders. The PASRR level I was to be forwarded to BLTC for further screening. On 11/21/24, Resident #4's PASRR Level II, documented diagnoses of bipolar, anxiety, and depression. Resident #4's PASRR level II was to be sent for further evaluation by a mental health authority. On 11/22/24, the mental health authority documented Resident #4 had diagnoses of Bipolar I, depression, and anxiety. Resident #4's MDS dated [DATE], did not document in section A1500, the resident had been evaluated by a PASRR level II and determined to have a serious mental illness. 2. Resident #30 was admitted to the facility on [DATE], and readmission on [DATE], with multiple diagnoses including muscle weakness and bipolar disorder. On 7/30/24, Resident #30's PASRR level I documented she had diagnoses of depressive disorders, bipolar disorder, and PTSD. The PASRR level I was to be forwarded to BLTC for further screening. On 8/1/24, Resident #30's PASRR Level II, documented diagnoses of depressive disorder, bipolar, and PTSD. Resident #30's PASRR level II was to be sent for further evaluation by a mental health authority. On 8/2/24, the mental health authority documented Resident #30 had diagnoses of major depression, bipolar, and PTSD. Mental health stable on medications. Resident #30's MDS dated [DATE], did not document in section A1500, the resident had been evaluated by a PASRR level II and determined to have a serious mental illness. 3. Resident #34 was admitted to the facility on [DATE], with multiple diagnoses including Guillain-Barre Syndrome (a condition which the body's immune system attacks the nerves causing weakness, numbness, or paralysis), bipolar disorder, and a history of PTSD. On 1/9/19, Resident #34's Preadmission Screening and Resident Review (PASRR) level I documented she had a diagnosis of personality disorder, bipolar disorder, and suspected anxiety. The PASRR level I was to be forwarded to BLTC for further screening. On 1/11/19, Resident #34's PASRR level II, documented she meets nursing facility level of care, has multiple diagnoses with medications and a recent psychiatric evaluation. Resident #34 requires further evaluation by a mental health authority. On 1/11/19, the mental health authority documented Resident #34 had a diagnosis of bipolar disorder, personality disorder, and suspected situational depression being treated with medication. She appears stable and no further evaluation is needed. Resident #34's MDS's dated 5/3/22, 10/24/22, 7/18/23, 4/23/24, and 2/27/25, documented in section A1500, the resident had not been evaluated by a PASRR level II and determined to have a serious mental illness. 4. Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including stroke, hypertension, and anxiety disorder. On 2/21/22, Resident #45's PASRR level I documented she had a diagnosis of bipolar disorder and suspected anxiety. The PASRR level I was to be forwarded to BLTC for further screening. On 2/22/22, Resident #45's PASRR level II, documented further evaluation by a mental health authority was required due to her diagnosis of bipolar, depression, and anxiety. On 2/24/22, the mental health authority documented Resident #45 had a diagnosis of bipolar disorder and anxiety. She was being treated with medication. She appeared stable and no further evaluation was needed. Resident #45's MDS's dated 1/5/23, 12/14/23, and 11/19/24, documented in section A1500, the resident had not been evaluated by PASRR level II and determined to have a serious mental illness. 5. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including esophageal obstruction (a blockage in the muscular tube that carries food from the throat to the stomach), malnutrition, and bipolar disorder. On 5/23/25, Resident #52's PASRR level I documented she had a diagnosis of bipolar disorder, and suspected anxiety. The PASRR level I was to be forwarded to BLTC for further screening. On 5/23/25, Resident #52's PASRR Level II, documented a diagnosis of bipolar, unspecified anxiety, and depression. Resident #52's PASRR level II was to be sent for further evaluation by a mental health authority. On 5/23/25, the mental health authority documented Resident #52 had a diagnosis of depression, anxiety, and bipolar disorder. Resident #52's MDS dated [DATE], documented in section A1500, the resident had not been evaluated by a PASRR level II and determined to have a serious mental illness. On 6/25/25, at 2:45 PM, the MDS Coordinator with the SSD and DON present, stated Residents #4, #30, #34, #45, and #52's MDS's, section A1500, should have been marked yes, the resident had been evaluated by a PASRR level II and determined to have a serious mental illness.

Based on incident and accident log review, record review and interviews, it was determined the facility failed to ensure resident representatives were notified following resident fall with injury. This was true to 1 of 4 residents (Resident #211) whose records were reviewed. This deficient practice created the potential for harm or adverse outcomes if the residents' representatives were not notified of resident injuries. Findings include: Resident #211 was admitted to the facility on [DATE], with multiple diagnoses including dementia and history of falls. On 6/23/25, reviewed documentation in the facility incident and accident log of a resident who fell with resulting injury to her elbow on 4/1/23, and resident representative had not been notified of the fall or injury. On 6/26/25 at 11:45 AM, the DON stated the facility failed to notify the family/POA of the resident's fall with injury.

Based on incident and accident log review, record review and interviews, it was determined the facility failed to ensure resident specific discharge paperwork was provided to the hospital during transfer to the hospital. This was true for 1 of 2 residents (Resident #211) whose records were reviewed. This deficient practice had the potential for harm if resident required health information was not provided to the hospital. Findings include: Resident #211 was admitted to the facility on [DATE], with multiple diagnoses including dementia and history of falls. On 6/23/25, reviewed documentation in the facility incident and accident log of resident who fell on 4/1/23, with resulting nasal fracture, two black eyes, and a facial laceration and no documentation the facility sent resident required information (hospice) to the hospital during transfer. On 6/26/25 at 11:45 AM, the DON stated the facility failed to send resident information to the hospital when she was transported to the hospital.

Based on record review, policy review, and staff interview, it was determined the facility failed to incorporate PASRR recommendations in MDS assessment and care planning. This was true for 1 of 19 residents (Resident #32) reviewed for Level I and II PASRR evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not incorporated in their care. Findings include: The facility's Pre-admission Screening and Resident Review (PASRR) policy dated 10/6/22, documented recommendations from PASRR Level II determination and PASRR evaluation report are to be incorporated into the person-centered care plan as well as in transitions of care. As part of the PASRR process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD) or intellectual disability (ID) has a significant change in their physical or mental condition. This will ensure that residents with a mental disorder or intellectual disability continue to receive the care and services they need in the most appropriate setting. Resident #32 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including difficulty walking and depression. On 6/25/25, reviewed Resident #32's PASRR Level I and PASRR Level II dated 1/12/24 and 11/13/24, documented she had schizophrenia as a MMI however, schizophrenia is not listed in the resident's medical record, MDS's, or care plan. On 6/25/25, reviewed Resident #32's PASRR Level I dated 1/24/25 and 6/23/25, documented she had schizophrenia as a MMI however, schizophrenia is not listed in the resident's medical record, MDS's, or care plan. On 6/25/25 at 1:39 PM, the DON stated Resident #32's PASRR Level I and Level II should have been caught and corrected and an updated PASRRs Level I and II should have been requested.

Based on observation, record review, and staff interview, it was determined the facility failed to follow current physician oxygen orders. This was true for 1 of 19 residents (Resident #26) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services had been provided that were not ordered by the physician. Findings include: Resident #26 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (refers to the lungs' inability to adequately oxygenate the blood (hypoxia) over an extended period, typically due to underlying chronic lung conditions) and diabetes. Resident #26's physician's order dated 9/11/24, documented oxygen at 2 liters/minutes continuously via nasal cannula and obtain oxygen sats every shift. Resident #26's care plan documented oxygen settings via nasal prongs, liters per current MD/NP orders. Resident #26's TAR for the month of June 2025, documented oxygen saturations from a low of 90% to a high of 97% on oxygen at the prescribed liter flow. On 6/24/25 at 4:23 PM, observed Resident #26's oxygen liter flow set at 4 lpm. On 6/25/25 at 1:43 PM, the DON stated Resident #26's oxygen liter flow had been increased by the physician, but it had not been documented in the resident's chart and should have been.

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure licensed nurses performed tasks which they had the knowledge, skills, and competencies. This was true for 7 of 28 licensed nurses. This had the potential for adverse effects to all residents when skin related issues were missed during assessments. Findings include: The facility's Skin Integrity and Pressure Ulcer/Injury Prevention policy dated 7/9/24, documented a skin assessment/inspection should be performed weekly by a nurse. Skin observations also occur throughout points of care provided by CNAs during ADL care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. CNAs will also report to the nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including chronic heart failure and chronic kidney disease. A medical visit progress note dated 8/30/24, documented APRN visited Resident #16 to assess possible growth on right cheek. APRN documented no growth or pain present on right cheek. Staff continue to monitor for growth and notify provider if worsens. Resident #16's licensed nurse weekly skin assessments dated 9/8/24, 9/22/24, and 9/29/24 documented no skin alterations noted. Resident #16's verbal physician order dated 10/4/24, documented dermatology to evaluate and treat growth to right side of face. Resident #16's licensed nurse weekly skin assessments dated 10/6/24, documented no skin alterations noted. Resident #16's nurse's progress note dated 10/7/24, documented resident with large growth on right side of face that did not get documented on skin check. Resident #16's licensed nurse weekly skin assessment dated [DATE], documented has a growth to right cheek. On 6/25/25 at 2:45 PM, the DON stated the growth on the right side of Resident #16's cheek should have been caught, documented, and physician notified by licensed nursing staff and was not.

