Every finding on record at Meadow View Nursing and Rehabilitation

Based on observation, facility's CNA job description, record review, and resident and staff interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 1 of 2 residents (Resident #64) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth. Findings include:The facility's Certified Nursing Assistant Job Description dated 12/17/21, documented staff are to knock before entering the resident's room. Resident #64 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including stroke and muscle weakness. On 9/22/25 at 12:38 PM, observed CNA #1 say the words knock, knock as he was walking down the hallway and then entered Resident #64's room without waiting to be invited into the room. On 9/22/25 at 12:40 PM, Resident #64 stated she expects the staff to knock on the door and wait to be invited into her room, not just say knock, knock and walk in. On 9/22/25 at 4:30 PM, observed CNA #1 say knock, knock as he was walking toward room [ROOM NUMBER] and then walk into resident room [ROOM NUMBER] without waiting to be invited into the room.On 9/22/25 at 4:35 PM, CNA #1 stated he should be knocking on the door and waiting to be invited into the room and had not.On 9/22/25 at 4:40 PM, the DON stated staff should be knocking on resident's doors and waiting to be invited into the room and had not been.

Based on record review and staff interview it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 3 of 23 Residents (#12, #72 and #88) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the resident's wishes were not followed or documented regarding their advance care planning. Findings include: The CMS SOM, Appendix PP, dated 7/23/25, defined: - Advanced Directive, as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State.) - Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. 1.) Resident #12 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stroke and diabetes. Resident #12's ACKNOWLEDGMENT OF PATIENT INFORMATION ON ADVANCED DIRECTIVES was completed on the day of admission, 2/3/25, and documented resident did not want to create an Advanced Directive at that time. Resident #12's Electronic Medical Record (EMR) contained a POST on file dated 9/9/24. The EMR did not contain documentation of an Advanced Directives, or documentation Advanced Directives were discussed with her. On 9/24/25 at 3:40 PM, the Social Worker #2 stated she has not asked Resident #12 about formulating an Advanced Directive specifically because she thought the POST was the same as an Advanced Directive. 2.) Resident #72 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure, diabetes, and chronic pain. Resident #72's ACKNOWLEDGMENT OF PATIENT INFORMATION ON ADVANCED DIRECTIVES was completed on the day of admission 9/26/24, and documented resident did not want to create an Advanced Directive at that time. Resident #72's EMR contained a POST on file dated 4/17/24. The EMR did not contain documentation of an Advanced Directives, or documentation Advanced Directives were discussed with her. On 9/24/25 at 3:45 PM, the Social Worker #2 reviewed Resident #72's EMR and stated she had not followed up on the Advanced Directive because Resident #72 had a POST in place, and Social Worker #2 thought they were the same thing. 3.Resident #88 was admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction (process that causes tissue death in the brain) and dementia. Resident #88's medical record contained a POST but did not contain documentation the facility had provided information on formulating an advance directive as requested by the resident/resident representative in the admission packet. On 9/23/25 at 12:31 PM, Social Services staff #1 stated the facility only had a POST document for Resident #88 and had no documentation the information on formulating an advance directive requested by the resident/resident representative in the admission packet had been provided or followed up on since admission to the facility. On 9/24/25 at 4:17 PM, Social Services staff #2 stated the facility had no documentation for Resident #88 that the facility had followed up on advance directives during the quarterly meetings.

Based on record review and staff interview, it was determined the facility failed to provide the Advance Beneficiary Notice (ABN - CMS-10055 form) for 2 of 3 residents (#19 and #70) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include: 1. Resident #19 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including amputation aftercare and malnutrition.A Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form documented beginning on 5/20/25, Resident #19 would have to pay out of pocket for his care. Resident #19 had not signed the document until 5/29/25, 9 days after the cares were being provided.2. Resident #70 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including left femur fracture and pulmonary fibrosis (a chronic lung disease characterized by the scarring and thickening of the lungs' interstitial tissue leading to shortness of breath and fatigue).A Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form documented beginning on 6/28/25, Resident #70 would have to pay out of pocket for his care. Resident #70 had signed the document, and it was not dated when it was signed.On 9/25/25 at 10:55 AM, the DON stated the ABNs should have been signed and dated by Resident #19 and Resident #70 prior to providing cares for which either resident could be billed for.

Based on policy review, record review, review of the Bureau of Facility Standards Long Term Care Reporting System (BFS) portal and staff interview, it was determined the facility failed to report allegations of potential abuse to the State Survey Agency within 2 hours. This affected 1 of 2 residents (Resident #3) whose records were reviewed for abuse reporting and investigation. This deficient practice created the potential for harm if allegations were not acted upon in a timely manner and the abuse continued. Findings include:The facility Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment policy revised April 2025, documented under Procedure: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will:a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment.are reported immediately but:Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury.Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury.b. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment .are reported to:The Administrator of the FacilityThe State Survey AgencyAdult Protective Services (as appropriate)Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cerebral palsy (a group of disorders that affect movement, muscle tone, and posture due to damage to the developing brain) and chronic obstructive pulmonary disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties).The complaint documented on 6/9/25 around 1:30 PM, CNA #3 observed CNA #1 roughly slam Resident #3 into the wall when turning her in the bed. CNA #3 reported this to the hall nurse and texted RN #1 nurse manager regarding the alleged abuse. CNA #3 did not report the alleged abuse to the Administrator until 6/11/25 at 1:00 PM. The Administrator had not reported the alleged abuse to the state survey agency or BFS portal. On 9/24/25 at 11:30 AM, the Administrator stated she had not reported the alleged abuse to the BFS portal within 2 hours and should have.

Based on review of state operations manual, observation, and interviews, it was determined the facility failed to ensure residents were provided with a safe homelike environment. This was true for 1 of 3 residents (Resident #64) whose rooms were observed. This deficient practice created the potential for diminished quality of life and water temperature burn risk. Findings include:State Operations Manual Appendix PP, revised 7/23/25, documented water temperature of 124 degrees F will cause a 3rd degree burn to occur within 3 minutes, and water temperatures of 120 degrees F will cause a 3rd degree burn to occur within 5 minutes. On 9/22/25 at 12:40 PM, Resident #64 in room [ROOM NUMBER] stated the room sink water gets very hot.On 9/22/25 at 4:15 PM, the sink water temperature in room [ROOM NUMBER] was 122 degrees F.On 9/22/25 at 4:18 PM, the sink water temperature in room [ROOM NUMBER] was 123 degrees F.On 9/22/25 at 4:20 PM, the sink water temperature in room [ROOM NUMBER] was 124 degrees F.On 9/22/25 at 4:30 PM, the DON stated the room sink water temperature should not be above 115 degrees F.On 9/22/25 at 4:55 PM, the assistant maintenance director stated the room sink water temperature should not be above 115 degrees F and he was going to do some testing.On 9/23/25 at 10:11 AM, the DON stated as for the water policy, the facility follows the regulation and checks water temperatures routinely. On 9/23/25 at 10:30 AM, the surveyor verified the calibration reading of his water temperature gauge by testing room [ROOM NUMBER] sink water temperature along with the maintenance director temperature gauges which had the same reading of 114 degrees on this day.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 4 residents (Resident #98) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: Resident #98 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease (a progressive neurodegenerative disorder characterized by the gradual loss of dopamine-producing neurons in the brain leading to a range of motor and non-motor symptoms, including tremors, rigidity, slowness of movement and difficulty with balance and coordination) and chronic obstructive pulmonary disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties).Resident #98's medical record had two physician orders for oxygen therapy as follows: - active order dated 12/23/24, documented O2 via NC at 2L-4 Lpm if O2 saturation is less than 90%. - active order dated 1/4/25 2 Lpm oxygen via nasal cannula at bedtime.On 9/23/25 at 8:49 AM, observed Resident #98 in his room sitting in his wheelchair with CNA #2 assisting him with his ADLs, without his oxygen cannula in his nose. The oxygen concentrator was running however all the oxygen tubing was in a plastic bag hanging on the oxygen concentrator. On 9/23/25 at 8:50 AM, observed Resident #98 was lethargic, not responding to most questions or prompts from CNA #2 while he was off his oxygen.On 9/23/25 at 8:51 AM, CNA #2 stated she had just moved Resident #98 into his wheelchair and would reapply his oxygen after finishing getting him ready for the day.On 9/23/25 at 9:00 AM, LPN #1 stated Resident #98 had to use oxygen during the day over the weekend due to SOB and low SpO2 and should be on his oxygen at 2 Lpm and she would check his SpO2. On 9/23/25 at 9:02 AM, LPN #1 stated Resident #98 had not stated he felt SOB but acknowledged he was acting confused and lethargic which is an indication of low SpO2. On 9/23/25 at 9:04 AM, LPN #1 stated Resident #98 oxygen level was low at 81% on room air and she applied the oxygen at 2 Lpm and had to increase the oxygen flow up to 4 Lpm to get the resident SpO2 above 90%. On 9/23/25 at 9:10 AM, LPN #1 stated she instructed CNA #2 to notify the LN if residents act lethargic, are not responding to prompts, and appear to be SOB so the LN can properly assess the resident.On 9/25/25 at 10:00 AM, the DON stated residents that appear lethargic and are not responding to verbal prompts should be assessed by a LN for low SpO2 and had not been.

Based on record review and staff interview, it was identified the facility failed to ensure residents were properly monitored for pain management. This was true for 2 of 4 residents (#8 and #72) whose records were reviewed for pain management. This failure had the potential to create harm when residents were not monitored adequately for pain. Findings include:The Idaho Board of Medicine report, The Appropriate Role of Unlicensed Medical Personnel, (Winter 2012/2013), documented that unlicensed personnel are not permitted to exercise independent judgment, provide assessments, interpretations or diagnoses, or perform invasive procedures. 1. Resident #8 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including myositis (an inflammation of the muscles) and dyspnea. Resident #8's medical record contained a physician order dated 9/2/25, for hydrocodone-acetaminophen oral tablet 7.5-325 MG to be given every four hours as needed for pain. Resident #8's MAR documented on 9/21/25 at 9:41 PM, the MAC documented Resident #8's pain level was 5 and she administered hydrocodone-acetaminophen oral tablet 7.5-325 MG. Resident #8's medical record had not contained any LN assessment of pain related to administration of this medication on 9/21/25 at 9:41 PM. On 9/23/25 at 7:31 AM, the DON stated that a licensed nurse should have documented their pain assessment of Resident #8 prior to the MAC giving Resident #8 the hydrocodone-acetaminophen oral tablet 7.5-325 MG but had not. 2.) Resident #72 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure, diabetes, and chronic pain. Resident #72's Quarterly MDS Assessment, dated 9/8/25, documented she was cognitively intact. Resident #72's care plan, revised on 3/11/25, documented the following interventions for pain: - Administer analgesic medication as per orders - Pain assessment every shift - Position for comfort A physician's order dated 4/17/24, directed staff to monitor level of pain every shift using the following scale: 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain A physician's order dated 5/5/25, directed staff to administer oxycodone (a narcotic pain medication) 5/325 MG, one-tablet by mouth every 6 hours as needed for moderate to severe pain. Review of Resident #72's Medication Administration Record (MAR) for September 2025, documented oxycodone was administered when her pain assessment was zero on the following dates. - 9/5/25 at 1:59 AM - 9/6/25 at 2:44 AM - 9/7/25 at 1:41 AM - 9/11/25 at 2:24 PM - 9/12/25 at 2:44 AM - 9/13/25 at 4:20 AM - 9/14/25 at 2:38 AM - 9/18/25 at 7:06 PM - 9/19/25 at 2:24 AM - 9/20/25 at 2:27 AM On 9/24/25 at 10:27 AM, the DON reviewed Resident #72's medical record and confirmed the oxycodone should only be administered as needed for a pain rating of 4 or higher to meet the order for moderate to severe pain and that the nurses needed to document better when administering as needed pain medications.

Based on review of the State Operations Manual, Appendix PP, observation, and staff interview, it was determined the facility failed to ensure the daily nurse staffing information was accurately posted for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels. Findings include:On 9/25/25 at 10:17 AM, the daily postings of licensed and unlicensed nurse staffing dated 3/20/25 - 9/20/25 was reviewed. There were no adjustments to the posted staffing when the scheduled hours did not match the actual hours worked.On 9/24/25 at 11:00 AM, the Human Resource Manager stated she was not aware the actual hours worked by the nursing staff had to be documented on the daily posting of licensed and unlicensed nurse staff.

Based on Policy review, observation, record review, and staff interview, it was determined the facility failed to ensure narcotic counts were consistently verified by the off going and on coming nurses. This was true for 3 of 3 medication carts. This failure created the potential for undetected misuse and/or diversion of controlled medications and the potential for harm if a controlled medication was not available when needed. Findings includeThe facility's Policy and Procedure regarding Controlled Drugs revised 4/2025, documented, A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. 1) The C - Hallway medication cart narcotic count sheet documented the following:* 9/24/25: 6:00 AM - the oncoming nurse signature space was blank.On 9/24/25 at 8:15 AM, LPN #2 confirmed the signature space for the oncoming nurse was blank and he stated he must have simply forgot to sign the log after the count that morning. 2) The Special Care Unit (SCU) - Hallway medication cart narcotic count sheet documented the following:* 9/24/25: 6:00 AM - the oncoming nurse signature space was blank.On 9/24/25 at 8:40 AM, LPN #1 confirmed the signature space for the oncoming nurse was blank and she stated she forgot to sign the log. 3) The A- Hallway medication cart narcotic count sheet documented the following:* 9/24/25: 6:00 AM - the off going nurse signature space was blank.On 9/24/25 at 9:25 AM, RN #3 confirmed the signature space for the off going nurse was blank but said she must have forgot to sign the log because the off going nurse signed in her spot by mistake. On 9/24/25 at 10:00 AM, the DON stated the expectation is for the off going and oncoming nurse to perform a narcotic count for the cart they are assigned to and sign the log when those counts are done.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This failed practice created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include: The facility's Policy and Procedure regarding Controlled Drugs revised 4/2025, documented, It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments.On 9/24/25 at 8:00 AM, with RN #2 present, observed the following in C Hallway medication storage room: -narcotic storage refrigerator was unlocked and unmonitored-a black metal box inside the refrigerator labeled Hall C Narcotic Box was not permanently affixed inside the refrigerator.On 9/24/25 at 8:04 AM, RN #2 stated, the narcotic fridge should not have been left unlocked, and the C-Hall narcotic box should have been secured inside the fridge.On 9/24/25 at 8:20 AM, the DON stated, the expectation is that the narcotic refrigerator is to remain locked, but in instances where the door is left unlocked, the narcotics inside are locked and secured to the inside. When asked about the C-Hall Narcotic Box, he removed it from the refrigerator and stated it should have been locked securely to the inside of the refrigerator.

Based on observation, interview, and review of the Idaho Food Code, the facility failed to ensure staff wore beard nets in the kitchen and appropriately stored, distributed, and labeled foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, 2-402.11 listed under hair restraints documented, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens.The Idaho Food Code, revised February 2021, documented, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On 9/22/25 at 12:30 PM, observed the assistant dietary manager in the kitchen food prep areas without a beard cover over his facial hair. On 9/22/25 at 12:35 PM, the assistant dietary manager stated he did not think he needed a beard cover because his facial hair was short. On 9/22/25 at 12:40 PM, observed an opened bottle of red food coloring not labeled with the opened date. On 9/22/25 at 12:52 PM, the assistant dietary manager stated all food items should be labeled with the opened and used by dates and were not. On 9/22/25 at 12:25 PM, during the initial dining observation, a carafe of cranberry juice with a use by date of 9/21/25 was being served to residents in the Bistro dining room. On 9/22/25 at 12:27 PM, RN #3 was asked about the use by date on the cranberry juice. She stated it should not be used if the date is past the use by date. On 9/22/25 at 12:13 PM, during the dining room observation, three containers of dry cereal with a use by date of 9/19/25 was available for residents' use on the back counter in the C dining room. On 9/22/25 at 12:31 PM, LPN #2 was asked about the use by date on the dry cereal containers. He stated it should not be used if the date is past the use by date. On 9/22/25 at 12:47 PM, [NAME] #1 removed the dry cereal containers and stated the cereal should have been removed and had not been.

Based on observation, staff interviews, and record review, it was determined the facility failed to ensure clean clothing were stored on a clean surface in the laundry area. This deficient practice created the potential for harm due to the increased risk of cross contamination and had the potential to affect all residents in the facility. Findings include:The facility's policy for Infection Prevention and Control Program, dated 06/2021 with revision/review date 04/2025, documented the following: The lnfection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals.process surveillance includes linen management (handling, storage, processing, and transport) .On 9/24/25 at 1:27 PM and 9/25/25 at 10:21 AM, observed in the laundry room multiple clear unsealed plastic bags on the floor near the washing machines containing folded clothing. On 9/24/25 at 1:36 PM, Laundry staff #1 stated the clothing in the bags are clean and were placed on the floor when staff returned from the laundromat and was trying to get the clean clothes sorted and returned to the residents but should not have placed the bags of clothing on the floor. On 9/25/25 at 10:23 AM, Laundry staff #2 stated the clothing in the bags are clean and should not have been placed on the floor.On 9/24/25 at 1:49 PM, the Executive Director stated she was aware of the issues with the laundry room washing machines not functioning, and the facility had been using outside laundry services which caused additional work for the staff to get the clean laundry back to the residents.

