Every finding on record at Mini-Cassia Care Center

Based on observation, interview, policy review, and U.S. Food and Drug Administration 2022 Food Code, the kitchen staff failed to appropriately store and label foods, wash hands prior to donning gloves, and prevent possible cross contamination of opened resident stored food items with kitchen stored food products. This deficient practice had the potential to affect all 58 residents who received meals prepared in the facility's kitchen. Findings include:The facility's Food Receiving and Storage policy dated 3/31/25, documented all foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date).The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 8/3/26 at 9:45 AM, observed the following in the kitchen:Reach-in refrigerator: - An opened bag of lettuce with a used by date (UBD) of 8/2/26.- A container of pink liquid (punch) with no open or UBD dates.- Various opened food items with residents' names on them stored in the kitchen refrigerator; tomato cocktail, cream cheese, potato salad, jar of mayonnaise, package of sandwich bologna. Reach-in Freezer:- An opened bag of frozen egg omelets with no open or UBD.- An opened bag of pizzas with no open or UBD. Panty: - An opened vanilla syrup 1 gallon container with a UBD of 6/17/26. - An opened 12 oz pancake syrup bottle with a UBD of 8/2/26. On 8/3/26 at 3:23 PM, observed [NAME] #1 with ungloved hands, carry some food product to the trash can, lift the lid with her bare hands and push the food product down into the trash can to crush the garbage down. She then went back to her cooking duties without washing her hands to include pouring soup into bowls for the residents. On 8/4/26 at 2:35 PM, observed [NAME] #2 cutting up celery with gloved hands. When she changed tasks to open a cupboard and move some bowls around, then returned to the cutting task and without changing gloves or hand hygiene she picked up the cut up celery to put in the bowl. [NAME] #2 took off one glove so she could get her glasses to read the recipe for the dinner meal. She then obtained another glove and donned it without washing her hands and then went back to food preparation.On 8/4/26 at 3:30 PM, the Maintenance Manager (acting food service manager) stated all food items in the refrigerator/freezers should have been labeled with UBD and proper hand hygiene practices need to be followed by kitchen staff and were not.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 58 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) cross contamination due to equipment not being cleaned between use b) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or c) residents were injured due to unsafe areas in the facility. Findings include:The facility's Cleaning and Disinfection of Environmental Surfaces policy, revision date August 2019, documented environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.The Facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revision date September 2022, documented Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.The facility's Maintenance Service policy dated December 2009, documented that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include maintaining the building in good repair and free from hazards. The following areas were observed for clean and homelike environment: On 8/4/26 at 8:46 AM, observed North Hall shower room: -Shower stall #1 floor with dark black residue in the separation of the lower portion of the shower stall and the flooring. -Shower stall #2 flooring with dark residue in the chipped and open penetration along the floor measuring from one side of the shower stall to the drain located between shower stall #1 and shower stall #2. On 8/4/26 at 5:27 PM, the Maintenance Manager stated he was aware of the shower room flooring issues and knew the showers needed to be repaired. The following areas were observed for safety issues: On 8/3/26 at 10:07 AM, observed plastic door panels on the outside of room [ROOM NUMBER] and room [ROOM NUMBER], with plastic edge protruding. On 8/5/26 at 9:40 AM, the maintenance director stated the panels needed to be fixed. On 8/3/26 at 3:20 PM, observed in the south hall shower room, two large holes that were missing tile about 6 inches wide by 12 inches long and 1/8 inch deep and a smaller crack about 1 inch wide by 2 inches long and 1/8 inch deep. Potential for a wheeled shower chair to tip from if wheel was caught in the hole. On 8/4/26 at 3:15 PM, the maintenance manager stated he had been watching this shower area and knew the flooring needed to be corrected The following areas were observed for facility cleanliness: On 8/3/26 at 9:54 AM, observed on the north hallway: - the vent at the end of the north hallway had a black substance and a cobweb-like substance - the ceiling around the vent had a gray fuzzy substance - the two vents outside room [ROOM NUMBER] with gray fuzzy substance - the wall at the end of the north hall with multiple gouges On 8/3/26 at 11:19 AM, observed in the north side dining room across from the TV room: - ceiling vent grates with a black substance - yellow, dry splattering substance on first ceiling light and on ceiling around the light - the second ceiling light had rust colored dry splattering The following areas were observed for equipment cleanliness: On 8/3/26 at 10:59 AM, Resident #46's wheelchair had dried, red, chunky substance to center of cushion, and splattering of dried, white substance to cushion. Right wheel lock of wheelchair, had a large chunk of dried, tan colored substance. All four wheels had a large amount of hair accumulated in wheel mechanism. On 8/3/26 at 11:01 AM, Resident #38's wheelchair had large, dried brown substance splattered on front left wheel. All four wheels had a large amount of hair accumulated in wheel mechanism. On 8/3/26 11:02 AM, CNA #3 stated night shift should have cleaned the wheelchairs. On 8/5/26 at 9:05 AM, the DON stated staff should clean wheelchairs on night shift. On 8/3/26 at 10:07 AM, observed in room [ROOM NUMBER]: - a mattress on the floor beside resident's bed with thick, dried, brown substance and smearing of dried, white substance - another mattress leaning against the wall with large amount of dried white substance - an isolation bin containing soiled linen with no cover - large gouges in wall between closets - bedpan on the floor uncovered under the sink - dark substance smeared on the wall by resident # 38's bed - cracked light cover containing multiple bugs - unknown dried, brown substance spilled on floor - dried yellowish colored substance on bed sheets On 8/3/26 at 10:17 AM, observed in room [ROOM NUMBER]: - Dried brown, sticky substance on floor - gouges along railing around bed - cracked light fixture - no door leading to the bathroom - thick black substance to room entrance threshold - mat at bedside covered with dried, brown substance On 8/3/26 at 11:47 AM, observed a bedside table in north side dining room/tv room with large amount of dry, brown substance on the base. On 8/3/26 at 3:00 PM, review of the facility's Deep Cleaning Logs and Environmental Services Checklist for Daily Cleaning of Resident Room forms did not include documentation of cleaning of vents in the hallway, mats and mattresses at resident's bedside. On 8/5/26 at 9:45 AM, the Housekeeping Supervisor stated there is a daily cleaning schedule and the vents should have been cleaned but it would have taken a ladder to reach them. She also stated the housekeepers should be cleaning the floors daily. On 8/5/26 at 9:51 AM, the Housekeeping Supervisor stated the nurse aides are required to clean BM, vomit, and blood off the mattresses and mats at the resident's bedside and then housekeeping cleans the mattress or mat. She also stated the bedside table should be cleaned daily whether they are in the resident's room or in the dining room.

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure a resident's call light was within reach for 5 of 18 Residents (#29, #50, #51, #56, and #57) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Answering the Call Light policy, revision date September 2022, documented.Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Resident #51 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including acquired absence of left leg below knee, bipolar disorder (extreme mood swings), and anxiety disorder. On 8/3/26 at 10:26 AM, observed Resident #51's call light button was under his bed which was against the wall and not accessible to him, so he had no way of calling for help if needed. Resident #56 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including stroke, traumatic brain injury, and Alzheimer's disease. On 8/3/26 at 10:31 AM, observed Resident #56 was lying in her bed without her call light button which was hanging from a hook on the wall about five feet high to the right of the head of bed out of her reach and not accessible. Resident #56's bed is very low to the ground, and she cannot self-ambulate or get out of bed and without the call light button she could not call for help because she does not verbally communicate. On 8/4/26 at 3:45 PM, the RNC stated the call light buttons should be accessible to Resident #51 and #56 at all times and were not. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (chronic mental health condition featuring a combination of hallucinations or delusions and mood disorders), post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event), and diabetes. On 8/3/26 at 10:47 AM, and 8/4/26 at 8:16 AM, observed Resident #29 lying in her bed with her call light plugged into the electrical outlet on the wall above the bed near the foot of Resident #29's bed. The call light was hanging down the wall at the foot of the bed and was resting on the floor under Resident #29's bed and not within her independent reach. On 8/4/26 at 8:17 AM, LPN #2 stated Resident #29's call light should be within reach and had not been. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (chronic mental health condition featuring a combination of hallucinations or delusions and mood disorders), anxiety, and unsteadiness on feet. On 8/3/26 at 10:09 AM, observed Resident #57 lying in her bed with her call light plugged into the electrical outlet on the wall above her bed with the cord coiled up and pinned to itself and not within Resident #57's independent reach. On 8/4/26 at 4:57 PM, the RNC stated Resident #57's call light should have been within reach and had not been. Resident #50 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania), and obsessive-compulsive disorder (a mental health condition characterized by unwanted thoughts that lead to repetitive behaviors). On 8/4/26 at 8:12 AM, observed Resident #50 lying in his bed with his call light plugged into the electrical outlet on the wall near the foot of his bed coiled up and pinned to itself and not within Resident #57's reach. On 8/4/26 at 8:14 AM, LPN #2 stated Resident #57's call light should be within reach and had not been. On 8/5/26 at 8:41 AM, the DON stated residents' call light should be within the resident's reach and had not been.

Based on observation, policy review, resident, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 4 of 8 residents (#4, #13, #19, and #44) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Findings include:The facility's Assistance with Meals policy dated March 2022, documented facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity.The facility's Dignity policy dated February 2021, documented that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. For example, resident are provided with a dignified dining experience.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a progressive disease of the nervous system that affects movement) and major depressive disorder.Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) and abnormal involuntary movement (uncontrolled body motions that include tremors, chorea, and dystonia).Resident #19 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, affecting all four limbs, the trunk, and the face) and anxiety disorder.Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including traumatic brain injury and dysphagia (difficulty swallowing).On 8/3/26 at 11:20 AM, observed eight residents in the assistive dining room during the lunch meal, with only four of the residents being assisted with eating their meal which had been delivered. Residents #4, #13, #19, and #44 were not served their lunch tray until after 12:10 PM (more than 50 minutes past the posted lunch mealtime). These residents were observed to be watching those who were being assisted with eating their lunch meals.On 8/3/26 at 1:05 PM, the DON stated Residents #4, #13, #19, and #44 should have been served their lunch meal tray at the same time as the other residents or not been brought into the dining room until their trays were ready.

Based on facility's Bowel Management - Clinical Protocol, record review, and staff interview, it was determined the facility failed to follow facility bowel care Clinical Protocol of delivering specific medications when residents do not have BM within 72 hours for 3 of 6 Residents (#4, #31 and #56) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The facility's Bowel Management - Clinical Protocol dated April 2026, documented the facility shall assess, monitor, and manage bowel and bladder function for all residents according to individualized needs, physician/provider orders, and applicable regulations.Intervention Protocol:DAY 2 NO BM: Encourage fluids, Licensed Nurse to offer prunes, prune juice or 2 Tablespoons of BAP po BID from dietary. Administer Senokot 8.6 mg one tab po BID today. DAY 3 NO BM: Encourage fluids, offer prune juice or 2 tablespoons of BAP po BID from dietary. Administer Senokot 8.6mg one tab po BID and Glycolax 17 GM in 8oz fluid po BID today. DAY 4 NO BM: Encourage fluids, Licensed Nurse to offer prunes, prune juice or 2 Tablespoons BAP po BID from dietary. Administer Senokot 8.6mg one tablet po BID, Glycolax 17GM po BID, Lactulose 30cc po BID and Dulcolox suppository 10mg per rectal in early AM today. If no BM by noon of day 4, notify physician for further instructions. Report any liquid stools with no formed BM to MD.DAY 5 NO BM: Continue to offer prunes, prune juice or BAP 2 Tablespoons po BID, Senokot 8.6mg po BID, Glycoloax 17 GM in 8oz fluid BID, Lactulose 30cc's po BID. If no BM Licensed Nurse to complete assessment, listen to bowel tones, abdominal distention, check rectal vault per nursing standards. If no BM by 2 p.m. on Day 5 notify MD for further orders. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a serious mental health condition that affects how people think, feel, and behave, including hallucinations, delusions, and disorganized thinking) and alcohol abuse. On 8/4/26 at 3:21 PM, Resident #31's medical record documented no BM from 7/27/26 at 2146 to 7/31/26 at 2130, and no documented nursing interventions related to lack of BM during this same time period. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a progressive disease of the nervous system that affects movement) and major depressive disorder. On 8/3/26 at 3:57 PM, Resident #4's medical record documented no BM from 7/9/26 to 7/12/26 and no documented nursing interventions related to lack of BM during this same time period. Resident #56 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including stroke, traumatic brain injury, and Alzheimer's disease. On 8/3/26 at 2:52 PM, Resident #56's medical record documented no BM from 7/21/26 to 7/28/26 and 7/29/26 to 8/2/26 and no documented nursing interventions related to lack of BM during this same time period. On 8/5/26 at 7:15 AM, the RNC stated Resident #4, #31 and #56 medical records had no documented BM related interventions for July and the first part of August 2026 and should have.

Based on record review, staff interview, and policy review, it was determined the facility failed to ensure residents' representatives were immediately notified when residents fell or had a change in condition. This was true for 2 of 4 Residents (#7 and #57) whose records were reviewed for changes in condition. This deficient practice placed residents at risk of harm due to lack of advocacy and support from their representatives when they were unable to make decisions for themselves due to decreased health status and level of consciousness. Findings include:The facility's Change in a Resident's Condition or Status policy, revised date February 2021, documented facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Resident #7 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including major depressive disorder, dementia, and anxiety. On 8/4/26 at 4:17 PM, review of Resident #7's medical record had documented a progress note dated, 7/26/26 at 00:27, Post Fall Evaluation: Date and Time of Fall: 7/25/26 12:28 AM. Resident #7 went to walk out of the doorway in the t.v. room, lost balance, and fell. A laceration to Resident #7's chin was noted. Provider notified 7/25/26 of resident's fall. On 8/4/26 at 4:22 PM, review of Resident #7's medical record documented a Nurses Note dated 7/26/26 at 00:19, Orders from Provider to place steri strips to laceration under chin, observe Q shift until chin is healed. Observe for further latent injuries from fall with vitals for the next 72 hours. Resident #7's medical record had not documented her representative was notified of her fall at the time of the event.Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (chronic mental health condition featuring a combination of hallucinations or delusions and mood disorders), anxiety, and unsteady on feet. On 8/4/26 at 5:02 PM, review of Resident #57's medical record documented a Nurses Note dated 4/19/26 at 00:07, Resident had a witnessed fall in her room, Provider and DON notified of falling.there is a skin tear to her left upper arm that measures 3cm x 1cm. Orders received to change dressing to left upper arm with Opti foam every 3 days until resolved. Resident #57's medical record had not documented her representative was notified of her fall at the time of the event. On 8/5/26 at 8:42 AM, the DON stated the residents' representative should have been notified at the time of the event and had not been.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure resident's right were protected to be free from abuse. This was true for 1 of 1 resident (Resident #56) observed during lunch assistive feeding. This failure placed all residents at risk for potential abuse and potential physical and psychosocial harm. Findings include:The facility's Resident Abuse Procedural Summary policy dated May 2017, documented BRP takes a number of measures to prevent resident abuse and neglect such as inspecting the facility's physical environment, placing cameras in certain areas of the facility, close supervision of staff and contractors, and care planning.The facility's Abuse Policy dated 5/31/17, documented residents are to be free from abuse, neglect, misappropriate of resident property, and exploitation. Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful.means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur, such as; the deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs.On 8/3/26 at 11:38 AM, the surveyor was standing about 3 feet from the lunch table, when he heard CNA #1 aggressively slap Resident #56's left wrist and witnessed CNA #1 grab Resident #56's left wrist and roughly pulled her hand off of his shirt sleeve that she had grabbed. The surveyor continued to observe the assistive feeding of residents and then reported this issue to the DON and Administrator around 1:10 PM.CNA #1 was hired at the facility on 3/4/24 and had signed the facility Resident Abuse Procedural Summary on 3/9/24. CNA #1 attended Behavior Training on 3/24/26.CNA #1 had received three disciplinary actions since his employment with the facility, with the last one on 10/20/25, for assistive feeding a resident too large of a bite from a food tray that was not appropriate for the resident. The resident choked and required assistance to include Heimlich maneuver to remove the food item from the resident throat. CNA #1 was suspended for 5 days from work following this incident and was required to attend or retake a feeding assistance class. CNA #1 completed the Assisted Dining: The role and Skills of Feeding Assistants Course on 11/5/25.On 8/3/26 at 1:18 PM, the Administrator stated CNA #1 had been suspended and sent home pending investigation.On 8/3/26 at 2:40 PM, the Administrator stated Resident #56 had been assessed by a licensed nurse and there were no bruises or cuts on her wrists.On 8/4/26 at 10:38 AM, the DON stated CNA #1 should not have slapped or grabbed Resident #56's wrist when this issue happened but should have asked for help if needed and had not.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 18 residents (Resident #55) whose care plan was reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include:The facility's Comprehensive Person-Centered Care Plan policy, revised March 2022, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (a condition where the respiratory system slowly loses its ability to bring enough oxygen into the blood) and diabetes. A physician's order dated 4/21/25, documented compression stocking to right leg on AM, off PM every morning and at bedtime for edema. A physician's order dated 6/7/26, documented administer O2 at 1-2 L/min continuously via nasal cannula as resident will allow, every day and night shift related to chronic respiratory failure with hypoxia. On 8/4/26 at 11:15 AM, Resident #55 was observed in her room with portable liquid oxygen unit on the back of her wheelchair and oxygen concentrator at bedside. She was not wearing oxygen or compression stockings. On 8/4/26 at 11:20 AM, CNA #2 stated Resident #55 did not have oxygen on and she should have. Review of resident #55's care plan had not documented the use of oxygen or compression stockings. On 8/4/26 at 3:00 PM, the DON stated Resident #55's care plan had not documented the use of oxygen or compression stockings and it should have. She also stated any refusals should be documented and they had not been.