Based on review of the staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as an NA were either in a State approved training and competency evaluation program or had recently and successfully completed such a program. This was true for 3 of 12 NAs (NA #1, #2, and #3) whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility. Findings include: NA #1 was hired on 1/2/25 and had not obtained their CNA certification and was not enrolled in a CNA program as of 6/23/25. NA #2 was hired on 8/28/24 and had not obtained their CNA certification as of 6/23/25. NA #3 was hired on 4/3/24 and had not obtained their CNA certification as of 6/23/25. On 6/25/25 at 2:35 PM, the DON stated NA #1, #2, and #3 had not yet obtained their CNA certification and should have.

Based on record review, resident and staff interview, review of investigations and grievances, and policy review, it was determined the facility failed to ensure a resident's pain was effectively managed and treated in a respectful manner. This was true for 1 of 6 residents (Resident #40) reviewed for pain management. Resident #40 was harmed when she felt publicly degraded when denied narcotic pain medication necessary to effectively manage her pain. Findings include: The facility's Pain Assessment and Management Policy, revised on 7/17/21, stated the purpose of the pain policy was to help residents attain or maintain their highest practicable level of well-being by proactively identifying, care planning, monitoring, and managing the resident's pain indicators. Based on record review, resident and staff interview, review of investigations, and policy review, it was determined the facility failed ensure a resident's pain was effectively managed and treated in a respectful manner. This was true for 1 of 6 residents (Resident #40) reviewed for pain management. Resident #40 was harmed when she felt publicly degraded when denied narcotic pain medication necessary to effectively manage her pain. Findings include: The facility's Pain Assessment and Management Policy, revised on 7/17/21, stated the purpose of the pain policy was to help residents attain or maintain their highest practicable level of well-being by proactively identifying, care planning, monitoring, and managing the resident's pain indicators. This policy was not followed. Resident #40 was admitted to the facility from a hospital on 11/10/21, following surgical repair of displaced bicondylar fractures of the right tibia (fracture of the medial and lateral surfaces of the shin bone that is difficult to repair). She also had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #40's Physician Orders, dated 11/10/21, included the following pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] * Tylenol (pain medication) 650 milligrams (mg) every four hours * [MEDICATION(S)] (narcotic pain medication) 5 mg every four hours PRN * [MEDICATION(S)] (less potent narcotic pain medication than [MEDICATION(S)]) 50 mg every six hours PRN Resident #40's quarterly MDS assessment, dated 1/17/22, documented she had intact cognition, no behaviors, and received scheduled and PRN pain medication. A Pain Evaluation, dated 12/10/21, documented Resident #40's most recent pain level was 7 based on a pain scale of 0 to 10, with 0 being no pain and 10 being excruciating pain. The Pain Evaluation documented Resident #40's acceptable level of pain was 4. The Pain Evaluation documented Resident #40's sleep, physical activities, and emotions were affected by her pain level. The Pain Evaluation documented PRN [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (muscle relaxant medication) alleviated her pain. Resident #40's care plan, dated 2/1/22, documented Resident #40 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: assess for pain, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The care plan stated to provide Resident #40 pain medication as ordered, evaluate the effectiveness of the pain interventions, and to notify the physician if the interventions were unsuccessful. The care plan documented Resident #40 could tell staff what increased or alleviated her pain and staff were to allow her as much control and support as possible. Resident #40's Physician Order, dated 1/12/22, included [MEDICATION(S)] 5 mg twice a day PRN for pain. A progress note documented by the Nurse Practitioner, dated 1/28/22, documented, Resident #40 continued with [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] 5 mg 3 times a day PRN. A Physician Order, dated 2/19/22, documented the addition of a [MEDICATION(S)] 4% (local anesthetic medication), to apply to Resident #40's right lower extremity topically for pain PRN. The order stated the [MEDICATION(S)] could be applied once daily. A follow-up Orthopedic Visit Note, dated 2/22/22, documented Resident #40 had hamstring (the three muscles that run along the back of the thigh from hip to just below the knee) irritation because of her surgery. The recommendation was to increase the frequency of [MEDICATION(S)] to every 4 to 6 hours for one to two weeks or until the hamstring exacerbation calmed down. Resident #40's Physician Order, dated 2/23/22, documented an increase of the [MEDICATION(S)] 5 mg to every six hours PRN for pain for 14 days and to hold the order for [MEDICATION(S)] 5 mg twice daily PRN for pain. On 2/28/22 at 9:52 AM, Resident #40 stated she had knee pain and did not get up until just before lunch on Sunday (2/27/22). She stated she went to the nurse's station and told LPN #5 she had a lot of pain in her leg and wanted an [MEDICATION(S)]. Resident #40 said LPN #5 did not ask her what her pain level was and told her she could not have [MEDICATION(S)] as the order was on hold. Resident #40 stated she tried to tell LPN #5 that when she saw the Orthopedic Surgeon the previous week, he told her the fracture was worse than they previously believed, and she had five fractures instead of four in her tibia. Resident #40 stated the surgeon had to cut the hamstring muscles to get to the fractured area, which was why she had a lot of pain in the leg. Resident #40 stated she was upset because she had very painful knee pain and LPN #5 would only give her a [MEDICATION(S)]. Resident #40 stated her pain was at a ten and she returned to her room. Resident #40 stated LPN #5 did not offer her any oral pain medication and did not offer to call the physician. Resident #40 stated although her pain level decreased to a seven after the [MEDICATION(S)], she still had significant pain, which was not acceptable to her. Resident #40 stated she did not ask LPN #5 for further pain medication as she told her she had nothing else ordered. Resident #40 stated LPN #5 did not came back to ask if the [MEDICATION(S)] helped her pain. Resident #40 stated on 2/27/22, after LPN #5 went home LPN #4 came in to talk to her and gave her an [MEDICATION(S)]. Resident #40 stated LPN #4 told her LPN #5 did not realize she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's investigation of Resident #40's concerns was initiated on 2/28/22. The investigation summary documented the Executive Director accessed the grievance box and found two grievances inside on 2/28/22 at 2:00 PM. The investigation included copies of separate grievances, dated 2/27/22, from Resident #40 and Family Member #1. An undated statement written by Resident #40 was provided by the Executive Director. Resident #40 documented she asked LPN #5 for pain medication and LPN #5 told her, no I can't give you one. When asked why, she abruptly told her You Know Why. Resident #40 was confused by her answer and very taken back by the way LPN #5 was treating her. Resident #40 tried to explain to LPN #5 why she was taking the pain medication and why the Orthopedic Surgeon prescribed the medicine for her. LPN #5 accused Resident #40 of going to two different physicians for prescriptions and that was why the [MEDICATION(S)] was put on hold. Resident #40 was confused and hurt in the manner she was being spoken to. Resident #40 informed LPN #5 she never went to two physicians asking for a prescription. LPN #5 told her she was only going by what she was told and what was written in her chart. Resident #40 documented she felt humiliated and very embarrassed by her treatment because it was said in an open area where other staff and residents were present. Resident #40 felt LPN #5 treated her unprofessionally and she felt degraded. The oncoming nurse (LPN #4) came to her room around 3:00 PM and explained that LPN #5 had misunderstood what was in her record. LPN #4 told her she showed LPN #5 where it was written in her record about having a current [MEDICATION(S)] order. Family Member #1's written statement attached to her grievance, documented on 2/27/22 she received a telephone call from Resident #40. Family Member #1 called and spoke to LPN #5, who told her Resident #40's pain medication was suspended for 14 days because Resident #40 had two different prescriptions. LPN #5 told her only the physician on staff could prescribe medication for Resident #40. Family Member #1 came to the facility and spoke to LPN #4, who told her there was a misunderstanding of what was in Resident #40's record and Resident #40 was able to receive [MEDICATION(S)] pain medication. The statement documented Resident #40 had numbness and discoloration in three toes and she had taken Resident #40 for an appointment with the Physician Assistant (PA) to have an X-ray, which was negative for fractures. There was no discussion of medications, however, the PA recommended Resident #40 have an evaluation with the orthopedic surgeon regarding her concerns. During that appointment, the surgeon told them he had cut Resident #40's hamstring in half during surgery, which would be painful, and the surgeon increased her pain medication for two weeks to aid in the pain and healing of the inflamed hamstring. An undated written statement by LPN #5 stated the night shift nurse (LPN #6) told her Resident #40's [MEDICATION(S)] was on hold, and she did not check the order after getting report. At 1:00 PM, Resident #40 requested pain medication. LPN #5 told Resident #40 I can give you a [MEDICATION(S)] but that is it. When Resident #40 asked why she could not have the [MEDICATION(S)], LPN #5 told her the [MEDICATION(S)] was on hold. Resident #40 told her that she had been to an appointment, her knee was worse, and the pain was bad. LPN #5 put the [MEDICATION(S)] on Resident #40 and Resident #40 went to her room. A written statement by LPN #6, dated 3/2/22, documented he was aware one of Resident #40's [MEDICATION(S)] orders was on hold and she had a newer order for PRN [MEDICATION(S)] every 6 hours, which he believed he gave to Resident #40 during the night. The statement documented he did not remember telling LPN #5 Resident #40's [MEDICATION(S)] order was on hold. During