Based on observation, record review, interview, and policy review, the facility failed to ensure a residents safety during a mechanical lift transfer resulting in the resident falling during a mechanical lift transfer and sustaining a spinal fracture and to prevent a cognitively impaired resident with wandering/exit seeking behaviors from gaining access to the parking lot without supervision for two of seven residents (Resident (R) 309 and R95) reviewed for accidents in the sample of 21. Findings include: 1. Review of R309's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] and readmitted on [DATE] with diagnoses including fracture of T7-T8 thoracic vertebra. Review of R309's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 revealed a Brief Interview for Mental Status (BIMS) could not be completed due to resident rarely being understood. Review of R309's care plan, located under the Care Plan tab of the EMR and dated 05/24/17, revealed, The resident was at risk for Activities of Daily Living (ADL) self-care performance related to profound intellectual disabilities. Interventions in place for transfer were that patient was dependent on staff for transfers and required two staff for Hoyer [mechanical lift] transfers. Review of a Nurse's Note, located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN) 4 on 06/29/24 at 5:35 PM revealed, called to resident room to assist with Hoyer transfer, resident in sling and ready for transfer when I arrived, I had the Hoyer control, lifted resident off the bed enough to move. As resident was being turned toward her chair the loop at her right hip came undone and resident slid feet first onto the floor. Review of Incident report, provided by the facility and dated 06/29/24 at 5:42 PM, revealed resident fell out of Hoyer during transfer. Left hoop came undone and resident slid feet first ono the floor. Resident still low to the floor at the time of the fall, her head landed on this nurse's foot, right shoulder onto Hoyer wheel. Resident is nonverbal. Review of Hospital Progress Notes, located under the Miscellaneous tab of the EMR and dated 06/20/24, revealed R309 was brought into the emergency room after a fall out of a mechanical lift and was assessed and found to have a T8 compression fracture. During an interview on 08/07/24 at 3:53 PM, LPN4 said Certified Nurse Aide (CNA) 4 asked her to assist with a mechanical lift transfer and she told CNA4 to give her a second. LPN4 recalled when she entered R309's room the resident was in bed and the sling was under her and hooked up. LPN4 stated she glanced at the loops, but she did not physically check them. CNA4 had the resident, and LPN4 took the mechanical lift control. As she lowered R309, the loop on the left hip came undone and R309 slid out, LPN4 grabbed her head but R309 hit the back of her leg on the lift. LPN4 assessed her, checked her back, the resident seemed alright and was responding at baseline, no range of motion at baseline, put her back into sling and then into her wheelchair. After a few minutes R309's face went pale and her breathing was rapid, called 911, and she was sent to the emergency room . An attempted call was placed on 08/08/24 at 11:24 AM to CNA4 but it was unsuccessful. During an interview on 08/08/24 at 1:42 PM, CNA1 said he was very familiar with R309 and was assigned to her regularly. CNA1 said staff should have checked the loops before R309 was lifted for safety. CNA1 said it was something that should and could be easily checked for to ensure its secure prior to lifting the resident and the fall that occurred was easily preventable. During an interview on 08/07/24 at 6:22 PM, the Director of Nursing (DON) stated he expected that all transfers be done with two people, and they should be focused on what they are doing. The DON stated the facility identified that the loops during R309's transfer were not secured causing them to come undone and resulting in her falling out of the mechanical lift. A review of the facility's policy title Safe Resident Handling/Transfers reviewed on 01/01/2023, revealed, it is the policy of the facility that the residents will be transferred/handled safely. 2. Review of R95's Admission Record located in the Profile tab of the EMR, revealed re-admission to the facility on [DATE] and with diagnoses including attention and concentration deficit, aphasia, and memory deficit. Review of R95's annual MDS, located under the MDS tab of the EMR, with an ARD of 02/29/24, revealed the BIMS could not be completed due to resident rarely being understood. Further review revealed his cognitive skills were moderately impaired due to poor decision making and he required cues/supervision. Review of R95's care plan, located under the ''Care Plan'' tab of the EMR and dated 03/18/24, revealed the resident was an elopement risk/wanderer due to a history of attempts to leave the facility unattended. Review of a Nurse's Note, located in the EMR under the Notes tab by Former Social Worker (FSW) on 08/15/23 at 1:51 PM, revealed, it was brought to the attention of the social worker that R95 has been gathering his stuff and trying to get to the front door of the facility to leave. Staff spoke with R95 who continued to wheel himself down the hall. After the DON spoke with R95 he agreed to stay. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Licensed Practical Nurse (LPN) 8 on 12/13/23 at 6:04 PM, revealed R95 continued on alert charting for increase in wandering. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Licensed Practical Nurse (LPN) 2 on 03/16/24 at 5:39 PM, indicated, R95 was outside in front parking lot, staff assisted R95 back inside the facility, unable to determine why R95 went outside into parking lot located about 20 feet from a main road. A review on weather.com revealed the weather forecast in Nampa, ID on 03/16/24 was 48 degrees that day and 37 degrees that night. During an interview on 08/07/24 at 3:55 PM, Licensed Practical Nurse (LPN) 2 said she was not sure how often the facility has training related to elopement or when the last one she attended was. LPN2 said she was not sure what the elopement protocol was, but she believed staff would go look for them, call 911 if they were unable to find them and the Administrator and Director of Nursing (DON) should be made aware. LPN2 said on 03/16/24 a CNA alerted her that R95 was in the parking lot, but she could not remember who the CNA was. LPN2 did not know how long R95 had been in the parking lot, but she said staff were not present with him and did not know he was out there. LPN2 was just told he was out there, and she did not ask the CNA any questions. LPN2 stated when she went to walk out to the parking lot, she observed another staff (unsure who) assisting R95 back inside. LPN2 thought she reported it to the on-call supervisor but unsure who that was. LPN2 said R95 was not a wanderer or elopement risk prior to that, and he did not have any interventions related to elopement or wandering and she was unaware of any other incidents with that resident or other residents. LPN2 said R95 was in the parking lot in his wheelchair, but she could not remember what he was wearing but she thought it was appropriate for the weather at the time. During an interview on 08/07/24 at 4:27 PM, the Assistant Director of Nurse (ADON) said that on 03/16/24 LPN2 called and told her R95 wheeled out the front doors and he was seen outside the front doors. The ADON stated after that staff put a wander guard on him to ensure he did not go out the front door again. The ADON could not recall if someone saw him go out the front door or if staff saw him outside the front door, and she did not know for sure how R95 actually got out of the facility or how long he was outside before staff observed him. During an interview on 08/07/24 at 6:22 PM, the DON said they did not have any documentation related to the elopement. The DON stated they did not report or investigate it, and they were waiting on guidance from the state because they did not consider the incident an elopement. The DON said the interdisciplinary team was aware R95 had known wandering behaviors and a documented desire to leave the facility, and he was not sure why nothing was put into place prior to 03/16/24 but stated they should have definitely put interventions in place. A policy was not provided for wandering/elopement.

Based on record review, interview, and facility policy review, the facility failed protect the resident's right to be free from physical abuse by staff for one of five residents (Resident (R) 13) reviewed for abuse out of a total sample of 21 residents. Findings include: Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/24, located in the electronic medical record (EMR) under the MDS tab, revealed R13 admitted to the facility on [DATE]. R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Per the MDS, the resident did not exhibit any behaviors during the assessment period. Review of the Resident Allegation of Abuse Investigation, dated 07/26/24, indicated, [R13] . with a primary diagnosis of aftercare following ulna fracture . Resident reported to social services on this date at approximately 9:45 AM to file a grievance against one of the facility's CNAs [Certified Nurse Aides] [CNA4] . [R13] said smoke break was in the process of ending and the aide announced smoke break was over and she needed to get back in the building. [R13] states [sic] she was in the process of taking a drag off her cigarette when [CNA 4] reached over and grabbed her arm and wrist in what she felt was an aggressive manner to put her cigarette out and ended up burning the resident and herself . On 07/26/24 at 10:45 AM, this administrator met with [another resident] . he stated [R13] was taking a smoke off her cigarette and the assistant reached over and grabbed her arm to put her cigarette out . He confirmed he felt it was done in an aggressive manner and was done intentionally. Director of Nursing [DON] will meet with staff member on 07/29/24 (remained on leave until this date) at which time she will be terminated. During an interview on 08/06/24 at 2:41 PM, R13 stated CNA4 grabbed her hand and put the cigarette in the ashtray. R13 stated she was startled she [CNA4] would do something like that. R13 said CNA4 grabbed her wrist, burned her finger and put her cigarette out. R13 stated it was not a bad burn just some redness, but it was enough to scare her. R13 completed a grievance form and then heard from the DON that CNA4 was fired. During an interview on 08/07/24 at 10:30 AM, R30 stated she was in the smoking area when CNA4 grabbed R13's arm. R30 stated she thought both R13 and CNA4 were burned when CNA4 grabbed R13 to put her cigarette out. During an interview on 08/07/24 at 5:00 PM, the Administrator stated she immediately investigated the grievance after hearing about it and terminated CNA4. Review of the facility's policy titled, Abuse: Prevention of and Prohibition Against, dated 12/2023, revealed All identified events are reported to the Administrator immediately . After receiving the allegation, and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm.

Based on record review, interview, and policy review, the facility failed to investigate an injury of unknown origin and an allegation of sexual abuse for two residents out of five residents (Resident (R) 73 and R63) reviewed for abuse out of a sample of 21. Failure to thoroughly investigate and take appropriate action for allegations had the potential to place other residents at risk of abuse/neglect. Findings include: 1. Review of R73's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] with diagnosis of mild cognitive communication deficit. Review of R73's annual Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab, with an Assessment Reference Date (ARD) of 02/02/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Licensed Practical Nurse (LPN) 1, dated 07/03/23 at 12:16 AM, revealed, results from x-ray to residents fifth toe came back, results are acute oblique fractures (break on an angle) are seen in the distal fourth and fifth metatarsals. Review of facility provided Incident report, dated 07/03/24 at 8:42 AM, revealed R73 was seen by the in-house podiatrist with an order to obtain an x-ray of the right 5th toe to rule out bone lesions. X-ray performed and results were an acute oblique fracture are seen in the distal fourth and fifth metatarsals. During an interview on 08/08/24 at 11:21 AM, LPN1 stated staff should notify the Administrator or main supervisor within 2 hours of any abuse concern or an injury of unknown origin. She said she was the nurse on shift when the results for R73's x-ray came back. But she was not sure if she reported the fractures to anyone, but she should have reported it to a supervisor and if she did, she should have documented that. During an interview on 08/07/24 at 6:22 PM the Director of Nursing (DON) stated they investigated R73's broken toes and provided a paper with five questions dated 07/09/24 but did not have any additional documentation. The questions were conducted six days after x-ray results were received by the facility. The DON did not know how R73's toes were broken. No additional documentation related to an investigation was provided. 36917 2. Review of the ''Bureau of Facility Standards Long Term Care Reporting system, dated 08/08/24 and completed by the Administrator, revealed a report of sexual abuse for R63 as reported by Licensed Practical Nurse (LPN) 7. The document was provided by the administrator as the incident report that was submitted to the State Survey Agency. The form did not indicate the date or time the report was online submitted. The ''incident type'' as documented on the form indicated ''resident to resident incident (verbal, physical, mental, or sexual) was not marked to specify sexual abuse. The incident description documented ''during routine rounds licensed nurse observed resident [R49] in the room of [R63] being affectionate, [R49] cooperated with being immediately redirected out of room to his room next door to [R63], family members of both residents were notified and aware of the situation. The ''immediate protective action plan'' documented on the form stated R63 and R49 were immediately separated, R49 was placed on 15-minute monitoring checks for intrusive wandering and referred to Nurse Practitioner on 07/15/24 to assess for any medical status changes. The document indicated R63 frequently invited passersby into her room and was being monitored for any psychosocial changes related to the incident. Review of R63's ''Face Sheet,'' located in the ''Profile'' tab of the EMR, revealed an admitted [DATE] with diagnoses to include but not limited to unspecified dementia with other behavioral disturbance, anxiety disorder, cognitive communication deficit, need for assistance with personal care, unspecified psychosis, and depression. Review of R63's ''MDS, located in the MDS tab of the EMR, with an ARD of 06/06/24, revealed a BIMS score of 4 out of 15 which indicated R63 was severely cognitively impaired. Review of R63's care plan, located in the Care Plan tab of the EMR and revised 07/15/24, revealed she was at risk for impaired cognitive function, Activities of Daily Living (ADL) self-care performance deficit, altered mood/behaviors, evidenced by yelling out to people passing her door to come into her room, and physically aggressive, with a history of wandering. The ''Nursing Progress Notes,'' located in the Progress Notes tab in the EMR, documented R63's family member was not concerned with leaving R49 next door to his mother. Also documented in the progress note was his comment that R63 frequently tried to kiss him inappropriately and was easily redirected. During an interview on 08/08/24 02:21 PM with R63 in her room with Caregiver (CGR) 1 present, R63 stated she did not remember any ''boys'' or men coming into her room or kissing her. R63 responded that no boys entered her room. R63 appeared happy and smiling with no fear of any ''boys'' coming into her room. Review of R49's ''Face Sheet,'' located in the ''Profile'' tab of the EMR, revealed an admitted [DATE] with diagnosis to include but not limited to mild dementia without behavioral disturbance. mild cognitive deficit, ambulatory and independent for ADL. Review of R49's ''MDS, located in the MDS tab of the EMR, with an ARD of 07/04/24, revealed a BIMS score of 15 out of 15 which indicated R63 was cognitively intact. Review of R49's care plan, located in the Care Plan tab of the EMR, dated and revised 07/04/24, revealed R49 had a language barrier and was Spanish speaking only. R49's care plan revealed he had a history of engaging in unwelcome sexual behaviors and non-reciprocated sexual advances toward others as evidenced by grabbing others, kissing others, and intrusive wandering, initially dated 07/01/20 and revised 07/15/24. Interventions included redirecting resident and assisting him to develop more appropriate methods of coping and interacting with others, and to protect other residents by closely monitoring his possible behaviors, counseling with him as needed to stay out of other resident rooms. Review of Practitioner Progress Note, located in the EMR Progress Notes tab and dated 07/17/24, documented the following, ''During a recent visit on 07/16/2024, [R49] was found in [R63's] room being affectionate, likely due to cognitive deficits from a previous subdural hemorrhage. He was placed on 15-minute checks and alert charting. During an interview on 08/07/24 at 5:36 PM, the Director of Nursing (DON) stated he had written a summary of the incident, but did not have documented evidence of date, time, or name of residents or staff that he had interviewed after the alleged abuse incident. On 08/08/24 at 8:39 AM, the DON provided a sheet of paper that contained the three questions below, along with the signatures of three residents, R17, R23, and R50. Has any person come into your room that has been uninvited? Has any male, resident or staff come into your room that has been uninvited. Has anyone resident or staff been wandering into your room that has been uninvited? No documentation of the interview conversation or the answers provided by the residents in response to the questions was provided. During an interview on 08/08/24 at 10:22 AM, the Administrator stated she was not aware of the care plan entry for R63 that documented his previous history of inappropriate behaviors and sexual advances and wandering into other resident's rooms. When asked about measures implemented to prevent further possible abuse of other residents, the Administrator stated she had discussed with other staff and family members about moving R49 and his spouse to another room/hall, but there were no other rooms available in the facility for a couple. The Administrator stated that additional craft and activity items were ordered for R63 on 07/15/24 to give R63 more things to do. The Administrator stated a ''owl'' door motion detector alarm was ordered and placed on the door of R63's room that would alert (by sounding loudly at her door) staff of anyone entering R63's room. Documentation of a ''15 Minute Check List'' of R63 was provided by DON. The documents indicated inconsistent random checks performed daily from 07/14/24 through 08/07/24. The DON stated R63 was only monitored during the same shift the initial allegation occurred on. During a phone interview on 08/08/24 at 4:34 PM, LPN7 recalled R49 standing in R63's room beside the recliner of R63 with his hands touching her face and her arms around his neck with their lips touching. LPN7 stated she calmly directed R49 out of R63's room and back to his room next door and then reported the incident to the administrator. Review of the facility policy titled ''Abuse Reporting and Investigation,'' revised February 2024, revealed ''all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by the facility.''

Based on record review, interview, and policy review, the facility failed to implement a care plan for a resident with a known history of wandering and exit seeking behaviors for a resident who gained access to the facility parking lot without staff supervision or knowledge for one of three residents (Resident (R) 95) reviewed for elopement. This has the potential to affect all residents who were at risk of wandering and elopement. Findings include: Review of R95's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] and with diagnoses including attention and concentration deficit, aphasia, and memory deficit. Review of R95's annual Minimum Data Set (MDS), located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 05/24/24, revealed the Brief Interview for Mental Status (BIMS) could not be completed due to resident rarely being understood. Review of R95's care plan, located under the ''Care Plan'' tab of the EMR and dated 03/18/24, revealed the resident was an elopement risk/wanderer due to a history of attempts to leave the facility unattended. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Former Social Worker (FSW) on 08/15/23 at 1:51 PM, revealed, it was brought to the attention of the social worker that R95 has been gathering his stuff and trying to get to the front door of the facility to leave. Staff spoke with R95 who continued to wheel himself down the hall. After the Director of Nursing (DON) spoke with R95 he agreed to stay. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Licensed Practical Nurse (LPN) 8 on 12/13/23 at 6:04 PM, revealed R95 continued on alert charting for increase in wandering. Review of a Nurse's Note, located in the EMR, under the Notes tab, written by Licensed Practical Nurse (LPN) 2 on 03/16/24 at 5:39 PM indicated, R95 was outside in front parking lot, staff assisted R95 back inside the facility, unable to determine why R95 went outside into parking lot. During an interview on 08/07/24 at 6:22 PM, the Director of Nursing said the interdisciplinary team (IDT) was aware R95 had known wandering behaviors and a documented desire to leave the facility, and he was not sure why nothing was put into place prior to 03/16/24 but stated they should have definitely put interventions in place. During an interview on 08/08/24 at 3:31 PM, the Former Social Worker (FSW) stated after staff became aware R95 verbalized a desire to leave the facility and exhibited an increase in wandering which made him an elopement risk it should have been care planned. A review of the facility's policy title Comprehensive Person-Centered Care Planning, reviewed 12/2023, revealed it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. A review of the facility's course transcript titled Wandering and Elopement, dated 2023 revealed once a resident has been identified as being high risk for elopement, develop an interdisciplinary plan of care that includes prevention strategies.