Based on observation, staff interview, policy review, and Occupational Safety and Health Administration (OSHA) Standard, it was determined the facility failed to ensure residents were free from accident hazards for 2 of 18 Residents (#15 and #41) whose room was observed for environmental safety. This deficient practice had the potential to cause physical harm if a power strip cord were to overheat and cause a fire. Findings include:The facility's Electrical Safety for Residents policy, reviewed date 8/2026, documented 8. Power strips shall not be used with medical devices in resident care areas. The Occupational Safety and Health Administration Standard 29 CFR S 1910.303(b)(2), documented power strips must be used only in accordance with manufacturer instructions and listings, which strictly prohibit covering them with bedding, placing them on flammable surfaces, or exposing them to heat accumulation and physical damage.Resident #41 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including, hemiplegia (loss of function to one side of the body), epileptic seizures, and anxiety. On 8/3/26 at 10:32 AM, observed Resident #41 lying in his bed with three electrical cords plugged in to a power strip that had been placed on his pillow at the head of his bed surrounded by other bed linens. On 8/3/26 at 10:40 AM, Resident #41 stated he used the power strip to keep his cell phone and other personal equipment charged because he could not reach the wall outlet. On 8/4/26 at 5:10 PM, the RNC stated the power strip should not have been placed on Resident #41's bed. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including, schizoaffective disorder (chronic mental health condition featuring a combination of hallucinations or delusions and mood disorders) and hypertension (high blood pressure).On 8/4/26 at 11:25 AM, observed a nebulizer machine sitting at the foot of Resident #15's bed on top of the bed linen and plugged in to a power strip at the wall outlet. On 8/4/26 at 11:29 AM, LPN #1 stated there is a shortage of power outlets in Resident #15's room and she would not allow staff to plug the nebulizer in at the wall outlet at the head of her bed so the nebulizer machine could be placed on her side table so the nebulizer machine was plugged in to a power strip at the foot of Resident #15's bed and the nebulizer machine placed on her bed on top of the bed linens. On 8/4/26 at 2:13 PM, Resident #15's medical record documented a physician order for Albuterol Sulfate Inhalation Nebulizer Solution - 1 vial inhale orally via nebulizer four times a day for pneumonia for 7 days. Order date - 8/1/26.On 8/4/26 at 5:12 PM, the RNC stated the power strip should not have been used for the nebulizer machine, and the nebulizer machine should not have been placed on Resident #15's bed.

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 3 of 3 residents (#6, #15, and #56) observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include: The facility's Administering Medications through a Small Volume (Handheld) Nebulizer policy, reviewed date 8/2026, documented Steps in the Procedure - 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. The facility's Assistance with Meals policy, revised date March 2022, documented . All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (chronic mental health condition featuring a combination of hallucinations or delusions and mood disorders) and hypertension (high blood pressure). A physician order, dated 8/1/26, documented Resident #15 was to receive Albuterol Sulfate Inhalation Nebulizer Solution 1 vial inhale orally via nebulizer four times a day for pneumonia for 7 days. Resident #15's MAR, dated 8/1/26 through 8/31/26, documented Resident #15 was receiving the nebulizer treatments four times a day as ordered. On 8/4/26 at 11:26 AM, Resident #15's nebulizer equipment was observed lying on her bed, dry and not in use, and unbagged. On 8/4/26 at 11:28 AM, LPN #1 stated Resident #15's nebulizer should have been stored in a bag when not in use and had not been. On 8/4/26 at 5:03 PM, the RNC confirmed the equipment was not appropriately bagged after use to prevent contamination of the equipment and should have been. Resident #6 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including stroke and chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness). Resident #56 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including stroke, traumatic brain injury, and Alzheimer's disease. On 8/3/26 at 11:20 AM, observed CNA #1 using his right hand to assist two different residents eat their lunch meal by picking Resident #6's spoon, scoop up a small amount of mashed potatoes and place the spoon in his mouth, then with the same hand and no hand hygiene conducted, pick up Resident #56's spoon and scoop a small amount of her potatoes and place the spoon in her mouth. CNA #1 did this action 4 times before using his left hand to assist Resident #6 and his right hand to assist Resident #56. CNA #1 also wiped both resident's mouths after several bites of food with their own cloth napkin without gloves or any hand hygiene conducted. On 8/4/26 at 9:25 AM, the RNC stated CNA #1 should have used hand hygiene when switching eating assistance between residents and had not.

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #6) received continuous oxygen via nasal cannula prescribed by the physician. This created the potential for residents to experience respiratory difficulties/impaired breathing and low oxygen saturations. Findings include:The facility's Oxygen Administration policy dated February 2024, documented Preparation staff will verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Steps in the Procedure, turn on the oxygen.start the flow of oxygen at the rate of 2 to 3 liters per minute. Place appropriate oxygen device on the resident ie, nasal cannula.Resident #6 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including stroke and chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness).On 8/3/26 at 10:17 AM, observed Resident #6 sitting in a wheelchair in his room without his oxygen cannula on and CNA #1 standing next to him. CNA #1 stated he was taking Resident #6 out of his room but was waiting for his portable oxygen unit to be filled. When the liquid oxygen unit arrived, CNA #1 attached the oxygen tubing to the unit and applied the nasal cannula to Resident #6 but did not turn on the liquid portable oxygen unit. On 8/3/26 at 10:26 AM, CNA #1 wheeled Resident #6 in his wheelchair to the nurse's station down the hallway and waited for the nurse to turn the liquid portable on to his liter flow. Resident #6's physician's oxygen order dated 6/25/26, documented Oxygen 2L to 4L NC continuous.Resident #6's care plan documented oxygen as per physicians ordered. Check room air saturation as ordered, wean as able/ordered.On 8/4/26 at 4:40 PM, the RNC stated the CNA should not have taken Resident #6 off his oxygen but should have had the nurse set the liquid portable unit at the proper litter flow before putting it on the resident and did not.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily 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 staffing levels. Findings include: The State Operation Manual, Appendix PP dated 7/23/25, documented S483.35(g) Nurse Staffing Information. S483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. On 8/5/26 at 11:00 AM, observed the Daily Staffing sheets for 5/1/26 through 8/4/26 noting they had not contained the following required information: - None of the daily staffing sheets included the actual hours worked by RNs, LPNs, and CNAs.- Many of the daily staffing sheets had not documented the Facility's name. On 8/5/26 at 2:30 PM, the Administrator and RNC stated the required information was missing from the daily staffing sheets.

Based on observation, interviews, and policy review, the facility failed to ensure residents were free of medication preparation and administration errors for 1 of 2 residents (Resident #8) observed for medication preparation and administration of insulin. This failed practice placed the resident at risk for not receiving their prescribed medication dosage and other adverse outcomes. Findings: The facility's Insulin Administration policy, reviewed date 4/2023, documented Preparation: 4. The nursing staff have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use. Insulin Delivery: 3. Pens - containing insulin cartridges deliver insulin subcutaneously through a needle. Prime the pen according to manufacturer instructions.Manufacturer Instructions for Use documented.Priming your Pen - Prime before each injection, if you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your pen, turn the dose knob to select 2 units. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (stroke), aphasia (inability to express oneself through speech), and diabetes. Resident #8's physician order dated 1/19/26, documented Humalog OG Kwik Pen Subcutaneous Solution (Lispro) Pen-injector 100 units/ml - Inject 5 units subcutaneously before meals for Type 2 diabetes. On 8/4/26 at 11:14 AM, observed LPN #1 remove Humalog (Lispro) insulin pen from the medication cart and dial the insulin pen to 5 units as ordered. LPN #1 did not prime the insulin pen with 2 units before dialing the ordered dose. On 8/4/26 at 11:15 AM, LPN #1 administered the Humalog (Lispro) insulin to Resident #8. On 8/4/26 at 11:18 AM, LPN #1 stated she did not prime the insulin pen and was unaware of the need to prior to administering insulin. On 8/4/26 at 11:23 AM, the DON stated insulin pens should be primed, according to the manufacturer's instructions, and had not been.

Based on observations, interviews, and policy review, it was determined the facility failed to ensure medications were properly stored and not expired. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: The facility's policy, Administering Medications, revised date March 2025, documented.13. The expiration/beyond use date on the medication label is checked prior to administering. The following was observed during the medication cart audits. On 8/4/26 at 8:57 AM, the South Hall medication cart was audited with LPN #1 present. Observed the following: - one bottle of Colace gel tablets with a manufacturer expiration date of 7/26 printed on the bottle. On 8/4/26 at 8:59 AM, LPN #1 stated the bottle of Colace gel tablets should have been discarded and had not been. On 8/4/26 at 11:41 AM, the DON stated the expired medication should have been removed from the medication cart and had not been.

Based on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include:The FDA Food Code Section 5-501.113 Covering Receptacles documented receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment. On 8/3/26 at 10:03 AM, observed the following in the kitchen main food prep area:- 55 gallon trash can with a hole cut in the lid so it cannot be securely closed. The trash can was overflowing with trash.The FDA Food Code Section 5-501.116 Cleaning Receptacles documented proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.On 8/4/26 at 9:45 AM, observed the following outside of the kitchen just in the alleyway:- The larger trash cans outside in the alley had two lids wide open and some empty box material on the ground just outside of the kitchen.On 8/4/26 at 1:38 PM, the RNC stated the kitchen garbage cans need to have a tight-fitting lid without holes and the garbage cans outside in the alley should always have their lids closed and had not.

Based on review of the State Operations Manual, Appendix PP dated 7/23/25, policy review, staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a nurse aide successfully completed a State approved training and competency evaluation program within 4 months of being hired. This was true for 1 of 1 nurse aides (NA #1) whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility. Findings include:The facility's Nurse Aide (NA) and Certified Nurse Aide (CNA) Hiring Policy dated August 2026, documented an individual may not be employed as a nurse aide for more than four months unless the individual has met the applicable federal and state requirements for nurse aide employment.On 8/5/26 at 7:47 AM, Nurse Aide #1's personnel file was reviewed and documented NA #1 was hired by the facility on 10/1/25 but had not started a CNA course.On 8/5/26 at 8:15 AM, the HR Director stated NA #1 is scheduled to begin classes on 8/17/26. The HR Director stated NA #1 should have completed the course within 120 days of hire and had not.

Based on observation, FDA Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was cleaned. These deficiencies had the potential to affect the 56 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include: The FDA Food Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 5/30/25 at 10:40 AM, it was observed the baking sheet used to make honey buns had a black residue along the edge of the pan, which flaked off with minimal abrasion. Two skillets had a ring of dark, encrusted residue around the majority of the pan's interior and exterior surfaces. The dark, encrusted residue did not scrape off. On 5/30/25 at 10:55 AM, the Food Services Manager stated the pans should not have the black, encrusted coating, and they should be replaced.

Based on observation, review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), Appendix PP, and resident and staff interviews, it was determined the facility failed to ensure the residents had an environment where housekeeping and maintenance services provided a sanitary shower room in good repair. This was true for 1 of 4 showers used in the facility. This deficient practice created the potential for psychosocial harm if residents felt they were not provided the same homelike environment as other residents. Findings include: On 5/27/25 at 5:10 PM, it was observed the main shower in the south wing had brown and black spots resembling mold on the floor of the shower and near the drain. The shower chairs had a ring of red built up residue on the underside portion of the seat. The edge of the shower wall bar did not have an end cap cover, and a sharp metal ridge was observed. On 5/30/25 at 10:33 AM, the CRN and DON stated the shower was in disrepair and should have been closed. The DON stated there would not be a build-up of mold/dirt if the showers were cleaned between uses and deep cleaned every day. On 5/30/25 at 11:15 AM, the Administrator confirmed the main shower room on the south wing was not clean or in good repair.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) assessment included correct information. This was true for 2 of 14 residents (#2 and #20) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #2 was admitted to the facility on [DATE], for care following a fracture and had multiple diagnoses including bipolar disorder (a mental health condition characterized by extreme mood swings including emotional highs or lows) and generalized anxiety disorder. Resident #2's medical record included documentation of a PASRR level I screening, dated 8/6/24, which identified she had serious mental illness diagnoses of bipolar disorder and anxiety. Resident #2's medical record included documentation of an abbreviated PASRR level II screening, dated 8/6/24, which identified she had diagnoses of serious mental illness per PASRR criteria. Resident #2's Admission MDS Assessment, dated 8/7/24, documented section A1500, PASRR Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability, or a related condition? The answer for this question was documented as no. On 5/29/25 at 3:17 PM, the Regional MDS Nurse stated, Resident #2 has a PASRR level II, so the MDS at A1500 should be answered yes to reflect her serious mental illness diagnoses. 50603 2. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder. An Annual MDS Assessment, dated 3/23/25, documented no at A1500, a PASRR level II was not completed. Resident #20's medical record included documentation of a PASRR level I screening, dated 8/20/21, which identified she had a serious mental illness diagnosis of bipolar disorder. Resident #20's medical record included documentation of an abbreviated PASRR level II screening, dated 8/23/21, which identified she had a diagnosis of serious mental illness per PASRR criteria. On 5/29/25 at 3:28 PM the Regional MDS Nurse stated in 2021, Resident #20's MDS documented yes at A1500, a PASRR level II had been completed, but beginning in 2022, it was marked no in error and it should have been corrected.