an interview on 3/3/22 at 1:49 PM, CNA #8 stated she heard Resident #40 ask LPN #5 for narcotic pain medication. CNA#8 stated she heard LPN #5 tell Resident #40 that she knew why she could not get the narcotic pain medication. CNA #8 stated approximately 15 minutes later, Resident #40 came out to the nurse's station upset and crying and yelled LPN #5 was accusing her [of drug seeking]. During an interview on 3/3/22 at 2:45 PM, CNA #9 stated on 2/27/22 between 12:00 PM and 1:00 PM, she heard Resident #40 tell LPN #5 she still had a lot of pain, did not know why the pain medication was on hold and wanted the pain medication. CNA #9 stated LPN #5 told Resident #40 the reason the [MEDICATION(S)] was on hold was because Resident #40 went to two different physicians for the pain medication. CNA #9 said Resident #40 was upset. CNA #9 said Resident #40 was observed making a phone call. After the phone call Resident #40 came out to the nurse's station again and yelled she 'was not like that' [drug seeking] and was in a lot of pain. CNA #9 said Resident #40 cried at the nurse's station and went back to her room. LPN #5 told her Resident #40 had all the pain medication she could have at that time. A progress note, dated 2/27/22 at 3:34 PM, documented it was reported to LPN #4 Resident #40 was upset because of some confusion in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 reported that she was still in a lot of pain and LPN #4 gave her the PRN [MEDICATION(S)]. A written statement from LPN #4, dated 3/2/22, documented LPN #5 told her Resident #40 was upset because she could not have an [MEDICATION(S)] as the order was on hold. LPN #4 told LPN #5 although one [MEDICATION(S)] order was on hold, Resident #40 had another order for [MEDICATION(S)] 5 mg every 6 hours, which she showed to LPN #5. Resident #40's MAR, dated 2/27/22, documented she received her scheduled pain medications during the day shift and a PRN [MEDICATION(S)] at 12:38 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40's MAR, dated 2/27/22, documented she received [MEDICATION(S)] 5 mg at 3:02 PM for a pain level of 7, 2 hours and 24 minutes after the [MEDICATION(S)] was applied. A progress note, dated 2/27/22 at 4:48 PM, documented Resident #40 had a follow-up pain level of 4 and the [MEDICATION(S)] pain medication was effective. During an interview on 3/3/22 at 2:31 PM and 3:40 PM, the Administrator said Resident #40 and Family Member #1 both filed grievances related to LPN #5's communication with Resident #40 regarding her pain concerns. The Administrator stated he and the Regional Director of Clinical Services completed an investigation regarding Resident #40's concerns. The Administrator stated LPN #5 did not check the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated LPN #5 did not document her assessment of Resident #40's pain level prior to and after the [MEDICATION(S)] was administered. The Administrator confirmed although LPN #5 gave Resident #40 a PRN [MEDICATION(S)], Resident#40 requested PRN [MEDICATION(S)], had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy was not followed. Resident #40 was admitted to the facility from a hospital on 11/10/21, following surgical repair of displaced bicondylar fractures of the right tibia (fracture of the medial and lateral surfaces of the shin bone that is difficult to repair). She also had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #40's Physician Orders, dated 11/10/21, included the following pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] * Tylenol (pain medication) 650 milligrams (mg) every four hours * [MEDICATION(S)] (narcotic pain medication) 5 mg every four hours PRN * [MEDICATION(S)] (less potent narcotic pain medication than [MEDICATION(S)]) 50 mg every six hours PRN Resident #40's quarterly MDS assessment, dated 1/17/22, documented she had intact cognition, no behaviors, and received scheduled and PRN pain medication. A Pain Evaluation, dated 12/10/21, documented Resident #40's most recent pain level was 7 based on a pain scale of 0 to 10, with 0 being no pain and 10 being excruciating pain. The Pain Evaluation documented Resident #40's acceptable level of pain was 4. The Pain Evaluation documented Resident #40's sleep, physical activities, and emotions were affected by her pain level. The Pain Evaluation documented PRN [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (muscle relaxant medication) alleviated her pain. Resident #40's care plan, dated 2/1/22, documented Resident #40 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: assess for pain, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The care plan stated to provide Resident #40 pain medication as ordered, evaluate the effectiveness of the pain interventions, and to notify the physician if the interventions were unsuccessful. The care plan documented Resident #40 could tell staff what increased or alleviated her pain and staff were to allow her as much control and support as possible. Resident #40's Physician Order, dated 1/12/22, included [MEDICATION(S)] 5 mg twice a day PRN for pain. A progress note documented by the Nurse Practitioner, dated 1/28/22, documented, Resident #40 continued with [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] 5 mg 3 times a day PRN. A Physician Order, dated 2/19/22, documented the addition of a [MEDICATION(S)] 4% (local anesthetic medication), to apply to Resident #40's right lower extremity topically for pain PRN. The order stated the [MEDICATION(S)] could be applied once daily. A follow-up Orthopedic Visit Note, dated 2/22/22, documented Resident #40 had hamstring (the three muscles that run along the back of the thigh from hip to just below the knee) irritation because of her surgery. The recommendation was to increase the frequency of [MEDICATION(S)] to every 4 to 6 hours for one to two weeks or until the hamstring exacerbation calmed down. Resident #40's Physician Order, dated 2/23/22, documented an increase of the [MEDICATION(S)] 5 mg to every six hours PRN for pain for 14 days and to hold the order for [MEDICATION(S)] 5 mg twice daily PRN for pain. On 2/28/22 at 9:52 AM, Resident #40 stated she had knee pain and did not get up until just before lunch on Sunday (2/27/22). She stated she went to the nurse's station and told LPN #5 she had a lot of pain in her leg and wanted an [MEDICATION(S)]. Resident #40 said LPN #5 did not ask her what her pain level was and told her she could not have [MEDICATION(S)] as the order was on hold. Resident #40 stated she tried to tell LPN #5 that when she saw the Orthopedic Surgeon the previous week, he told her the fracture was worse than they previously believed, and she had five fractures instead of four in her tibia. Resident #40 stated the surgeon had to cut the hamstring muscles to get to the fractured area, which was why she had a lot of pain in the leg. Resident #40 stated she was upset because she had very painful knee pain and LPN #5 would only give her a [MEDICATION(S)]. Resident #40 stated her pain was at a ten and she returned to her room. Resident #40 stated LPN #5 did not offer her any oral pain medication and did not offer to call the physician. Resident #40 stated although her pain level decreased to a seven after the [MEDICATION(S)], she still had significant pain, which was not acceptable to her. Resident #40 stated she did not ask LPN #5 for further pain medication as she told her she had nothing else ordered. Resident #40 stated LPN #5 did not came back to ask if the [MEDICATION(S)] helped her pain. Resident #40 stated on 2/27/22, after LPN #5 went home LPN #4 came in to talk to her and gave her an [MEDICATION(S)]. Resident #40 stated LPN #4 told her LPN #5 did not realize she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's investigation of Resident #40's concerns was initiated on 2/28/22. The investigation summary documented the Executive Director accessed the grievance box and found two grievances inside on 2/28/22 at 2:00 PM. The investigation included copies of separate grievances, dated 2/27/22, from Resident #40 and Family Member #1. An undated statement written by Resident #40 was provided by the Executive Director. Resident #40 documented she asked LPN #5 for pain medication and LPN #5 told her, no I can't give you one. When asked why, she abruptly told her You Know Why. Resident #40 was confused by her answer and very taken back by the way LPN #5 was treating her. Resident #40 tried to explain to LPN #5 why she was taking the pain medication and why the Orthopedic Surgeon prescribed the medicine for her. LPN #5 accused Resident #40 of going to two different physicians for prescriptions and that was why the [MEDICATION(S)] was put on hold. Resident #40 was confused and hurt in the manner she was being spoken to. Resident #40 informed LPN #5 she never went to two physicians asking for a prescription. LPN #5 told her she was only going by what she was told and what was written in her chart. Resident #40 documented she felt humiliated and very embarrassed by her treatment because it was said in an open area where other staff and residents were present. Resident #40 felt LPN #5 treated her unprofessionally and she felt degraded. The oncoming nurse (LPN #4) came to her room around 3:00 PM and explained that LPN #5 had misunderstood what was in her record. LPN #4 told her she showed LPN #5 where it was written in her record about having a current [MEDICATION(S)] order. Family Member #1's written statement attached to her grievance, documented on 2/27/22 she received a telephone call from Resident #40. Family Member #1 called and spoke to LPN #5, who told her Resident #40's pain medication was suspended for 14 days because Resident #40 had two different prescriptions. LPN #5 told her only the physician on staff could prescribe medication for Resident #40. Family Member #1 came to the facility and spoke to LPN #4, who told her there was a misunderstanding of what was in Resident #40's record and Resident #40 was able to receive [MEDICATION(S)] pain medication. The statement documented Resident #40 had numbness and discoloration in three toes and she had taken Resident #40 for an appointment with the Physician Assistant (PA) to have an X-ray, which was negative for fractures. There was no discussion of medications, however, the PA recommended Resident #40 have an evaluation with the orthopedic surgeon regarding her concerns. During that appointment, the surgeon told them he had cut Resident #40's hamstring in half during surgery, which would be painful, and the surgeon increased her pain medication for two weeks to aid in the pain and healing of the inflamed hamstring. An undated written statement by LPN #5 stated the night shift nurse (LPN #6) told her Resident #40's [MEDICATION(S)] was on hold, and she did not check the order after getting