Based on observations, record review, and interview, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level and failing to administer nebulized medication correctly for two of two residents (Resident (R) 48 and R103) reviewed for professional standards of 21 sample residents. Findings include: 1. Review of R48's Face Sheet, located under the Resident tab of the electronic medical record (EMR), documented R48 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus with chronic kidney disease. Review of R48's annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 06/28/24, located under the MDS tab of the EMR, documented R48 had a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating, R48 was cognitively intact. Review of R48's care plan, dated 08/06/24 and located under the Care Plan tab of the EMR, documented R48 had diabetes mellitus and would remain free of signs and symptoms of hypoglycemia through the next review date. Review of R48's active orders for August 2024, located under the Orders tab of the EMR, indicated to check blood sugar before bedtime to make sure the resident was not hypoglycemic. During an observation on 08/08/24 at 11:07 AM, Licensed Practical Nurse (LPN) 3 checked R48's blood sugar. LPN3 cleaned R48's finger with an alcohol wipe prior to sticking R48's finger with the lancet. LPN3 then used the dirty alcohol pad to wipe away the first drop of blood prior to obtaining the blood sample. During an interview on 08/08/24 at 11:20 AM, LPN3 stated she should have used a clean alcohol pad or a dry cotton ball/gauze to wipe away the first drop of blood. LPN3 stated she accidentally picked up the dirty alcohol swab. During an interview on 08/08/24 at 3:20 PM, the Director of Nursing (DON) stated you should introduce yourself, explain what you are going to do, and gather your supplies. The DON stated you then cleanse the finger with alcohol, let it air dry, stick the finger with the lancet, discard the first drop of blood with gauze and not the alcohol pad, and then use the next drop for the test sample. During an interview on 08/08/24 at 5:36 PM, the DON stated he did not have a policy regarding how to properly check a blood sugar. He stated they just follow physician orders. 2. Review of R103's Face Sheet, located under the Resident tab of the EMR, documented R103 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea and morbid obesity. Review of R103's admission MDS with an ARD of 07/01/24, located under the MDS tab of the EMR, documented R103 had a BIMS of 15 out of 15, indicating she was cognitively intact. Review of R103's care plan, dated 07/01/24 and located under the Care Plan tab of the EMR, indicated R103 had chronic obstructive pulmonary disease (COPD, a lung disease causing restricted air flow), shortness of breath (SOB) and wheezing. The care plan indicated R103 would be free of signs or symptoms of infection through review date and aerosol bronchodilators would be given as ordered. Review of R103's current physician orders, located under the EMR Orders tab, dated August 2024, documented the following order, started 07/02/24, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML inhale one vile three times a day for COPD. During an observation on 08/08/24 at 1:06 PM, LPN6 administered a nebulizer breathing treatment to R103. Ipratropium bromide (a medication used to treat COPD) one ampule was administered. A clear liquid was observed in the medication chamber when LPN6 and the surveyor entered the room. LPN6 added the ampule of ipratropium to the medication chamber and began the treatment. R103 was observed coughing. R103 stated she took the breathing treatments for her COPD diagnosis. During an interview on 08/08/24 at 1:13 PM, LPN6 stated he did not notice the liquid in the medication chamber prior to adding the current dose of medication. LPN6 stated the equipment should be rinsed, dried and stored in a plastic bag between each use. LPN6 stated he should have checked the chamber to ensure it was clean and ready for use. During an interview on 08/08/24 at 3:20 PM, the DON stated the nursing staff should check the respiratory equipment prior to use and ensure they are clean, free of debris, residue, or liquids. The DON stated staff should rinse the equipment after it is used, let it dry, and then place it in a plastic bag. Review of the undated document provided by the Administrator and obtained at lung.org titled ABCs of Using a Nebulizer indicated the following: 1. After each treatment, disassemble and wash the nebulizer part in warm soapy water or in the dishwasher 2. Rinse and let the pieces air dry and store in [a] clean dry place.

Based on record review, policy review, Incident and Accident (I&A) review, and resident and staff interview, it was determined the facility failed to implement established fall prevention and assessment measures to meet residents' needs. This was true for 1 of 4 residents (Resident #3) reviewed for falls. This failure created the potential for harm if residents sustained bone fractures or other serious injuries related to falls due to lack of supervision and/or assessment. Findings include: The facility's policy for Fall Management System, revised on 06/2018, documented the following: * Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. * Care plan interventions were developed to prevent falls by addressing the resident's risk factors, and the care plan was updated. This policy was not followed. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including cognitive communication deficit, need for assistance with personal care, history of falling, and dementia. Resident #3's quarterly MDS assessment, dated 12/7/20, documented she was cognitively intact, and she had two or more falls since admission or the prior assessment. Resident #3's care plan documented she was at risk for falls related to general muscle weakness, hypertension (high blood pressure), poor balance, and poor mobility. The following interventions were implemented related to her fall risk: * Every 15-minute checks related to her fall history, initiated on 12/7/20. * PT to evaluate, orthostatic blood pressure (measure blood pressure while lying, sitting, and standing) and to be reviewed by physician for medication, initiated on 1/28/21. Resident #3's I&A reports documented the following falls: * She fell on [DATE], 12/6/20, 12/22/20, 1/27/21, and 2/20/21. * On 12/6/20 at 10:15 AM, she had a non-injury fall in her room. She was placed on every 15-minute checks for increased supervision. * On 1/27/21 at 10:15 PM, she had an unwitnessed, non-injury fall, and nursing was to monitor her orthostatic blood pressures for 72 hours during the day and evening. Resident 3's January 2021 MAR documented Orthostatic B/P lying/sitting/standing one time only for 1 day, and it was initialed as completed by a nurse on 1/28/21 at 5:52 PM. The MAR also documented Orthostatic B/P lying/sitting /standing one time only for 1 day . in the morning, and it was initialed as completed by a nurse on 1/29/20 at 11:10 AM. A Weights and Vitals Summary documented Resident #3's blood pressures as follows: * 1/28/21 at 1:00 PM = 135/59 (lying). * 1/28/21 at 5:52 PM = 139/64 (sitting). * 1/28/21 at 5:53 PM = 138/83 (standing). * 1/29/21 at 11:11 AM = 135/58 (sitting). * 1/29/21 at 11:12 AM = 157/67 (standing). A nursing Progress Note, dated 1/29/21 at 3:00 PM, documented Resident #3's orthostatic blood pressures as follows: lying = 130/58, sitting = 135/58, and standing = 157/67. Resident #3's orthostatic blood pressures were monitored for 26 hours instead of 72 hours as noted in the 1/27/21 I&A report. On 2/23/21 at 10:07 AM, Resident #3 said she had fallen four or five times since she had been in the facility because she moved around a lot. Resident #3 said staff did not check on her a lot, and she thought they checked on her once or twice during the day and once or twice during the night. On 2/23/21 at 10:20, the ADON said she did not know if the 15-minute checks were being done for Resident #3, and she would go look for the documentation. On 2/23/21 at 11:45 AM, the DON said if the 72-hour orthostatic blood pressures were not documented on Resident #3's MAR, the nurse might have set it up wrong. On 2/23/21 at 11:55 AM, the ADON said she could not find documentation of the 15-minute checks being completed for Resident #3. On 2/23/21 at 1:10 PM, CNA #1 said Resident #3 had several falls in the facility, and she was currently on 15-minute checks. CNA #1 showed the surveyor a clipboard, which was on the counter at the nurse's station, and the clipboard contained a 15 Minute Checklist which documented Resident #3's 15-minute checks starting on 2/22/21 at 6:00 AM. CNA #1 said she last took care of Resident #3 approximately two weeks ago, and she was not on 15-minute checks at that time. On 2/23/21 at 1:30 PM, LPN #1 said Resident #3 was on 15-minute checks as of that day, and as far as she knew that was the first day the 15-minute checks were done. Resident #3 sustained multiple falls in the facility, and the facility did not provide documentation the established fall prevention strategies were implemented.

Based on interview and record review, the facility failed to ensure three of 12 sampled residents (Resident (R) 11, R12, and R10) were updated regarding the number of new COVID-19 positive cases for residents and staff, the cumulative number of COVID-19 cases for residents and staff, and the mitigating factors the facility was using to help control/stop the spread of [MEDICAL CONDITION] by 5:00 PM the next day. This systemic failure had the potential to affect any of the 82 of 91 cognitively capable residents of the facility at the time of the survey. Findings include: Review of the facility policy Meadow View Notification and Reporting of Suspect/Positive COVID, dated 06/2020, showed:COVID-19 Reporting. The facility will - .3. Inform residents, their representatives, and families of those residing in facility by 5 pm the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must - a. Not include personally identifiable information; b. Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and c. Include any cumulative updates for residents, their representatives by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. d. Families will be notified via their preferred method of communication (email, phone call, or mail). e. Residents will be notified by staff in person by communication officer or designee. f. Staff will be notified in person or via phone call. In an interview on 12/07/20 at 12:40 PM, R11 and R12 (in the same room) were asked if the facility informed them of COVID-19 activity in the building and what the facility was doing to mitigate its spread in the building. R11 stated, I don't think they're telling us. R12 added No, they didn't tell me. R11 continued, We have no clue. They're testing us a lot . but no idea how many (have COVID). 1. Review of R11's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/24/20, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Review of the Progress Notes in R11's Electronic Health Record (EHR) revealed the following entry:12/01/2020 08:22 Nursing Note Text: Patient given written education on covid 19 prevention, as well as wearing a mask to help reduce the spread. Patient is aware to wear a mask when out of the room, denies any concerns with the education. Family and MD (doctor) are aware of current plan of care for this patient. Further review of the Progress Notes from 10/15/20 - 12/07/20 revealed no evidence that the information about COVID-19 cases was provided to the resident. 2. Review of R12's quarterly Minimum Data Set (MDS) assessment with an ARD of 09/25/20, revealed the resident had a BIMS score of 15/15, indicative of being cognitively intact. Review of the Progress Notes in R12's EHR revealed the following entry: 12/01/2020 08:31 Nursing Note Text: Patient given written education on covid 19 prevention, as well as wearing a mask to help reduce the spread. Patient is aware to wear a mask when out of the room, denies any concerns with the education. Family and MD (doctor) are aware of current plan of care for this patient. Further review of R12's Progress Notes from 10/01/20 - 12/07/20 did not reveal evidence information regarding the facility's COVID-19 cases was provided to the resident. 3. In an interview on 12/07/20 at 4:10 PM, R10 responded to the question of the facility providing informing about COVID-19 activity in the building that the stating, No, they never tell us anything. The surveyor noted a pink newsletter on R10's roommate's overbed table and asked if R10 had received one. R10 opened a dresser drawer and pulled out a newsletter, reading it, stating Just got this today. Review of R10's quarterly MDS assessment with an ARD of 09/19/20 revealed R10 had a BIMS score of 15/15, which indicated cognitively intact. Review of the Progress Notes in R10's EHR revealed the following entry: 12/01/2020 08:24 Nursing Note Text: Patient given written education on covid 19 prevention, as well as wearing a mask to help reduce the spread. Patient is aware to wear a mask when out of the room, denies any concerns with the education. Family and MD (doctor) are aware of current plan of care for this patient. Further review of the HER Progress Notes from 10/01/20 - 12/07/20 revealed no evidence that the information about COVID-19 cases had been previously provided to the resident. Review of the Newsletter, dated December 7, 2020, showed: GENERAL UPDATES: COVID-19 Updates Number of positive cases since 11/30/20 -Staff: 6 -Residents: 1 Residents will be tested every Monday! ENCOURAGED PPE (personal protective equipment) FOR RESIDENTS -Mask while staff members are in the room -Mask when out in the hall -6 foot social distancing -Good hand hygiene REQUIRED PPE for STAFF . In an interview on 12/07/20 at 5:15 PM regarding if the facility was providing residents with the mitigating factors, the Director of Nursing (DON) stated, The newsletters had gone out to C hall already but I grabbed the other halls and put something about housekeeping at the bottom. A review of the revised newsletter showed the addition at the bottom: Housekeeping and nursing staff continue to clean high touch areas 2 - 3 times per day. In an interview on 12/07/20 at 5:42 PM regarding resident notification of COVID-19 activity, cumulative numbers, and mitigating factors by 5:00 PM the next day, the DON stated: Just been doing the verbal with residents - noted it wasn't real effective so we started the newsletter, but that doesn't meet the 5 pm the next day deadline.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were implemented and maintained consistent with CDC COVID-19 guidance. This was true for 3 of 3 residents (#1, #2 and #3) observed for the use of facemasks. This failure created the potential for negative outcomes by exposing residents to the risk of COVID-19 infection. Findings include: The CDC website, accessed on 9/15/20, Clinical Questions about COVID-19: Questions and Answers stated as part of universal source control measures, all residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room. The CDC Duration of Isolation and Precautions for Adults with COVID-19 recommended all people, whether or not they have had COVID-19, take steps to prevent getting and spreading COVID-19. These steps included washing hands regularly, staying at least 6 feet away from others whenever possible, and wearing facemasks. This guidance was not followed. 1. Resident #2 had a positive COVID-19 test result on 7/29/20 and she was placed in isolation with standard plus droplet precautions (includes hand hygiene; use of gloves, gown, facemask, eye protection, or face shield) on the COVID-19 unit for 14 days. A Nurse Practitioner progress note, dated 8/13/20, documented Resident #2 was asymptomatic throughout her quarantine period and she could be released from quarantine and return to the facility's general population. On 9/14/20 at 12:26 PM, Resident #2 was observed propelling her wheelchair in the facility's C hallway and was not wearing a facemask. On 9/14/20 at 2:35 PM, Resident #2 said she was not required to wear a facemask 2. Resident #3 had a positive COVID-19 test result on 8/12/20 and was placed in isolation with standard plus droplet precautions on the COVID-19 unit for 14 days. A Nurse Practitioner progress note, dated 8/31/20, documented Resident #3 was not immunocompromised and remained asymptomatic throughout her quarantine period. The Nurse Practitioner recommended Resident #3 be released from quarantine and return to the facility's general population. On 9/14/20 at 2:40 PM, LPN #1 was in front of her medication cart by the nurses' station and CNA #1 was sitting at the nurses' station. Resident #3 propelled her wheelchair to the nurses' station and was not wearing a facemask. Resident #3 made a phone call and when she finished she returned to her room. LPN #1 and CNA #1 did not remind Resident #3 to wear a facemask when she came out of her room. 3. Resident #1 had a positive COVID-19 test result on 8/12/20. Resident #1 was moved to the COVID-19 unit and placed in isolation with standard plus droplet precautions for 14 days. Resident #1's record documented she recovered from COVID-19 on 8/27/20. On 9/15/20 at 2:45 PM, Resident #1 was observed in her wheelchair in the facility's C hallway and was not wearing a facemask. Resident #1 said she did not need to wear a facemask anymore. On 9/14/20 at 2:47 PM, CNA #1 in the presence of LPN #1 said Residents #1, #2 and #3 were recovered from COVID-19. CNA #1 said she was told by the DON when a resident recovered from COVID-19 they did not need to wear a facemask. On 9/14/20 at 3:05 PM, the DON said when a resident recovered from COVID-19 they were not required to wear a facemask when they were outside of their room.