Based on review of the CMS SOM, Appendix PP, record review, and staff interview, it was determined the facility failed to ensure 1 of 14 residents (Resident #21), mental health needs were evaluated through the State's level II PASRR process. This deficient practice had the potential to cause harm if the resident's mental health needs were not adequately met. Findings include: Resident #21 was admitted to the facility 8/16/23, with multiple diagnoses including major depressive disorder and post-traumatic stress disorder (PTSD). A PASRR level II, dated 8/16/23, documented, A 30-day exemption rehabilitation - if [Resident #21] stays (30 days) past admission, please submit most current MDS, physician's order, social notes and psych[iatric] information to [agency name]. If discharged , please notify [agency name] per information below. A PASRR level II, dated 5/13/25, documented Resident #21 had serious mental health diagnoses including depression, anxiety, PTSD, and the PASRR level II was forwarded to [agency name] for further review. On 5/29/25 at 10:42 AM the Administrator stated Resident #21 had received a 30-day PASRR level II exemption due to medical issues. An updated PASRR level II was completed on 5/13/25. On 5/29/25 at 1:44 PM, the Resident Services Director (RSD) stated Resident #21 was given a 30-day exemption on admission for a PASRR level II, and the PASRR level II should have been submitted when Resident #21 stayed past 30-days in September 2023.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 7 of 13 residents (#6, #13, #26, #35, #44, #48, and #51) whose records were reviewed for quality of care. Specifically: - Resident #35 suffered harm when she sustained a [CONDITION(S)] with pain after a fall and the fracture was not diagnosed until 10 days after the fall. - Resident #48 and #51 were at risk for undetected injury and neurological changes when fall assessments and neurological assessments were not completed after falls. - Resident #44 was at risk for undetected injury when fall assessments were not completed after falls. - Resident #13 was at risk for increased psychiatric symptoms related to missed doses of her antipsychotic medication. - Resident #51 was at risk for abnormally high or low blood sugar when his insulin was administered per physician order. - Resident #26 was at risk for abnormally low blood pressure when his blood pressure medication was not administered per physician ordered parameters. - Resident #6 was at risk for constipation or fecal impaction when physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The facility's policy for Assessing Falls and Their Causes, revised March 2018, stated the assessment procedure after a fall included identifying the cause of a fall and fall risk within twenty-four hours and performing a post-fall evaluation. The policy further stated a Fall Risk Assessment was required when a resident fell . The facility's policy for Neurological Assessment, revised October 2010, stated a neurological assessment was completed upon physician order, following an unwitnessed fall or a fall with a suspected head injury, or when indicated by the resident's condition. The policy included a required assessment schedule as follows: - Every 15 minutes x 1 hour. - Every 30 minutes x 2 hours. - Every hour x 5 hours. - Every 8 hours x 16 hours. The facility's Fall Clinical Protocol policy, revised 3/2018, stated nursing staff monitored the neurological status of the resident if the fall was unwitnessed or if a resident hit his or her head. Staff followed up until the resident was stable and delayed complications such as late fracture, was ruled out. The policy stated delayed complications could occur within hours, days or even weeks after a fall. These policies were not followed. 1. Resident #35 was admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35's quarterly MDS assessment, dated 2/9/22, documented she was severely cognitively impaired. The facility did not ensure timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note, dated 3/8/22 at 4:55 PM, documented Resident #35 fell as a CNA was entering her room. A nurse then entered the room and saw Resident #35 lying on the floor, crying. Resident #35 was unable to state what happened or if she was in pain. Staff used a blanket to lift Resident #35 into her Comfort Chair. Neurological checks were initiated, and the PA was notified. A progress note, dated 3/8/22 at 5:56 PM, documented the PA ordered one dose of [MEDICATION(S)] for pain from Resident #35's fall. A progress note, dated 3/10/22 at 6:48 PM, documented Resident #35 appeared to be in pain and she was yelling and screaming. A progress note, dated 3/11/22 at 6:47 AM, documented Resident #35 had signs and symptoms of increased pain to her left hip and right upper arm. The note documented Resident #35 refused cares and screamed louder with all cares. She received two doses of [MEDICATION(S)] Sulfate during the previous night shift. A PA note, dated 3/11/22, documented Resident #35 needed a refill of her pain medication, and ordered [MEDICATION(S)] every two hours for pain, as needed. A progress note, dated 3/11/22 at 3:32 PM, documented Resident #35 had no latent injuries noted from her recent fall. The note documented she received Tylenol for her pain. A progress note, dated 3/12/22 at 4:30 AM, documented Resident #35 had signs and symptoms of increased pain to her left hip and right upper arm. The note documented Resident #35 refused care, turning and repositioning, and screamed louder with all cares. The note documented Resident #35 was medicated with four doses of [MEDICATION(S)] during the previous night. A progress note, dated 3/12/22 at 5:03 PM, documented Resident #35 had no latent injuries from her fall and she received Tylenol for her pain. The note documented Resident #35 was displaying increased anxiety and was agitated throughout the shift. A progress note, dated 3/13/22 at 4:09 AM, documented Resident #35 yelled and screamed in agony with cares. The note documented [MEDICATION(S)] was not covering her extreme pain symptoms which were documented as 8 - 10 on a 1 - 10 pain scale (a measure of pain severity, with 0 meaning no pain and 10 being the most extreme pain). The note further documented Resident #35 was screaming for an hour or two, despite being medicated, and the physician was notified. A progress note, dated 3/13/22 at 4:37 PM, documented Resident #35 had extreme pain between 8 and 10. Staff turned Resident #35 every two hours, and determined it was painful for her. A progress note, dated 3/14/22 at 1:11 PM, documented Resident #35 had been medicated with [MEDICATION(S)] at 6:00 AM and 9:00 AM for pain and was yelling out and crying. An NP note, dated 3/14/22, documented Resident #35 had increased pain and required multiple doses of [MEDICATION(S)] for pain control. The note documented nurses were requesting increased pain medication for Resident #35. The note documented Resident #35's left leg was shortened and externally rotated, and Resident #35 was protecting her left leg. The note further documented Resident #35 was able to point to her left hip when asked where she was hurting. The NP ordered an x-ray of Resident #35's left hip related to her fall on 3/8/22. A progress note, dated 3/15/22 at 3:44 AM, documented Resident #35 was in pain during the night shift and required several doses of [MEDICATION(S)]. The note documented the NP examined Resident #35 and determined Resident #35 needed to have an x-ray of her left hip. A progress note, dated 3/15/22 at 10:29 AM, documented Resident #35 would have an x-ray of her hip the following day. A progress note, dated 3/16/22 at 1:46 AM, documented Resident #35 tolerated an increase of [MEDICATION(S)], which controlled her pain for longer periods of time. A progress note, dated 3/16/22 at 3:27 PM, documented Resident #35 had her pain controlled with Tylenol and nursing staff did not need to use [MEDICATION(S)] for her pain. The note documented an x-ray was to be taken the following day. A progress note, dated 3/18/22 at 1:52 AM, documented Resident #35 was medicated with some relief of pain in her left hip. The note documented Resident #35 screamed in agony with cares provided by staff. The note stated the x-ray report documented Resident #35 had a left [CONDITION(S)] which caused her leg to turn inward. Messages were left for the facility Administrator, ADON, Resident #35's PA, and Resident #35's representative, notifying them of the fracture. A progress note, dated 3/18/22 at 2:20 AM, documented Resident #35's representative returned the facility's phone call and was informed of Resident #35's [CONDITION(S)] related to the fall on 3/8/22, 10 days after the fall. A progress note, dated 3/18/22, documented the NP examined Resident #35 and her x-ray report and ordered transport for Resident #35 to the emergency room for further treatment. On 5/25/22 at 10:00 AM, the DON stated on initial examination it did not appear Resident #35 sustained injuries from her fall on 3/8/22. The DON stated Resident #35 was non-verbal and often cried out when cares were performed, making it difficult to assess the true nature of her pain. The DON stated Resident #35 was assessed every morning and it was not apparent she had a fracture. The DON stated staff were to notify her if Resident #35 had a change in condition or continued to be in severe pain. Resident #35 was harmed when she fell and sustained a [CONDITION(S)] with increasing pain and did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #51 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #51's Quarterly MDS assessment, dated 5/2/22, documented he was mildly cognitively impaired. The facility did not ensure Fall Risk Assessments or Neurological Assessment were completed for Resident #51 as follows: - An I&A report, dated 10/2/21, documented Resident #51 had an unwitnessed fall at 2:00 AM. There was no Fall Risk Assessment documented in Resident #51's record after the fall. - An I&A report, dated 11/22/21, documented Resident #51 had an unwitnessed fall at 10:10 PM. There was no Fall Risk Assessment or Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 1/7/22, documented Resident #51 had an unwitnessed fall at 12:15 PM. There were no Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 1/16/22, documented Resident #51 had an unwitnessed fall at 9:54 AM. There was no Fall Risk Assessment or Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 1/17/22, documented Resident #51 had at 2:00 AM. There was no Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 5/11/22, documented Resident #51 had an unwitnessed fall at 11:50 PM. There was no Neurological Assessment documented in Resident #51's record after the fall. On 5/27/22 at 10:45 AM, the DON stated Resident #51 did not have Fall Risk Assessments or Neurological checks completed for his falls as required by their policies. 3. Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not ensure a Fall Risk Assessments was completed for Resident #44 as follows: - An I&A report, dated 7/11/21 at 6:05 AM, documented staff heard a loud thump and found Resident #44 sitting on the floor between the wheelchair and his bedside. Resident #44 said he slipped when coming back from the bathroom and fell . A nurse's note, dated 7/11/21 at 6:05 AM, documented that Resident #44 was observed in pain, and his left knee was swelling. Resident #44 was sent to the hospital for evaluation at 7:15 AM. A hospital discharge summary, dated 7/14/21, documented Resident #44 was admitted to the hospital on 7/11/21 with a left femur lateral condyle (on the end of the thigh bone near the knee) fracture. He had an open reduction and internal fixation surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 7/15/21 at 3:53 PM, documented that Resident #44 returned from the hospital on 7/14/21. Resident #44's record did not include a Fall Risk Assessment after his fall on 7/11/21 after returning to the facility. - An I&A report, dated 9/19/21 at 7:33 AM, documented staff was alerted by Resident #44's roommate that he needed assistance. The staff found Resident #44 sitting on the floor in his room on his buttocks with his legs extended. Resident #44 said he was trying to get into his wheelchair and did not make it. There was no Fall Risk Assessment documented in Resident #44's record after his fall. On 5/26/22 at 1:05 PM, the clinical resources nurse said the Fall Risk Assessment was not completed for Resident #44's fall incidents on 7/11/21 and 9/19/21, and it should be completed within 24 hours after the fall or upon readmission. 4. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48's I&A reports, from 2/2021 to 4/2022, documented he had nine falls in approximately 14 months. There were no Fall Risk Assessments documented in Resident #48's record after the nine falls on 7/7/21, 2/18/21, 7/29/21, 10/5/21, 12/10/21, 3/20/22, and 4/15/22. Resident #48's I&A report documented he had two unwitnessed falls on 7/29/21 and 3/20/22. There was no Neurological Assessment documented in Resident #48's record after the two unwitnessed falls. On 5/25/22 at 3:15 PM, the DON said Resident #48's Fall Risk Assessments were not being completed after each of the nine falls, and they should be completed within 24 hours after the fall. On 5/25/22 at 3:15 PM, The DON said per policy, a neurological assessment should be performed after each unwitnessed fall. She said Neurological Assessments were not completed after Resident #48's unwitnessed falls on 7/29/22 and 3/20/22. 5. Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy for Administering Medications, revised 4/2019, stated medications were administered in accordance with prescribed orders, including any required time frame. Medication administration times were determined by resident need and benefit, not staff convenience, including enhancing optimal therapeutic effort of the medication, preventing potential medication or food preferences, or honoring resident choices and preferences. Medications were administered within one hour of their prescribed time. This policy was not followed. Resident #13's quarterly MDS assessment, dated 3/8/22, documented she was mildly cognitively impaired. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #13 one time a day every 14 days related to [CONDITION(S)] disorder. Resident #13's MAR did not document [MEDICATION(S)] was administered on 5/6/22 or 5/20/22. On 5/26/22 at 4:45 PM, the DON stated there was no documentation in Resident #13's MAR or in the nursing notes to determine whether or not Resident #13 received her [MEDICATION(S)] as ordered. The facility did not administer Resident #13's [MEDICATION(S)] as ordered by the physician. 6. Resident #51 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Mayo clinic website, accessed on 6/3/22, stated, Blood sugar that's either too high or too low for too long may cause various serious conditions, all of which can lead to a diabetic coma. The facility's policy for Administering Medications, revised 4/2019, stated medications were administered in accordance with prescribed orders, including any required time frame. Medication administration times were determined by resident need and benefit, not staff convenience, including enhancing optimal therapeutic effort of the medication, preventing potential medication or food preferences, or honoring resident choices and preferences. Medications were administered within one hour of their prescribed time. This policy was not followed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was ordered to be given at 7:00 AM. Resident #51's insulin [MEDICATION(S)] was not documented as given as ordered or within 1 hour per the facility policy, as follows: - Resident #51's insulin [MEDICATION(S)] was administered on 3/1/22 at 3:33 PM, greater than 8 hours from the time it was scheduled. - Resident #51's insulin [MEDICATION(S)] was administered on 3/10/22 at 3:28 PM, greater than 8 hours from the time it was scheduled. - Resident #51's insulin [MEDICATION(S)] was administered on 3/25/22 at 1:15 PM, greater than 6 hours from the time it was scheduled. - Resident #51's insulin [MEDICATION(S)] was administered on 5/15/22 at 12:11 PM, greater than 5 hours from the time it was scheduled. On 5/26/22 at 4:45 PM, the DON stated Resident #51's insulin [MEDICATION(S)] was administered late on 3/1/22, 3/10/22, 3/25/22 and 5/15/22. The facility did not administer Resident #51's insulin [MEDICATION(S)] as ordered by the physician or facility policy. 7. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's May 2022 MAR, documented his systolic blood pressure was less than 110 mmHg on the following dates: -5/6/22: blood pressure was 102/60 -5/10/22: blood pressure was 101/63 -5/13/22: blood pressure was 101/59 Resident #26's May 2022 MAR, documented he received 25 mg of [MEDICATION(S)], on 5/6/22, 5/10/22, and 5/13/22. On 5/25/22 at 10:32 AM, the DON stated Resident #26's [MEDICATION(S)] should have been withheld on the days when his systolic blood pressure was less than 110 mmHg. The facility did not follow Resident #26's physician ordered parameters when administering his blood pressure medication. 8. Resident #6 was admitted to the facility on [DATE], discharged to the hospital on 5/11/22, and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Resident #6's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Day 2 no BM (bowel movement): Encourage fluids; licensed nurse to offer prunes, prune juice, or 2 tablespoons of BAP (a constipation recipe with a mix of bran, applesauce, and prune juice) by mouth from dietary. Administer [MEDICATION(S)] ([MEDICATION(S)] and stool softener) 8.6 mg, one tablet by mouth BID (twice a day). Report any liquid stools with no formed BM to the physician as needed. Document the results of [MEDICATION(S)] (color, odor, blood, soft, hard, large or small amounts, if gas was expelled,) as applicable, how the resident tolerates the procedure, if the Resident refuses the procedure, and why. Order start date 6/11/18. - Day 3 no BM: Encourage fluids, offer prune juice or 2 tablespoons of BAP by mouth, BID from dietary. Administer [MEDICATION(S)] 8.6 mg one tablet by mouth BID and [MEDICATION(S)] ([MEDICATION(S)]) 17 gm (gram) in 8 oz (ounce) fluid by mouth BID. Report any liquid stools with no formed BM to the physician as needed for constipation. Document the results of [MEDICATION(S)] & [MEDICATION(S)] (color, odor, blood, soft, hard, large, or small amounts, if gas was expelled,) as applicable, how the resident tolerates the procedure, if the resident refuses the procedure, and why. Order start date 6/11/18. - Day 4 no BM: Encourage fluids; licensed nurse to offer prunes, prune juice, or 2 tablespoons BAP by mouth BID from dietary. Administer [MEDICATION(S)] 8.6 mg one tablet by mouth BID, [MEDICATION(S)] 17 gm by mouth BID, [MEDICATION(S)] (synthetic sugar used to treat constipation) 30 cc (cubic centimeter) by mouth BID, and Dulcolax suppository 10 mg per rectal early in the morning. If there is no BM by noon of day 4, notify the physician for further instructions. Report any liquid stools with no formed BM to the physician as needed for constipation. Document the results of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] & Dulcolax (stimulates bowel movement) suppository (color, odor, blood, soft, hard, large, or small amounts, if gas was expelled,) as applicable, how the resident tolerates the procedure, if the resident refuses, and why. Order start date 6/11/18. - Day 5 no BM: Continue to offer prunes, prune juice, or BAP 2 tablespoons by mouth BID, [MEDICATION(S)] 8.6 mg by mouth BID, [MEDICATION(S)] 17 gm in 8 oz fluid BID, [MEDICATION(S)] 30 cc by mouth BID. If there is no BM, the licensed nurse will complete the assessment, listen to bowel tones and check abdominal distention, and check the rectal vault per nursing standards. If there is no BM by 2 PM on Day 5, notify the physician or further orders as needed for constipation. Document the results of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and Dulcolax suppository (color, odor, blood, soft, hard, large, or small amounts, if gas was expelled,) as applicable. How the resident tolerates the procedure, if the resident refuses, and why. Order start date 6/11/18. An ADL report for May 2022, documented Resident #6's BM as follows: - One normal medium BM on 5/3/22 and no BM for 7 days from 5/4/22 to 5/10/22. - One normal large BM on 5/17/22 and no BM for 8 days from 5/18/22 to 5/26/22. Resident #6's MAR for May 2022 did not include documentation bowel care was administered as ordered. On 5/26/22 at 5:00 PM, the DON reviewed Resident #6's MAR and record and said Resident #6's bowel management orders were not being administered and documented for May 2022. The DON said Resident #6's last BM was on 5/17/22, and she had no BM until today, 5/26/22. The DON said if Resident #6 did not have BM later today, it would be the 9th day. The DON said the nurse was to follow the bowel management order and notify the physician if the resident had no BM on the fourth day and to receive new orders.

Based on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat a pressure ulcer. This was true for 1 of 2 residents (Resident #22) reviewed for wound care. This failure resulted in harm when Resident #22 developed an abrasion on his right trochanter (upper end of the thigh bone that is connected to the hip bone) which became an unstageable pressure ulcer. Findings include: The National Pressure Injury Advisory Panel website, accessed on 6/2/22, defined pressure injury as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (friction to the skin causing it to separate from the bottom layer of skin). Stages of pressure injury are as follows: Stage 1- Intact skin with localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration these may indicate deep tissue pressure injury. Stage 2- Partial thickness skin loss with exposed dermis. The wound bed is viable, pick or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3- Full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4- Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this in an Unstageable Pressure Injury. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment, dated 3/15/22, documented Resident #22 was severely cognitively impaired, at risk of developing pressure ulcers, and no pressure ulcers were present. Resident #22's care plan, initiated on 3/24/22, documented he was at risk for skin impairment related to his history of incontinence of bowel and bladder and due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly Skin Assessments, dated 3/7/22, 3/10/22, 3/15/22, and 3/21/22, documented Resident #22 had no alteration to skin integrity and no new skin issues were noted during a 24-hour period. A nurse practitioner's note, dated 3/21/22, documented Resident #22 had a wound to his right trochanter (bony top of the thigh bone in the hip area). The nurse practitioner directed staff to cleanse Resident #22's wound to his right hip every three days and PRN with a wound cleanser, pat dry, cover with [MEDICATION(S)] (a transparent film dressing), and monitor him for signs and symptoms of infection and wound healing. A Nurse's Note, dated 3/23/22 at 1:13 PM, documented Resident #22 had a lesion (wound or injury) present to his right hip that was blanchable (the reddened area turns white when pressed on) throughout the reddened area and the top layer of the skin was missing. The note documented the reddened area matched the size and shape of the incontinence brief adhesive tab. The Nurse's Note documented when the adhesive tab was removed it took off the top layer of Resident #22's skin. The note also documented it was on the side Resident #22 preferred to lay on. The note further documented orders to clean the wound every three days with wound cleanser, pat dry with gauze, and cover the wound with Allevyn (foam dressing). Resident #22's care plan was not updated to include the lesion/wound to his right hip. A Weekly Skin Assessment, dated 3/31/22, documented Resident #22 had no alteration to skin integrity and no new skin issues were noted during a 24-hour period. A nurse practitioner's progress note, dated 4/11/22, documented Resident #22 had a 4x4 [sic] wound to his right trochanter with necrotic eschar [dead tissue] covering and surrounding [CONDITION(S)] [redness]. The nurse practitioner documented Resident #22 would benefit from a wound specialist. The nurse practitioner directed staff to refer Resident #22 to a wound care specialist, cleanse his wound every 72 hours and PRN with wound cleanser, pat dry, apply Medi-Honey (helps create a moist wound healing environment which aids in debridement and removal of necrotic tissue), cover with Allevyn dressing, off-load Resident #22's right hip, and turn him every two hours. A physician note, dated 4/13/22 at 8:10 AM, documented an order to administer [MEDICATION(S)] (antibiotic), one tablet two times a day for 14 days to treat the wound on Resident #22's right hip. A physician assistant's note, dated 4/15/22, documented Resident #22 had severe anxiety and significant behaviors. The note stated Resident #22 would be difficult to transfer out of facility for cares, and will try to treat in house first. The physician assistant discussed Resident #22's right hip wound with the staff and documented will try to tx [treat] here first with Santyl [medicine that removes dead tissue from wounds so they can start to heal] if it does not improve will have to send out to wound care. A Nurse's Note, dated 4/22/22 at 10:32 AM, documented Resident #22's wound had changed to eschar and it was breaking-up and pink tissue was remaining, and there was no drainage. The April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Note, dated 4/30/22 at 2:23 PM, documented Resident #22's wound to his right hip was cleansed with normal saline, patted dry, Santyl was applied with a sterile cotton tipped swab, and the wound was covered with an adhesive border gauze. The note documented the wound continued to have a moderate amount of yellow/green drainage and the bandage was completely saturated. The Nurse's Note further documented Resident #22's wound had some redness to the peri-wound (tissue surrounding a wound) and he might require more frequent dressing changes due to increased drainage. A Nurse's Note, dated 5/3/22 at 4:49 PM, documented Resident #22's wound dressing was changed, and the top of the wound was black. The note documented there was redness to the outer border and no drainage was noted. Resident #22 stated the wound was tender and he appeared to feel discomfort during wound cleansing. A care plan, initiated on 5/3/22, documented Resident #22 had an unstageable area to his right hip and staff were to assess him for signs and symptoms of pain with wound care, schedule/administer analgesic (pain reliever) prior to treatment, communicate with the physician if area was not healing or worsened, perform wound care as ordered, encourage Resident #22 not to sleep on his right hip, and perform skin checks weekly. The care plan was updated five weeks after it was noted in Resident #22's record. A Weekly Wound Observation Tool, dated 5/6/22 at 12:11 PM, documented Resident #22 had an unstageable open area to his right hip that measured 5.25 cm x 1.6 cm, with black eschar that was sluffing off (shedding) and there was more pink tissue present. The wound had no drainage or odor, infection was not suspected, and it was being treated with Santyl and a [MEDICATION(S)] dressing (waterproof). A Nurse's Note, dated 5/11/22 at 4:21 PM, documented Resident #22's wound was very odorous with signs and symptoms of infection present. The note documented sluff was present to the outer bed of the wound with redness on the peri-wound. The note also documented the wound was very painful for Resident #22 and Resident #22's provider would be notified. A Weekly Wound Observation Tool, dated 5/13/22 at 10:36 AM, documented Resident #22 had an acquired unstageable open area to his right hip that measured 6.5 cm x 4.25 cm, with 70% eschar that was pulling away from the wound edges, the peri-wound was pink. Resident #22's wound had no odor or drainage, and was treated with Medi-Honey and covered with a [MEDICATION(S)] dressing. A physician assistant's note, dated 5/13/22, documented Resident #22 was seen due to staff concerns the wound looked worse, with increased drainage and smell. The note documented Resident #22 was on [MEDICATION(S)] prior and it seemed to help. The physician assistant assessed the wound as [CONDITION(S)] and ordered [MEDICATION(S)] for 10 days and try Medi-Honey, if does not improve consider wound care next. Resident #22's wound had increased in size by 1.25 cm x 2.65 cm in 7 days. There was no documentation he was referred to a wound clinic. A nurse practitioner's note, dated 5/16/22, documented Resident #22 had increased pain to his right hip wound and was on a low dose [MEDICATION(S)] (skin patch containing [MEDICATION(S)], an opioid/narcotic pain medication) pain patch. The note documented Resident #22 would benefit from additional pain control. Resident #22 was prescribed [MEDICATION(S)] (an opioid/narcotic pain medication) 50 mg, one tablet two times a day. A Weekly Wound Observation Tool, dated 5/20/22 at 10:39 AM, documented Resident #22 had an unstageable open area to his right hip that measured 6.5. cm x 4.25 cm and was treated with Santyl and a [MEDICATION(S)] dressing. The note documented the wound had no drainage or odor, and infection was not suspected. A physician's assistant order, dated 5/23/22 at 10:09 AM, documented to refer Resident #22 to the wound clinic for his right hip wound. This was ordered 22 days after it was first ordered by the nurse practitioner on 4/11/22 and nine weeks after the wound was first identified. A Nurse's Note, dated 5/23/22 at 12:01 PM, documented Resident #22 had complaints about his wound and the wound was slightly odorous, with blackened content. The note documented they would continue to monitor the wound. The May 2022 MAR, documented Resident #22 completed his second round of [MEDICATION(S)] on 5/26/22. On 5/26/22 at 3:25 PM, the DON stated Resident #22 went to a Wound Clinic that morning. The DON stated Resident #22's unstageable pressure ulcer to his right trochanter started as a small abrasion from the sticky part of his undergarment and he always laid on his right side. The DON stated staff encouraged Resident #22 to lay on his left side, but he always refused. When asked why Resident #22 was not referred to a wound care specialist as ordered by the nurse practitioner on 4/11/22, the DON stated Resident #22 was seeing a podiatrist for a lesion on his left big toe and also saw an eye specialist. The DON stated they wanted to avoid causing Resident #22 anxiety by leaving the facility so often. The DON stated she talked to the nurse practitioner who then ordered to clean and treat Resident #22's right hip wound with Santyl first. The DON stated Resident #22's wound started to peel from the side, then became unstable in the center. When asked about the Weekly Skin Assessment, dated 3/31/22, which documented Resident #22 had no alteration to skin integrity, and the Nurse's Note, dated 3/23/22, documented he had a lesion to his right trochanter, the DON stated she performed weekly wound assessments and documented them on paper. The DON provided Resident #22's paper wound assessment and the assessment did not include the date the abrasion was first identified. Resident #22 was harmed when the abrasion on his right hip deteriorated and became an unstageable pressure ulcer.