report. At 1:00 PM, Resident #40 requested pain medication. LPN #5 told Resident #40 I can give you a [MEDICATION(S)] but that is it. When Resident #40 asked why she could not have the [MEDICATION(S)], LPN #5 told her the [MEDICATION(S)] was on hold. Resident #40 told her that she had been to an appointment, her knee was worse, and the pain was bad. LPN #5 put the [MEDICATION(S)] on Resident #40 and Resident #40 went to her room. A written statement by LPN #6, dated 3/2/22, documented he was aware one of Resident #40's [MEDICATION(S)] orders was on hold and she had a newer order for PRN [MEDICATION(S)] every 6 hours, which he believed he gave to Resident #40 during the night. The statement documented he did not remember telling LPN #5 Resident #40's [MEDICATION(S)] order was on hold. During an interview on 3/3/22 at 1:49 PM, CNA #8 stated she heard Resident #40 ask LPN #5 for narcotic pain medication. CNA#8 stated she heard LPN #5 tell Resident #40 that she knew why she could not get the narcotic pain medication. CNA #8 stated approximately 15 minutes later, Resident #40 came out to the nurse's station upset and crying and yelled LPN #5 was accusing her [of drug seeking]. During an interview on 3/3/22 at 2:45 PM, CNA #9 stated on 2/27/22 between 12:00 PM and 1:00 PM, she heard Resident #40 tell LPN #5 she still had a lot of pain, did not know why the pain medication was on hold and wanted the pain medication. CNA #9 stated LPN #5 told Resident #40 the reason the [MEDICATION(S)] was on hold was because Resident #40 went to two different physicians for the pain medication. CNA #9 said Resident #40 was upset. CNA #9 said Resident #40 was observed making a phone call. After the phone call Resident #40 came out to the nurse's station again and yelled she 'was not like that' [drug seeking] and was in a lot of pain. CNA #9 said Resident #40 cried at the nurse's station and went back to her room. LPN #5 told her Resident #40 had all the pain medication she could have at that time. A progress note, dated 2/27/22 at 3:34 PM, documented it was reported to LPN #4 Resident #40 was upset because of some confusion in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 reported that she was still in a lot of pain and LPN #4 gave her the PRN [MEDICATION(S)]. A written statement from LPN #4, dated 3/2/22, documented LPN #5 told her Resident #40 was upset because she could not have an [MEDICATION(S)] as the order was on hold. LPN #4 told LPN #5 although one [MEDICATION(S)] order was on hold, Resident #40 had another order for [MEDICATION(S)] 5 mg every 6 hours, which she showed to LPN #5. Resident #40's MAR, dated 2/27/22, documented she received her scheduled pain medications during the day shift and a PRN [MEDICATION(S)] at 12:38 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40's MAR, dated 2/27/22, documented she received [MEDICATION(S)] 5 mg at 3:02 PM for a pain level of 7, 2 hours and 24 minutes after the [MEDICATION(S)] was applied. A progress note, dated 2/27/22 at 4:48 PM, documented Resident #40 had a follow-up pain level of 4 and the [MEDICATION(S)] pain medication was effective. During an interview on 3/3/22 at 2:31 PM and 3:40 PM, the Administrator said Resident #40 and Family Member #1 both filed grievances related to LPN #5's communication with Resident #40 regarding her pain concerns. The Administrator stated he and the Regional Director of Clinical Services completed an investigation regarding Resident #40's concerns. The Administrator stated LPN #5 did not check the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated LPN #5 did not document her assessment of Resident #40's pain level prior to and after the [MEDICATION(S)] was administered. The Administrator confirmed although LPN #5 gave Resident #40 a PRN [MEDICATION(S)], Resident#40 requested PRN [MEDICATION(S)], had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, and record review, it was determined the facility failed to ensure that 2 of 15 (#4 and 7) sampled residents did not acquire a new/recurrent pressure ulcer as evidenced by: - Resident #7's had a healed Stage IV pressure sore on the coccyx that reopened, and - Resident #4 had boggy soft heels found on admission that returned and formed a Stage II pressure sore of the left heel. Resident #7 was harmed when the healed pressure sore to her coccyx reopened to a stage IV. Findings include: 1. Resident #7 was admitted to the facility, on 12/22/11, with [DIAGNOSES REDACTED]. The resident's decubitus ulcer was a Stage IV ulcer over the coccyx area. The most recent quarterly MDS assessment, dated 2/28/13, documented the resident: - was cognitively intact, BIMS=15, - required extensive assistance of one staff for dressing, personal hygiene and bathing, - required total assistance of two staff for transfers, - had limited range of motion of the lower extremities, - had a foley catheter, - had a Stage IV pressure sore that measured 0.2 x 1.4 x 0.2 cm deep. The most recent annual MDS assessment, dated 12/4/12, documented the resident: - had a Stage IV pressure sore that measured 0.7 x 1.5 x 0.3 cm deep. The resident's care plan, dated 12/23/11, for "Risk for Pressure Ulcers" documented problems of, "admitted with Stage IV sacral Decubitus Ulcer. Risk factors include impaired sensation, R (right) foot bunion, decreased strength and mobility with (increased) risk for shearing and friction, likes to stay in bed, incontinence, non ambulatory, chronic pain, rarely eats a complete meal, max assist with moving and complete lifting without sliding is impossible, noncompliant with skin program." There was an undated hand written entry of, "Resident has [MEDICAL CONDITION] with cauda equina syndrome." Additional hand written entries, dated 4/18/13 and 5/28/13, documented, "Note: resident sacral area will always be a increase risk of breakdown r/t hx of extensive stage IV ulcer here and (decrease) tensile strength of scar tissue" and "Resident refusing to let staff turn her at noc (during night time). Screams out if they try." The target date for the goal was 6/6/13. The approaches the facility put in place were: (Note: none were dated so unable to determine when they were added to the care plan.) "- Special Protective Devices Used: Air overlay Mattress with bolsters, ROHO cushion to Tilt in space wheelchair for pressure redistribution." "- LN to evaluate weekly with daily heel and coccyx checks." "- Treatment per current MD order." "- Monitor sacral decubitus ulcer daily until resolved." (Note: There was an X through this approach with an undated notation "resolved") "- Minimize exposure to moisture and keep skin clean, especially fecal contamination." "- Maintain or improve nutrition and hydration status, where feasible." "- Daily coccyx and heel checks at noc." "- 2/21/? - non compliant with off load." "- Monitor for adverse reactions to medications that may increase risk factors for development of pressure ulcers ie; causing lethargy, anorexia, or creating/increasing confusion." "- Nutritional supplement as ordered for wound healing." "- Be aware: (Resident #7) is not always compliant with skin program/interventions in place, continue to encourage and educate on risks/benefits. (Resident #7) often refuses to turn side to side d/t (increase) c/o leg spasms and shoulder pain. Resident wants bed 45 degrees - elevated but noncompliant." "- 4/19/13 -Prafo boot when (up) in WC to left foot. May velcro strap boot to left foot rest as per request from resident for sense of security." "- Float heels in bed as resident allows." Review of all the areas on the care revealed there was no plan for: 1) repositioning to include frequency of turning and off loading the resident's coccyx. 2) the leaky catheter and what staff should do to prevent skin breakdown. 3) a bed bath 3 time a week to keep skin clean and dry. (Refer to MD order of 5/14/13 below.) The ADL care plan documented, "Shower/bath at least 1x/week." 4) addressing what the facility identified as "non-compliance" with positioning. On 6/3/12, 11/28/12, 2/6/13 and 5/22/13 a BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK was completed. The resident scored a 12 each time which equals high risk. The risk factors that were identified were: "SENSORY PERCEPTION: Has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.; MOISTURE: Very moist: skin is often, but not always moist. Linen must be changed at least once a shift.; ACTIVITY: Chair fast: Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.; MOBILITY: Very limited.; NUTRITION: Probably inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered...; FRICTION AND SHEAR: Potential problem: Moves feebly or requires minimum assistance. during a move, skin probably slides to some extent against sheets, chair...occasionally slides down." The Braden information did not appear to be used to develop a care plan such as: - Pain: There was no plan for the resident's pain issues as it corresponds to positioning in bed. The resident's lower extremity and shoulder pain was not addressed. - Moisture: The leaky catheter was not addressed in the care plan. Bathing more frequently than once a week to decrease skin issues from sweat and urine was not care planned. -Mobility: The resident had limited mobility and positioning; there was no plan for off loading and frequency for turning in bed. - Friction and shear: The resident frequently liked to have the head of the bed elevated to 45 degrees. The facility failed to have a plan to ensure the resident did not slide down in the bed when the head was elevated. The resident was admitted to the facility on [DATE] at 5:00 p.m. The admission Nurses Notes documented the resident, "admitted with wound to sacrum with 3.5 cm x 5.5 cm open area, 1.5 cm deep, undermining of 1 cm at 12 o'clock, 1 cm at 6 o'clock, 1.5 cm at 3 o'clock and 1 cm at 9 o'clock with large area of deep tissue injury surrounding, deep red and purple in color." The interventions in place at that time were: "alternating pressure air mattress overlay, Prevalons to bilateral lower extremity when in bed, and foot cradle to bed as well as weekly skin checks..." The nursing notes documented the resident had some behaviors that put the resident at increased risk for the sores not healing or new and further skin breakdown. These behaviors were: refusal of repositioning every 2 hours, remaining up in the wheelchair for more than 4 hours, elevating the head of the bed greater than 30 degrees, and not changing clothes. The care plan did not address these behaviors nor was there documentation to the number of times the resident exhibited the behaviors. There was lacking documentation the risk and benefits were discussed with the resident when the resident exhibited the behaviors. Below is sequential documentation including the wound nurse documentation from the time the Stage 4 pressure sore was healed to when it returned. PN: = Progress notes; WMD: = Wound clinic/MD documentation; MFR: Monthly Flow Report; and PMD: = Primary physician documentation. WMD: 3/14/13 Wound Care Progress Report: "CHIEF COMPLAINT: (name of Resident #7) is seen for evaluation of a stage - IV sacral pressure ulcer that has been present now for about 15 to 16 months. HISTORY OF PRESENT ILLNESS: She has been showing steady improvement, particularly with initiation of regular debridement and low-air-loss mattress....She continues to get the area wet from her leaking Foley catheter.... PAST MEDICAL...: Her healing is impaired by cauda equina syndrome with [MEDICAL CONDITIONS], noncompliance with off loading, and a leaky Foley catheter that leaves her ulceration damp with urine quite frequently. SKIN WOUND: Examination of her sacrum demonstrates that the ulceration is now completely [MEDICATION NAME]: 1. Stage-IV sacral pressure ulcer; now healed..." PN: 3/14/13 at 12:46 p.m., "Wound care. Res admitted approx(imately) 15 months ago with an extensive stage 4 pressure ulcer to sacrum. Wound has now closed. There is and always will be an indented crevice scar surrounded by pink scar tissue. This area will always be at high risk of reopening d/t decreased tensile strength of scar tissue. Son, (name), notified and was very pleased. Res is aware and was able to take a shower vs.