Based on record review and staff interviews it was determined the facility failed to follow physician orders [REDACTED]. This was true for 1 of 4 sampled residents (#6) reviewed for diabetes management: The facility failed to notify Resident #6's physician or implement interventions when blood glucose (BG) levels were less than 70 mg/dl, recheck the BG after interventions were implemented, and notify the physician when BG levels fell below 70 mg/dl or exceeded 400 mg/dl and interventions were refused. This deficient practice placed the resident at risk for complications related to unmanaged hyper- and [DIAGNOSES REDACTED]. Findings included: Resident #6 ws admitted to the facility in 2004 and readmitted in January of 2015 with multiple [DIAGNOSES REDACTED]. The resident's care plan documented the problem, Labile blood sugars r/t (related to) IDDM (insulin dependent diabetes mellitus) in February 2013. Goals included an A1C (lab test) below 7.0 and BGs in a range between 70-400 through 10/31/15. Interventions included consistent carbohydrate diet (CCD), dietary supplement and diabetic medications per orders, monitor for signs and symptoms (s/sx) of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] and BGs as needed for s/sx of hypo/[MEDICAL CONDITION]. The resident's October 2015 recapitulation (recap) of Physician order [REDACTED]. The CCD, 8 ounces of Glucerna at night, BG checks before meals, at bedtime and at 3:00 am, and A1C lab test orders were all dated 1/2/15. The order, Record meal intake in MAR. If consumed < (less than) 50% of meal give 1 can Glucerna via bottle and document mls (milliliters) consumed was dated 9/24/15. The October 2015 recap also included the following orders for hypo/[MEDICAL CONDITION], Glucagel Guideline: for BG < 70 and resident is alert, give 15 mg Glucagel P.O. (by mouth). Re-check BG in 15 minures (sic). Notify MD (physician). If BG remains < 70 after Glucagel, provide snack/meal and re-check in 1 hour. [MEDICATION NAME] Guideline: for BG < 70 & (and) not alert, [MEDICATION NAME] 1 mg IM (intramuscular injection), re-check BG in 15 min. If BG remains < 70 & not alert, may repeat X (times) 1 to = 2 doses, Notify MD or call 911. If awake/alert, refer to Glucagel Guideline. If BG > (greater than) 400 administer insulin per orders notify MD. All of these orders were dated 4/28/15. A Facsimile Transmittal Sheet (fax) to the physician on 7/27/15 at 4:35 pm documented the resident's BGs were 422 before breakfast, 435 before lunch and 406 before dinner. The facility asked if the carb count could be discontinued and a higher sliding scale started. On 7/28/15, the physician replied, .last A1C (June was 6.7). This is the best its been for quite awhile. Would base med changes on (resident's) next A1C. The MARs and Blood Glucose Tracking Sheets for July 1 through October 17 2015 documented the resident's BG was less than 70 twice before dinner in July, once before breakfast and three times at 3:00 am in August, once at 3:00 am in September, and once before dinner and three times at 3:00 am in October. These Blood Glucose Tracking Sheets documented a slash mark or arrow followed by a number, such as 48 (arrow) 101, for 3 of 4 low BGs in August, once in September, and for 3 of 4 low BGs in October. In addition, all of the spaces to document the administration of Glucagel or [MEDICATION NAME] were blank in the July through October MARs. Nurse's Notes (NN), dated 1/2/15 through 10/19/15, did not document the resident's condition, interventions, recheck BGs or physician notification when the resident's BG was less than 70 in July, August, September and October. The MARs and Blood Glucose Tracking Sheets documented the resident's BG was over 400 once before breakfast and twice before lunch and dinner in July, once before lunch and dinner in August, once before lunch in September, and on 10/17/15 at 3 am it was noted as 400. The spaces to document physician notification when the BG was over 400 were all blank in the July through October MARs. The NN contained a 7/27/15 entry which did not mention the three consecutively high BGs before each meal that day, and a 7/28/15 entry which noted the physician's reply as noted above. The resident was seen by the attending physician on 10/16/15. The Assessment/Plan section of the office visit note documented the resident's most recent A1C was 0.7 on 9/7/15 and there were no significant episodes of [DIAGNOSES REDACTED]. The visit note also documented, Continue current management .History of pancreatitis. The resident's record documented a fall from bed on 10/17/15 at 1:45 AM. At 3:00 AM, her BG was 400, re-checked with a second gloucometer at 399. The NN documented, No action taken @ this time. Scheduled 03:00 .glucerna (sic) one 8 oz can held (secondary to) blood glucose 400. HS (bedtime) blood glucose documented as 228, report received .poor PO (oral) intake for the day of 10-16-15 .Pt (patient) (without) s/sx [MEDICAL CONDITION] at this time . On 10/17/15 at 7:10 am, NN documented the resident flinched and had s/sx of pain when examined at 6:50 am and a large purplish black bruise was noted at the resident's right hip and knee, the resident's BG before breakfast was Hi (up arrow) 600, the BG was still over 600 after [MEDICATION NAME] was administered before breakfast, and a repeat BG was over 600 with increase lethargy & s/sx (up arrow) [MEDICAL CONDITION] noted. The physician was notified, 911 was called, the family was called and by 7:50 am, the resident was tranported emergently to the hospital. On 11/4/15 at 4:25 pm, LN #1 said she worked the day shift on 10/17/15 and after report and narcotic count with the night nurse, she examined the resident who was in a wheelchair. The LN said normally the resident would push staff away and make a face but the only response to the exam that morning was the resident's facial expression. The LN said the resident's AC breakfast BG was over 600, she gave [MEDICATION NAME] as scheduled and rechecked the BG which was still over 600. The LN said the resident's breathing pattern changed and level of consciousness decreased. The LN said the resident's condition was not good and she had staff transfer the resident back to bed while the physician, then 911, was called and the family was notified. On 11/5/15 at 11:15 am, the physician said the resident would eat what the resident wanted and the resident's BGs were always up and down. When asked if he was notified each time the resident's BG was over 400, the physician said it was standard protocol to be notified but if not, That really doesn't bother me. The physician said he was more concerned about severly low BGs than high BGs unless it was over 400 and the resident was symptomatic. On 11/5/15 at 12:00 p.m., the ADON and LN #2 were shown the MARs, Blood Glucose Tracking Sheets and NN and asked to provide documentation regarding the time of interventions, if any, the time of recheck BGs, if any, and physcian notification when the resident's BGs were less than 70. They were also asked for documentation of physician notification when the resident's BG was over 400. The ADON said the resident often refused Glucagel when the BG was low. The ADON was asked to provide that documentation. The ADON said they would get back with the surveyor. LN #18 was on duty during the 10/17/15 night shift, which began at 6:00 pm on 10/16 and ended at 6:00 am on 10/17/15. Attempts to interview LN #18 by telephone or in person were not successful. LN #18 did not return any telephone calls on 11/5/15 even after the Administrator was informed and said the LN would stay by her telephone. LN #18 was not present for her scheduled shift on 11/5/15. The facility did not provide any other documentation regarding interventions, recheck BGs, resident refusals of Glucagel, physician notification about refusals of Glucagel or when the BGs were low or high.

Based interview and record review, it was determined the facility failed to adequately supervise and provide services to residents to prevent falls and injury. This was true for 1 of 3 residents (#6) sampled for falls and resulted in harm when Resident #6 fell out of bed and sustained bilateral femur fractures while staff were providing incontinence cares and required hospitalization . Findings included: Resident #6 was admitted to the facility in 2004, and readmitted [DATE], with Type I diabetes mellitus, seizure disorder, Rett's syndrome (a neurodevelopmental disorder), history of pancreatitis, and diabetic keotacidosis. The most recent quarterly MDS assessment, dated [DATE], documented the resident's cognition was severely impaired; required extensive assistance of 1 staff for bed mobility; total assistance of 2 staff for transfers; and was functionally limited in range of motion (ROM) in both lower extremities. The resident's ADL Care Plan, initiated [DATE], documented the resident required assistance with all ADLs, had developmental delay with the mentality of a one-year old, and care planned for the following approaches: * Extensive assistance of 1 staff for bed mobility * Total assistance of 2 staff for toileting; * Incontinent of bowel and bladder, will not use the toilet, staff to check and change ,[DATE] times per shift and as needed (PRN), pericare and barrier cream after each incontinent episode; and, * May climb out of bed and walk on her knees. The resident's Fall Care Plan, initiated [DATE], related to developmental deficits, no safety awareness, diabetes mellitus, seizure disorder and osteoporosis, and documented the following approaches: * Two-staff assist with hoyer lift transfers; * Staff to monitor changes in condition that warranted increased supervision/assistance, and MD notification of these changes; * 15-minute checks for safety; * Bed in low position when in bed and due to ability to crawl on knees. A Pain Evaluation Form, dated [DATE], documented the resident was unable to verbalize pain but could indicate its presence with nonverbal/noncognitive expressions, including clenched jaw/teeth; moaning; gasping and crying/whimpering. An undated Fall Scene Investigation Report (FSIR) documented Resident #6 fell from bed while staff were in the room providing incontinent cares on [DATE] at 1:45 AM. An illustration on the FSIR depicted the resident laying on her right side on a fall mat approximately 12 inches from the bed and the bed was raised to a height of six inches from the floor at the time of the fall. The FSIR documented the resident was both rolling/sliding out of bed and sitting up in bed at the time of the fall. The FSIR did not document when the resident was last toileted prior to the incontinence care being performed at the time of the fall. A Resident Incident Report (RIR), dated [DATE], documented an RN assessed the resident for injury, assisted Resident #6 back to bed, and the resident was then monitored for injury. A [DATE] witness statement by CNA #19 documented she provided incontinence care alone for Resident #6 at the time of the fall. CNA #19 did not state when the resident last received a 15-minute check, when incontinent care was last provided, or why a second staff did not assist with toileting the resident as care planned. The [DATE] witness statement and an [DATE] interview with CNA #19 revealed she provided incontinence care at 1:45 - 1: 50 AM, changed and lowered the resident's bed, and turned and stepped away from the bed to retrieve a blanket from the window cabinet ledge when the resident fell . The statement documented the resident flipped or rolled out of the left side of the bed and onto her right side. CNA #19 stated the resident appeared startled or scared and began to cry, but otherwise did not move or crawl around. The CNA activated the call light for assistance. LN #18 responded to the call light, moved the resident's arms and legs, and then instructed and assisted CNA #19 to roll the resident back and forth onto a bed sheet, which was then used to slide the resident back into bed. CNA #19 stated she was unsure why LN #18 directed the use of a bed sheet to transfer the resident, other than because the bed was in a low position. CNA #19 stated LN #18 did not want vital signs taken because the resident was care planned to crawl out of bed and around on the floor, so this event was not considered a fall. CNA #19 was unable to explain how LN #18 determined the resident purposefully crawled out of bed given her own description of the event and Resident #6's demeanor at that time. A Nurse's Note (NN) by LN #18 and dated [DATE] at 7:00 AM documented the ADON was notified the resident rolled out of bed to the floor mat, the bed was in the lowest position during cares, and the resident did not have obvious injury. The NN documented the event occurred at 1:45 AM and that the nurse assessed Resident #6 approximately five minutes later. The resident was noted to have 20 bpm (breaths per minute) that were even and unlabored; was tearful; and displayed no bruising, abrasions, or evidence of pain when passive range-of-motion was performed to her wrists and ankles. The NN documented the resident was assisted back into bed with bed linen by sliding with two person assist, which she tolerated without pain or discomfort. The NN documented cares were administered to the resident for the remainder of the night shift with no unusual behaviors noted. It could not be determined how Resident #6 was assessed to be free of pain when tearfulness was documented as one of the resident's nonverbal expression of pain; vital sign documentation after the event did not include blood pressure, heart rate, temperature or oxygen saturations; and it was unclear why the resident was assisted back into bed with a sliding bed linen rather than the Care Plan-required mechanical lift. A summary witness statement and facility interview of by LN #18 documented she entered the room to find the resident on her right side on a padded mat next to the low bed. The statement documented the resident had tears in her eyes. After assessing PROM (passive range of motion) to all joints, LN #18 rolled the resident onto her back and assessed ROM to the resident's hips and pelvis. LN #18's statement documented Resident #6 did not have any painful response to assessment and she did not think the resident was seriously hurt. The statement documented LN #18 discussed the fall with CNA #19, who reported the resident just appeared to accidentally roll off/out of bed. The statement did not document why the resident's vital signs were not taken at this time or why Resident #6 was transferred back to bed by sliding her with a bed sheet rather than the mechanical lift as required by the resident's Care Plan. The resident's record did not document whether 15-minute checks were completed as care planned, and none of the witness statements or interviews confirmed the checks were completed. CNA #19's typed statement documented she asked LN #18 to check on the resident, who she could hear crying and whimpering intermittently between 2:30 and 3:00 AM. LN #18's statement documented the resident's blood glucose (BG) level was 400- and 399 mg/dl at 3:00 AM. At 4:30 AM, LN #18's statement documented CNA #19 told her Resident #6 was tearful during cares, which LN #18 perceived as fear. Between 5:00 and 5:30. AM, LN #18 checked on the resident who was sleeping with even respirations. At 6:00 AM, LN #18 provided report to an oncoming day shift LN. LN #18's statement documented CNA #14 asked her to assess the resident, now in the shower room, but this request did not indicate any urgency. Several attempts were made to contact LN #18 for interview during survey, but the LN could not be reached, did not return phone calls, and did not report for work at the facility as scheduled while survey was in process. CNA #14's written witness statement documented that at 6:10 AM she and CNA #20 rolled the resident to remove her pajama pants and placed the mechanical lift sling under the resident. CNA #14 stated Resident #6 whimpered during movement and that there was a bruise emerging on the resident's right knee. CNA #14 stated she perceived the resident's whimpering as she was transferred by mechanical lift to a shower gurney as an expression of fear rather than of pain. There was no documentation the nurse was alerted or that the resident was assessed prior to- or during the transfer. At 6:15 AM, CNA #14 took the resident into the shower room and rolled the resident side-to-side to remove her adult brief and Hoyer lift sling. Resident #6, who was documented as normally sitting up with her legs crossed and inclined to play with the water during showers, laid still on the gurney on this day, according to CNA #14's written witness statement, which noted the resident appeared traumatized following the fall. CNA #14's written statement documented she opened the shower room door at 6:25 AM and called to nurses in shift report down the hall that Resident #6 was in pain. The statement documented LN #1 looked up from report but did not respond. CNA #14 then completed the resident's shower, partially dressed and covered her, and took her back to her room. CNA #20 joined CNA #14 to dress the resident and LN #1 instructed the two CNAs to transfer the resident to her W/C, which was accomplished with a Hoyer mechanical lift. At 7:15 AM, CNA #14 was asked to assist the resident back into bed. CNA #20's written statement for the [DATE] event documented CNA #19 reported to her that Resident #6 rolled out of bed and onto the padded mat that morning and now appeared 'traumatized. CNA #20 stated there was a change in the resident's normal level of participation and demeanor during the transfer from bed to shower gurney. A NN by LN #1, dated [DATE] at 7:10 AM, documented Resident #6 was receiving a shower at 6:30 AM when a CNA reported an increase in pain to the resident's right hip and leg as she was transferred and repositioned to a shower gurney. The NN documented the resident was examined at 6:50 AM, after the resident was showered and placed in a W/C (wheelchair). LN #1 documented she examined the resident's right hip and knee, where she noted a large purplish black bruise. LN #1 stated the resident flinched with increased signs of pain during the assessment, recorded a BG reading exceeding 600 mg/dl, and was increasingly lethargic. A summary witness statement and interview for LN #1 documented CNA #14 asked her to see the resident in the shower room at 6:25 AM. LN #1 did not perceive this request to be urgent, and told CNA #14 she would check after morning report. At 7:00 AM, EMS was called after the resident's third consecutive BG check of Hi(gh) 600 (mg/dl), and an observed change in the resident's breathing. LN #1 called the physician, had staff assist the resident to bed, and readied information for the hospital and paramedics, who arrived at approximately 7:15 AM and transported Resident #6 to a local hospital. On [DATE], LN #1 stated she worked the day shift on [DATE] and after report and narcotic count with the night nurse, she examined the resident who was then in a wheelchair. The LN said normally the resident would push her away and make a face, but the only response to the exam that morning was the resident's facial expression. The LN said the resident's BG was over 600 mg so she gave Lantus (long acting, not quick acting) insulin as scheduled and rechecked the BG, which was still over 600 mg/dl. The LN said when the resident's breathing pattern changed and her level of consciousness decreased, she determined Resident #6's condition was not good and she had staff transfer the resident back to bed while the physician then 911 was called and the family was notified of the need for emergency services. On [DATE], CNA #14 stated she and CNA #20 went into Resident #6's room on [DATE] at 6:05, where they found the resident in bed on her back with her right leg bent outwards. She noticed a bruise-like ring closer to the inside of the leg by the knee. The resident groaned, the hoyer sling was placed under the resident, and she was transferred to the shower gurney. The CNA stated the resident was normally alert, had more color and liked to sit up in the shower and play in the water, but that morning she only laid still on the gurney. CNA #14 stated the resident yelled and grabbed her shirt when she washed the resident's peri-area, and the resident's leg was turned inward. CNA #14 stated at this point, she realized the resident was in pain so she opened the shower door and yelled for a nurse. When no nurses responded, CNA #14 said she finished the shower, dressed the resident, and took her back to her room. On the way back to the resident's room, CNA #14 stated, she asked LN #1 whether the resident should be laid down or positioned in her chair; LN #1 directed CNA #14 to transfer the resident to the chair, where she appeared uncomfortable and made groaning noises. After the resident was transferred via hoyer mechanical lift to her chair, CNA #14 stated, LN #1 did not come in until approximately one-half hour later. CNA #14 stated she was concerned for the resident's safety, and felt the nurse should have come more quickly to assess the resident. Resident #6 was harmed when she was hospitalized following a fall from bed when: *The CNA provided incontinence care alone, rather than with two staff as required in the care plan; *The CNA turned away from the resident before cares were completed, and the resident fell from bed; *The resident was lifted back into bed by a bedsheet, rather than by mechanical lift required for her transfers; *15 minute checks, which were part of the resident's care plan, were not performed after the fall; *Licensed nursing staff did not assess developing symptoms of injury and shock, incuding an evaluation of the risk to the resident prior to three additional transfers and a bathing activity; and *Licensed nurses did not respond with the urgency to the CNA's requests to assess the resident's developing symptoms.