Based on policy review, record review, review of I&A reports, and staff interview, it was determined the facility failed to ensure adequate supervision was provided to residents to prevent falls. This was true for 1 of 5 residents (Resident #47) reviewed for falls. This resulted in harm to Resident #47 when he sustained bruises and a fracture to his finger. Findings include: The facility's policy Fall and Fall Risk Managing, revised 3/2018, documented staff completed a fall risk assessment and enter it into the resident's medical record. Staff would identify the cause of the resident's fall and document interventions related to a resident's specific risks and causes, try to prevent the resident from falling, and try to minimize complications from falling. Staff were to implement a resident-centered fall prevention plan to reduce specific factors of falls for each resident at risk and would monitor and document each resident's response to interventions. If a resident continued to fall, staff would re-evaluate the situation and determine if interventions were appropriate or needed to be changed. This policy was not followed. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including dementia with behavioral disturbance, altered mental status, [CONDITION(S)] (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and [CONDITION(S)] (a neurological disorder that causes seizures or unusual sensations and behaviors and sometimes loss of awareness). A quarterly MDS assessment, dated 5/5/22, documented Resident #47 had severe cognitive impairment, required extensive assistance of one to two person with ADLs and set-up for eating. The MDS also documented: - He was not steady with moving from a seated to standing position but able to stabilize with human assistance. - He was not steady with walking, turning around and facing the opposite direction while walking and moving on and off the toilet but able to stabilize with human assistance. - He had two or more falls since admission. Resident #47's care plan documented he was at risk for falls related to his diagnosis of unsteady gait and [CONDITION(S)]. Interventions included the following: - Encourage him to sit-up and stand slowly, initiated on 12/20/16 and revised on 7/20/18. - Fall risk assessment after any fall, quarterly and PRN, initiated on 3/9/18. - Encourage adequate hours of sleep at night and rest periods during the day, initiated on 6/5/19. - Encourage appropriate nonskid footwear when ambulating, initiated on 6/14/19. - Support bars were installed around his toilet related to his report of attempting to sit and missing the seat, initiated on 3/28/18 and revised on 12/6/19. - Continue to encourage to ask for assistance with cares to address fall risk/actual fall, initiated on 12/23/19. - Provide him a safe place to sit in his room. Physical Therapy(PT) to evaluate and treat him as needed. Remind and encourage him frequently to call for staff assistance, initiated on 5/10/19 and revised on 12/26/19. - Move nightlight from bedside to area by the sink due to bed being moved per his preference and nightlight would be near his head when he is trying to sleep, initiated on 5/20/19 and revised on 1/29/20. - Encourage him to sit all the way back on the chairs and not on the edge of the chair, initiated on 2/25/19 and revised on 4/6/20. - Assure his room is lit at night. He uses a night light in his room, initiated on 6/14/19 and revised on 4/6/20. - Remind him to slow down when changing positions, transferring and ambulating, initiated on 5/17/20. - Ensure he has a cold soda in the refrigerator at all times, initiated on 12/16/19 and revised 5/25/20. - Move him closer to the nursing station for higher observation, initiated on 8/18/21. - When he is in common area there is a Visual Aide to keep him in line of sight at all times, initiated on 11/12/21. - Bed should be in lowest position and locked when in bed, initiated on 11/12/21 - Be sure the call light is within reach and encourage him to use it for assistance as needed was initiated on 2/16/22. - Redirect/Assist him to the nearest bathroom if he is having sudden toileting needs, initiated on 2/16/22. Resident #47's record, documented he experienced a total of 7 falls in five months, as follows: A Fall Scene Investigation Report, dated 1/20/22 at 2:11 PM, documented Resident #47 had an unwitnessed fall. He was found on the floor in his room. Resident #47 stated he wanted to lay down after using the toilet. No injuries were noted. An Interdisciplinary Team (IDT) Review for the fall on 1/20/22, dated 1/27/22, documented the root cause of the fall was that Resident #47 had no safety awareness and he did not recognize his limitations. Resident #47 believed he was more independent that he really was. The IDT review documented Resident #47 was on 15 minute checks, and had a pressure sensitive alarm in his wheelchair. The IDT documented his interventions were appropriate. A Fall Scene Investigation Report, dated 4/29/22 at 1:00 AM, documented Resident #47 had a witnessed fall. Staff heard Resident #47 getting out of his bed unassisted and went to his room. Staff observed Resident #47 fall forward and hit his head on the nightstand which was next to his bed. He was assisted to a sitting position on his bed. An IDT review of the fall on 4/29/22, dated 5/6/22, documented the root cause of Resident #47's fall was he attempted to self-rise and ambulate. The IDT documented Resident #47 had 1:1 staff which would often cause him to have increased agitation at times. Resident #47 had been on 15 minutes checks in the past and no changes to him falling. Interventions were initiated to have Physical Therapy screen Resident #47. Resident #47 was evaluated on 5/2/22, 4 days prior to the IDT review. A Fall Scene Investigation Report, dated 4/29/22 at 10:03 PM, documented Resident #47 had an unwitnessed fall. Resident #47 was found on the floor next to his bathroom door. Loose watery stool was observed on the floor, on the back of his clothing, and in his wheelchair. Resident #47 stated he could no longer hold it and lost his balance. An IDT review of the fall on 4/29/22, dated 5/2/22, documented the root cause of Resident #47's fall was he had loose/watery stool and slipped in the bowel and fell . The IDT review stated it was an isolated incident. A Physical Therapy Evaluation and Plan of Treatment, dated 5/2/22, documented Resident #47 was willing to participate. However, his cognitive deficits negatively affected his overall progress. A Speech Therapy, progress note, dated 5/3/22, documented Resident #47 had severe dementia and required 24-hour care for ADLs and safety. The note stated Resident #47 and caregivers would benefit from identification of additional supports or aides to use as dementia progressed. A Fall Scene Investigation Report, dated 5/9/22 at 11:03 PM, documented Resident #47 had an unwitnessed fall. He was observed sitting on his buttocks on the floor in his room and leaning backwards in front of his endtable with socks in his hand. All three drawers of the endtable were open. Resident #47 appeared to be agitated and he was noted to have bleeding above his right eye with his right eye turning red and bruising and an abrasion was also noted above his left eye. Resident #47's right hand was noted to have some redness to his ring finger as well as to his chin, and right cheek. An IDT review for the 5/9/22 fall, dated 5/11/22, determined the root cause of Resident #47's fall was he was self-rising and attempted to ambulate and stand when he needed assistance for safety. Resident #47's physician was made aware and reviewed his medications and laboratory results. The physician gave an order for Resident #47 to see his neurologist. A Fall Scene Investigation Report, dated 5/10/22 at 6:10 PM, documented Resident #47 had a witnessed fall. He was seen leaning over to pick-up his cup off the floor and his wheelchair went out from under him and he fell on his coccyx. An IDT review of the fall on 5/10/22 at 6:10 PM, dated 5/11/22, determined the root cause of Resident #47's fall was his wheelchair rolled out from under him when he stood. A Fall Scene Investigation Report, dated 5/10/22 at 9:05 PM, documented Resident #47 had an unwitnessed fall. Resident #47 had been going to the double doors between the North and South areas of the building to wait for morning and meet with Social Services when staff heard a loud sound, went to the area and observed him on the floor. Resident #47 was mumbling and was noted to have difficulty formulating his words. An IDT review of the fall on 5/10/22 at 9:05 PM, dated 5/11/22, documented Resident #47 had been experiencing changes in his mental and physical functioning and they would continue to reach out to his neurologist for an appointment. A Fall Scene Investigation Report, dated 5/10/22 at 11:32 PM, documented Resident #47 had an unwitnessed fall. He was observed on the floor in his room between his bed and his door. Resident #47 was yelling help me over and over and it was difficult to understand what he was saying. An IDT review of the fall on 5/10/22 at 11:32 PM, dated 5/11/22, documented Resident #47 experienced an acute change of condition. Resident #47's medications were reviewed, and staff were trying to get him into his neurologist. Resident #47 experienced 3 falls on 5/10/22 between 9:05 PM and 11:32 PM. Resident #47's care plan was updated on 5/12/22, and directed staff to change his dresser to a plastic dresser to help prevent injuries. A Nurse's Note, dated 5/13/22 at 1:50 AM, stated Resident #47's physician gave an order for Resident #47 to start on [MEDICATION(S)] (ant-epileptic) 500 mg twice a day, decrease his [MEDICATION(S)] (anti-convulsant) to 150 mg twice a day in two days and then check his [MEDICATION(S)] (anti-[CONDITION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]) levels in three weeks. Resident #47's care plan was updated on 5/13/22 and staff were directed to place an anti-roll back bars on his wheelchair. A physician's progress note, dated 5/13/22, documented Resident #47 injured his ring finger on his right hand during one of his falls. The physician documented Resident #47 had some swelling and bruising to the area and gave an order to x-ray Resident #47's right hand. A Physical Therapy discharge summary note, dated 5/18/22, documented Pt [patient] demonstrated progress initially with therapy with having decline and platue of progress d/t [due to] change in medical condition that nursing is currently treating. An X-ray report, dated 5/19/22, documented Resident #47 had an acute fracture right ring finger. A physician's order, dated 5/20/22, directed staff to buddy tape (act of bandaging a damaged or particularly fractured finger or toe together with a healthy one) Resident #47's fourth finger. On 5/23/22 at 12:22 PM, Resident #47 was observed in his room standing by the foot of his bed. Resident #47's bed was placed against the wall and in low position. There were two fall mats and a mattress next to his bed. On 5/26/22 at 2:57 PM, the DON stated she was informed every time Resident #47 had a fall. The DON stated Resident #47 used to have a 1:1 staff but he did not like to have a staff next to him he became more agitated, angry and combative. The DON stated a Visual Aide was provided to Resident #47 whenever he was in the common area. When asked the meaning of a Visual Aide, the DON stated it meant within the line of sight of the staff.The DON stated Resident #47 was moved to another room closer to the nurse's station, so he could be within the line of sight of the staff when they were in the nurse's station charting. When asked if there was a Visual Aide during the night, the DON stated the Visual Aide only worked until 8:00 PM. On 5/27/22 at 10:29 AM, the Administrator stated the 1:1 staff for Resident #47 was discontinued due to his behavior with the staff. The Administrator stated Resident #47 did not like to have 1:1 staff next to him, he became more agitated and angry when he had them, and he would yell and hit his 1:1 staff. The Administrator stated when they discontinued the 1:1 staff, Resident #47 started to talk and smiled at the other residents, and his wanting to leave the facility and hitting of the staff decreased. When asked the meaning of 1:1 staff supervision, the Administrator stated the staff should be within an arm's length of the resident. When asked about the Visual Aide, the Administrator stated the resident should be in the line of sight of the staff. When asked why Resident #47 was not provided with a Visual Aide while he was in his room since he had several falls in his room, the Administrator stated one of their interventions was moving Resident #47 to a room across the nurse's station, so the staff could easily see him when they were in the nurse's station. On 5/27/22 at 2:15 PM, the surveyor observed Resident #47 while he was in his room lying on his bed. Resident #47's bed was placed against the wall to the right side of his room as you enter, and he was not in direct view of the staff in the nurse's station. When the staff were in the nurse's station it was not possible for them to see Resident #47 directly, facing the nurse's station was the wall of Resident #47's room. Resident #47 experienced multiple falls which resulted in injury including a fractured finger.

Based on staff interview, record review, and review of a skin assessment spreadsheet, it was determined the facility failed to prevent the development and worsening of pressure ulcers. This was true for 1 of 3 residents (#1) reviewed for pressure ulcers. This failure resulted in harm to Resident #1 when she developed an unstageable pressure ulcer to her left heel. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A hospital discharge summary, with a print date of 1/13/18, documented Resident #1 was admitted to the ER (emergency room ) from the facility on 1/10/18 following a fall with a a left [MEDICAL CONDITION]. The summary stated Resident #1 was discharged from the hospital back to the facility on [DATE] following surgical repair of her left [MEDICAL CONDITION]. The Admit Nursing Assessment, dated 1/13/18 at 5:00 PM, documented Resident #1 was readmitted to the facility at 2:30 PM on 1/13/18. The assessment documented there were no abnormal skin areas on her feet, there were bruises on both of her arms, and a dressing was in place on Resident #1's hip which was dry and intact. The annual Minimum Data Set (MDS) assessment, dated 1/31/18, documented Resident #1 was moderately impaired cognitively and required extensive assistance from 2 plus staff for bed mobility and transfers. Resident #1's Care Plan included a focus area of Skin at risk, which was initiated on 2/9/17 and revised 5/9/18. The Care Plan included instructions, dated 1/19/18, to monitor the unstageable wound on Resident #1's left heel, which was present on her return from hospital. Interventions for the care and treatment of [REDACTED].#1's Care Plan. Resident #1's Treatment Administration Record first directed staff with treatment to the left heel pressure ulcer on 3/22/18. A nursing progress note, documented by the MDS Coordinator on 1/19/18 at 11:35 AM, stated Was asked to go to resident's room to observe something on her (Resident #1's) skin. In room, resident was lying on R (right) side as CNAs had just finished cares. They pointed to a dark area on her L (left) heel. I noted a dark purple fluid-filled area on the back of her L heel, obtained measuring tape and noted it to be 4.0 x 6.0 cm (and) unstageable. A nursing progress note at 11:45 AM on the same date, documented Podus boots (pressure relief) were to be placed on Resident #1's heels and the wound nurse was contacted regarding the pressure ulcer. A Weekly Body/Skin Check assessment, dated 1/22/18, documented left heel bruising that measured 3.5 x 5.5 cm and was described as a suspected deep tissue injury. The form had RN #1's name in the top right corner of the first page. A nursing progress note, dated 1/23/18, documented the deep tissue injury on Resident #1's left heel measured 3.5 x 5.5 cm. The note also stated Resident #1 was wearing Podus boots and applied weight on her left leg. A progress note, dated 2/12/18, documented Resident #1 returned from the hospital with a deep tissue injury to her left heel that was improving, Podus boots were encouraged in bed, along with floating Resident #1's heels. The note documented Resident #1 continued to get around by pushing her wheelchair with her feet. A Doctor's Progress Note, dated 2/20/18, noted a pressure ulcer under Resident #1's left heel. A Podiatry Routine Foot Care Report, dated 2/28/18, documented an ulcer on Resident #1's left heel which was 4+ (plus) cm in diameter, debridement (removal) of black eschar (crusty dead tissue), and a good wound base. A nursing progress note, dated 3/7/18, documented Resident #1's left heel was progressing nicely and it measured 1.5 x 2.0 cm with a small amount of discharge noted. An Orthopedic Office Clinic Note, dated 3/14/18, documented Resident #1 had been in a Posey (pressure relief) boot for treatment of [REDACTED]. The Note documented the heel ulcer was resolving very nicely and was fully [MEDICATION NAME] (growth of tissue just below the outer layer of skin). A Physician Assistant visit note, dated 3/16/18, documented Resident #1 was complaining of left foot pain and the Physician Assistant suspected it was due to the boot in place related to Resident #1's boggy heels. The visit note documented biofreeze was applied to Resident #1's foot and she was encouraged to continue using heel protectors. A nursing progress note completed by the wound nurse, dated 4/4/18, documented Resident #1's unstageable wound measured 1 x 1 cm and the wound bed was 100% adherent black eschar. The note documented duoderm paste was being replaced with Santyl to see if faster enzymatic debridement could be achieved. A Doctor's Note, dated 4/17/18, documented Resident #1's left heel pressure ulcer was healed and she was to continue using the walking boot. A nursing progress note, dated 4/24/18 at 4:45 PM, documented Resident #1's left foot was warm to the touch with slight [MEDICAL CONDITION] (swelling) and that she often crossed her ankles. The note documented the licensed nurse educated Resident #1 of the risks and encouraged her to wear the boot at all times. The note documented the Resident often threw the boot across the room and refused to wear it. A nursing progress note, dated 4/24/18 at 11:13 PM, documented increased [MEDICAL CONDITION] in Resident #1's legs and feet and her feet were shiny and became dark pink when in a dependent position. The note documented Resident #1 had a wound over her left heel and the skin of the foot was very warm to the touch. The note also included documentation that Resident #1 was able to self propel her wheelchair by using her feet and the physician was in to examine her and orders were written. A Doctor's Progress Note, dated 4/24/18, documented Resident #1 complained of left foot pain and swelling. The note stated Resident #1's pressure ulcer on her left heel was improving but the [DIAGNOSES REDACTED] (redness of the skin), swelling, and pain of her left foot was disconcerning. The note indicated the physician ordered an X-ray. A nursing progress note, dated 4/25/18, documented staff tried to educate Resident #1 to keep the boot on to protect her heel. The note documented Resident #1 would keep the boot on for approximately 30 minutes, then take it off and refuse to keep it on for about 2 hours. The note also indicated an X-ray was scheduled. A nursing progress note, dated 4/26/18, documented Resident #1 was encouraged to keep the boot on her left heel, but she did not like to do so. A nursing progress note, dated 4/30/18, documented Resident #1 used a wheelchair for locomotion and was able to self-propel with her feet. A dietary note, dated 5/3/18, documented Resident #1's left heel wound measured 1.0 x 1.5 cm and per the wound nurse, it was shrinking in size with stable eschar on the heel which would likely take a long time to debride. An MDS note, dated 5/9/18, documented Resident #1 was in the hospital in (MONTH) (YEAR) and returned with an unstageable wound to the left heel. The note documented the wound was 1.0 x 1.5 cm eschar. A Condition Change Form, dated 6/29/18, requested a podiatry consult related to Resident #1's foot wound. A Physician Assistant visit note, dated 6/29/18, documented Resident #1's had a lesion that was not healing. The note directed staff to obtain a podiatry consult. A Physician Telephone Order, dated 7/3/18, documented the wound nurse requested the cancellation of the out of building podiatry consult and made arrangement for Resident #1 to be seen by the in-house podiatrist in (MONTH) (YEAR). A nursing progress note, dated 7/1/18, documented Resident #1 generally went to bed just after 7:00 PM with complaints of left foot pain. The note documented Resident #1 requested Tylenol and went to bed with her left foot elevated. On 7/13/18 at 8:40 AM, the DON stated skin assessment sheets were completed by the certified wound nurse, RN #1. The DON said the skin assessment sheets were not kept in residents' paper or electronic medical records. The DON stated RN #1 kept them on a computer spreadsheet. The DON provided a spreadsheet titled Weekly Pressure Injury Record, which documented the pressure injury was present at the time of Resident #1's readmission on 1/13/18, and included the following assessments of Resident #1's left heel wound: * 4/4/18 - 1 x 1 cm, no depth, no drainage, black eschar, non-stageable, no change in wound appearance, changing duoderm paste to Santyl * 4/14/18 - 1 x 1 cm, no depth, no drainage, black eschar, non-stageable, no change in wound appearance, slow debridement of Santyl will allow better control of wound bed and healing process. * 4/18/18 - 1 x 1 cm, no depth, no drainage, black eschar, non-stageable, no pain, eschar appears to be starting to soften at edges, remains stable with no major concerns, will continue with current treatment. * 4/25/18 - 1 x 1 cm, no depth, no drainage, black eschar, non-stageable, no pain, eschar appears to be starting to soften at edges, remains stable with no major concerns, will continue with current treatment. * 5/3/18 - 1 x 1 cm, no depth, no drainage, black eschar, non-stageable, no pain, eschar appears to be starting to soften at edges, remains stable with no major concerns, will continue with current treatment. * 5/10/18 - 1 x 1 cm, no depth, no drainage, black eschar, non-stageable, no pain, eschar has shrunk in size, approximately 70% remains and 30% yellow slough (dead tissue, usually cream or yellow in color) around edges. * 5/17/18 - 1 x 1 cm, 0.2 cm depth, yellow slough, non-stageable, no drainage, no pain, eschar in wound bed was loosely adhering, was able to mechanically debride with rigorous cleansing and completely remove remaining eschar, wound bed 100% yellow slough, will continue to use Santyl to debride slough from wound bed. * 5/24/18 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 100% yellow slough, non-stageable, no pain, no signs of infection, continue with current treatment. * 5/31/2018 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 90% yellow, 10% granulation tissue, non-stageable, no pain, no signs of infection, continue with current treatment. * 6/7/18 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 90% yellow, 10% granulation tissue, non-stageable, no pain, no signs of infection, continue with current treatment. * 6/14/18 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 80% yellow, 20% granulation tissue, non-stageable, no pain, no signs of infection, continue with current treatment. * 6/21/18 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 80% yellow, 20% granulation tissue, non-stageable, no pain, no signs of infection, continue with current treatment. * 6/28/18 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 75% yellow, 25% granulation tissue, non-stageable, no pain, no signs of infection, continue with current treatment. * 7/5/18 - 1 x 1 cm, 0.2 cm depth, yellow/scant drainage, 75% yellow, 25% granulation tissue, non-stageable, no pain, no signs of infection, continue with current treatment. The spreadsheet did not provide documentation from 1/19/18 to 4/4/18 of wound assessments for Resident #1's left heel pressure ulcer. On 7/13/18 at 8:40 AM, the DON stated she did not know why the weekly wound assessments were not started until 4/4/18 or why there were no interventions for the pressure ulcer on the Care Plan. The DON stated there should have been. The DON stated there was a Weekly Body/Skin Check assessment that was completed on Resident #1's day of admission which provided the documentation of the pressure ulcer, but she could not find it. On 7/13/18 at 12:15 PM, the DON provided a Weekly Body/Skin Check. It was dated 1/13/18 at 11:33 AM, and documented a 5 x 5 cm unstageable pressure ulcer to the left heel and a left heel tissue wound, not open, and her heels were floated. The form had the administrator's name in the top right corner of the first page. A nursing progress note, dated 1/13/18 at 3:51 PM, documented Resident #1 arrived back at the facility from the hospital at around 1:45 PM that day. Resident #1's Admit Nursing Assessment, dated 1/13/18 at 5:00 PM, documented Resident #1 was readmitted to the facility at 2:30 PM on 1/13/18. The time of completion of the 1/13/18 Weekly Body/Skin Check, was 11:33 AM, prior to Resident #1's return to the facility. On 7/13/18 at 12:40 PM, LPN #1 stated the initial skin assessments were completed on the Admit Nursing Assessment and Weekly Body/Skin Checks were started the week after a resident was admitted to the facility. LPN #1 stated she could not think of a reason to complete a Weekly Body/Skin Check assessment on the date of admission as the information would be documented on the Admit Nursing Assessment. On 7/13/18 at 2:00 PM, the DON stated Resident #1 was readmitted to the facility on [DATE] at 1:45 PM. The DON stated she did not know why the completion time of the Weekly Body/Skin Check was prior to the time of Resident #1's readmission to the facility.