(versus) bed bath today. Request to continue air overlay to bed and apply [MEDICATION NAME] daily to sacrum daily..." PMD: On 3/14/13 NURSING HOME VISIT: "HISTORY OF PRESENT ILLNESS: .... Since she has been here, she has been followed by the wound team for a stage 4 sacral pressure sore. (wound MD name) basically has indicated that this wound has, for all intents and purposes, healed. She is quite noncompliant as far as offloading pressure. She has also been seen by urology because of problems with her leaking catheter, but that does not seem to be as much of a problem now as prior...." PN: There was frequent documentation that the resident had some problems with a catheter that was leaking. Nursing documentation indicated the resident had redness to the peri area and inner thighs. The facility was using barrier cream when she was changed and turned. PN: 3/25/13 at 2:48 p.m., "Wound care. Res continues with closed stage 4 to sacrum. Scar presents as an indented crevice. Periwound pink scar tissue....Res has some MASD (Moisture Associated Skin Damage) to inner thighs and groin d/t long hx of foley use which now chronically leaks. Res has been see by urologist and has refused any surgery in the past. Continue frequent pericares and barrier creams." PN: 4/1/13 at 1:09 p.m. "Wound Care. Res closed stage 4 to sacrum remains stable. Small indented crevice scar to area with pink scar tissue around it. Res has no sensation here. Res inner thighs with mild redness d/t chronic leaking foley; urine pools between thighs spontaneously. Res does not like pads pulled up closer between legs d/t comfort complaints. There are no open areas, blisters or unblanchable redness ntoed. (sic) Continue freq(uent) pericares and barrier creams." PN: 4/4/13 at 1:45 p.m. "Barrier cream to peri area and inner thighs r/t redness. Redness resolving slowly, no open areas....Repositioned as will tolerate, prefers to lay on back. N.O. (new order) to d/c ensure r/t recent wgt gain. (discontinue ensure related to recent weight gain) Res upset about not getting ensure as she believes it is helping her to heal..." PN: 4/9/13 at 12:42 p.m. "Wound Care. Resident stage 4 to sacrum remains closed. Between thighs sl(ight) pink d/t chronic leaking foley pooling urine here frequently. I spoke to resident about suprapubic catheter placement and/or discontinuing foley all together as is no longer functional. Res is fearful of 'surgery' and is reluctant to give up foley. Res became upset and I explained we could talk about it again another time..." PN: 4/30/13 3:03 p.m. "Wound Care. Res has recently closed stage 4 to sacral area. Indented scar remains stable. no open area or unblanchable redness noted." PN: 5/8/13 at 3:43 p.m. "1200 pm -resident old sacral area with two small pinpoint open area. surrounding areas appeared macerated. xanaderm cream applied and peri care given frequently. will continue to monitor. nursed on air mattress.(sic)" PN: 5/14/13 at 2:25 pm. "Wound Care. I have been monitoring res sacral area since closure of large /complex stage 4 pressure wound [MEDICATION NAME] 16 months before closing. Wound closed into a white, indented scar. Today, I note that res scar is (slightly) macerated and soft today. No open areas noted at this time. Res has no sensation d/t spina equida. Res scar tissue covering sacrum will only be 30% the tensile strength of original tissue and will always by at high risk for breakdown esp d/t size and depth of original wound. Request resident no longer have baths; change to bed baths. Sitting in (increased) moisture (water) may macerate scar and also bath chair is a firm/plastic surface. Reimplement Ensure Immune 1 can daily. Cover scar with [MEDICATION NAME] and foam 3 x week. Res also has been enjoying getting up more in w/c; I will not limit at this time but I did ask resident to try and be mindful and not spend more than 3 - 4 hours up daily." The primary physician was contacted on 5/14/13 and ordered, "1) Sacral scar: cleanse, place small piece of [MEDICATION NAME] over scar and cover with non-adhesive foam 3 x week and prn. 2) no showers, bed bath 3 x week. 3)Ensure Immune 1 can po (orally) daily protein supplement." PN: 5/20/13 at 1:41 p.m. "Wound Care. Resident admitted with a very large stage 4 sacral wound....Res scar tissue here is not stable at this time. Indented scar has one pinpoint area that is too moist and very soft. No open areas at this time, no drainage, no redness, no c/o pain. Res has no sensation to this area and does not like to reposition side/side d/t shoulder pain....Continue air overlay, roho. Soft scar tissue cleansed and covered with [MEDICATION NAME] and foam 3 x week to protect." PN: 5/25/13 at 12:33 p.m. "MDS ---A & O (with) bouts of confusion....Requires assist x 2 (with) hoyer lift for transfers....Incontinent of bowel; indwelling cath patent & draining clear yellow urine to gravity bag. No c/o of urinary discomfort/pain. Indented linear scar continues to be moist & soft with no drainage noted....Staff attempted numerous times to change resident's clothes to no avail. Resident continues to state that they are clean..." WMD: On 5/29/13 WOUND CARE PROGRESS REPORT: "CHIEF COMPLAINT: (Name of Resident #7) is a prior patient of ours last seen 2-1/2 months ago when she had healed a chronic stage-IV pressure ulceration of the sacrum... HISTORY OF PRESENT ILLNESS: The ulceration had been present for well over a year but healed nicely, particularly with the addition of a low-air-loss mattress. The patient has [MEDICAL CONDITION] secondary cauda equina syndrome and is noncompliant with offloading. She is also incontinent of urine and stool, making healing of that area difficult.... In the past, she did very well with regular debridement and [MEDICATION NAME]. The recurrent ulcer was found simply at a regular check of her sacrum.... PROCEDURE: The procedure performed today included debridement. The patient's ulcer was cleansed, topically anesthetized with 4% [MEDICATION NAME], and debrided with a #3 curette down to healthy, bleeding granulation tissue. Depth of tissue excised is skin and sudcu, less than 20 cm2... IMPRESSION: 1. Stage III sacral pressure ulceration; recurrent..." The physician ordered a culture of the open wound. The culture returned on 6/2/13 and the results were a group B Beta Streptococcus. The resident was started on Keflex 500 milligrams four times a day for seven days. PRESSURE ULCER STATUS RECORD: for 5/29/13 documented by the wound nurse was: "STAGE: IV; SURFACE AREA: 0.3 x 0.3 cm; DEPTH: less then 0.2 cm; DRAINAGE: scant; COLOR: sanguineous; APPEARANCE OF WOUND: granular; and RESPONSE TO TREATMENT: deteriorated." PN: 5/30/13 at 2:31 p.m. "Wound Care. Resident admitted with a very large, extensive stage 4 p.u.... I asked facility wound MD to assess res this week. Indented scar not stable and macerated, therefor MD debrided unhealthy tissue down to health sub-q. One small crater revealed with measurable depth....Wound cleansed and [MEDICATION NAME] and foam placed 3x week. Periwound intact. Res continues on air overlay, bed bath only, ensure daily, roho to w/c, res encouraged to allow turning and repositioning." MFR: The May 2013 Daily Care report documented the resident received the following for bathing and cleansing of the skin. Sponge Bath: 5/4/13 on days and evenings; Shower: 5/10/13 on days: and Bed Bath 5/22/13, 5/31/13 on days. The May MAR indicated no showers, bed bath 3 times a week" which the days of the month were blank. The documentation indicated the resident received skin cleansing/bath/shower four times for the month of May. There was no documentation that the resident refused a bath. PN: 6/2/13 at 3:10 p.m. "DRSG CDI (dressing clean dry intact) to denuded linear sacral area. No drainage or odor. However, area is inflamed & open. (Primary physician's name) is aware. C/O pain x 1 (8/10) prn med administered with positive results...." PN: 6/4/13 at 2:07 p.m. "Wound Care. Res admitted with a very extensive stage 4 pressure wound to entire sacral area. Linear small scar became instable and macerated: debrided by wound MD last week. Small, indented, linear scar is now open and shallow. Pink, moist, shallow wound bed. no drainage noted. periwound pink scar tissue. No odor and no c/o pain d/t cauda equina...." PRESSURE ULCER STATUS RECORD: for 6/4/13 documented by the wound nurse was: "STAGE: IV; SURFACE AREA: 0.3 x 1.3 cm; DEPTH: 0.3 cm; DRAINAGE: none; COLOR: none; APPEARANCE OF WOUND: granular; and RESPONSE TO TREATMENT: deteriorated." WMD: On 06/06/13 WOUND CARE PROGRESS REPORT: "CHIEF COMPLAINT: (Name of Resident #7) is seen for evaluation of a recurrent stage IV pressure ulcer of the sacrum. She had healed several months ago. HISTORY OF PRESENT ILLNESS: Her healing is impaired by [MEDICAL CONDITION] and pain issues with turning and offloading. She apparently is having some problems with some moisture issues. We were successful in the past with Pomogran and a cover and have been using that again and things have been stable but the periwound has remained macerated....PROCEDURE: Procedure performed today included debridement....IMPRESSION: 1. Ulceration at the site of prior stage 4 pressure ulcer....PLAN: 4. We will continue offloading and we will check (each) shift for moisture and change if there is moisture. We will continue turning (every) 2 hours. If she continues to stay macerated we will have to increase the frequency of moisture checks." The physician