Based on observation, staff interview, record review and a public complaint it was determined the facility did not ensure that measures to keep 1 of 1 sampled resident (#16), who was blind, safe from hazards when a mechanical lift was left in the pathway of the resident, causing a trip hazard the resident could not visualize. In addition, 1 of 4 sampled residents (#9) reviewed for falls, was harmed when staff transferred her without the use of a gait belt and the resident fell hitting her head. This resulted in a subdural hematoma and the resident expired at the hospital. Findings include: 1. Resident #9 was admitted to the facility on [DATE] from a hospital. The resident had been treated for [REDACTED]. Additional [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated [DATE], documented the following: *Extensive assistance by one staff for bed mobility. *Extensive assistance by one staff for transfers. *Over the 7 day look back period the resident had not walked in her room. *The resident walked in the corridor with extensive assistance and one staff provided weight-bearing support. *The resident used the toilet with extensive assistance by one staff who provided weight-bearing support. *Balance unsteady when moving from seated to standing position (could only stabilize with staff assistance). *This balance problem was the same for walking, turning when walking, moving on and off the toilet and for surface to surface transfers (could only stabilize with staff assistance). *Wheelchair was checked for mobility device (NOTE: Use of walker not checked). *Fall history in last ,[DATE] months prior to admission. The MDS Care Area Triggers (CAT) indicated a fall concern. However, the Care Area Assessment (CAA) worksheet for falls did not indicate why the resident was at risk for falls. The majority of what was documented on all the CAA worksheets was repetitive documentation that was copied and inserted for each indicated CAA area. The falls documentation did not indicate why she was at risk for falls or mention what they planned to do to keep the resident safe. The Physical Therapy (PT) department evaluated the resident on [DATE]. Documentation included: "This (age) female presents to therapy with a decline in ADLs of functional transfers and gait due to recent hospitalization and immobility due to sepsis. The patient's (family identified) has noticed a decrease in self care/ADL ability for the past 2 weeks in which patient has had multiple falls, resulting in decreased safety and an increased need for assistance...Precautions: Very high fall risk, dementia." The assessment indicated the resident had been using a front wheel walker with assistance. A contact guard assist (due to unsteadiness) was required for when the resident was standing, ambulating when using front wheel walker. A facility "Resident Risk Assessment Profile" was dated [DATE]. The assessment for falls documented the resident as moderate risk for falls. The assessment indicated the resident had poor balance while standing and used a walker and a wheel chair. A facility "Initial Nursing Summary" form dated [DATE], consisted of 12 pages that indicated various identified problems, and required the reviewer to check mark items as they applied to the resident. The form was a combination of an assessment and "Nursing Intervention/Initial Care Plan." A section for "Physical Function and Structural Problems" documented the following: * The resident required 2 person assist for ambulation * Was not independent for transfers (did not indicate level of assistance needed even though there was a place to check mark how many staff should assist). * Assistive devices did include a wheel chair and walker. * No falls in last 30 days. (NOTE: The PT assessment indicated the family member indicated "multiple falls" over the last 2 weeks). * Falls in the last 6 months. Interventions included: * Refer to PT and OT (Occupational Therapy). * A question asked, "Why does this resident require assist of 1 or 2 to transfer?" There was no documentation to explain the necessity for assistance while transferring. * A question asked, "Does the resident have physical complications or restrictions? This was answered, "No." *Check marks indicated the resident should have appropriate footwear, an environment free of clutter and a bed in the low position. A facility "Incident Report" was dated [DATE]. The report indicated the resident fell at 8:00 pm. The report had sections identified that had various questions to be check marked or documented if necessary as follows: *"Bruise - (illegible) back of head and (left) elbow bruise 3 cm x 2 cm (illegible)." *"Fall- Lying B/P (blood pressure) ,[DATE], Standing B/P ,[DATE]." Checked for: complained of dizziness, complaints of weakness during day was checked yes and no, walker in use, floor dry. "Just got toileted (with stand by assist)." *Employees- "Was a Transfer Belt used? N/A (not applicable)." *Section E- the fall was witnessed. "Could this injury have been prevented? See attached PAR note." The attached PAR note was dated [DATE]. It contained the following information: "Review of occurrence on [DATE] (at) 2000 (8 pm), resident was being assisted from bathroom by CNA while ambulating with her FWW (front wheel walker). As resident was walking towards recliner and turned, she started to fall at which time, the CNA attempted to assist to the (sic) resident to floor. CNA stated she fell quickly but, was able to slow fall to buttocks however, resident continued backwards and inadvertently hit occiput (sic) of head on recliner arm...Res(ident) also has a history of calcification and Dural thickening post cranitotomy (sic) (CT scan ,[DATE])...Upon investigation res had no c/o (complaints of) dizziness prior to ambulating to the bathroom...Neuro checks were initiated and (within) normal limits times 4. On last neural check res presented with abnormal speech pattern and subsequently sent to ER (emergency room ) for evaluation and treatment. In summary the resident has had no history of falls and was a moderate fall risk. This appears to be a neurological related event outside any control and couldn't be prevented. There is no apparent correlation to BP or fall risk. Medical Director was notified." This PAR note was signed by the DON. (NOTE: The occurrence date of [DATE] is different from incident report and nurse notes that date the incident for [DATE]). The nurse progress notes documented the following: *[DATE] (4:00 pm)- "(Family) in to visit resident, stopped this nurse in front area of facility re: concerns of resident's recent c/o dizziness. Floor nurse present as well. Plan is to check ortho(static) BP's and notify MD (Medical Doctor) of any concerns, also to obtain prn (as needed) for c/o nausea. LN to start ortho BP monitoring and hold BP meds if BP (down). Will cont(tinue) to monitor." This note was followed by a "Condition Change Form" dated [DATE] (4:00 pm). "Res. c/o dizziness & nausea. (Nursing) request orthostatic B/P (every day times 3 days). Send to MD (appointment). on Thursday." This condition change form lacked a request to have the physician order [REDACTED]. However, the resident received a new order on the same day for Compazine to treat nausea and dizziness. It was never administered as was transferred to the hospital. The resident already had physician orders [REDACTED]. The physician also indicated that for BP less than 100 (systolic) and less than 60 (diastolic) the medication was to be held. The record showed a blood pressure was taken on the day of admission, on ,[DATE] and twice a day, every day to [DATE]. The resident had one low BP on [DATE] and her medication was held. The medication was also held for the 3:00 pm administration on [DATE] although it was not due to a low BP. There was no documentation as to why it was held. *[DATE] (6:00 pm)- "...At 1900 (7:00 pm) started IV abx (antibiotics, then illegible) patent flush after infusion in while res was sitting in her recliner. At 2000 (8:00 pm) SB (unknown acronym) res was ambulated to the bath room with FWW ambulated back to her recliner res got dizzie (sic) when she was turning around to get in her recliner and fall in front of the recliner. CNA call me in, assessed res- good ROM, upper and lower extremities, (no signs or symptoms) of pain with mobility noticed a bumped (sic) on back of her head, and bruise to left elbow- 3 cm x 3 cm. good ROM, res was able to assist (with) standing up with FWW BP standing ,[DATE]. (After) fall - place resident in her w/c assist her to bed. BP lying ,[DATE] (after) fall. Place ice to back of her head. (Head of bed elevated) 35 degrees res c/o back of head hurt, dizzie (sick). Wanted (family member) called. Family member came in at 8:45 pm... Asked (Family) if she wanted to send resident to ER...(family) request for her to go to ER... Ambulance here at 9:45 pm out with resident at 10:00 pm..." The note referred to neurological assessment form. The form indicated B/P for [DATE] at specific times of 8:30 pm, 8:45 pm, 9:00 pm and 9:15 pm. However, the numbers had been re-written on top of the original documentation and were illegible. This was the case for temperatures at 8:30 pm and 8:45 pm as well. A "Temporary Care Plan Posting" was dated [DATE] and documented the resident had complaints of dizziness and nausea. Direction was for nursing to assess the resident for blood pressure medication and blood pressures. LN#14 was interviewed on [DATE] at approximately 6:00 pm. She was the writer of the nurse note documented the night that Resident #9 fell and was sent to the hospital. LN#14 was asked to state in her own words the series of events that happened when Resident #9 fell . LN#14 told what happened almost exactly as documented in the nurse note on [DATE] (6:00 pm). The Physical Therapist (PT) was interviewed on [DATE] at 3:10 pm. The surveyor asked, "What does contact guard mean when a resident is weak, unstable on feet and a fall risk?" The PT replied, "That means you should have your hand on the resident at all times and you should use a gait belt while ambulating or transferring a resident." On [DATE] at 9:07 am, the PT was interviewed and she stated she wanted to clarify what she had told the surveyor on the previous day about contact guard. She said if she knew the resident really well she may not use a gait belt. She then gave an example of a resident she had worked with a lot who had a stroke. She indicated the resident does well usually but at times the resident "just goes down." For this reason PT always uses a gait belt when working with this resident. The surveyor asked if the resident was known to be shaky and had balance problems but used a walker should a gait belt be used. PT responded, "Yes, I would." On [DATE] the DON was asked to provide a gait belt policy for the facility. Later at approximately 5:50 pm, the DON came to the dining room to talk to the surveyor. He indicated he had not been able to locate a policy on gait belts for the facility. It was noted that direct care staff in the facility had not been observed to have gait belts for use during cares. The DON stated that the gait belt did not prevent a fall and mainly were used for dignity so the staff did not use the resident's pants to pull the resident up. He indicated that the gait belts were not used to lift residents. The DON was asked to find staff training modules for how and when to use a gait belt. The Administrator became involved in locating the requested items as the DON was new to the facility. A copy of a "Lift Evaluation Form" was provided. The evaluation was dated [DATE] and completed for Resident #9. The evaluation documented the resident used a wheel chair but did not document a walker. The form asked if the resident was a 1 or 2 person assist for transfer. The documented answer was illegible. In addition, the resident was a pivot transfer, total weight bearing, had no complications and a lift was not recommended. On [DATE] at approximately 11:50 am, the DON provided a form he said was retrieved from their "sister facility." (Meaning owned by same corporation and close by). The form was not dated and did not have the facility name on it. The administrator was present and said she was still in the process of updating corporate policies. The form was titled, "Gait Belts." The directions indicated how to use a gait belt. One directive indicated, "After resident is standing, use the gait belt to assist in the stabilizing and turning resident." Also, "When walking a resident, one hand of the (staff) should be on the belt and the other hand should be on the resident's shoulder." Special considerations included, "If a traditional gait belt is unable to be used, alternative safety devices (walkers, canes...) and/or additional staff will be utilized to decrease risk for falls and injury." The education list provided by the Administrator did not include a specific topic for teaching staff how or when to use a gait belts. CNA#15 was present and providing care to Resident #9 when she fell . CNA#15 was interviewed on [DATE] at 2:35 pm. CNA#15 said she usually brought her own gait belt in a bag as she had her own from working at a prior facility. She said that gait belts were available at each nurses' station if needed. She was asked if she used a gait belt and said she had not. CNA#15 was asked if she received training at the facility for the use of gait belts. She said she could not recall that but it is a no lift facility and only certain residents were care planned for use of a gait belt. CNA#15 was asked if the aides received a care plan or check list to direct basic care for the residents they are assigned to. She said there was not but that she looks at the care plans. She indicted resident assignments could change so then she would not know the directions for every resident. She was asked if she was informed the resident had been dizzy that day. She answered she had not. The surveyor asked what would she have done differently with this information. CNA#15 said she would have gotten help from another aide or nurse. She was asked, "Would you have used a gait belt?" She answered, "Yes." Documentation was obtained from the hospital. The resident was admitted from the ER at the hospital at 1:08 am on [DATE]. The hospital discharge summary was dated [DATE] and documented, "This patient is a (age)-year-old female who recently had taken up residence at (name of the facility) with a previous history of intracranial bleed that was treated interventionally by neuro surgery with burr hole in 2010 who suffered a ground level fall and subsequently had a recurrent subdural hematoma. The patient presented to ED (Emergency Department) with a rapidly deteriorating mental status and became non-responsive to verbal or painful stimuli. On CT scan she was found to have a large actively bleeding subdural hematoma. The patient was admitted into the ICU. After discussion with the family comfort care measures were initiated. The patient died after less than 24 hours of admission at 2:10 pm. The facility did not ensure they kept the resident safe from a fall after she had complained of dizziness earlier in the day. The resident was a known fall risk and was not steady upon standing or turning to be seated. The resident fell when transferred by only one staff and toileted. The resident was using a front wheel walker to return to her recliner when she turned and fell hitting her head. The CNA was not able to help the resident fast enough to prevent the fall, did not have a gait belt around the resident and was not using contact guard precautions. The CNA had not been advised the resident had been experiencing dizziness. The resident was sent to the hospital where she subsequently expired as a result of the head injury she obtained when she fell in the facility. 2. Random Resident #16 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * was cognitively intact (BIMS =15), * required limited assistance of one person for ambulation off the unit. The resident lived on the 300 hallway. The resident ate in the Bistro dining room which was on the opposite side of the facility. The resident ambulated using a white cane for detection of objects and utilized the handrails to move independently from his room to other areas in the facility. The resident used the same pathway daily to go to the dining area and return to his room. On [DATE] at 9:20 a.m. the resident was observed ambulating back from the dining area. Staff members had parked the mechanical lift along the hand rail between rooms 304 and 306. The legs were positioned together, but the leg frame had a separation of about two feet between the legs, and the boom of the lift was elevated. Resident #16 was walking toward his room and the white walking cane went between the legs of the lift without making contact with the cane. The surveyor had to stop the resident before he ran face first into the boom of the lift. An LN was in the area and assisted with redirecting the resident and getting the mechanical lift moved so the resident could move about the facility without an accident. The Administrator and DON were informed on [DATE] at 3:30 p.m. No further information was provided.

Based on observation, staff interview and record review it was determined the facility did not ensure that 2 of 3 sampled residents who had recently fallen (#s 32 and 33) were provided supervision and/or assistive devices to prevent accidents. Resident #32 was harmed when she sustained a hip fracture as the result of staff's failure to ensure care plan interventions were followed. Resident #33 was harmed when she sustained a hip fracture and an intracranial hemorrhage. Findings include: 1. Resident #33 was admitted to the facility on [DATE] with senile dementia, osteoarthrosis, senile osteoporosis, depression and anxiety. Resident #33's 12/11/08 Care Plan (CP) identified the resident was at risk for falls related to a history of falls and poor safety awareness. The CP included the following interventions: 9/17/12 - low bed 10/8/12 - body pillow for positioning 10/9/12 - Resident moved to a different area for decreased external stimuli and 15 minute checks 10/16/12 - Keep in line of sight when in wheelchair Undated - contour mattress, Hoyer lift, tab alarm used at all times (check every shift for placement and working). Resident #33's medical record included the following Incident Reports (IR) for falls: 9/17/12 at 9:00 p.m. - Found sitting on floor at bedside. No injuries were documented. The IR documented the tab alarm activated prior to the fall. 10/6/12 at 8:00 p.m. - Was found in bed with torso off of the bed. No injuries were documented. The IR documented staff heard the alarm sound. 10/8/12 at 6:15 p.m. - The resident was found face down on the floor and appeared to be in pain. The IR documented staff responded immediately when the tab alarm sounded. The Nurses Notes dated 10/8/12 at 7:45 p.m. documented the resident was transported to a local hospital. The hospital emergency room dictation report documented Resident #33 had sustained a small intracranial hemorrhage and a right hip fracture. During an observation on 10/18/12 at 10:40 a.m. LN #1 was asked if Resident #33 used an alarm in her bed. LN #1 went to where the resident was lying in bed and pulled back the cover. The tab alarm was not connected to the resident. LN #1 connected the tab alarm to the resident. On 10/18/12 at approximately 1:30 p.m. Resident #33 was observed lying down and CNA #2 was standing by the bed. CNA #2 was asked if the resident moved a lot while in bed. The CNA stated Resident #33 was frequently "fidgety" but it "comes and goes." On 10/19/12 at 8:00 a.m. the Administrator and the DON stated an investigation had been done regarding Resident #33 not having the tab alarm on 10/18/12. The investigation revealed the hospice CNA had not ensured the tab alarm was placed back on the resident. The Administrator stated the facility had contacted the hospice agency. The hospice agency provided documentation of an e-mail sent to all staff stating "It is very much a part of our responsibility to make sure the alarms are on." Resident #33's CP to prevent falls included staff were to check to make sure the tab alarm was connected and working. Resident #33 fell on [DATE] and suffered with a hip fracture and intracranial hemorrhage. The facility failed to revise the CP to keep the resident in line of sight until after she suffered harm, even though she had fallen 2 times when the alarm had sounded. In addition, the facility failed to notice the tab alarm was not connected until the surveyor asked the LN to check for the alarm. 2. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 8/8/12 documented the resident: * had moderate cognitive impairment (BIMS = 11) * required extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene and bathing. * had a fall without injury since admission. The resident's care plan dated 6/13/12 documented a problem of, "Potential for falls r/t (related to) cognitive deficits and physical limitations (as evidenced by) need for assistance with transfers and ambulation. Has history of falls." The interventions were: * Assist me with one staff member for all ambulation, * Ensure non-slip footwear at all times, * Remind her to use call light and wait for assist with transfers, * Pressure alarm to bed and (wheelchair). On 7/16/12 the following interventions were added to the care plan: "* Ask resident what she needs when calling out, * offer resident to use the restroom, * offer 1 on 1 time, * offer snack, * give resident assurance that things are ok, * let her know the plan for the next hour, * nursing to administer medications per MD orders, * redirect resident, * offer to ambulate resident, * offer activity of choice." On 7/06/12 the physician ordered the resident to have a, "pressure pad alarm to wheelchair and bed for safety awareness, check q (every) each shift to placement and working order." The nursing documentation for the first fall on 7/27/12 at 10:20 p.m. indicated the resident, "attempt(ed) to transfer to bed and fell without injury noted." Subsequent nursing documentation indicated the resident was already on an antibiotic for a urinary tract infection (UTI). The resident fell on [DATE] at 2:00 a.m. and was discovered to have a fractured left hip. Nursing notes documented: 10/13/12 - 6:00 a.m., "The resident had been transferred with assist from bed to wheelchair earlier in the evening per request. Had (illegible) with fluids. Then patient hollered for nurse and requested to go back to bed. Resident requested to get up, go to bathroom multiple times which aides (illegible). Alarms were sounding throughout shift until last attempt to self transfer at (2:00 a.m.). Resident had been toileted at (1:00 a.m.). Ativan was given for anxiety about (11:00 p.m.) with little effect. Resident would sleep on and off for about 20 minutes max here and there. Staff at nurses station when sound could be heard down hallway. Found resident on floor between foot of bed and wall close to the sink area on left side...." The IR, dated 10/13/12, documented the incident and investigation. One question on the report was, "How long did it take to respond to alarm?" The response was, "Not switched on." The Administrator and DON were interviewed on 10/19/12 at 8:30 a.m. They were questioned about the alarm not being on. They indicated after the 1:00 a.m. toileting, the staff member had forgotten to turn the alarm back on and as a result the resident was able to sit up and attempt to transfer which led to the fall. The Administrator confirmed the resident was diagnosed with [REDACTED].