Based on observation, interview, facility policy review, and record review, it was determined the facility failed to provide adequate supervision for 1 of 12 (#7) sampled residents. The failure to prevent elopement placed Resident #7 in Immediate Jeopardy of serious impairment or death. It also resulted in harm to Resident #7. The Immediate Jeopardy was identified to have existed since 9/9/17, when the facility failed provide necessary supervision to prevent the resident from eloping. Resident #7 eloped through the window in his room on 9/9/17 and was missing for approximately 10 hours when the facility was notified by a local establishment of his whereabouts. On 9/26/17 Resident #7 broke his window and eloped through the broken window receiving a severe laceration to the left hand which required 43 sutures. The facility was not aware Resident #7 had eloped until law enforcement contacted the facility and notified them Resident #7 had been transported to the hospital for treatment. The Administrator, Director of Nursing Services (DNS) and the Regional Clinical Director (RCD) were notified of the Immediate Jeopardy on 10/25/17 at 5:30 p.m. The immediate jeopardy was removed on 10/27/17 at 11:15 a.m. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's quarterly MDS (Minimum Data Set) dated 9/13/17 documented facility staff assessed the resident needed assistance for daily decisions in new or unfamiliar situations and wandered one to three days out of the previous 7 days. Resident #7's care plan, initiated 3/27/17, documented the resident had the potential to wander. There were no interventions specific to Resident #7's wandering, and there was no care plan for elopement potential, prior to 9/9/17. Resident #7's Behavior Monthly Report documented for August 2017, Resident #7 had 63 episodes of wandering. The behavior report had the total number of times Resident #7 had wandered but it did not detail each event (i.e., time of day, whether the resident had been trying to elope, etc.) a. Elopement #1 on 9/9/17: On 9/6/17, Resident #7's Wander assessment documented the resident had risk factors for elopement of Alzheimer's disease, dementia with behavioral disturbances, major depression, restlessness and agitation; and was independently mobile without a wheelchair. The assessment documented the responses on the form placed the resident at High Risk of elopement, and elopement precautions should be addressed in the resident's care plan. The area of the form to document the care plan interventions implemented was blank. An undated Mini-Cassia Care Center Investigation Report documented that between 3:45 pm and 5:15 pm on 9/9/17, Resident #7 opened the window in his room, pushed out the screen, and climbed out the window. The report documented Resident #7 had severe cognitive impairment at the time of the elopement, but had not been considered an elopement risk. The report documented an employee at a local gas station, located approximately one mile from the facility on a busy highway, contacted the facility to inform them Resident #7 was at that location, but did not document what time the resident was located. A Cassia Co (County) Sheriff Case Report dated 9/9/17 at 5:34 pm documented Resident #7 was reported missing by the facility. Resident #7's Elopement report on 9/10/17 at 6:39 pm documented, (Resident) had left the lobby area between (3:30 and 4:00 pm). I did have meds to give the resident so myself and the aide did begin to look for (him). We looked into each room and bathroom in the building and we could not find the resident. Staff did state the window in his room was open and it appeared the screen was hanging open. Myself and several (staff) members did get into our cars and began to look for this resident. I covered north and south streets. Began to get dark and we returned to the facility. It was unclear what time the facility discovered that Resident #7 was missing. The facility's North and South Assignment Sheet for nursing staff dated 9/9/17, documented there were two LPN's, two CNA's and one float (helped on both wings of the facility) CNA caring for 51 residents during the evening shift on 9/9/17 when Resident #7 eloped. On 9/10/17, Resident #7's Wander assessment documented he was at High Risk for elopement. The assessment documented the resident's care plan would be updated to include routine monitoring of Resident #7's whereabouts, and the resident would be involved in activity programs during times of restlessness. Resident #7's interdisciplinary team note dated 9/11/17 at 10:27 am documented, Resident stated the facility was trying to poison him and he eloped from the facility by opening his window and knocking out his screen. Police and staff were called to provide needed support to search for the resident. He stated he hid under a tree until it was dark .The facility has secured his window and is providing frequent visual checks to ensure his safety. On 9/9/17, Resident #7's dementia care plan was updated to include, Actual elopement from the facility. An intervention of, encourage to attend supervised outdoor activities, frequent visual checks, Spanish speaking staff as much as possible, medication review, and psych consult, was added on 9/11/17. Resident #7's clinical record did not include documentation the frequency of visual checks following his 9/9/17 elopement. An intervention of, I may at times believe that I am being poisoned and refuse my medications, was added on 9/21/17. On 9/12/17, Resident #7's Doctor's Progress Notes documented, .quite agitated lately (and) threatening to elope . There was no documentation in Resident #7's clinical record that Activities staff was made aware the resident was to be encouraged to attend supervised outdoor activities. b. Elopement #2 on 9/26/17 On 9/26/17 at an undocumented time (later confirmed through staff interview to be prior to his elopement on evening shift), Resident #7's psychiatric progress notes documented, .Nursing reported that the patient eloped for about 7.5 hours a few weeks ago. He still continues to make a lot of decisions that put his own safety and health at serious risk. The patient has mood symptoms manifesting as aimless wandering, physical and verbal assault to staff. Resident #7's Cassia County Sheriff's Case Report dated 9/26/17 at 7:32 pm documented, On September 26, 2017 .was dispatched to a call .Upon walking upon the victim I observed it was an elderly man with a severe laceration to his left hand. The victim spoke no English but upon communicating through a translator, I established he had escaped from Mini-Cassia Care Center. He stated that he cut his hand when he broke the window with his hand and arm .Mini-Cassia Care Center was notified and they stated he was a resident but was (sic) unaware he was missing. They then confirmed he was missing. On 9/26/17 at 11:24 pm, Resident #7's progress notes documented, Res (resident) was in bed resting and was checked on 30 min (minutes) prior and was content. Between (7:00 and 7:30 pm) res broke out window by bed with fist and climbed out window. At approx. (approximately) (7:30 pm) Cassia County Dispatch called and asked if we had a resident by the name of (Resident #7) was confirmed that he was from here and that they would bring him back to us. Dispatch called back and said that they were taking him to (the hospital) because he had cuts on his hand from breaking the window to escape. Has been in the ER (emergency room ) since approx. (7:45 pm). Facility staff .went to transfer resident back to the facility via company van. On 9/26/17 at 11:35 pm, Resident #7's History and Physical from the emergency room documented the resident had multiple lacerations to his hand after he broke his window at the facility and eloped. The History and Physical documented the resident required 43 sutures, which took over 2 hours to complete. On 9/26/17, Resident #7's dementia care plan was updated to include, Actual elopement from facility. On 9/27/17, a new intervention documented, room change to room with window that opens to a secure courtyard. 1:1 staff (at all times) - needs to be Spanish speaking aide. On 9/27/17 at 1:10 am, Resident #7's progress notes documented, Resident eloped from the facility after breaking a window to exit. He has serious lacerations on his hand for which he was treated at (the hospital) .will provide very close monitoring until (psychiatric inpatient) placement can be achieved. On 9/27/17 at 1:58 am, Resident #7's progress notes documented, Res arrived back from (hospital) via facility van with staff van driver and another aide. Resident was escorted back to facility and taken to a new room assignment by staff that remained with resident .Administrator and DNS was (sic) notified and was assisting in decision how to treat . On 9/27/17 at 10:47 am, Resident #7's progress notes documented, Resident was relocated to a bed not next to a window. He has a 24 hour 1:1 (attendant). Resident #7's Wander assessment, dated 9/27/17, documented he was at high risk for elopement from the facility. The form documented the resident's demographic and emergency contact information was added to the facility's Elopement Binder. The facility's 9/26/17 North and South Assignment Sheet for nursing staff documented there were two LPN's and three CNA's caring for 50 residents on the evening shift. The assignment sheets for 9/27/17 and 9/28/17 documented Resident #7 did not have 1:1 staff assignment as documented in his progress notes and care plan. c. Observations and resident interview Resident #1 was observed with a 1:1 attendant on 10/24/17, 10/25/17, and 10/26/17, on all shifts. Through an interpreter, Resident #7 declined an interview, or to have observations made of the injury to his hand. d. Staff interviews On 10/24/17 at 12:15 pm the DNS stated, The first time he eloped, he was gone about 9 hours. He (Resident #7) walked into (local business) and he didn't have any injuries. The second time he was gone about 1 to 1½ hours and the police recognized him and his hand was bleeding so they called us and took him to the hospital. She said the facility did not know he was missing the second time until the police contacted them. When asked why he did not have a 1:1 CNA on 9/27/17 and 9/28/17 per the care plan and investigation documentation, she stated, we probably had him in the lobby with a hall monitor or other people watching him. We were probably short on staff and that's why he wasn't 1:1. On 10/25/17 at 9:15 am, the RSD said she had tried to get Resident #7 into a psychiatric unit but they would not take him because he did not have a payor source. She said the psychiatrist that comes to the facility had last seen Resident #7 sometime in September 2017. She said she and the IDT (Interdisciplinary team) met on 9/27/17 to discuss Resident #7 and they decided to put the resident on 1:1 supervision with a Spanish speaking CNA 24/7 (24 hours a day, 7 days a week). During an interview on 10/26/17 at 12:20 am, E #2 (one of the CNA's assigned to Resident #7 for 1:1 supervision) said she had been pulled away from her duties 2 to 3 times (8 hour shifts) when she was supposed to be 1:1 with Resident #7 because the facility was short of CNA's on the floor. She said that when she was pulled, Resident #7 was not assigned another 1:1 attendant for the rest of that shift. On 10/26 /17 at 12:45 am, LPN #3, the charge nurse on the night shift, said s/he had to pull the CNA's who are providing 1:1 care to Resident #7, 1 to 2 times a week, if not more, because we work so short of staff. S/he stated, no one stayed with residents who required 1:1, including Resident #7, when he had to pull CNAs to work the floor. LPN #3 stated s/he was working when Resident #7 eloped on 9/26/17 and, we were short 4 people. S/he said s/he was in another room caring for another resident at the time it was thought Resident #7 broke the window and eloped. S/he said s/he did not know the resident was missing until the police called said they found him. LPN #3 stated, (Resident #7) had a previous elopement. He kept saying you guys can't keep me here. I'll get out again. e. Policy and procedures The facility's undated Elopement, Risk, Prevention, and Management of Missing Residents policy and procedure documented, .Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . About 80 percent of elopements involve residents known to be chronic wanderers with prior elopements . An elopement risk assessment is completed by the nursing staff on all residents on admission, quarterly, and upon change of condition .If the resident has not been found after a period of ten minutes, the Administrator or Director of Nursing calls the police and reports the resident missing . There was no elopement risk assessment found in Resident #7's clinical record. f. Immediate Jeopardy notification and removal plan The Administrator, Director of Nursing Services (DNS) and the Regional Clinical Director (RCD) were notified of the Immediate Jeopardy on 9/25/17 at 5:30 pm. An acceptable plan alleging removal of the Immediate Jeopardy was received on 7/27/17 at 9:03 am. After verifying the implementation of the plan, the immediate jeopardy was removed on 10/27/17 at 11:15 am. The plan to remove the Immediate Jeopardy documented in full: 42 CFR: 485.25 (D) (2) Supervision: The facility will ensure adequate supervision to prevent elopement from those identified as potential elopement risks by: 1) Completing elopement tool for those identified as elopement risk. All residents will have elopement tool completed on 10/26/17. All residents will be evaluated quarterly and as appropriate. 2) Restore hall monitor on North side to help implement 15-minute check for those residents identified as potential elopement risks. 3) MAR (Medication Administration Record) to be updated for all identified as potential elopement risks and nurse to follow up with Q (every) 4-hour checks (in addition to the staff 15 minute checks). 4) Care plans of residents identified as potential elopement risks have been updated to include 15 minute checks. 5) All new elopement episodes will have 1:1 assigned to the resident until all the above interventions have been implemented and there is a psychiatric medication review. If there is not an extra, available CNA staff to act as 1:1, on call management is contacted to provide or find needed support for floor staff. Resident #7 will not be without a 1:1 during his stay at the facility. 6) Inservice-service training on the elopement policy for all employees to be reviewed and signed prior to working with residents as of 10/26/17 2 pm shift. The removal was confirmed by: -RN #12 and LPN's #6 and #13 said they had been in-serviced on the new hall monitor job description that requires them to perform 15-minute checks when needed, the policy and procedure on elopement, who was on-call in administration so they can be called if a 1:1 CNA needs to be pulled to the floor and that 1:1 is not to be pulled unless the administrator, DNS or administration on-call is contacted first. -CNA's #7, #8, #14, #15 and #16 said they had been in-serviced on the new hall monitor job description that requires them to perform 15-minute checks when needed, the policy and procedure on elopement and 1:1 is not to be pulled unless the administrator, DNS or administration on-call is contacted first. On 10/27/17 at 1:30 p.m., a review of the in-services and sign-in sheets confirmed staff had received the in-service training regarding elopement prior to their shifts starting. Resident #7 was placed in immediate jeopardy of serious harm, impairment, or death when the facility failed to recognize the resident was at high risk for elopement, as evidenced by their policy and a Wander assessment completed on 9/6/17. The facility failed to develop and implement care plan interventions based on that assessment. Resident #7 first eloped on 9/9/17 by opening the window in his room and exiting the facility, the facility failed to provide a safe environment or increased supervision to prevent a second elopement. On 9/26/17, Resident #7 used his hand to break the window to his room and eloped through the broken glass, which resulted in the resident receiving 43 sutures. The facility updated the resident's care plan to require 1:1 supervision after the second elopement, but that intervention was not consistently implemented.