wrote an ADDENDUM: "(Resident #7), several weeks ago, was noted to have some [DIAGNOSES REDACTED] scar tissue at the site of a previously healed stage-IV pressure ulcer. The area was debrided to remove the unhealthy [DIAGNOSES REDACTED] scar tissue. It was debrided down to healthy granulation tissue. The granulation tissue is tissue that had filled in from her prior stage-IV pressure ulceration. Based on the fact that it has not been that long since it has healed, I left it as a stage-IV rather than a new pressure ulceration....This is standard practice to remove the unhealthy tissue whether it is closed or not in hopes of creating new healing with a more stable [MEDICATION NAME] surface. There is nothing unusual about this procedure, and I believe that the unhealthy tissue is simply the way it has scarred and healed in place...." The electronic medical record was reviewed and "Daily Care" documentation for May 2013, for repositioned every 2 hours was lacking for: Days: 5/2, 5/3, 5/4, 5/6, 5/9, 5/13, 5/19, 5/20, 5/25 to 5/28, and 5/30; Evenings: 5/1 to 5/4, 5/6, 5/7, 5/8, 5/10, 5/12 to 5/16, 5/19, 5/20, 5/22, 5/24, 5/28, and 5/29; Nights: 5/1 to 5/4, 5/6 to 5/10, 5/12 to 5/21, and 5/23 to 5/31. On 6/4/13 at 12:25 p.m. the resident's sacrum pressure sore was observed. The area had a crater that was about 10 cm across where the original pressure sore was. In the center was a 0.3 x 1.3 x 0.3 cm open sore. The sore was pink and clean with some noted granulation. The wound nurse redressed the area and the resident got up for activities. On 6/4/13 at 12:25 p.m. and 1:40 p.m., Resident #7 was interviewed about the sore. She said the oiginal occurred in the hospital when they were trying to teach her to use a slide board for transfer after she broke her leg. Then they did an [MEDICATION NAME] and thats what caused her to not have much feeling in her back and lower legs. The sore did not hurt because she could not feel it. The resident during interview indicated that positioning on the left side was painful on her shoulder and hip area. She enjoys activities especially Bingo, she makes her own decisions about what she does during the day but she said has some memory problems sometimes and forgets how long she is up in the wheelchair. She didn't know how the second sore developed only that the nurse and Dr worked on it. On 6/6/13 at 8:40 a.m. the DON and unit manager were interviewed about the resident's recurrent Stage IV pressure sore. The resident's rights were discussed along with the non-compliance. There was no documentation about the resident being informed of risk verses benefits or documentation of frequency for non-compliance. On 6/6/13 at 9:00 a.m. the wound nurse and wound physician were interviewed. The discussion was about the resident's cooperation with staff to ensure the sore healed. The physician indicated that their clinic had an off loading program they could adapt to the resident. The resident was harmed when a healed stage-IV sore deteriorated and reopened to a Stage-IV pressure sore. Some of the possible causative factors were: 1) Facility failed to develop a plan for the resident's non-compliance behaviors. 2) Facility failed to give a bed bath to the resident 3 times a week as ordered. 3) Facility failed to address the nursing observation of 5/8/13 related to, "two small pinpoint open areas and surrounding areas that appeared macerated," and aggressively implement interventions to prevent further breakdown. 4) Facility failed to develop a care plan for the information identified on the Braden assessment. 5) Failed to address the MASD from a leaking catheter. 6) Failed to develop a plan for off-loading and frequency for turning and positioning. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing notes reflect the resident had "red/boggy heels" when she was admitted . The most recent quarterly MDS assessment, dated 3/23/13, documented the resident: - had short and long term memory problems, - had severely impaired decision making skills, - required extensive assistance of one person for transfers, dressing, eating, personal hygiene and bathing. - the resident did not have a pressure sore. Resident #4's care plan for "Risk for Pressure Sores" dated 12/4/12, documented a problem of: Potential for skin breakdown r/t decreased strength & mobility, chronic pain, SOB (shortness of breath), limited ambulation, spends majority of each shift in bed or w/c, unable to make frequent or significant changes independently, max assist with moving. Complete lifting without sliding against sheets is impossible, potential for side affects from psych med use, hx of Left upper extremity [MEDICAL CONDITION]. An undated, hand written addition of res admitted with soft/red heels and scars to buttocks. A note, dated 5/30/13 documented, "Note: res unknowingly rubs feet vigorously on mattress greatly increasing friction. The approaches the facility put in place were: (Note: most were not dated so unable to determine when they were added to the care plan.) "- Special protective devices used: Pressure redistributing Mattress. cushion to wheelchair." "- Observe skin daily and report any broken areas to nurse. Turn and redistribute pressure every 2 hours or more frequently. Requires extensive to dependent assist of 1-2 persons with repositioning." "- LN to evaluate weekly." "- Treatment per current MD order." "- Geri-sleeves to bilateral upper extremity." (dated 1/15/13) "- Minimize exposure to moisture and keep skin clean, especially of fecal contamination." "- Maintain or improve nutrition and hydration status, where feasible." "- Monitor for adverse reactions to medications that may increase risk factors for development of pressure ulcers ie; causing lethargy, anorexia, or creating/increasing confusion." "- Prafo boots on at all times except during shower et tx." (dated 5/24/13) "- Tx to left inner heel per MD order."(dated 5/24/13) "- Padding to w/c arm rest and rails on both sides." (dated 5/29/13) "- Skin prep to bilateral heels - prevent skin breakdown" (was d/c on 5/24/13) On 3/14/13 and 5/29/13 a BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK was completed. The resident scored a 12 each time which equals high risk. The risk factors that were identified were: "SENSORY PERCEPTION: Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.; MOISTURE: Very moist: skin is often, but not always moist. Linen must be changed at least once a shift.; ACTIVITY: Chair fast: Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.; MOBILITY: Very limited.; NUTRITION: Probably inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered...; FRICTION AND SHEAR: Problem: requires maximum assistance in moving. Complete lifting without sliding against sheets is possible. Frequently slides down in bed of chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction." The Braden information did not appear to be used to develop a care plan. The progress notes (PN) were reviewed along with other documentation and the following notations were found: PN: On 5/23/13 at 3:15 p.m. "Wound Care. Res admitted with bilat(eral) red/soft heels. To resolve this we treated with skin prep to heels BID, span am mattress, prevalons in bed and res wears darco shoes when up. Today, I note left inner heel has an area that is sl boggy and has a faint purple ring around circumference. There are no open areas to unblanchable redness, but friction and pressure need to be alleviated to protect. Res noted to be rubbing heels persistently back and forth on bed, which removes prevalons. Res has advanced dementia and is unable to verbally respond and/or retain education. Request to d/c Prevalon and d/c skin prep. Start Prafos to bilateral lower extremity at all times and cover left heel with triact ag/foam/kerlix 2x week...." On 5/29/13 the PRESSURE ULCER STATUS RECORD documented by the wound nurse was: Date first observed: 5/29/13, Location: Left inner heel, "STAGE: II; SURFACE AREA: 0.8 x 0.6 cm; DEPTH: less then 0.2 cm; DRAINAGE: none; COLOR: none; APPEARANCE OF WOUND: [MEDICATION NAME]." PN: On 5/30/13 at 3:59 p.m. "Wound Care. Res admitted with bilat red, boggy heels. This was resolved with tx. Over the past 6 months at this facility, staff has continued to protect heels with twice daily skin prep to 'toughen' skin, Prevalons in bed, res had soft Armco shoes when up and span am mattress. Res has recently been quite ill with PENA (pneumonia) and has been noted to vigorously rub heels and feet on bed. For these reasons, despite all interventions in place, a small open area is noted to left inner heel at this time. Small and superficial. Pink epithelium. No drainage, odor or redness. Periwound intact.... Prafos bilateral lower extremity at all times." On 6/3/13 the PRESSURE ULCER STATUS RECORD documented by the wound nurse was: "STAGE: II; SURFACE AREA: 0.8 x 0.6 cm; DEPTH: less then 0.2 cm; DRAINAGE: scant; COLOR: [MEDICAL CONDITION]; APPEARANCE OF WOUND: [MEDICATION NAME] and granular." PN: On 6/3/13 at 1:24 p.m. "Wound Care. Res admitted with bilat red, boggy heels.... Res is not ambulatory....noted to rub heels vigorously on bed back and forth. Despite interventions in place res obtained a left inner heel small open area.... Res has dementia and is unable to answer my questions or retain/offer any information at this time. No c/o pain noted. Open area is small and shallow. Wound bed is pink and moist. Periwound is intact; no redness or bogginess. Scant [MEDICAL CONDITION] drainage without odor noted. Left heel is cleansed and covered with triact ag and foam 2x a week, followed with wound rounds, Prafo boots on at all times...." The electronic medical record documentation showed that repositioning every 2 hours documentation for May 2013 was lacking. The resident record had 93 opportunities for documentation. The documentation only had 11 times the staff documented the resident was repositioned. On 6/3/13 at 3:50 p.m. the sore on the left heel was observed. The area was a stage II, 1 x 0.8 cm. The wound nurse redressed the sore. The DON and Unit manager were interviewed on 6/6/13 at 8:40 a.m., the resident's behavior of rubbing her feet on the bed was discussed and the resident did have a behavior program but that was not part of it. They believed that the resident's increased leg activity correlated to the pneumonia and illness she had at the time. The resident rubbed her feet againt the mattress enough to get the prafo boots off and cause enough friction to create a sore without staff intervention. A Stage II pressure sore developed on the left heel when the facility failed to: 1) Prevent breakdown of the heel when she had a history of [REDACTED]. 2) Ensure the Prafo boots stayed in place, the resident was not physically able to remove them. 3) Monitor the resident closely when she was rubbing her heel against the bed.