Based on a complaint from the general public, observation, staff interview, and record review, it was determined the facility failed to provide personal hygiene care for those residents unable to bathe, wash their hair and/or shave without assistance. Resident #3 was harmed when the facility failed to give the resident a bath for 12 days which resulted in the development of a rash with a possible yeast infection under her abdominal folds. For residents #1, 2, 8, 9, and 11 failure to provide bathing and grooming had the potential to cause psychosocial harm for the residents left unbathed and/or ungroomed in the company or in view of staff, visitors, and other residents. This was true for 6 of 11 residents (#s 1, 2, 3, 8, 9, and 11) sampled for personal hygiene and grooming. Findings include: This is a repeat deficiency from the 3/6/12 complaint survey. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission nursing assessment and care plan dated 5/5/12 documented the resident: * was severely cognitively impaired * preferred to have her hair washed 2 time a week * preferred to have a shower in the mornings and required assistance * did not have any skin problems identified and had a [MEDICAL CONDITION] There was no care plan for frequency of personal hygiene and bathing. The May 2012 ADL flow sheets documented that the resident had not had a bath since her admission to the facility. This was 12 days. The resident's nurses note documented that the resident had skin problems identified. The documentation was: * 5/12/12 at 5:50 p.m. "Found red rash, yeast smelling under (right) abdo(minal) fold. [MEDICATION NAME] applied. Family notified..." * 5/12/12 at 6:00 p.m. "Will keep area under (right) abdominal fold dry and clean (every) shift." * 5/13/12 at 1:00 p.m. "...Rash on (right) abdomen under fold cleaned, dried, will monitor possible yeast." * 5/15/12 at 12:45 p.m. "Assessed abdominal fold distal to [MEDICAL CONDITION]. No redness noted at site, some pink irritation. No smell observed. Site does not appear to be yeast. Will continue with monitoring as need (sic). NP (name) assessed is not yeast." The resident was observed on 5/16/12 at 1:00 p.m. in the dining room seated at a table. The resident's hair appeared oily/greasy, matted down, uncombed and in need of a shampoo. The facility failed to: * ensure a resident received baths frequently enough to prevent skin problems * ensure the resident's hair was washed at least two times a week per her preference The administrator was informed of the bathing problem on 5/16/12 at 3:15 p.m. No further information was obtained. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * had short and long term memory problems * had moderate impairment for decision making abilities * did not exhibit any behaviors of refusing care * was totally dependent on staff for personal hygiene and bathing The resident's care plan dated 8/10/11, documented a problem with, "ADL self care deficit with potential for decline related to...." One of the interventions was, "Offer shower 2 X/wk (two times per week) per schedule for personal hygiene.... Shave daily." The resident was observed on 5/16/12 at 12:45 p.m. with oily looking hair and several days of beard growth. The May 2012 bath records were reviewed and the resident had a bath on May 3, 2012 but none since. The resident went 13 days without a bath. The April 2012 bath records were reviewed and the resident had two occasions where the staff failed to bath him, these were: 4/7/12 to 4/16/12 - 8 days without a bath. 4/25/12 to 5/3/12 - 7 days without a bath. The resident had not had a bath since 5/3/12, which was 13 days without a bath at the time of survey. The administrator was informed of the bathing problem on 5/16/12 at 3:15 p.m. No further information was provided. 3. Resident #2 was admitted to the facility 6/21/05 with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * had short and long term memory issues * was severely impaired for decision making skills * did not have rejection of care behaviors * required total dependence for personal hygiene and bathing The resident's 6/21/05 care plan documented a problem of, "Personal hygiene (related to) oral care and showers." The approaches were: * "Offer bath/shower 2 x per week per schedule for personal hygiene. Shave PRN (as needed)...." * "Charge nurse needs to document when resident refuses oral care or showers." Review of the April 2012 ADL flow sheet it was found that the resident did not have a bath: * From 4/7/12 through 4/17/12. This was 11 days without a bath. * From 4/21/12 through 4/26/12. This was 6 days without a bath. 4. Resident #8's ADL flow sheets were reviewed with the following documentation for showers/bathing present: *March 2-13, 12 days without shower/bath given *March 18-27, 10 days without shower/bath given *April 15 - 24, 10 days without shower/bath given *May 1 - 16, 16 days with no shower/bath given The flow sheet documented the resident was to receive showers/bath 2 times per week. No refusals of showers were documented as having occurred for April or May 2012. 5. Resident #11's ADL flow sheets were reviewed with the following documentation for showers/bathing present: *April 23 - May 9, 16 days with no shower/bath given The flow sheet documented the resident was to receive showers/bath 2 times per week. No refusals of showers were documented as having occurred for April or May 2012. 6. Resident #9's ADL flow sheets were reviewed with the following documentation for showers/bathing present: *April 17 - 23, 7 days with no shower/bath given *April 25 - 30, 6 days with no shower/bath given The flow sheet documented the resident was to receive showers/bath 2 times per week. No refusals of showers were documented as having occurred for April. The Administrator was informed of the findings on 5/16/12 at 3:30 p.m. No further information was provided by the facility.