Based on observation, interview, and record review, the facility failed to accurately assess for pressure ulcers and implement timely interventions to prevent deterioration of pressure ulcers for one of 1 (Resident #4) residents sampled for pressure ulcers. Resident #4 was harmed when she developed an unstageable pressure ulcer on her left ankle. Findings included: The facility's undated Pressure Ulcers Treatment policy documented, .Definitions and Descriptions: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear .General Guidelines: .6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/13/14, Resident #4's care plan documented the resident was at high risk of skin impairment due to poor mobility, bowel incontinence, diabetes, and the use of a feeding tube to meet her nutritional needs. The care plan documented a weekly skin assessment from a licensed nurse beginning 5/12/15, and the addition of a chronic scab to her left ankle on 8/9/16. Interventions included a Podus boot (plastic boots lined with soft material to protect the skin) to the left foot at all times. There were no further updates to Resident #4's care plan. Resident #4's quarterly Minimum Data Set (MDS), (a standardized screening and assessment tool) dated 7/19/17 documented the resident was at risk for developing pressure ulcers but did not have any unhealed pressures ulcer. Resident #4's physician's orders [REDACTED]. *Weekly skin checks every Tuesday, beginning 8/11/15. *Monitor black scab to the lateral aspect of the left ankle area. 1 cm (centimeter) x 1 cm. Check Q (every) day till resolved, use dressing of choice if condition of area changes or is indicated PRN (as needed) every shift for check till resolved, beginning 5/16/17. Resident #4's clinical record contained no additional details or documentation regarding the appearance or characteristics of the black scab discovered to her ankle on 5/16/17. Resident #4's Nurse's Notes (NN) between 6/6/17 and 6/29/17 documented the resident's skin was intact, with no new issues noted. There were no further entries in Resident #4's NN regarding the condition of her skin until 10/23/17. Resident #4's physician's progress note dated 8/29/17 documented her skin was intact. On 10/23/17 at 10:31 am, Resident #4's NN documented, .socks on and scab to left lower ankle no redness. Resident #4's Treatment Administration Record (TAR) for October 2017, was blank in the area to document the resident's skin check on 10/17/17, as was the area to monitor her left ankle. Resident #4's clinical record documented an untitled form completed by the Certified Nurse Aides (CNAs) when the resident had a shower. The forms from 5/12/17 to 10/20/17 documented there were no skin issues on Resident #4's left ankle. On 10/23/17 at 2:45 pm, Resident #4 was in a chair in the common area. Resident #4 was not wearing a Podus boot on her left foot. On 10/24/17 at 8:38 am, Resident #4 was lying in bed. She was not wearing a Podus boot. On 10/24/17 at 9:45 am, Resident #4 was observed with 6 discolored areas to the left ankle. The resident was not wearing a Podus boot. On 10/24/17 at 2:35 pm, Resident #4 was in the common area. The resident was not wearing a Podus boot on her left foot. On 10/24/17 at 4:15 pm, Resident #4 was in the common area. There was no Podus boot on her left foot. On 10/24/17 at 3:30 pm, the Director of Nursing Services (DNS), the Regional Clinical Director (RCD), and surveyor observed Resident #4's left ankle. The observation included: - One 1.5 x 1.5 cm round purple spot to the ankle bone. - Four 0.1 x 0.1 cm brownish black areas on left foot, just below the ankle. -One 2 x 3 cm black area on left foot, just below the ankle. The RCD stated the purple area was not a scab, but a deep tissue injury. On 10/24/17 at 9:45 am CNA #17 (a CNA) said she did not know Resident #4 was to have a Podus boot on her left foot to prevent pressure ulcers. CNA #17 was not aware Resident #4 had wounds on her ankle. On 10/24/17 at 2:35 pm, LPN #6 said she did not know where Resident #4's Podus boot was. She stated, She won't leave it on. The LPN could not find the boot in the room. On 10/24/17 at 5:25 pm, the DNS stated the facility's skin assessment process was, The CNA looks at the resident's skin during the resident's shower and fills out the skin form and gives it to the nurse. The nurse then signs the form. The DNS said the LN does not look at the resident's skin unless the CNA indicated the resident had a skin issue found during the resident's shower. She said if a pressure ulcer was found, an incident report had to be completed and the treatment would be put on the TAR. On 10/26/17 at 12:15 am, RN #1 stated he did not know that Resident #4 had wounds to the left ankle or that she was supposed to have a Podus boot on the left foot. On 10/26/17 at 2:40 pm, Resident #4's physician said he did not know Resident #4 had wounds to her left ankle and foot. On 10/26/17, Resident #4's NN documented, .Chronic/re-occurring wound on L (left) lateral malleolus, small round less than 1.5 cm x 1.5 cm dark purple in color, eschar covered. A care plan update for that date documented, . chronic wound suspect DTI (deep tissue injury) L lateral malleolus.

Based on observation, staff interviews, and record review, it was determined the facility failed to ensure there was adequate staffing to provide for the needs and well-being of residents. This failed practice had a direct negative impact on the level of supervision and/or services provided to 1 of 11 sampled residents (#7) and placed the health and safety of all 48 residents in the facility at risk of harm should the staffing shortage result in the failure to deliver care as physician ordered, as included in their care plans, or otherwise needed. Resident #7 was harmed when the facility's lack of sufficient staff to provide supervision allowed the resident to break a window with his hand, which resulted in the resident receiving 43 sutures. Findings include: The Facility's Hall Monitor job description documented the primary purpose of this assignment was to monitor activity of residents attempting to leave the building in the common area near the front entrance. Duties and Responsibilities included: * Stay at their station at all times. * Monitor residents for LWOA (leave without assistance) and falls. * Engage residents in simple activities - ball throw, trivia, reading the newspaper . * Not to act in the capacity of one to one assistance. 1. On 9/9/17, the facility's census was 51. Daily Assignment Sheet documented for North Hall per shift as follows: Day Shift: * One hall monitor, four residents required 1:1 supervision, two floor CNA's and one CNA assigned as a Breaker (CNA that relieves another CNA for a 15-minute break or lunch break). There was one LN working from 5:00 am to 5:00 pm and one LN working 7:00 am to 1:00 am. Evening Shift: * One hall monitor, four residents required 1:1 supervision, one floor CNA, and one CNA assigned as a float between both the North and South halls. There was one LN working 5:00 pm to 5:00 am, and one LN working 3:00 pm to 7:00 pm. Night Shift: * One hall monitor, and four residents required 1:1 supervision, one floor CNA, and one LN. One of the four 1:1 assignments was vacant for that shift. On 9/9/17, the facility's Daily Assignment Sheet documented for South Hall per shift as follows: Day Shift: * One hall monitor, two floor CNAs, one Restorative Nurse Aide (RNA), and one LN. A Breaker was scheduled, but called in sick and was not replaced. The assignment sheet called for a Bath Aide, but that assignment was vacant. Evening Shift: * One hall monitor, one floor CNA, one CNA float between both halls, and one LN. One CNA was assigned to provide 1:1 care. Night Shift: *One hall monitor, one floor CNA, and one LN. One resident was scheduled to have 1:1 supervision, but that assignment was vacant. Resident #7 was admitted to the facility's north hall on 3/16/17 with diagnoses, including [MEDICAL CONDITION], dementia with behaviors, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #7's quarterly MDS (Minimum Data Set) assessment, dated 9/13/17, documented Resident #7 had minimal behavioral symptoms and wandering. A Nurse's Note, dated 9/9/17 at 10:18 am, documented Resident #7 was compliant and cooperative with staff. A Cassia County Sheriff Case Report, dated 9/9/17 at 5:34 pm, documented Resident #7 left the facility through his window, and the facility was not sure how long he was missing. The facility told the Sheriff's Department they believed Resident #7 had been missing for about 2 hours. The Cassia County Sheriff Case Report, dated 9/9/17 at 11:26 pm, documented Resident #7 had been returned to the facility, and Resident #7 stated to the officer, he would get out again. A Nurse's Note, dated 9/10/17 at 1:57 am, documented Resident #7 was found at a gas station, which was one mile away from the facility, and returned to the facility with no injuries. A Interdisciplinary Team Note, dated 9/11/17 at 10:27 am, documented the facility has secured his window and is providing frequent checks to ensure his safety. The facility was unable to provide documentation Resident #7 received frequent checks. 2. On 9/26/17, the facility's census was 50. Daily Assignment Sheet documented for North Hall per shift as follows: Day Shift: * One hall monitor and two floor CNA's. One LN was working from 5:00 am to 5:00 pm and one LN 7:00 am to 11:00 am. Four residents required 1:1 supervision. The assignment for the Breaker was vacant. Evening Shift: * One hall monitor, one floor CNA, one CNA assigned to float between both the North and the South halls from 2:00 pm to 6:00 pm. One LN was working from 5:00 pm to 5:00 am, and one LN from 3:00 pm to 7:00 pm. Four residents required 1:1 supervision Night Shift: * One hall monitor, one floor CNA, and one LN. Four residents required 1:1 supervision. One of the four 1:1 assignments was vacant for that shift. On 9/26/17, the facility's Daily Assignment Sheet documented for South Hall per shift as follows: Day Shift: * One hall monitor, two floor CNAs, a bath aide, and one RNA. A Breaker was assigned from 10:00 am to 6:00 pm. One resident required 1:1 supervision. There was one LN working. Evening Shift: * One hall monitor, one floor CNA, and one LN. There was one CNA to float between the North and South halls between 2:00 pm and 6:00 pm. One CNA had called in sick, and the assignment was left vacant. Night Shift: * One hall monitor, two floor CNAs, and one LN. One resident was assigned 1:1 supervision. The assignment for a third CNA was left vacant. A Cassia County Sheriff Case Report, dated 9/26/17 at 7:32 pm, documented an officer was dispatched to a location with an elderly man, who had a severe laceration to his left hand. The officer was able to establish that Resident #7 eloped from the facility. The officer contacted the facility and the staff was unaware Resident #7 was missing. Resident #7 returned to the facility after receiving 43 sutures to his left hand. A Nurse's Note, dated 9/27/17 at 1:58 am, documented Resident #7 returned from the hospital and a staff member was assigned to provide 1:1 supervision. The facility's Daily Assignment Sheet for North Hall, dated 9/27/17, documented Resident #7 as a 1:1, but was left blank for the day shift and evening shift. 3. Staff interviews and observations: * On 10/24/17 at 12:30 pm, the DNS stated to be fully staffed for the census of 48 and the acuity of residents that the facility had, it would have been one hall monitor, two floor CNA's and one Breaker for each hall, along with the six residents that required 1:1 supervision. The DNS stated after Resident #7 eloped on 9/26/17, the facility did not have enough staff to assign 1:1 supervision until 9/28/17. On 10/25/17 at 10:00 am, E #11 stated after the survey team left on 10/24/17 at 6:00 pm, the other CNA was sent home and she was left as the only floor CNA for the North Hall. The census for North Hall was 32 residents. On 10/25/17 at 11:15 am, E #10 stated her position was the CNA scheduler since August 2017. E #10 stated when she was unable to fill vacancies on the schedule, she would work the floor, work as a 1:1, or work as a hall monitor. E #10 stated she was not informed that Resident #7 required 1:1 supervision until 9/28/17. E #10 stated to be fully staffed the day and evening shifts would need two CNA's per hall, one hall monitor per hall, five residents assigned as 1:1 supervision on the North Hall, one resident assigned as a 1:1 supervision on the South Hall, and one breaker to give breaks between the two halls. E # 10 stated the night shift required the same as day and evening shift, except four residents required 1:1 supervision on the North Hall. On 10/26/17 at 12:00 am, one hall monitor was observed on the South Hall, one licensed nurse, and one resident had 1:1 supervision. The licensed nurse stated the floor CNA was providing cares at this time. On the North Hall, one floor CNA was observed walking quickly to answer a call light down the hallway. The licensed nurse was administering medications, and one CNA walking with a resident to the common area to watch television. E #9 stated she was scheduled as an extra CNA and both nurses asked her to stay and help with monitoring the residents who are 15-minute checks. E #1 stated the North Hall had eight residents required 15-minute checks. E #1 stated by the time the assigned staff member was completed with the 15-minute checks, it was time to check on the residents again. On 10/26/17 at 12:20 am, Resident #7's call light went on, E #17 answered the light, came back out to get the nurse, and they both went back to Resident #7's room. Resident #7's had punched his 1:1 in the face, and E #17 was reassigned by the nurse to stay with Resident #7 as a 1:1. The nurse assigned E #9 to the floor and the nurse was documenting the 15-minute checks. The nurse stated the facility did not have enough staff to both monitor and assist residents, which compromised safety. On 10/26/17 at 12:20 am, E #2 said she had been pulled to work as a floor CNA 2 to 3 times when she was assigned to be the 1:1 supervision for Resident #7 because the facility was short of CNA's on the floor. E #2 said when she was reassigned to work the floor, Resident #7 did not have 1:1 supervision for the rest of that shift. On 10/26 /17 at 12:45 a.m., E #3 said he has had to pull the CNA's who are providing 1:1 care to Resident #7, 1 to 2 times a week, if not more, because we work so short of staff. He stated, no one sits with the 1:1 residents when he has to pull a CNA to work the floor. When asked if he was working the night of 9/26/17 when Resident #7 eloped, he said yes. He stated, we were short 4 people. He said none of the staff heard anything and he was in room [ROOM NUMBER] when he thought Resident #7 broke the window and eloped. He said he did not know the resident was missing until the police called him and told him they had found him. E #3 stated Resident #7, Had a previous elopement. He kept saying you guys can't keep me here. I'll get out again. The facility failed to ensure sufficient nursing staff were available to meet the needs of the residents.