Based on observation, record review, and staff interview, it was determined the facility failed to implement sufficient interventions and supervision to prevent residents from falling and subsequently being harmed. This was true for 1 of 4 (#1) residents sampled for falls. Findings included: Resident #1 was harmed when she sustained numerous falls, two falls that resulted in separate fractures of her left upper extremity. Resident #1 was documented as severely cognitively impaired with poor safety awareness, staff assistance needed for transfers, resisted utilizing her call light for assistance and yet, the facility failed to address these issues and provide the necessary supervision to protect the resident from harm. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/5/12, documented the following: * Severe cognitive impairment * Inattention and disorganized thinking present continuously * Altered level of consciousness and psychomotor retardation present on fluctuating basis * Extensive assistance requiring one person for physical assist with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing * Not steady and only able to stabilize with human assistance for moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers * Wheelchair for locomotion * Always continent of bowel and occasionally incontinent of bladder * No falls since prior assessment To reference the change in condition for the resident, the following past MDS assessments are noted: The resident's significant change MDS assessment, dated 2/2/11, documented the following changes from the most recent quarterly MDS assessment: * No documented signs of delirium, ie. inattention, disorganized thinking, altered level of consciousness, or psychomotor retardation * Limited assistance for walking in the room and in the corridor * Walker and wheelchair used for locomotion * Falls without injury since prior assessment The resident's quarterly MDS assessment, dated 4/28/11, documented the following changes from the most recent quarterly MDS assessment: * No signs of delirium except disorganized thinking which was present but not continuously * Verbal behavior symptoms directed towards others occurred 4 to 6 days * Limited assistance requiring one person for physical assist for bed mobility, transfers, walking in the room, corridor or on the unit, dressing, toilet use, and personal hygiene * Not steady but able to stabilize without human assistance with moving from seated to standing position, walking, turning around while walking, moving on and off the toilet, and surface-to-surface transfers * No falls since prior assessment The resident's most recent annual MDS assessment, dated 7/13/11, documented the following changes from the most recent quarterly MDS assessment: * No inattention or altered level of consciousness * Did not walk in room or corridor * Walker and wheelchair for locomotion * Falls since prior assessment, with and without injury These changes documented an increase in signs of delirium, assistance required for ADL's, and balance. The CAA Worksheet for Resident #1, dated 7/13/11, documented the following: * "(Resident) has had recent multiple falls r/t (related to) confusion and cognitive/memory losses with poor safety awareness secondary to progressive dementia syndrome.." * "(Resident) requires limited to extensive assist for transfers r/t debility." * "(Resident) continues to receive Seroquel, Haldol, Celexa, and Clonazepam as ordered for mgmt (management) of Progressive Dementia with associated Depression, Delusion and Psychosis (See MAR of 7/2011)." * "Res (resident) has Dx (diagnosis) of HTN (hypertension), Angina, and AFIB (atrial fibrillation) and is currently receiving medications as ordered..." * "(Resident) is at high risk for alteration in safety r/t recent multiple falls. Potential for side effects form (sic) med (medication) use, decreased strength and mobility, impaired balance and ROM (range of motion), decreased sensation, occ (occasional) pain, occ incontinence, cognitive/memory losses with poor safety awareness and impulsivity secondary to progressive dementia syndrome, [DIAGNOSES REDACTED], cardiac conditions. Res has been transitioned to Hospice Services secondary to debility (See MD T/O (physician telephone order) of 7/07/11). (Resident) required limited to extensive assist for transfers-w/c (wheelchair) is primary mode of locomotion and is able to self propel on and off unit, however, she gets lost easily and often receives assist form (sic) staff...Has alarms, transfer handle, medication monitoring, toileting assist, pain mgmt..." According to the facility Incident/Accident Date Entry Questionnaire (IADEQ), the resident fell on [DATE] at 4:30 am. The report stated the resident was attempting to get out of bed to use the bathroom and lost her balance, attempted to grab the wheelchair on her way to the floor. (This report also documented 1/25/11 as the date of the fall so it is unclear when it actually occurred.) The report documented the only interventions in place at the time were the call light within reach of the resident and a non-skid rug at the bedside. It also documented the resident had fallen in the past 30 days. A review of the resident's Care Plan in effect at the time of the fall documented the following: * Problem onset: 7/2/07 * Problem/Need: At risk for Falls r/t poor standing balance, impaired ROM, decreased strength and endurance, hx (history) of falls, ST (short term) memory deficits, potential for side effects from Med use, Dx osteoarthritis, cardiac conditions, dementia with (illegible) depression and anxiety." Interventions included the non-skid rug at the bedside and a signed waiver dated 9/07 for the FallGard (sic) Program of Hipsters and Alarm use, and supervision to transfer from bed to standing position/chair and back. After the 1/26/11 fall, the following problem was added to the Care Plan: * (Resident) self transfers and ambulates without asking for assist (secondary to) impulsivity and poor safety awareness," dated 2/10/11. After the 1/26/11 fall, the following interventions were added to the Care Plan: * Transfer handle x 1 (one) (for) bed mobility, dated 1/27/11 * Ambulation with FWW (forward wheeled walker) and supervision for mobility about facility "for short distances only," and "with black Darko shoes with one assist," dated 1/31/11 * Supervision to transfer was changed to "Limited to extensive assist," with no date * Wheelchair when outside room with Darko shoes on, no date * PT (Physical Therapy) per POC 5xwk x 12 wks (five times per week for 12 weeks) Nurse's Notes for Resident #1 documented on: 5/17/11 at 12:00 pm, "...Awake, alert and confused. Increased confusion today..." 5/18/11 at 10:20 am, "Res (resident) has poor safety awareness, alarms cause her increased anxiety et (and) confusion et becomes unredirectable." According to the IADEQ, the resident next fell on [DATE] at 11:30 pm. The incident report stated the resident was found in the hallway on the floor. It also stated there were alarms to her bed and wheelchair although there was no mention of them sounding. It documented the resident stated she heard sirens and wanted to see what was going on. This form also documented the resident had fallen in the past 0-30 days although there was no report found. It indicated post-fall interventions of non skid socks and labs to rule out infection. It also indicated, "Resident has cancer and having changes in cognition at times, she refuses alarms and needs frequent supervision for safety." An Interdisciplinary Care Plan indicated on 5/21/11 that the resident was to have a tag alarm. There was no documenation of what frequent supervision would entail for this resident. Nurse's Notes for the resident documented on 5/20/11 at 10:35 am, "...Res more confused today. Will cont (continue) to monitor." The next fall documented on the IADEQ was on 5/21/11 at 10:30 pm. The incident report stated the resident was found on the floor in her room. It also stated a hi lo bed with side rails were the interventions in place at the time of the accident. There was no mention of alarms. It indicated the resident's walker was removed from her room after the fall and the resident was brought to the nurse's station for increased supervision. It also documented the resident had fallen in the past 30 days. Nurse's Notes for the resident documented on 5/22/11, on the day/evening shift, "...Res has x 3 hallucinations (3 episodes of hallucinations), medicated with Haldol-ineffective. Res has increased agitation and restlessness most of day..." The next fall was on 5/27/11 at 11:15 pm. The IADEQ stated the resident was observed to lose her balance and fall to a sitting position at the end of her roommate's bed. It stated a bed/chair alarm was in place and the CNA heard the alarm sounding but could not reach the resident before she fell . It indicated interventions of obtaining orthostatic BPs for 72 hours, placement on the Falling Stars program, placement of a splint to her left wrist, and an orthopedic consult. This form indicated the resident had fallen in the past 30 days. This fall resulted in a fracture to the resident's left distal radius. An Interdisciplinary Care Plan documented that alarms to the resident's bed and wheelchair, dated 5/31/11. Nurse's Notes for the resident documented on 5/27/11 at 11:30 pm, "Resident had a witnessed fall at 2315 (11:15 pm). CNA saw her lose her balance and fall to the floor. Landed in a sitting position at the end of her roommate's bed...Res stated she was going to restroom. Did not have her shoes on. Reminded her to use her call light and have staff help her. Bed alarm was sounding at time of fall." NOTE: The facility was cited at F323 in a complaint survey with an alleged correction date of 6/10/11. The above mentioned falls were prior to this correction date. However, for historical purposes of demonstrating the fall history for Resident #1, they have been included for reference. The survey timing would preclude the fall that resulted in a fracture on 5/27/11 from being cited as harm to the resident but the resident did fall again and fractured a different area of her left arm, as documented below. Nurse's Notes for the resident documented the following: 6/11/11 at 10:55 am, "Res has been attempting to self transfer this morning and has been redirected multiple times..." 