Based on observation, staff interviews, record review, policy review and a complaint received from the general public, it was determined the facility failed to develop and implement appropriate interventions in a timely manner related to pressure ulcers. This failed practice resulted in serious harm, constituting immediate jeopardy to 2 of 5 (#s 4 and 6) sampled residents reviewed for pressure sores. Resident #6 was seriously harmed when he was placed at risk for serious injury and/or death due to the facility's failure to prevent, identify, obtain treatment, and follow physician orders [REDACTED].#6 deteriorated and lead to hospitalization due [MEDICAL CONDITION] and surgical debridement of an infected Stage III pressure sore. Resident #4 was in immediate jeopardy and at risk for serious harm when a pressure sore that was identified on 1/27/11 as a 1 cm by .5 cm black area on the coccyx deteriorated to a Stage IV sore that was 7.0 cm by 6.2 cm and 1.4 cm deep on 10/27/11. In addition, 2 of the 5 residents reviewed for pressure sores (#8 and #9) were harmed when they developed Stage III and/or multiple pressure ulcers and 1 of 5 residents reviewed (#1) was at risk for the development of pressure ulcers on the heels. *Resident #8 was harmed when he developed an ischial tuberosity and upper thigh wound that progressed to a Stage III pressure ulcer. *Resident #9 was harmed when he developed a Stage III on the left ankle and two Stage II sores on the buttocks in April 2011. *Resident #1 was assessed at high risk for pressure sores with documentation of red heels; however, there was no evidence of weekly skin checks. The facility's Administrator and Director of Nursing Services were informed verbally and in writing of the immediate danger to Residents #4 and #6. The facility was provided with specific details of the failure to ensure prevention of avoidable pressure sores and the need for residents with pressure sores to receive immediate attention to the wounds. On 10/28/11 at 9:15 a.m., the facility provided the survey team with an acceptable plan of correction and the immediate jeopardy was abated. The summary plan of correction was: Corrective action for those residents affected: - Resident #6 no longer resides at this facility. - Resident #4's attending physician has been notified of the resident's current condition. A Certified Wound Care nurse will conduct a skin assessment of Resident #4 on 10/27/11. - Resident #4 will receive necessary treatment and services as directed by resident's attending physician related to skin care. Plan to identify other residents: - Wound nurse will assess residents with pressure ulcers; recommend treatment and plan of care. - A 100% audit of skin integrity and condition for current resident's who reside in the facility. - A 100% review of all care plans related to pressure sores. Systemic changes and monitoring to ensure continued compliance: - The facility Medical Director has been notified of the Plan of Correction/Action related to pressure sores. - Re-in-servicing staff on the policies, procedures and programs. Monitoring of action quality assurance program: - Wounds will be reviewed in PAR. - Should the resident refuse to accept a treatment; 1. Detailed information relating to the refusal will be entered into the resident's medical record. 2. The attending physician will be notified of such refusal without delay. 3. The resident and/or representative will be informed. 4. Facility will determine if able to meet their needs. 5. Social Worker to be involved in the resident ' s plan of care as it relates to their behaviors and refusal of cares, and educate the residents on risk vs. benefits. - Other QA tracking and trending related to pressure sores was identified in the plan. Findings include: The facility's "Skin and Wound Care Program" was reviewed at the time of the complaint investigation. The "Skin Program" policy stated, "The facility will follow steps to minimize the risk of skin breakdown from occurring in the facility and to maintain good skin integrity." The "Procedure" documented: 1. The Wound and Skin Care Program must be implemented in order to maintain good skin integrity and to prevent skin breakdown. 2. By using this program, correctly assess the risk factors and monitoring appropriately, skin problems will be prevented and/or identified, treated and healed quickly. 3. A "Body Audit and Hydration Report" should be completed on admission and a risk level assigned based in the Resident Risk Assessment Profile. This will initiate a tracking system to monitor for skin breakdown on a routine basis; daily, weekly, or monthly. 4. If skin breakdown occurs, medical justification must be documented. If wounds do not heal, documentation by the physician must justify the reason for the occurrence of the breakdown. Please refer to the "Pressure Ulcer Notification" form. 5. Use this skin care program in conjunction with the current Wound and Skin Reference Guide. 6. The Dietary Manager and RD consultant must document what is being done nutritionally to assist with prevention and healing of pressure sores. The "Sample Protocol" documented: * Complete the "Resident Risk Assessment Profile." * Assign Risk level on the "Body Audit and Hydration Report"; refer to Plan of Care Protocols. * Schedule the resident to have a body audit completed based on the risk level; low, medium, or high. Low - assess monthly Moderate - assess weekly High - assess weekly unless resident is totally dependent for bed mobility (G1a), then assess "Daily." * Residents who are at high or medium risk should be referred to the Registered Dietitian for review. Assess need for protein, vitamin and mineral supplementation. * If a pressure sore or other skin breakdown occurs, the "Weekly Pressure Sore Progress Report" should be initiated. * Evaluation of the risk factors should also include determination if the mattress is sufficient to reduce pressure. The facility mattresses are pressure reducing, but residents with several pressure sores or Stage III or IV on the coccyx or trunk may require low air loss overlay. Central supply should be notified of a resident who needs a low air loss mattress overlay. * Initiate the "Pressure Sore Notification" form. This communication to the physician should be updated as often as needed to keep the physician informed of any changes in the wound. * The wound will be re-assessed for needed changes in treatment at least every two to four (2 - 4) weeks. Re-evaluation of the treatment plan including determination whether to continue or modify the current interventions should be documented. * The nurse providing treatment should monitor the resident for signs of pain while administering the treatment. If pain is apparent, through verbal or non-verbal indications, administer pain medication before proceeding and schedule pain medication prior to treatment in the future. Facility staff failed to follow the procedures for the identified residents. Resident records lacked documentation as outlined for tracking and measuring the pressure sores. There was no evidence that residents' physicians were always notified when changes occurred nor was there evidence of physician justification related to the development or deterioration of the wounds. The facility failed to evaluate risk factors to determine if interventions were effective to prevent resident from acquiring a pressure ulcer and/or to aid in healing pressure ulcers. 1. Resident #6 was admitted to the facility, on 7/11/11, with [DIAGNOSES REDACTED]. The most recent significant change MDS, dated [DATE], documented the resident: * had short and long term memory problems, * had moderate impaired decision making skills, * had verbal and other behaviors directed at others from 1 to 3 days a week, * had behaviors that interfered with resident care, puts others at risk, interferes with social activities, and was disruptive to the living environment, * rejected care 1 to 3 days a week, * wandered 1 to 3 days a week, * required extensive assistance of two staff for transfers, ambulation and dressing, * required limited assistance for personal hygiene and bathing, * had two stage II pressure sores with the oldest being found on 8/22/11. The resident's 7/21/11, "Risk Assessment Totals" documented the resident for "skin risk score" was scored a "MED (medium)." It was not clear after interview with the corporate nurse consultant on 10/25/11 at 12:25 p.m. how the facility came up with the total, this was a computer generated document. The resident's care plan dated 7/11/11 had a problem identified as "Potential for skin breakdown." The facility approaches for the problem were: "* Treat [MEDICAL CONDITION] per MD current orders. * Ensure (Resident #6) repositions every 2 hours. * Monitor his skin with cares and ensure his skin is clean, dry and report any redness, discoloration, open areas, blisters. * LN to check his skin weekly and chart. * Offer shower/bath.... *Meds (Medications), treatments ..." The care plan had three updates these were: 8/23/11- problem: "Right buttocks open area measures 1 cm diameter with pink moist base. Left buttock open area measures 2 cm diameter requested treatment to cleanse apply zinc oint and cover with foam dressing...."The approach that was added documented, "Requested treatment to Left buttock and Right buttock - Cleanse, zinc, [MEDICATION NAME]. req(uest) wound nurse eval(uate)...." 8/30/11- problem: " Right buttocks open area measures 1 cm x 0.8 cm. Left buttock open area measures 1.8 cm x 1 cm....Right buttocks with bloody drainage pink after cleansing, Left buttocks pink...."The approach that was added documented, "orders for zinc to both buttocks wounds...." 9/7/11- problem: "Rt(right) buttock - wound measured, Small area above wound near coccyx measures 2" x 3" wide and is red, wound swollen to touch. Rt Buttock wound bed Dk (dark) - red with dk red center .2 cm, tunneling @ (at) 1 o'clock white yellow discharge from under wound bed expressed when cleaning wound- foul odor noted. Res(ident) is non-compliant with laying down throughout the day and into evening hours - res with preference to stay in w/ch (wheelchair) putting pressure on buttocks and coccyx region. Lt (left) Buttock 1.8 cm x 1 cm wound bed pink with blood tinged drainage."There were 10 additional approaches these were: "1. MD notified of wound progression. 2. Request for ABx (antibiotic). Therapy to request for x-ray r/t (related to) osteo[DIAGNOSES REDACTED]. 3. Rehab Dept changed - cushion to gel-foam. Ordering a Roho cushion. 4. Rehab Dept has changed w/ch to high back - to help try and correct poor posture. 5. Dietary supplement in place to promote wound healing. 6. Family have brought in recliner to help with position changes. 7. Sleeping better at night since starting psych meds - Maint Dept have provided resident with an air bed to promote skin integrity at noc-time. 8. Treatment (unable to read the word)- changed - zinc, (unable to read the word) and [MEDICATION NAME] to area's. 9. Setting up wound - clinic consult with the (local wound clinic). 10. Cont(inue) to encourage - position change's despite non- compliance." The resident had a history of [REDACTED]. The "Medicare Nursing Notes" document the resident continued to stand and fall frequently at the facility. On 8/5/11 the physician ordered, "Pommel cushion placed to assist resident with positioning in w/c and to help prevent from sliding out of w/c - resident able to stand has poor safety awareness." The resident frequently attempted to stand up from the wheelchair and he preferred to sleep in a recliner at night. The resident slept in a recliner at home. The resident's physician was notified 8/21/11 at 1:25 p.m. that the "Resident has been combative x 2 days, refuses to stay seated in w/c, fell out of w/c at 1245 (12:45 p.m.), he hit elbow on wall and opened an old skin tear.... The physician gave a telephone order for: "1 on 1 sitter, [MEDICATION NAME] 0.2 mg po tid prn, [MEDICATION NAME] 2 mg tid po prn, bandage L elbow monitor until healed." On 8/22/11 the 1 to 1 sitter was discontinued, and a psychiatric consult was requested. A PAR (patient at risk) meeting was held on 8/22/11 in addition to the pommel cushion in the wheelchair the resident had a "tab alarm to alert staff @ (about) attempts to self transfer and has anti-tipping on w/c for safety." On 8/22/11 at 3:30 a.m. a Condition Change Form was completed and sent to the physician. It documented, "Discovered x 2 pressure sores on buttocks. L = 2 cm R = 1 cm." The "Weekly Pressure Sore Progress Report" dated 8/22/11, documented' "L Buttocks, size: 2 cm diameter, stage: II, color: red/pink wound bed, odor: none, drainage: none noted." and "R buttocks, size: 1 cm diameter, stage: II, color: pink wound bed with red ???, odor: none, drainage: none noted." On 8/23/11 at 11:20 a.m. the PAR note documented, "R buttock open wound measures 1 cm diameter (with) pink wound base, L buttock wound measures 2 cm diameter (with) pink wound base...." On 8/24/11 the "Condition Change Form" documented two pressure sores on the right buttock and no documentation for the one on the left buttock. The first sore documented: "R buttock top sore, size: 1 cm, stage: II, color: red/pink wound bed, odor: none, drainage: none, progress: new sore 8/24/11." The second documented: "R buttocks bottom sore, size: 1.5 cm, stage: II, color: red wound bed, odor: none, drainage: none noted, progress: greater than .5 cm in 48 hours." On 8/25/11 at 2:30 p.m. the physician ordered, "wound clinic eval(uation) bilat(eral) LES (lower extremity's) and buttock wounds." On 8/25/11 at 3:20 p.m. the nursing staff received an order for [REDACTED]. The resident was seen by a mental health practitioner on 8/27/11 at 2:45 p.m., the "Initial Psychiatric Evaluation" documented, "Since admission staff report that he is physically and verbally aggressive toward female staff.... He is able to ambulate at this point with significant lower extremity [MEDICAL CONDITION] related to his multiple falls.... No sleep disturbance, although he does appear somewhat sedated today, although he did engage in conversation." The resident's "Mental Status" at the time of the evaluation was: "He was sleeping in his wheelchair but he easily aroused. His mood and affect appear restricted. He limitedly engaged in conversation. Difficult to assess if having paranoid or delusional thoughts. He did not appear preoccupied. He did not appear in distress." The nurse practitioner discontinued the [MEDICATION NAME] and started the resident on "[MEDICATION NAME] 25 mg one-half b.i.d. and [MEDICATION NAME] sprinkles 125 mg one b.i.d. The "Weekly Pressure Sore Progress Report" documented for 8/29/11, "location: L buttocks, size: 1.8 x 1 cm, color: pink, odor: none, drainage: scant bloody." and "location: R buttocks, size: 1 cm x .8 cm x depth 0, color: pink, odor: none, drainage: scant bloody." The "Medicare Nursing Notes" documented on 8/30/11 that the resident had "no behavior problems at this time." There was lacking documentation about the resident's pressures sores and behaviors until 9/7/11. The LN documented on a "Weekly Pressure Sore Progress Report" and a "Medicare Nursing Note." The note documented, "Buttocks wound increasingly worse. Coccyx area to the right and above it measures a 2 inch wide by 3 inch long red area, warm to touch (with) induration (hardening of a tissue because of excess fluid retention, inflammation). When pressure applied white drainage seeping from reddened area, then turned brownish/red. On R side of buttocks within the intergluteal fold is Stage III pressure sore measuring 6 cm in length, appears to have tunneling. Brownish/red moderate drainage on attends. (No) dressing intact upon assessment. Wound bed has red, black and white tissue. Resident flinching and grimacing (with) wound care. C/O (complained) pain. [MEDICATION NAME] 10/325 admin(istered). Cleansed area (with) wound cleanser, applied zinc with [MEDICATION NAME] per treatment orders. Positioned the resident on L side in bed.... Wound to buttocks also had very foul odor." On 9/7/11 the PAR committee evaluated the wound. The documentation in the "Medicare Nursing Notes" was: "Rt buttocks wound measures 7.1 cm x 1.9 cm. Small area above wound and near coccyx - measures 2" x 3" (2 inches by 3 inches) wide and is red, warm and swollen to touch. Rt buttocks wound bed - Dk red (with) Darker red center. 0.2 cm tunneling at 1 o'clock. White yellow discharge from under wound bed expresses when cleaning wound foul odor noted...." The "Medicare Nursing Note" for 9/8/11 at 3:00 a.m. documented, "Resident lying in bed upon arrival of shift. Drsg (dressing) saturated (with) exudate from buttocks wound. Large amount on attends also. Drainage mostly yellow in color with greatest amount. Also brownish/red drainage with small moderate amount. Removed soiled drsg, cleansed wound, yellow/brown/red drainage expelled from top of wound when dressing applied.... Foul odor noted with drsg (change) and resident diaphoretic and also c/o severe pain.... Positioned patient on L side in bed. Will continue to monitor." On 9/8/11 between 3:00 a.m. and the 11:45 p.m. nursing documentation only addressed physical therapy, occupational therapy and speech therapy. There was no documentation related to the deterioration of the resident's health. On 9/8/11 at 11:45 p.m. a "Condition Change Form" documented, "Resident's body shaking, responsive to verbal stimuli. VS (vital signs): (temperature) 102.9 axillary, 120-pulse, 36 resp(irations), (oxygen saturation) Sats in 60's on RA (room air) increased to 92 % continuous flow via NC (oxygen was started by nasal cannula), BP (blood pressure) 110/60. Buttock drsg coming off - completely saturated with wound drainage. Very foul odor." The physician was contacted on 9/8/11 at 11:25 p.m. and ordered, "Send to ER (emergency room ) for evaluation." The resident was admitted to the local hospital intensive care unit. The "Emergency Physician Record" documented "Clinical Impression: Infected Decubitus ulcer,[MEDICAL CONDITION] severe and L lower lobe pneumonia." The residents condition was "poor" and "critical." The attending physician's "History and Physical" documented an assessment of: "1.[MEDICAL CONDITION] with lactic acidosis. 2. Urinary tract infection. 3. Left lower lobe pneumonia. 4. Grade III pressure ulcer in the gluteal area...." On 9/9/11 at 12:38 a.m. a wound culture was done on the drainage from the pressure sore and the results were "Proteus Mirabilis, Escherichia coli, and Staphylococcus Aureus." The hospital did a "Blood Culture" that also produced [MEDICAL CONDITION]. Color digital photographs were taken on 9/9/11 at 4:00 a.m. when he was admitted to the hospital, these confirm the size and staging of the pressure sore. On 9/11/11 the wound was debrided and color photos show that it was a Stage IV after the dead tissue was removed. LNs # 6, 7 and 8 were interviewed on 10/27/11 starting at 11:15 a.m. The three LN's all felt that the resident did have some behaviors but after the medication changes on 8/27/11 the resident was more manageable. Two of the LN's (#s 6 and 7) were on the night shift and indicated that the resident did sleep in the bed, the DON and RN consultat indicated resident refused to sleep in bed but slept in a recliner. The bed did have an air mattress to decrease pressure. The resident was harmed because the facility failed to: - Accurately assess the resident's risk for skin breakdown. The corporate nurse consultant was unable to explain how the facility arrived at the "skin risk score" that was documented for the resident. - Develop or modify the care plan to address the resident's "behaviors" that interfered with proper positioning. - Obtain a wound nurse consultation that was identified as a need in the 8/23/11 care plan approach. - Get an appointment with the wound clinic when ordered on [DATE]. - Monitor the resident after a pommel cushion was placed in the wheelchair. - Obtain medical attention 8/28/11 for the Stage II pressure sore when it was bleeding. - Notify MD of foul-smelling wound drainage on 9/7/11. - Seek medical attension on 9/8/11 when the resident was diaphoretic and in pain. - Seek a change in treatment when wound was deteriorating but continued with Zinc and foam dressing. 2. Resident #4 was admitted to the facility 5/21/10 with [DIAGNOSES REDACTED]. The most recent significant change MDS, dated [DATE], documented the resident: * was severely cognitively impaired, * rejected cares on a daily basis, * required extensive assistance from staff for transfers, dressing, personal hygiene and bathing, * had a stage II pressure sore that was acquired in the facility on 1/27/11. The resident's 10/18/11, "Risk Assessment Totals" documented the resident's "skin risk score" was "High." It was not clear after interview with the corporate nurse consultant on 10/27/11 how the facility came up with the total; this was a computer generated document. The resident's care plan for "Skin breakdown to buttocks" was printed 10/16/2011 at 10:06 p.m. There was a hand written problem addition dated 10/15/11 that documented, "updated," "Rt (right) heel - post blister." The care plan goal was, "will have no further skin breakdown AEB (as evidenced by) redness, blisters or open area through next receives(sic). 11/30/11." The "Approaches" were: "* Keep heel and other bony areas covered.... * Place resident on pressure reduction mattress while in bed. *Memory foam cushion in w/c (wheelchair). (Resident #4) insists a pad be put over the memory foam cushion, which causes increased pressure. She was educated, but still insisted that the pad be placed.... * Two person assist with Hoyer lift.... * Licensed nurse to check her skin weekly and chart results. * Use lotion to ensure skin is well moisturized. * Watch for clothing that restricts blood flow. * When doing cares monitor for redness, discoloration, blisters... * Ensure that turning and toileting/peri care is offered and done on a 2 hour rotation at a minimum. * TRY TO POSITION PATIENT TO KEEP PRESSURE OFF SACRAL AREA AS MUCH AS POSSIBLE. * CHART NON COMLIANCE (sic) WITH LYING DOWN. * Assess/observe bilat(eral) heels every shift. * Offer pain medication 30 minutes before wound care. * Vitamin C 500 .... * Multivitamin.... * 10/07/2011--According to a consent singed (sic) by POA (Power of Attorney). The facility is to continue to offer to assist (Resident #4) to reposition, or rest to relieve pressure, and to offer pressure relieving cushions giving to (Resident #4) the opportunity to accept, or refuse. * Medications, treatments, Labs per physician's current orders. * For wound measurements and current wound treatment see wount(sic) treatment sheet." The care plan failed to have any approaches to identify how staff were to intervene if the resident refused to lie down or otherwise refuse care that did not promote healing of the skin breakdown. The resident was observed on 10/25/11 at 9:55 a.m. to have a stage IV pressure sore on the coccyx area. The sore, when the dressing was removed, had a strong pungent odor to it. The appearance of the wound bed showed black/tan loose tissue. The wound bed itself was black/tan and had tan drainage. The sore measured 5.6 cm long, 5.3 cm wide, and 1.5 cm deep. The nurse used a cotton swab to measure the tunneling that was there, and it was 2 cm in length. The tip of the swab was dark tan after the measurement was taken. An area on the inferior side of the sore was about 6 inches on the left buttock and 8 inches on the right buttock. This area was deep pink in color and did blanch with touch. The nurse did the treatment and covered the sore with gauze. The DON spent 20 minutes talking to the resident just prior to the obove observation of the wound. The resident was crying, she appeared to be frustrated and upset with two things. One, was that she was no longer able to read the newspaper like she used to and second, was the incontinent care skin prep that the staff used on her bottom "burned" and she was unhappy that the staff continued to use it. The resident then allowed the dressing change to occur. The care plan did not have any notation for staff to use any specific approaches with the resident to make the resolution of the pressure sores more successful. The pressure sore was first documented as observed on 1/27/2011 at 1:30 p.m. on a "Condition Change" form attached to a Nurses Note. The form documented, "With shower res(ident) noted to have area to coccyx measuring 1 cm X .5 cm with small black area and red (unreadable) area. Cleansed area and applied mediceptin with clear dressing." The facility placed an air mattress on the bed and had a cushion placed in the wheelchair. The documentation in the nurse's notes for January and February show the resident preferred to be up in a wheelchair or a recliner in her room. The resident did not like to be in bed during the day and spent time up out of bed. On 2/28/11 the "Weekly Pressure Sore Progress Report" documented an area of 1.2 cm length by 1.5 cm width and 0 depth. The color was "pink bed, top layer off." There was no odor or drainage. The pressure sore by 3/24/11 had progressed to 1.8 cm length by .7 cm width. It was staged as a II and the color was "pink." There was no odor or drainage noted. The Nurses Notes for March had four documented notes about the resident's behavior of refusing "to lay down to promote healing." The resident was started with a hospice agency on 3/15/11. The sore on the coccyx continued to deteriorate through the months of April and May 2011. The documentation on 6/12/11 showed the area to measure 1 cm x 1 cm. The Stage: red L cheek blanching, Color: yellow wound bed, odor: none, and drainage: scant yellow. (Note: Prior documentation indicates the wound was a Stage II on the coccyx but this document describes it as blanching on the left cheek of the buttock. It is unclear if this is referring to the original wound or a second wound.) The PAR team met 6/14/11 at 10:00 a.m. The documentation stated, "Resident continues to be monitored for wound to Lt buttocks essentially unchanged ....Hospice was contacted about wound consult. They only have someone out of state who evaluates wounds. So facility will call Dr (Resident's physician) for wound eval(uation) at facility using Misti Treatment nurse. Lt buttocks measures 1cm x 1cm Tx at this time is for Zinc, foam and clean dressing. Will request (change) after eval. Wound bed yellow with scant yellow drainage. 2nd wound to Lt buttocks resolved toward the top .... " The Nurses Notes documented for 6/16/11 at 5:00 p.m. the facility had, "received fax order Dr (Resident' s physician) having hospice nurse eval wounds to suggest tx - due to not - improving, Hospice will not pay for outside evaluation and tx for wound." The documentation on 6/29/11 showed the area to measure 1 cm length, .5 cm width, and .1 cm in depth. The color was "Red wound bed." There was an odor and "scant red blood" was present. Nurse's notes continued to document the resident refusals and the resident wanting to be out of bed during the day. (Note: It could not be determined if the measurement referred to the original wound on the coccyx or to the wound on the left buttock." The 7/1/11 at 4:00 p.m. Nurses Notes documented, " L buttock wound measures 1 cm x 0.5 cm. Wnd(wound) bed red (with) serosang drainage ...uses memory foam in recliner. Hospice delivered a specialty w/c to help relieve pressure." On 7/4/11 the Weekly Pressure Sore Progress Report documented "2 wounds" then went on to describe "#1 - 1.5 cm x 1 cm, red irritated and yellow" and #2 - "3 cm x 1 cm and yellow." There were "Weekly Pressure Sore Progress Reports" on two different wounds generated. On 7/15/11 the report documented one location of: "bottom wound" L(eft) buttock, Size: 2.5 cm x 2 cm, Color: yellow pink, Odor: positive, Drainage: positive yellow. The other sore was located: "top wound" L buttocks, size 2 cm X 2 cm, Color: yellow/brown, Odor: positive, Drainage: positive yellow. The PAR team documented on 7/4/11 at 10:15 a.m.," L buttocks wounds has two open areas. Top wound measures 1.5 cm x 1 cm - below this is #2 wound measures 3 cm x 1 cm. Small abrasions area noted from adhesive on dressing measures 1.5 cm x 1 cm. Resident c/o discomfort (with) dressing (change). Tx is [MEDICATION NAME] to fit wound and cover (with) [MEDICATION NAME] (change) 2 X per week. Hospice to provide dressings. Specialty wheelchair (with) memory foam in w/c and recliner - Broda w/c. Res remains under hospice care. Non complaint (with) multiple request and education to lay down between meals. Both wounds (with) yellow bed and yellow drainage. Foul odor to wounds. Notification sent today to MD of wounds ... " On 7/26/11 at 11:00 the PAR team documented, "Res condition - continues to decline - at this time she has elected to use both w/c's ... Both w/chs - have use a foam w/c cushion memory - foam cushion used when in recliner. Res cont to refuse to lay down between meals ...Top wound to Lt Buttock - measures - 2.1 x 1.3 cm, wound bed yellow with odor and drainage yellowish pink - Res expresses pain (with) treatment. Middle wound - U - shaped approx(imately) 2.4 cm x 1.6 cm - wound bed is pink/red (with) white edges (with) pinkish yellow drainage (with) foul odor and pain with tx/drsg (dressing change) Bottom wound - new this week - 1.1 x 0.4 cm. Wound bed pink, (with) pink drainage - + odor and pains (with) tx. CP updated, MD notified of wound progression meal intakes 90/52/55% (with) 187% of fluids at each meal - TX directed by hospice .... " (Note: The resident now has 3 wounds documented on the left buttock described as top bottom and middle wounds.) The Nurses Notes on 8/16/11 at 11:30 include a PAR team meeting note which documented, "Res cond(ition) cont to decline. Cont to use both w/c's - and sits in the recliner between meals. She cont to refuse to lay down between meals. Top L buttock wnd (wound) measures 3cm x 3.4 cm and lower wound L buttocks measures 1 cm x 1.2 cm. Both wound beds are yellow (with) sm amt green drainage. Tx cont - cleanse with wound cleanser. Apply [MEDICATION NAME] and [MEDICATION NAME] daily. C/o pain (with) tx, receives routine pain rxs (medications). Hospice is directing care of wound ... " (Note: Documentation only includes measurements of a "top" wound and a "bottom" wound. There was no mention of the "middle U shaped" wound identified on 7/26/11) The Nurses Notes on 8/30/11 at 2:00 p.m. documented, "Call to hospice to request reeval(uation) of wound care. (Hospice RN name) from hospice called and stated a PA will be out to facility to eval(uate) wound and poss(ibly) order a different dressing this week or next." The Nurses Notes on 8/31/11 at 6:20 p.m. documented, "Received signed fax from (MD) hospice (Name) - 1) cleanse (with) wound cleanser, apply [MEDICATION NAME] cut to size of wound, cover with [MEDICATION NAME] and [MEDICATION NAME] (change) daily until healed." NOTE: This is the same treatment that is described in the 8/16/11 notes Both wounds continued to be present and documented in the "Weekly Pressure Sore Progress Report" in September 2011. The "Weekly Pressure Sore Progress Report" documented: 9/19/11- Left buttock top wound: Size: 2.8 x 1.8 cm, Color: Black, (lower) edge red, Odor: none, Drainage: red, Progress: bogginess, skin protruding around wound. Left Buttock lower wound: Size: 1cm x 1cm, Stage: II, Color: red, Odor: none, Drainage: bleeding. 9/27/11 - L top buttock: Size 3.3 x 4.8 cm, Color: black yellow edges, Odor: positive, Drainage: thin yellow, Progress: Black area soft center indented. There was no documentation on the Lower wound. 9/29/11 - L top buttock: Size: 3.3 x 4.8 cm x 1 cm depth, Progress: Black covering has opened. No tunneling noted. There was no documentation on the lower wound. (Note: the lower wound was present because there was documentation in October 2011 about it.) The Nurses Notes on 10/1/11 at 600 a.m. documented, "ZXXX