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure residents with pressure ulcers received thorough wound assessments and interventions and failed to develop and implement systems for prevention of pressure ulcers. This was true for 3 of 15 sample residents (#s 2, 5, & 15) reviewed for pressure ulcers. Resident #5 was harmed when he developed multiple pressure ulcers and Resident #15 was harmed when her single pressure ulcer deteriorated from a Stage I to a Stage IV wound. These failures also created the potential for harm for Resident #2, who was not provided pressure relief interventions according to care plan. Findings included: The facility's Pressure Ulcer Risk Assessment and Pressure Ulcers/Skin Breakdown Policy and Procedures, dated February 2014, documented: *"...Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated...the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers..." *"...the nurse shall describe and document/report the following: ...Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue..." 1. Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 2/16/15, documented: *BIMS score of 1, severely impaired; *Bed mobility, transfers, toilet use, personal hygiene, bathing, total dependent with 2 person assist; *Walk in room, walk in corridor, locomotion off unit, did not occur; *Frequently incontinent of bladder; *Always incontinent of bowel; *Risk of pressure ulcer, yes; and, *Had no unhealed pressure ulcers, no. Resident #5's current Skin Care Plan identified the focus: "I have high risk for impairment to skin integrity r/t (related to) fragile skin, medication use, decreased mobility/need for assist with ADLs, dementia/[MEDICAL CONDITION], and incontinence," with goals documented as, "I will have no complications r/t skin breakdown or injury through the review date," and "Pressure related breakdown to coccyx will be resolved by review date," dated 12/3/14. Documented interventions included: "Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short," dated 12/3/14. "Dressings/treatments to open areas as ordered," dated 12/3/14. "Follow facility protocols for treatment of [REDACTED]. "I need pressure relieving/reducing cushion to protect the skin while up in chair (and) while in bed," dated 12/3/14. "Incontinent products/skin protectant with incontinence," dated 12/4/14. "Keep skin clean and dry. Use lotion on dry skin. Do not apply on coccyx," dated 12/3/14. "Monitor/document location, size and treatment of [REDACTED]. to MD," dated 12/3/14. "Encourage me to lay down first after meals and up last before meals," dated 2/25/15. The resident's MD progress notes documented: 11/18/14 - (2 days prior to admit, resident's current MD but assessed at another facility) "...Lesion on his coccyx is healed. They are still using Allevyn for skin protection. He is more ambulatory now and because of this is less likely to develop pressure sore..." 12/1/14 - "...Coccyx lesion is healed, but still protected with Alevyn...observe coccyx closely and make sure remains healed..." Resident #5's Physician orders [REDACTED]. * Apply Allevyn dressing to coccyx, change every 72 hrs for protection (hx of skin breakdown). Apply skin prep with each change. Order date: 11/20/14 and D/C (discontinued) date 12/30/14. 12/5/14 to 12/29/14 on the MAR/TAR - Marked with an H to signify "on Hold by physician." * Weekly Skin Assessments - Order date: 11/20/14. 1/8/15 and 1/22/15 on the MAR/TAR - Blank signified the weekly skin assessments were not done. * Monitor approx 1 cm irregular triangle - reopened old area over coccyx. Monitor daily for improvement, apply [MEDICATION NAME] as ordered with incontinence changes. Order date: 12/29/14 and D/C date 1/15/15 1/8/15 on the MAR/TAR - Blank signified it was not done. *Zinc/[MEDICATION NAME] to bilateral buttocks and coccyx until resolved. Encourage resident to lay down between meals and position on side, three times a day for open areas to bilat ischium and coccyx. Order date- 12/4/14. 12/15, 12/19, & 12/25/15 at 2:00 PM; 1/6/15 at 2:00 PM; 1/8/15 at 7:00 AM & 2:00 PM; 1/20/15 at 7:00 AM & 2:00 PM; 2/12/15 at 2:00 PM; 2/14/15 at 2:00 PM; 3/9/15 at 2:00 PM; 3/10/15 at 2:00 PM; and 3/19/15 at 2:00 PM on the MAR/TAR - Blank signified it was not done. * Monitor reddened area to coccyx, right, and left buttocks one time a day for approx 1 cm reopened old area over coccyx. Monitor daily for improvement, apply [MEDICATION NAME] as ordered with incontinence changes. Order date: 1/15/15 and D/C date: 1/31/15. 1/20/15 on the MAR/TAR - Blank signified it was not done. * Monitor coccyx/gluteal crevice wound daily, ensure that dressing is staying in place and amount of drainage if any until healed, one time a day. Order date: 2/19/15. * Cleanse wound on coccyx/gluteal crevice with NS (normal saline), and apply dressing of choice appropriate for wound based on wound characteristics and stage of healing, change every 3 days and PRN. Order date: 2/20/15. The resident's Nursing Progress Notes (NPN) documented: 11/20/14 - "Resident arrived at 11:30 by facility van...Res able to stand with assistance during transfers and cares...Dressing over coccyx changed, some non-blanching discoloration noted at indentation over coccyx. No other skin issues noted." 12/3/14 - "Aids called me in to assess resident's buttocks. Resident Allevyn was missing and there was a 1.5cm diameter open area to coccyx and 3X2cm open areas to bilat ischium. Allevyn re-applied to cover all 3 areas." 12/29/14 - "Old skin issue reappeared - 1 cm triangle reopened on coccyx, , 0.1 cm deep. Discussed w/ (with) wound care nurse, cont w/ [MEDICATION NAME] to coccyx, discussed finding ways of moving resident from WC more often..." 1/17/15 - "Coccyx area nearly healed, [MEDICATION NAME] liberally applied..." 2/19/15 - "...while doing skin check and Tx (treatment) completely cleaned off old [MEDICATION NAME] and spread buttocks and discovered in upper inner crevice/coccyx area a wound, that was deep tissue in nature, complicated by friction/shear/pressure and incontinence, wound is irregularly shaped and partially covered with hard non-viable tissue, parts of the wound had small openings, but non-viable skin was adhering to wound bed...approximated measurements at 3cmX4cm, cleaned area and applied allevyn dressing, doctor notified by fax..." 2/20/15 - "...unstageable pressure sore in upper crevice of buttocks/coccyx. Resident is totally dependent with mobility, is incontinent of bowel & bladder..." 2/21/15 - "...last one up and is (first) one down...repositioned every to (two) hours side to side, dressing is still in place and [MEDICATION NAME] continues to be applied to rest of buttocks..." 2/23/15 - "[MEDICATION NAME] cream applied to wound on coccyx with Allevyn dressing not staying adhered to skin..." 2/24/15 "...wound on resident's coccyx is starting to slough some of the old non-viable tissue, about 90% of wound red and open, no drainage or foul odor noted, no s/s of infection, peri wound that was denuded is starting to resolve..." 2/27/15 - "...Coccyx healing well. Open area decreasing in size. Dark purple areas noted to be resolving..." 2/28/15 - "...coccyx area pink and blanchable, closed with no open areas..." 3/1/15 - "Wound to coccyx healing well...Open area to right buttock decreasing in size. No bleeding or discharge noted..." 3/4/15 - "Wound to coccyx area has opened larger. Continue with [MEDICATION NAME] at this time. Wound cleansed..." 3/11/15 - "...open area to bottom that appears to be healing well, new dressing was applied...no drainage, foul odor..." 3/14/15 - "...Remains slightly red with no open areas." 3/21/15 - "...Changed dressing to coccyx area...reddish pink...clean site with NS (normal saline) and applied [MEDICATION NAME] dressing..." 3/28/15 - "...Coccyx closed with no open areas. No discharge or drainage..." 3/30/15 - "Resident repositioned every 2 hours continues with redness to buttock although not open healing well." No NPN regarding skin/pressure issues from 3/31/15 to 4/9/15. The resident's weekly Skin Conditions/Reports documented six open sites with start dates ranging from 11/20/14 through 1/4/15 and all 6 of these sites with resolutions dated 1/31/15. a. Site- Identified as "tailbone" with no date of onset, not marked on admit, described as open, pressure, and the diagram had 5 circles on the buttocks area: 11/20/14 - No measurements for length/width or depth, listed as red and nonblanchable, no odor, no tunneling, Stage I, and no pain. 1/31/15 - Line through the measurements, color/drainage, odor, tunneling, stage, and pain. The word "resolved" and the LN's initials. Note: There was no weekly documentation of assessments on the Skin Condition/Reports from 11/20/14 through 1/31/15, when the open pressure wound had resolved. b. Site- Identified as left gluteal fold with no date of onset, not marked on admit, described as open, pressure, and the diagram had 5 circles on the buttocks area: 12/3/14 - No other information documented except the LN's initials. 1/31/15 - Line through the measurements, color/drainage, odor, tunneling, stage, and pain. The word "Resolved" and the LN's initials. Note: There was no weekly documentation of assessments on the Skin Condition/Reports from 12/3/14 through 1/31/15, when the open pressure had resolved. c. Site- Identified as right gluteal fold with no date of onset, not marked on admit, described as open, pressure, and the diagram had 5 circles on the buttocks area: 1/4/15 - No other information documented except LN's initials. 1/31/15 - Line through the measurements, color/drainage, odor, tunneling, stage, and pain. The word "Resolved" and the LN's initials. Note: There was no weekly documentation of assessments on the Skin Condition/Reports from 1/4/15 through 1/31/15, when the open pressure had resolved. d. Site - Identified as left ischium with no date of onset, not marked on admit, described as open, pressure, and the diagram had 5 circles on the buttocks area: 12/3/14 - No other information documented except LN's initials. 1/31/15 - Line through the measurements, color/drainage, odor, tunneling, stage, and pain. The word "Resolved" and the LN's initials. The DNS added a late entry, dated 4/8/15, with the measurements for this pressure ulcer documented as 3 X 3 cm and identified as a Stage II wound on 12/3/14. Note: There was no weekly documentation of assessments on the Skin Condition/Reports from 12/3/14 through 1/31/15, when the open pressure had resolved. e. Site - Location was blank, but identified as a second area on the left ischium by the DNS on 4/8/15, with no date of onset, not marked on admit, described as open, pressure, and the diagram had 5 circles on the buttocks area: 11/29/14 - Measurements 3 X 1 cm, no depth, wound color as purple and scattered, no odor, no tunneling, N/A written for staging, No for pain, and open to air with LN's initials. 1/1/15 - All information the same as above. 1/9/15 - All information the same as above except measurements of 3 X 1.5 cm. 1/31/15 - Line through the measurements, color/drainage, odor, tunneling, stage, and pain. The word "Resolved" and the LN's initials. Note: There were no weekly documentation of assessments on the Skin Condition/Reports after 11/29/14 until 1/1/15 and then again, from 1/9/15 to 1/31/15 when the open pressure had resolved. f. Site - Identified as right ischium with no date of onset, not marked on admit, described as open, pressure, and the diagram had 5 circles on the buttocks area: 12/3/14 - No other information documented except LN's initials. 1/31/15 - Line through the measurements, color/drainage, odor, tunneling, stage, and pain. The word "Resolved" and the LN's initials. Note: There was no weekly documentation of assessments on the Skin Condition/Reports from 12/3/14 through 1/31/15 when the open pressure had resolved. 2. There was 1 identified pressure ulcer as of 2/19/15: a. Site- Identified as coccyx with date of onset as 2/19/15, described as pressure ulcer, and the diagram had 1 large circle on the buttocks area: 2/19/15 - Length/Width 3.0 X 4.0 CM; Depth 0.25; drainage color as Serosanguineous; Amount as Scant; color as red; odor as 0; Stage III; pain-Yes; "Monitor daily until resolved, treat (tx) as ordered"; and LN's initials. 2/23/15 - Length/Width 1.5 X 0.7 & 0.5 X 0.5 Depth <0.1; 0 drainage; color as Pink; odor as 0; Stage N/A; pain-No; "Monitor daily until resolved, treat as ordered; and LN's initials. 3/14/15 - No information marked on this line except the date. 3/22/15 - "Coccyx area sl (slightly) reddened, [MEDICATION NAME] drsg (dressing) intact;" "Monitor daily, tx as ordered; and LN's initials. 4/1/15 - "Closed"; 0 drainage; color as red; "Reddened, barrier cream (Zinc)" and no additional information except the LN's initials. 4/7/15 - "Closed"; color as red; "Reddened, barrier cream (Zinc)" and no additional information except the LN's initials. On 4/8/15 at 1:35 PM, the Wound Care Nurse (WCN) was observed while a weekly skin assessment of the buttocks was completed on Resident #5. The resident had no open pressure sores on the coccyx. The area from the sacrum down through the gluteal cleft was red, blanchable, no open areas, no drainage, no odor. The WCN did not clean the area and there was white ointment present, throughout the time the buttocks area was being assessed. The WCN said she forgot to take measurements while in the room and would need to return and measure. On 4/10/15 at 2:55 PM, the DNS was interviewed regarding the facility's policy and procedures for residents with skin integrity concerns. The DNS stated, "The policies and procedures are evaluation, assessing for risks, implementing interventions, completion of I & As, documentation on the resident, and notification to the resident, family, and MD." The DNS said the skin checks and documentation need to be done weekly at least and more often as needed. The wound or pressure sore documentation needed to include measurements, drainage, and staging. When the DNS was asked if the staff were following policy and procedure for pressure sores, she stated, "No." 2. Resident #15 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #15's MDS Assessments coded the following: - Admisson MDS, dated [DATE], one unstageable deep tissue injury; - Quarterly MDS, dated [DATE], one Stage 2 pressure ulcer, which developed on 7/10/14; - Quarterly MDS, dated [DATE], documented one Stage 2 pressure ulcer, worsened since prior assessment; and - Quarterly MDS, dated [DATE], one Stage 3 pressure ulcer, which measured 0.8 cm (length) x 0.4 cm (width) x 4.7 cm (depth). For the above identified assessments the resident was coded as extensive assist to total assist for bed mobility, transfers, toileting; limited range on motion in bilateral upper/lower extremities, and did not ambulate. Resident #15's Skin care plan documented the resident was at risk for pressure ulcer development related to immobility and quadraplegia. * Interventions implemented on 4/22/14 included, assess skin weekly and prn (as needed), halo bar and trapeze bar to assist with positioning in bed, and, air mattress for fragile skin. * Interventions implemented on 7/30/14 included, only up for meals and to work with therapies, reposition every 2 hours, and wound nurse consult as needed. * Intervention implemented on 8/15/14 was wound clinic consult. The following information was obtained from physician's orders [REDACTED]. 1. Right Ischium Wound: * 6/27/14 (SIS) - Unstageable right ischium wound identified and measured 4 cm x 3 cm. * 7/10/14 (WN) - "Pt (patient) has an unstageable wound to the Rt (right) ischum (sic). She is on an air bed and as of yesterday was on a firm w/c (wheelchair) cushion but is on a Roho cushion now. The wound is 4.5 cm approx(imately) with approx(imately) 2.5 cm center is white with slough. This appears to be a sitting wound. Turn every 2 hours, 24 hours a day, side, back, side. Air flo chucks on bed; do not leave chucks or lift sheet under the resident while in bed; Incontinent brief on only when up, monitor Roho cushion for air, last up and first down for meals, and only up for meals and therapies. * 7/9/14 - through 7/31/14 - There was nothing documented on the SIS related to the wound on the right ischium. * 8/1/14 through 8/18/14 (SIS) - Right ischium wound measured 4.5 cm x 2.5 cm. * 8/15/14 (PN) - Resident taken to Physician's office for evaluation of wound. * 8/17/14 (PN) - "Resident is currntly on antibiotics [MEDICAL CONDITION] ischeal wound has pink peri wound white 1.5 (cm) x 1.5 cm area debreaded (sic) by wound doctor...awaiting progress notes, no odor present serosangneous (sic) drainage small amount." * 8/18/14 to 8/22/14 (SIS) - Unstageable right ischium wound measured from 4.5 cm x 2.5 cm to 4.5 cm x 1.5 cm x 0.1 cm. * 8/22/14 (PN) - "Resident returned from the wound DR (doctor) order to use iodasorb and cover with dressing 3 x a week and f/u 2 weeks." * 8/25/14 (PN) - "Moderate amount of serosanguineous drainage present, no odor, peri-wound measured 3.5 cm beefy red tissue 1 cm depth in the center of the wound." It could not be determined if the length of the wound was measured as it was not documented. * 8/26/14 (SIS) - "Unstageable" Right ischeal wound measured 4.5 cm x 0 cm x 0.1 cm. It could not be determined if the length of the wound was measured as it was not documented. Additionally, it was unclear how a wound with depth was documented as "unstageable." * 9/5/14 (SIS) - Right ischeal Stage 3 pressure ulcer measured 3 cm x 1.5 cm x 1 cm. * 9/7/14 (PN) - "Resident returned from wound clinic with orders for wound vac to right ischiem (sic) (change) every 2 days and prn. Wound vac placed on resident as ordered, resident educated on the importance of repositioning and order for bed rest for 2 weeks." * 9/9/14 (PN) - ... some odor detected with removal of old dressing. Skin pink, serosangneous (sic) drainage. Area cleansed and new dressing applied. * 9/13/14 (PN) - Wound vac in place and continues to drain serosanguineous fluid. When resident rests on the right side tubing can be compressed and the wound vac stops working. * 9/14/14 throught 9/17/14 (PN) wound vac intact and functioning properly. * 9/18/14 (PN) - "She (resident) has been upset stating there is a problem with the turning schedule on day and evening shifts." The resident's record did not document what the problem was or that the facility had addressed and resolved the resident's concern. * 9/27/14 (PN) - Right ischeal wound area smaller and measured 0.8 cm x 0.8 cm x 0.5 cm. 2. Right Trochanter Wound: * 7/10/14 (TAR) - Monitor 4.5 cm x 2.5 cm open area on right trochanter everyday for dressing placement. * 7/11/14 (CP) - Right trochanter wound measured 4.5 cm x 2.5 cm. * 8/1/14 (PN) - Wet to dry dressing change three times a day for three days and then return to regular dressing change. Call Wound Consultant on monday (8/4/14) and report. NOTE: The resident's record documented the Wound Consultant was not called until 8/13/14. * 8/3/14 (PN) - "...Noted open area with red drainage out of wound, and very strong odor is noted when changing this dressing." * 8/5/14 (PO) - "...HOB (head of bed) at or less than 30 degrees at all times, up in chair 1 hour with breakfast and dinner only, do press ups every 15 minutes while up in chair, turn q 2 hrs while in bed, order KCI (wound)vac ASAP (as soon as possible)..." * 8/10/14 (PN) - "Wound to right trochanter measures 1x cm (sic) and beefy red periwound with white slouth (sic) in the center, serosangneous (sic) drainage." * 8/13/14 (PN) - "Called Wound Consultant to clarify dressing order. Apply wet guaze pack into wound. Gauze over the top. Cover with clear [MEDICATION NAME]. Don't use Allevyn. Physician notified." * 8/14/14 Lab results - Wound culture grew 2+ Staphylococcus aureus, 2+ [MEDICATION NAME] faecalis, and 1+ Escherichia coli. Physician order [REDACTED]." * 8/15/14 (PN) - Resident transported to doctor appointment to assess wound. Resident stated the doctor's office would fax orders. "Have not seen any new orders thus far." * 8/16/14 (PN) - "TX (treatment) nurse called provider concerning culture results. N.O. (new order) to DC (discontinue) Bactrim start [MEDICATION NAME] and [MEDICATION NAME]." The resident was started on [MEDICATION NAME] for [MEDICAL CONDITION] based on the identified organisms being susceptible to that antibiotic. The resident was not taking Bactrim for this wound, therefore it could not be determined why the nurse requested the Bactrim to be discontinued. * 9/1/14 (PN) - Resident has been in bed most of the day per her preference and has been repositioned q (every) 2 hours and prn (as needed). Replace (sic) dressing on the right trochanter. Noted minimal yellow drainage. Note wound bed to be pink, and noted wound to be yellow and red in appearance. Applied [MEDICATION NAME] island dressing to wound." * 9/2/14 (PN) - Resident continues to be repositioned every 2 hours and head of bed is at 30 degrees. 3. Left Outer Buttock Wound: * 6/27/14 (CP) - Left outer buttock abrasion identified and measured 4 cm x 3 cm. * 7/8/14 (PN) - Left buttock wound, measured 5 cm x 4 cm with 2 cm of eschar in the middle of the wound. Due to the lack of documentation provided by the facility to the survey team, it could not be determined if the facility had assessed this wound from 6/27/14 to 7/8/14, at which time the left buttock wound had deteriorated from an "abrasion" to a stage 2 pressure ulcer. * 7/9/14 (PN) - A Wound consult and wound culture ordered for the left buttock wound. Registered Dietician (RD) recommended 1 ounce of extra protein three times a day with meals to aid in wound healing. NOTE: The postioning schedule for the resident was not added to the resident's care plan until 7/30/14. * 7/11/14 - Lab results idenitified the resident had 3+ Staphylococcus in the left buttock wound. The resident was started on Bactrim DS twice a day for 10 days. * 8/11/14 (PN) - "...dressing changed to lt (left) buttocks as ordored (sic); small amt (amount) grey/green drainage noted on old dressing slight odor." Wound nurse consulted order received for minesota solution wet to wet dressing three times a day for seven days; obtain a wound culture; and consult with specialty clinic wound doctor. * 8/13/14 (PN) - "Refuses (to get) out of bed today due to wound on buttocks. Resident stated she didn't know what caused the wound and asked about w/c (wheelchair). Patient educated on causes and effects." 4. Right Buttock Wound: * 7/28/14 (PN) - "Resident #15 has developed a wound to her right buttocks. It is assessed...as a stage 2, involving [MEDICATION NAME] and some dermal tissue there are 2 small areas of wound which have sloughing or eschar tissue and these areas are unstageable, however most of the wound is a stage 2." * 8/8/14 (PN) - ...right buttock wound non-stageable. * 8/10/14 (PN) - Resident is compliant with staying off of her bottom for wound healing. * 8/29/14 (PN) - "...Dressing was satureated with pink-brown drainage on gauze..." * 9/6/14 (PN) - "Resident has been turned q 2 hours. Wound on R(ight) buttock cleaned and [MEDICATION NAME] (sic) applied. Covered with bordered (sic) dressing. Resident requested picture of wound be taken..." On 4/10/15 at 5:30 PM, the Administrator and DNS were informed of the concerns with the development of worsening of pressure ulcers in the facility. On 4/13/15 the facility faxed additional information to the Bureau of Facility Standards, however this information did not resolve the concerns. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 2/2/15 quarterly MDS assessment documented the resident was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility. The resident's 8/8/14 annual MDS assessment documented the resident was cognitively intact and required extensive assistance of 2 staff for bed mobility. The resident's April 2015 Medication Review Report (recapitulation orders) included to encourage the resident to stay off of his buttocks. The resident's 11/12/14 Skin at Risk Care Plan included an intervention to encourage the resident to lay down and to turn every 2 hours. During an observation on 4/7/15 at 8:20 a.m., the resident was observed in bed with a pillow to his right side. At 10:45 a.m. the resident was observed with the same pillow to his right side. The resident stated he did not get turned every 2 hours. At 11:45 a.m., the resident was observed in the same position with the same pillow to his right side. At 1:01 p.m. the resident remained in the same position with the same pillow observed to the right side. At 2:28 p.m. the resident was observed in the same position but informed the surveyor he had requested to be repositioned. At 4:35 p.m., the resident had been repositioned and the pillow was now to his left side. The resident stated staff had repositioned him at 3:29 p.m. On 4/8/15 at 9:38 a.m., the resident was observed in bed with a pillow to his right side. At 11:29 a.m., the resident was observed in bed with the same pillow to his right side. At 12:07 p.m., the resident informed CNA #4 he would like to be turned after he received a pain pill. After receiving his pain pills at 12:10 p.m., CNA #4 and CNA #5 repositioned the resident by moving the pillow to his left side. On 4/9/15 at 5:45 p.m., the Administrator and the DON were informed of the above concern. The facility provided no further information.