6/12/11 at 2:00 am, "...Res cont (continues) self transferring, call light in reach, encourage res to use call (light). Cont to monitor." The next fall was on 6/15/11 at 9:30 pm. The IADEQ stated the resident stood up to get her water and a mat had been placed over the nonskid rug at her bedside. The mat moved when she stood on it, causing the resident to fall. The incident report does not state this was an observed fall nor does it state the alarms sounded. The Physician order [REDACTED]. Nurse's Notes however, indicate the alarm sounded. The IADEQ indicated staff education was done regarding not placing a mat on top of the nonskid rug as it created a fall hazard. Nurse's Notes for Resident #1 documented on: * 6/16/11 at 9:45 pm, "...Resident found walking in room without alarm in place. Placed alarm after laying resident down. Alarm was taken off constantly (by the resident) after resident up and walking. Resident redirected and alarm placed on opposite side. Intervention effective. Resident laying down quietly and alarm in place and out of resident's sight. No further injuries from fall. Will continue to monitor." * 7/9/11 at 5:30 pm was documented, "...res has increased delusion at this moment..." * 7/14/11 at 2:00 am, "Res alert with confusion, noncooperative (sic) with cares, tab alarm in place r/t (related to) poor safety awareness, attempts to ambulate in room..." * 7/15/11 at 2:35 am, "Resident...woke up at 2325 (11:25 pm) set off alarm (sic). Helped to toilet. One person assist...Fall risk high, 1 person assist with all transfers. Brace to left arm..." * 7/25/11 at 3:40 am, "...Several attempts to go to restroom on her own..." * 7/27/11 at 12:00 am, "Resident very agitated and paranoid delusional..." * 7/28/11 at 8:00 pm, "...Had delusional behaviors x 2 (2 episodes)..." * 7/31/11 at 8:00 pm, "...Alert and confused...Res can be delusional at times..." * 8/1/11 at 10:30 pm, "...very mild delusional behaviors noted at this time..." * 8/3/11 at 1:00 am, "...Res alert with confusion, attempt to self transfer, res toileting, no further attempts to self transfer." * 8/4/11 at 2:30 pm, "...Resident with increased agitation/paranoia after breakfast..." * 8/4/11 at 8:00 pm, "...Resident with paranoid and delusional episodes..." * 8/7/11 at 10:00 pm, "Res alert and delusional..." * 8/12/11 at 8:40 pm, "Resident more confused this evening..." The next fall was on 8/24/11 at 1:15 am. The IADEQ stated the staff heard a noise and observed the resident on the floor in the hallway. The report indicated the resident had removed the bed alarm. It also indicated staff would be educated on proper alarm placement and use of alarms. Nurse's Notes for the resident documented on 8/25/11 at 1:00 am, "...Alarm sounded, staff assist res to bathroom...," and at 10:10 pm, "...Increase of agitation, PRN (as needed) Haldol given..." The next fall was on 9/3/11 at 3:40 am. The IADEQ stated the resident was observed on the floor by her roommate's bed in a sitting position. It indicated the resident stated she needed to go to the bathroom and that her alarm had not sounded. It also indicated staff would be educated on alarm placement and functioning, to attempt to toilet the resident at night at 1:00 am and 4:00 am, and alarm checks twice a shift. An Interdisciplinary Care Plan documented to check the alarms twice per shift for two weeks and implement a night toileting program, dated 9/6/11. Nurse's Notes for the resident documented the following: * 9/9/11 at 9:45 am, "Res got up from her wc (wheelchair) unassisted at this time. Alarm sounded. Will cont to monitor." * 9/11/11 at 9:10 pm, "Resident has increased anxiety..." * 9/16/11 at 2:20 am, "Resident was up walking in hall holding on to tag alarm twice between 11 p and midnite (11:00 pm and midnight). Advise her to call for help. Reminded her we did not want another fall. She stated she was fine, put her back to bed." * 9/18/11 at 10:00 pm, "Res removed tab alarm. Noted resident walking down the hall. Cont (continue) to encourage res to use light (call light) for assistance." * 9/21/11 at 1:00 am, "Alarms in place. Cont attempts to set up (sic) in bed, ambulate in hall. Self transfers. Res cont increased confusion..." * 9/25/11 at 8:45 pm, "Alarms in place and functioning. Patient often stands up and they alarm." * 9/30/11 at 9:00 pm, "Resident up in door. Alarms in place. Resident still not cooperating with call light and calling staff." * 10/1/11 at 10:55 pm, "Resident still uncooperative with alarms..." * 10/7/11 at 1:30 am, "Resident alert with confusion...Poor safety awareness, has alarms which she removes frequently. Doesn't use call light..." * 10/7/11 at 5:00 pm, "...Many instances of delusions...Due to confusion, unable to comply with call light and other cares...Resident noncompliant with asking for help for transfers..." * 10/9/11 at 9:30 pm, "...Resident does not comply with call light procedures r/t confusion..." * 12/18/11 at 10:20 pm, "Resident was walking down hallway this evening with alarm in her hands. Made multiple attempts to hide alarm. Resident is unstable on feet." * 1/2/12 at 9:45 pm, "...Safety alarm in place. Often found self transferring...Showing signs of increased anxiety et agitation..." The next fall was on 1/22/12 at 1:30 pm. The IADEQ indicated the resident was observed on the floor in her room next to her bed. It indicated the resident stated she slid out of bed. It also stated the resident complained of left wrist pain and was sent to the ED (emergency department) for evaluation and treatment. The report indicated the resident's bed alarm was in place but that it was covered with a jacket and pillow. The resident was placed on line of sight and 1:1 supervision after return from the hospital for the next 72 hours, with Q 15 minute (every 15 minute) checks after that. A self-releasing alarming seat belt for the resident's wheelchair was also ordered. This fall resulted in a fracture to the resident's left wrist. The Care Plan that was in effect at the time of that fall included the following interventions: * Monitor for side effects from medication use that may increase risk for falls * Non skid rug at bedside * Transfer handle x 1 * Limited to Extensive assist at times for transfers. FYI: (Resident) does self transfer without assist. Encourage her to ask for help. * Wheelchair as primary mode of locomotion, able to self propel on and off unit but may require assist for longer distances. FYI: Res to wear tan orthopedic shoes * Alarms at all times when in w/c and in bed * Falling Star Program The resident's Care Plan after the fall documented the following changes: * bed in lowest position when (resident) in it, dated 2/1/12 * adj (adjustable) hi/low bed with 1/4 SR (siderails) x 2 (two), dated 2/1/12 * Discontinued the transfer handle, dated 2/1/12 * Bathroom door alarms, dated 1/31/12 * Self-releasing seat belt, dated 2/1/12 * 1:1 for 72 hours, dated 1/22/12 * Line of sight until 1:1 staff available, dated 1/22/12 NOTE: The resident was not continued on every 15 minute checks for safety. The DON was interviewed on 3/1/12 at 1:00 pm regarding the fall history for Resident #1 and asked for further documentation. The DON indicated Resident #1 was resistant to requesting help with transfers. The facility failed to implement effective supervision interventions to prevent the resident from falling, such as checking on her at more frequent intervals. The resident's diminished cognitive status left her vulnerable to impaired safety awareness and resulted in numerous falls with two fractures in 7 months, one fall with fracture since the last compliance date for falls. She repeatedly showed an inability or unwillingness to utilize her call light and ask for help, removed her alarms, and attempted to muffle their sound. Although the 5/27/11 fall with fracture was before the alleged date of compliance, it and the other previously documented falls demonstrated a need to increase supervision for this resident. Instead, she fell repeatedly and eventually, fractured her left arm again. Her increasingly diminished cognitive status, confusion, delusions, hallucinations, and paranoia were documented by the facility and yet, the facility did not increase supervision for this resident but continued with ineffective fall interventions. The Administrator and DON were informed of this issue on 3/1/12 at 1:15 pm. Nurse's Notes from May 2011 to January 2012 were received on 3/2/12.