Based on a public complaint, observation, staff interview and medical record review, the facility failed to obtain timely assessment and treatment by a wound care clinic for pressure related wounds. The delay in assessment and treatment resulted in harm to 3 of 5 (#s 4, 6 and 9) sampled residents with wounds. Resident #9 had a recommendation from a WOCN, Resident #6 had a physician order [REDACTED]. Residents # 6 and 9 had referrals to a wound clinic to address the care of the residents' wounds. In addition, Resident #7 did not have an initial care plan to direct his care including frequency of bathing. Findings include: 1. Resident #6 was admitted to the facility, on 7/11/11, with [DIAGNOSES REDACTED]. The most recent significant change MDS, dated [DATE], documented the resident: * had short and long term memory problems, * had moderate impaired decision making skills, * had verbal and other behaviors directed at others from 1 to 3 days a week. * had behaviors that interfered with resident care, puts others at risk, interferes with social activities, and was disruptive to the living environment, * rejected care 1 to 3 days a week, * wandered 1 to 3 days a week. * required extensive assistance of two staff for transfers, ambulation and dressing, * required limited assistance for personal hygiene and bathing, * had two stage II pressure sores with the oldest being found on 8/22/11. The resident's care plan dated 7/11/11 had a problem identified as "Potential for skin breakdown." The facility approaches for the problem were: "* Treat [MEDICAL CONDITION] per MD current orders. * Ensure (Resident #6) repositions every 2 hours. * Monitor his skin with cares and ensure his skin is clean, dry and report any redness, discoloration, open areas, blisters. * LN to check his skin weekly and chart. * Offer shower/bath.... *Meds, treatments ..." The care plan had three updates the these were: 8/23/11- a problem of: "Right buttocks open area measures 1 cm diameter with pink moist base. Left buttock open area measures 2 cm diameter. requested treatment to cleanse apply zinc oint and cover with foam dressing...." The approach that was added documented, "Requested treatment to Left buttock and Right buttock - Cleanse, zinc, [MEDICATION NAME]. req(uest) wound nurse eval(uate)...." 9/7/11- a problem of: "Rt(right) buttock - wound measured, Small area above wound near coccyx measures 2" x 3" wide and is red, wound swollen to touch. Rt Buttock wound bed Dk (dark) - red with dk red center .2 cm, tunneling @ (at) 1 o'clock white yellow discharge from under wound bed expressed when cleaning wound- foul odor noted. Res(ident) is non - compliant with laying down throughout the day and into evening hours - res with preference to stay in w/ch (wheelchair) putting pressure on buttocks and coccyx region. Lt (left) Buttock 1.8 cm x 1 cm wound bed pink with blood tinged drainage." There were 10 additional approaches these were: "1. MD notified of wound progression. 9. Setting up wound--clinic consult with the (name of wound clinic)." On 8/22/11 at 3:30 a.m. a Condition Change Form was completed and sent to the physician. It documented, "Discovered x 2 pressure sores on buttocks. L = 2 cm R = 1 cm." The "Weekly Pressure Sore Progress Report" dated 8/22/11, documented' "L Buttocks, size: 2 cm diameter, stage: II, color: red/pink wound bed, odor: none, drainage: none noted." and "R buttocks, size 1 cm diameter, stage: II, color: pink wound bed with red ???, odor: none, drainage: none noted." On 8/25/11 at 2:30 p.m. the physician ordered, "wound clinic eval(uation) bilat(eral) LES (lower extremity's) and buttock wounds." The "Weekly Pressure Sore Progress Report" documented for 8/29/11, "location: L buttocks, size: 1.8 x 1 cm, color: pink, odor: none, drainage: scant bloody." and "location: r buttocks, size: 1 cm x .8 cm x depth 0, color: pink, odor: none, drainage: scant bloody." There was lacking documentation about the resident's pressures sores and behaviors until 9/7/11. The LN documented on a Weekly Pressure Sore Progress Report" and a "Medicare Nursing Note." The note documented,"Buttocks wound increasingly worse. Coccyx area to the right and above it measures a 2 inch wide by 3 inch long red area, warm to touch (with) induration. When pressure applied white drainage seeping from reddened area, then turned brownish/red. On r side of buttocks within the intergluteal fold is Stage III pressure sore measuring 6 cm in length, appears to have tunneling. Brownish/red moderate drainage on attends. (No) dressing intact upon assessment. Wound bed has red, black and white tissue. Resident flinching and grimacing (with) wound care. C/O (complained) pain. [MEDICATION NAME] 10/325 admin(istered). Cleansed area(with wound cleanser, applied zinc with [MEDICATION NAME] per treatment orders. Positioned the resident on L side in bed.... Wound to buttocks also had very foul odor." On 9/7/11 the PAR committee evaluated the wound. The documentation in the "Medicare Nursing Notes" was: "Rt buttocks wound measures 7.1 cm x 1.9 cm. Small area above wound and near coccyx - measures 2" x 3" (2 inches by 3 inches) wide and is red, warm and swollen to touch. Rt buttocks wound bed - Dk red (with)Darker red center. .2 cm tunneling at 1 o'clock. White yellow discharge from under wound bed expresses when cleaning wound Foul odor noted...." On 9/8/11 at 11:45 p.m. a "Condition Change Form" documented, "Resident's body shaking, responsive to verbal stimuli. VS (vital signs): (temperature) 102.9 axillary, 120-pulse, 36 resp(irations), (oxygen saturation) Sats in 60's on RA (room air) increased to 92 %continuous flow via NC (oxygen was started by nasal cannula), BP (blood pressure) 110/60. Buttock drsg coming off - completely saturated with wound drainage. very foul odor." The physician was contacted on 9/8/11 at 11:25 p.m. and ordered the resident to be "Send to ER (emergency room ) for evaluation." The resident was admitted to the local hospital intensive care unit. The "Emergency Physician Record" documented "Clinical Impression: Infected Decubitus ulcer,[MEDICAL CONDITION] severe and L lower lobe pneumonia." The residents condition was "poor" and "critical." The attending physician's "History and Physical" documented an assessment of: "1.[MEDICAL CONDITION] with lactic acidosis. 2. Urinary tract infection. 3. Left lower lobe pneumonia. 4. Grade III pressure ulcer in the gluteal area...." On 9/9/11 at 12:38 a.m. a wound culture was done on the drainage from the pressure sore and the results were "Proteus Mirabilis, Escherichia coli, and Staphylococcus Aureus." The hospital facility did a "Blood Culture" that also produced [MEDICAL CONDITION]. The resident was harmed because: * The facility failed to obtain a wound nurse evaluation of the resident's wounds which was identified as a care plan approach in the 8/23/11 care plan update. * The facility failed to implement the physician's orders [REDACTED]. The Administrator and DON were informed on 10/28/11. They provided a schedule that showed the resident was scheduled for 9/13/11 but the resident was in the hospital by then. 2. Resident #9 was admitted to the facility, on 11/19/10 with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * was severely cognitively impaired, * had verbal behaviors 1 to 3 days a week, * rejected cares 1 to 3 days a week, * required total to extensive assistance for transfers, dressing, eating, personal hygiene and bathing., * had one unstageable 1 cm by 1 cm pressure sore. The significant change MDS, dated [DATE], documented the resident: * had a stage I pressure sore that had [MEDICATION NAME] tissue present. The resident's care plan dated 11/19/10 documented problem of, "Skin at risk with potential for breakdown" related to diabetes mellitus, [MEDICAL CONDITION], tendency to slide forward in wheelchair, incontinence of bowel and bladder, and limited ability to reposition self on a regular basis without assist. The goal was, "will maintain intact skin or not develop any new skin issues thru next review." The approaches that were developed were: "* Assist to reposition (every) 2 hours (and) prn." * Pressure reducing mattress on bed and pressure reducing pommel cushion in w/c." * Monitor skin during cares for redness, discoloration, increased warmth, rash, blister, and/or open areas and notify LN if present. * LN to monitor skin weekly thru SAR (skin at risk) and prn. * Apply lotion as needed for dry skin during cares. * Watch for clothing that restricts blood flow. * Keep heels and other bony areas covered to reduce friction. * Meds, labs, and treatment per current MD orders." The resident had an updated care plan that was printed 10/16/11 and it had additional information to the problem of, "See tx (treatment) wound report and tx sheet for wound measurements and current treatment of [REDACTED]." Additional approaches were added, these were: "* Gel foam boots on bilateral heels and feet at all times. Check (each) shift for placement. * Pommel cushion in w/ch to assist with maintaining a better position in her w/ch to assist with preventing falls, check (every) shift, release, (every) 2 hours. * Lotion feet at HS. *Vit(amin) C 500 mg(milligrams) po bid for wound healing. * Resource 2.0 120 cc po tid 8 AM, 12 PM, 4 PM for supplement. * Wound clinic following and making recommendations for treatment. See wound sheet for the latest measurements and treatment. * See Tx wound report and tx sheet for wound measurements and current treatment of [REDACTED]. The "Weekly Pressure Sore Progress Note" for the left outer heel documented on a weekly basis starting on 4/25/11. There was not much change to the sore for the first four months. Some of the notes were: 4/25/11 - size: 3 cm x 2.7 cm, color: grey white, odor and drainage: none. 5/2/11 - size: 2.5 x 2.5 cm, color: white middle with brown edge, odor and drainage: none. 6/7/11 - size: 1 cm x 1 cm, color: black scab, odor: none, drainage: scant yellow. 7/4/11 - size: 1 cm x 1 cm, color: black scab, odor: none, and drainage: none. 8/2/11 - size: 1 x 1 cm, stage: unstageable, color: black scab, odor and drainage: none. 9/20/11- size: 0.8 x 0.5 cm, color: brown moist covering white wound base, odor: none, drainage: scant yellow, and progress: covering soft and lifting from wound. The resident was seen on 5/24/11 at 2:00 p.m. by a WOCN. The nurse documented: "Unable to determine how long wound has been in place. Currently softening 1 x .9 cm black eschar lateral L heel. Foam dressing in place (with) scant amount serous drainage. L foot warmer than R foot, some [MEDICAL CONDITION]. Non palpable pedal pulses. Monophasic dorsalis pedis pulse (with) doper (sic).... history of DM concerned about potential for healing, suggest referral to (wound clinic name)wound center for workup...." A physician's orders [REDACTED]." The wound did not change for several months. Another physician's orders [REDACTED]." The resident was seen at the wound clinic on 9/23/11 and documented: "The left heel measures 1 x 1 x 0.2 cm with granulation tissue mixed white tissue in the actual central base.... The ulcer was debrided down to a clean and bleeding base..." The "Impression:" was 1) Wagner 2 [MEDICAL CONDITION] to the left heel. and 2) Healing impaired by the patient's positioning and inability to follow and remember instructions." The DON was interviewed 10/26/11 about the resident's foot wound and indicated it was improving after being seen in the wound clinic. The DON indicated there was some delay in getting the resident to the wound clinic because the residents family did not sign the consent, but thought it was only a couple weeks. The resident was harmed because the: - facility failed to get consult from a wound clinic in a timely manner. The WOCN made a recommendation on 5/24/11 but the resident was delayed in going to the wound clinic until 9/23/11. 3. Resident #4 was admitted to the facility 5/21/10 with [DIAGNOSES REDACTED]. The most recent significant change MDS, dated [DATE], documented the resident: * was severely cognitively impaired, * rejected cares on a daily basis, * required extensive assistance from staff for transfers, dressing, personal hygiene and bathing, * had a stage II pressure sore that was acquired in the facility on 1/27/11. The resident's 10/18/11, "Risk Assessment Totals" documented the resident for "skin risk score" was scored a "High." It was not clear after interview with the corporate nurse consultant on 10/27/11 how the facility came up with the total; this was a computer generated document. The resident's care plan for "Skin breakdown to buttocks" was printed 10/16/2011 at 10:06 p.m. There was hand written " problem " addition dated 10/15/11 that documented, "updated," "Rt (right) heel - post blister." The resident ' s pressure sore was first documented as observed on 1/27/2011 at 1330 (1:30 p.m.) on a "Condition Change" form attached to a "Nurses Note." The form documented, "With shower res(ident) noted to have area to coccyx measuring 1 cm X .5 cm with small black area and red (unreadable) area. Cleansed area and applied mediceptin with clear dressing." The resident was observed, eight months later, on 10/25/11 at 9:55 a.m. to have a stage IV pressure sore on the coccyx area. The sore, when the dressing was removed, had a strong pungent odor to it. The appearance of the wound bed showed black/tan loose tissue. The wound bed itself was black/tan and had tan drainage. The sore measured 5.6 cm long, 5.3 cm wide and 1.5 cm deep. The nurse used a cotton swab to measure the tunneling that was there, and it was 2 cm in length. The tip of the swab was dark tan after the measurement was taken. There was an area on the inferior side of the sore was about 6 inches on the left buttock and 8 inches on the right buttock. This area was deep pink in color and did blanch with touch. The nurse did the treatment and covered the sore with gauze. The wound progressed from a 1cm x .5 cm pressure sore on 1/27/11 to a 5.6 cm long 5.3 cm wide and 1.5 cm deep. The nurse used a cotton swab to measure the tunneling that was there, and it was 2 cm in length on 10/25/11. There was no documentation to show the resident ' s physician or a certified wound nurse ever looked at the wound and provided direction for treatment. The documentation on 6/12/11 stated, " Resident continues to be monitored for wound to Lt buttocks essentially unchanged ....Hospice was contacted about wound consult. They only have someone out of state who evaluates wounds. So facility will call Dr (Resident ' s physician) for wound eval(uation) at facility using Misti Treatment nurse " The Nurses Notes documented for 6/16/11 at 5:00 p.m. the facility had " received fax order Dr (Resident ' s physician) having hospice nurse eval wounds to suggest tx - due to not - improving, Hospice will not pay for outside evaluation and tx for wound. " The resident ' s sore was looked at by the hospice physician on 9/8/11. The documentation was: "Subjective/Objective Assessment: ....Has sacral pressure ulcer, not deep, approx(imately) 2 cm diameter.... Past Medical History: ...3) Sacral Decubitus ulcer.... Assessment/ Plan / New Orders: 1) Continue above.... 3) keep pressure off sacral area...." The physician wrote orders for: "1) Continue present wound care, 2) Soap and water clean wound area and entire peri-anal area daily, 3) Try to position patient to keep pressure off sacral area as much as possible." There were no treatment orders for the sore from the physician. The wound treatment and treatment supplies, according to PAR team documentation, continued to be directed by the Hospice Agency. The Hospice "Interdisciplinary Team Plan of Care and Comprehensive Needs Assessment" were reviewed. The Hospice agency had a meeting every two weeks on the resident and generated the information on the document. The 10/12/11 and 9/28/11 documents stated that the resident "refuses to lay down or to stay off the wound." There was no documentation that Interdisciplinary team addressed the problem of the pressure sore getting increasingly worse nor did they develop a treatment plan to address the sore. The DON, Corporate RN consultant, Corporate Quality Assurance consultant and Hospice RN were interviewed about the pressure sores. The Hospice Nurse stated that the agency had a Certified Wound Care nurse that reviewed resident pressure sores, the wound nurse was "back East" and that the hospice nurses take pictures of pressure sores then the nurse reviews them. A description of the wound was sent to the Certified Wound Nurse to evaluate. There was no documentation of any evaluation in the medical record. The resident was harmed because the facility: - failed to provide treatment to prevent pressure sores and new sores from occurring - failed to have the resident ' s physician or a Certified Wound professional evaluate the pressure sore and provide treatment options. A certified wound nurse evaluated the resident on 10/27/11 and documented, "Presents with UIV (Unstageable Stage IV) with 100% tan/grey stringy slough adhered to wound bed, undermined 180 degrees (with) 1.0 cm induration, approximately measures 7.0 cm x 6.2 cm x 1.4 cm." The wound nurse made definitive treatment recommendations that were sent to the physician for approval. 4. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident left the facility against medical advice on 10/3/11. Upon review of the resident's closed record an initial care plan could not be located. On 10/27/11 the surveyor asked the Medical Records supervisor if any overflow records had not yet been filed in Resident #7's record. She asked what specifically the surveyor was looking for. An initial care plan was requested. On 10/28/11 at 8:50 am, the Medical Records supervisor told the surveyor she had asked about the initial care plan and was told by the MDS nurse that the facility used the initial MDS assessment for the first 21 days after admission. This turned out to be a possible miscommunication as on 10/28/11 at approximately 11:45 am, the DON provided the surveyor with a copy of a 12 page "Initial Nursing Summary" dated 9/27/11. The DON said the LN consultant wanted the surveyor to have the copy and it was what the facility used for an initial care plan. The "Initial Nursing Summary" was a nursing assessment but not a care plan. The assessment did not have measurable objectives or timetables and did not identify which services the facility should perform and who was designated to perform them. For instance, the first page of the printed form had a section related to vision. A list of items in the "visual acuity" box were check marked by the assessor. They included: moderately impaired vision, uses glasses, reading glasses and "Resident preferred use of glasses out of bed." This did not direct care givers if the resident required help in keeping his glasses clean, if he required them just for reading or used them all the time, or if he could care for the glasses himself. It did not indicate who should be responsible if any of these things were required. The same scenario was for the section on hearing acuity and other sections of the assessment such as, hair care, nail care, oral care, hygiene and shaving. The section on bathing indicated he needed assistance but did not say who would assist him, level of assistance or indicate frequency of bathing. There was no indication of how much participation the resident or his personal representative had in developing a plan for bathing/showers. While the facility is required to develop a comprehensive care plan in 21 days after the initial MDS assessment and related to triggered CAAs, they are required to develop initial care plans upon admission to address the needs of the resident upon admission.