Based on observation, incident report review, record review, and staff interview the facility failed to ensure residents received supervision to prevent accidents. There were three residents who were harmed due the facility's failure to supervise residents which resulted in falls with major injuries and increased pain. - Resident #6 was harmed when he had two falls then fell and fractured his right hip causing increased pain. - Resident #8 had a previous history of falling and was harmed when she fell and fractured her left hip then fell again injuring her ribs which resulted in increased pain. - Resident #5 was harmed when the staff failed to use a mechanical lift as outlined in the care plan and fractured his Humerus. The failure to supervise residents was found to be true for 4 of 12 (#s 5, 6, 8, & 9) residents sampled. There was a potential for harm to Resident #9 when she had unsupervised wandering, the resident could fall and sustain injuries requiring major medical intervention. Findings include: 1. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had [DIAGNOSES REDACTED]. The most recent significant change MDS assessment dated [DATE], documented the resident was: - moderately cognitively impaired with a BIMS of 11, - required extensive assistance for bed mobility, transfers, dressing, personal hygiene and bathing. - required staff assistance to stabilize him with standing, transferring on and off toilet, and surface to surface transfers. An LN documented at 7:00 p.m. on the day of admission, the resident had an "ace wrap and immobilize" on the right leg. The resident was started with 1 : 1 staff for 24 hours a day. (Note: The DON confirmed during an interview on 1/30/14 at 8:45 a.m. the resident had a previous fall and fractured the tibia and fibula.) The Resident Service Director (RSD) was interviewed on 1/29/14 at 11:15 a.m. and stated all residents are admitted with a 1 : 1 for 24 hours and then slowly over a week are taken off 1 : 1. She further stated the resident was off 1 : 1 on 8/25/13 and the resident was receiving therapy for the right leg and was improving with strength and transfers. On 9/1/13 at 5:54 a.m. an LN documented in a nurses note (NN), "Resident self-transferring from bed to W/C and did not ask for help. Rested in bed thru noc (night) with eyes closed..." On 9/1/13 at 12:10 p.m. an incident and accident report (I&A) documented the resident fell in his room attempting to transfer, he was alone and unattended. The resident told staff, "I was trying to transfer to my bed and I didn't lock the brakes." The I&A documented the resident "doesn't listen to staff." There was no change in the level of supervision for the resident. (Note: the "Interventions to prevent future falls:" area on the I&A was blank.) The facility does not use alarms, according to the DON and RSD interview on 1/30/14 at 8:30 a.m. On 9/4/13 at 7:47 a.m. an LN documented in a NN, "Resident found to have latent injuries r/t fall. Above right hip there is a purple/yellow discoloration measuring 5 cm x 2 cm, on right mid back there is a purple yellow discoloration measuring 5 cm x 2 cm, and on mid forehead there is a 1 cm x 1 cm red scabbing area. resident denies pain to these area...." On 9/21/13 at 2:43 p.m. an LN documented in a NN, "Resident found sitting on side of bed when nurse went in to answer call light. Resident was getting a brief from drawer when nurse went in...." On 9/21/13 at 6:00 p.m. an I&A documented the resident fell in his room attempting to transfer, he was alone and unattended. The I&A documented the resident "was attempting to go to the bathroom." The I&A investigation report documented, "Resident is self mobile in w/c. Was told numerous times prior to fall that he needs to ask for assistance (with) transfer. Immediately prior to fall resident was told by nurse to wait for assistance." The documented interventions to prevent future falls was, "Assist x 2 for transfers." There was no change in the level of supervision documented. On 10/3/13 at 12:40 p.m. an LN documented in a NN, "Resident self transferred to toilet in room, by walking across room...." On 10/8/13 at 7:05 p.m. an I&A documented the resident fell in his room. The resident was "found on the floor", "attempting self-transfer", and was "alone and unattended." The resident was, "trying to return to his w/c (after) using the rest room...Missed handrail of w/c, lost his balance and fell on to his right side. 'Heard a pop' also." The I&A further documented the resident had made it back to the wheelchair and stood up to adjust his clothing and then fell when he attempted to sit down. The resident was assessed and was transferred to the local medical center. The resident sustained [REDACTED]. The resident's behavior monitoring program (BMP) for 2013 documentation for wandering, revealed for September 2013 he had 57 episodes and October 2013 he had 186 episodes. The resident returned to the facility on [DATE]. Review of the resident's pain assessments documented the resident had increased pain. The 8/19/13 assessment documented the resident had "frequent" pain in the right leg tibia and fibula. The resident's pain intensity was "moderate," a pain rating of "hurts a little more" and it did not interfere with his sleeping. When the resident returned from the hospital the 10/15/13 pain assessment documented "almost constant" pain in the hip area. The resident's pain was rated 8 on a 1 to 10 ratio, a pain rating of "hurt even more" and "pain made it hard to sleep at night." The EMR from 8/18/13 to 10/8/13 documented the resident spent most of the time in his room. The resident's supervision was not increased as he became more ambulatory which resulted in the resident falling a fracturing his hip. 2. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had [DIAGNOSES REDACTED]. The most recent significant change MDS assessment, dated 11/18/13, documented the resident: - was severely cognitively impaired. - required extensive assistance for bed mobility, transfers, dressing, personal hygiene and bathing. The initial admission MDS assessment, dated 10/22/13, documented the resident: - had short and long term memory problems. - severely impaired decision making skills. - had wandering on a daily basis. - required minimal to no assistance for transfers and ambulation. - had a history of [REDACTED]. The resident's admission care plan dated 10/30/13 documented a focus of, "I am at Moderate risk for falls r/t confusion, poor communication/comprehension, wandering, seizures and past history of falls." The interventions were: "-Anticipate and meet my needs. -Follow facility fall protocol. - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. - 24 hour 1 : 1 - will reduce as needed." The residents care plan failed to have any approaches for supervision of the resident with a history of falls. The 1 : 1 was reduced over a 7 day period then discontinued. The care plan completed after the resident fractured her hip and was readmitted , documented on 11/19/13 a focus of, "I am at Moderate risk for falls r/t confusion, poor communication/comprehension, wandering, and past history of falls with fractures." The interventions were: "- Anticipate and meet my needs. - Follow facility fall protocol. - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes." The facility did not have interventions for more supervision until after the resident injured her ribs. Then the 1 : 1 staffing was added. The DON and RSD were interviewed on 1/30/14 at 8:30 a.m. They confirmed the resident had 1 : 1 for 7 days on the initial admission. The 1 : 1 was discontinued on 10/22/13. On 10/15/13 at 3:10 p.m. an LN documented an initial admission NN of, "Resident arrived....Resident ambulates (independently) without c/o pain or discomfort....There is also a large bruise on her left eye r/t fall previously...Resident ambulates (independently) and has a difficult time making (sic) needs known. Currently one on one present for safety." On 10/20/13 at 2:52 p.m. an LN documented in a NN, "Resident does wander and did need to be redirected several times as she would attempt to trespass into other (resident) rooms. (Resident) does listen to staff when we attempt to help her sit in a chair..." On 10/21/13 at 6:03 a.m. an LN documented in a NN, "(Resident) up and ambulating thru the eve....Wandered the halls and attempting to go in other rooms, but would stop. Confused." On 10/21/13 at 3:14 p.m. an LN documented in a NN, "...She does wander aimlessly. (Resident) was redirected by staff multiple times but she will turn and go the other way. Continuously walking...." On 10/24/13 at 7:25 a.m. an LN documented in a NN, "...Wanders thruout (sic) hall while up this shift. Confused....Hanging around this nurse this eve...." On 11/5/13 a late entry was made by an LN in the NN. It documented, "Late entry: 0320 (3:20 a.m.) Resident's nurse called for assistance for resident who had fallen and had unnatural leg alignment upon standing. Nurse called EMS. I found resident back in bed, aide providing traction to Left leg. Resident had a soft bump to back of head approximately 2 inches in diameter....handed over to EMS for transport." On 10/5/13 at 3:05 a.m. an I&A documented the resident fell in her room. The resident was "found on the floor (unwitnessed)", "ambulating, attempting self-transfer", and was "alone and unattended." The resident was, "trying to get out of bed." The I&A further documented the resident was "forgetful" and had "dementia." The resident was assessed and found to have a blood sugar of 61 the resident was transferred to the local medical center. The resident sustained [REDACTED]. On 11/11/13 at 2:54 p.m. an LN documented in a NN, "Resident arrived...Resident transfers with assist and walker, can ambulate for short distances..." On 11/13/13 at 6:21 a.m. an LN documented in a NN, "...While in W/C, res tried to stand alone but was stopped by staff..." On 11/13/13 at 1:26 p.m. a LN documented in a NN, "...Does attempt to self transfer at times....Does not remember to use call lite...Requires two assist with transfers. Was able to ambulates two to three steps with staff..." On 11/17/13 at 2:25 a.m. a LN documented in a NN, "... Resident is currently in bed. Earlier in the night resident has been attempting to self transfer. Noc aides observed resident to sit up on the right lateral side of the bed. Noc aides assisted resident with incontinent cares and repositioned her in bed..." On 11/18/13 at 9:36 a.m. a LN documented in a NN, "(Resident) awake early this morning and was rubbing the left leg, i (sic) asked if she was having pain and she states 'oh boy am I.' res was medicated....At lunch time again res was rubbing left leg again asking her if she was having pain and she states "yes" this time was medicated....has helped as she did have a decrease in restlessness and fidgeting in her w/c..." On 11/21/13 at 6:15 p.m. an I&A documented the resident fell in her room. The resident was "found on the floor (unwitnessed)", and was "alone and unattended." The I&A further documented the resident was "confused" and "carefree." The resident was transferred to the local medical center for x-rays. The emergency room physician report, dated 11/21/13, documented: Chief Complaint: Ground level fall. History: The resident "has pain in her left hip area as well as in her right ribs...She states that she did have pain in her left hip but is more concerned about the right side of the ribs because she did land on her right side..." Physical Exam: Musculoskeletal: "...Palpation of the right sided rib cage is moderately tender to palpation at the mid axillary line as well as the rib angle..." (Note: There was multiple discussions about the residents injury to the ribs during the survey. The x-ray reports from 5/13, 11/5/13 and 11/21/13 show fractures of the ribs on the right side. It is not clear when the fractures occurred. It was noted the resident experienced increased pain in the rib area secondary to lack of supervision resulting in a fall.) The residents EMR documented the resident had pain in the left hip area and was observed guarding her right side due to pain. The resident was getting Norco 5-325, two tablets every four hours as needed for pain. The DON and RSD were interviewed on 1/30/14 at 8:30 a.m. The resident has a 1 : 1 staff with her 24 hours a day. This started after the injury to the resident's ribs. The 1 : 1 continued throughout the survey. Review of the BMP documentation it was found the resident for October 2013 (15 days) had 484 attempts of elopement, 514 episodes of pacing and 548 episodes of wandering. The documentation for November 2013 was 119 episodes of elopement, 132 episodes of pacing and 116 episodes of wandering. Resident #8 was harmed when the facility failed to supervise the resident. As a result the resident, who had a history of [REDACTED]. The resident returned to the facility and ten days later fell , and injured her ribs which caused increased pain and discomfort. 3. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly and Significant Change MDS assessments, dated 4/4/13 and 12/10/13 respectively, both coded, in part: * Severely impaired cognition; * Total dependence of 2 or more people for bed mobility, transfers, and toileting. The resident's 4/8/13 Care Plan (CP) for ADL included in the intervention section for transfers "I require 2 staff participation with transfers and the use of a Hoyer lift." The intervention had an initiation date of 4/8/13. An Incident Report (IR) dated 11/23/13 at 4:00 p.m. documented CNA #8 reported to LN#4 the resident "winced" when his left arm was moved. LN #4 assessed the left arm and documented "swelling - resident winced when I lifted arm..." A Nurses Note (NN) dated 11/23/13 at 4:30 p.m. documented it was a late entry of the above incident and the resident occasionally had swelling in the arm due to immobility. The NN documented the nurse instructed the aides to elevate the left arm, had notified the next shift and had put the incident on the 24 hour report for further monitoring. The NNs had no further documentation of the injury until 11/25/13 at 6:19 p.m. which documented the resident continued to have swelling to the left elbow and ice was applied. A NN dated 11/26/13 at 5:17 p.m. documented the resident returned from the emergency room with a cast on his left arm. A physician report, dated 11/26/13 documented the resident was sent to the emergency room after an x-ray revealed a fracture of the left humerus. Note: The 11/26/13 x-ray was done 3 days after the resident's pain was reported to the nurse. Attached to a 11/26/13 Investigation Report was a "Records Review: Significant Information" (SI). The SI documented the following: * The resident was to only be a 2 person mechanical lift transfer. * All staff working from 11/20/13 - 11/23/14 on the the hall the resident resided on gave statements. * Night shift reported they used the mechanical lift, however, the video recordings from the night shift did not show the mechanical lift go into the residents room. * Day shift reported they never transfer the resident. * All of staff on the evening shift reported a 2 person stand pivot was used when the resident is transferred. * The shower team stated a 2-3 person stand pivot was used to transfer the resident. Communication Forms attached to the Investigation Report (statements by nursing staff) documented at least 7 staff used a stand pivot to transfer the resident. One of the Communication Forms documented a CNA had been trained to use a stand pivot transfer with 2-3 staff when transferring Resident #5 and nurses and other CNAs had witnessed the staff use a stand pivot transfer with the resident. The investigation of the fracture of the resident's humerus did not state the fracture was the result of staff using a stand pivot to transfer the resident. However, the investigation documented the resident was care-planned to be transferred with a mechanical lift and page 10 of the Investigation Report documented: "Repeated failure to follow a care plan Harm occurred because of failure to follow a care plan." A 12/9/13 "Facility Requested Fracture Investigation" (FREI) documented the resident had severe osteoporosis and an x-ray had revealed a fracture of the Humerus. The FREI also documented "Because there had been no witnessed injury a thorough investigation was performed, the most likely root cause identified..." On 1/30/14 the DON stated a hold on new admissions was initiated on 11/27/13 due to the nursing staff not following the CP to use a Hoyer lift and resident #5's fracture. Additionally all CNAs were required to attend training to demonstrate competency in CNA skills. The facility was informed of the above concern on 1/30/14 at 3:45 p.m. The facility provided no further information. 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 10/15/13, documented the resident: - had short and long term memory problems, - had severe impairment of decision making skills, - required limited assistance with bed mobility, transfers. - required extensive to total assist with dressing, personal hygiene and bathing. - the resident wandered every day. The resident's care plan, dated 8/5/13, documented a focus of, "I am an elopement risk/wanderer AEB(as evidenced by) impaired safety awareness, Significantly intrudes on the privacy or activity." The interventions were: "- Assess for fall risk, - Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Resident prefers: - Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. - Monitor for fatigue and weight loss. - Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes." The resident had a "Behavior Management Plan" dated 7/30/13. The resident had multiple behaviors. The plan for wandering documented: "Defined as going aimlessly from place to place, with no purpose. Goal: Resident will have an average of 2 (wandering) for 3 consecutive months. Intervention: 1. Redirect to day room. 2. Escort the resident to an appropriate area for the resident to be in." The plan for trespassing documented: "Defined as going into other room uninvited, going into room mates space/belongings not honoring others personal boundaries. Goal: Resident will have an average of 4 (trespassing) for 4 consecutive months. (Interventions) 1. Explain in simple terms that it is not her room or belongings. 2. Remove from area and show her where her room and belongings are. 3. Encourage to be involved in activities. 4. Ask what she is looking for." The multidisciplinary EMR has frequent documentation of the resident not being supervised and being found either wandering to trespassing. Some of the documentation was: On 7/14/13 at 1:09 a.m. an LN documented a NN, "Resident asked to rest on bed when she arrived...Resident immediately began wandering when she arrived. Did climb into closet and was assisted out of closet. Wandering in other residents rooms....Attempted to climb on bed with another resident and no injuries or issues." On 7/18/13 at 3:25 p.m. an LN documented a NN, "...Res does use her FWW (front wheel walker) but she tends to pull it along behind her and then she is ready to sit down..." On 7/19/13 at 12:38 a.m. an LN documented in the NN, "Resident awake and alert. Wandering in lobby. Has to be closely watch or will trespass in other residents room, nurses stations. Was in lobby in the evening and removed clothing several times, removed shirt and nothing underneath. Took off pants and sat on chair in attends. Has to be closely watched." On 7/20/13 at 3:07 a.m. an LN documented in the NN, "Resident has been up most of night. Trespassing in rooms. does strip clothes off where ever she is at - such as lobby or dining room...." On 7/28/14 at 3:07 a.m. an LN documented in the NN, "Resident up and wandering during the night. Went into room (#) and urinate in trash can. Assisted back to room..." On 8/4/13 at 1:38 a.m. an LN documented in the NN, "...Continues to wander and requires close supervision for safety. Does trespass in others rooms at times..." On 8/16/13 at 1:08 p.m. an LN documented in the NN, "Res has not shown any latent injuries noted from fall..." (Note: No documentation was found during survey for this fall.) On 8/18/13 at 4:45 a.m. an LN documented in the NN, "Restless and awake most of night. Has to be closely monitored or trespasses in other residents rooms. Will take cloths off in lobby." On 9/7/13 at 5:52 p.m. an LN documented in the NN, "...Res does ambulate freely at times she does have a FWW she uses and she does sometimes forget where she leaves the FWW. Gait is low but fairly steady..." On 9/16/13 at 6:25 p.m. an LN documented in the NN, "Resident lost balance and fell backward hitting the floor, head hit the table leg causeing (sic) two small laceration on the back of her head. Floor was wet from coffee spill, shoes on. ROM within normal limits for resident Neuro checks (within normal limits) for resident. Resident assisted up off the floor, no other injury noted at that time. No c/o pain resident taken per facility van to (medical facility) for evaluation and treatment..." (Note: The resident required staples to close the lacerations on the head.) On 9/16/13 at 6:00 p.m. an I&A documented "Resident - hit her she fell back" and fell to the floor (witnessed), in the dining room, and she was alone and unattended. The resident told staff, "Resident was folding wash cloths." The interventions to prevent future falls was, "Monitor ambulation." The 9/18/13 Investigation report documented, "Resident was folding towels and when she got up to leave the table had put her hand on another resident's wheelchair to steady herself and was moving away, when the resident in the chair told her not to touch her chair. When a staff member intervened, the staff member got between (Resident #9) and the other resident which threw the resident off balance and she fell ." On 9/29/13 at 11:58 a.m. an LN documented in the NN, "No latent injuries from fall. But resident very anxious and agitated. Keeps ambulating around halls and confused. Attempting to enter other resident rooms." 10/11/13 at 7:00 a.m. an LN documented in the NN, "Resident has increasing times on being non-compliant. Trying to leave, pulling her pants down, trying to force her way down the halls. Has not been violent. Just persistent..." 11/23/13 at 6:06 a.m. an LN documented in a NN, "Resident had dinner, ambulated around during evening ambulated to south doors and was re-directed back with no complications..." On 12/3/13 at 9:33 a.m. an LN documented in a NN, "Res is alert and does smile and wave at staff...Res does need staff to redirect her at times. This res does wander aimlessly and does at times trespass into other rooms, again staff does redirect her..." On 1/20/14 at 4:01 p.m. the RSD documented a Resident Services note, " ...(Resident) does ambulate independently with a front wheel walker. She does require reminders to use the walker as she will forget due to her dementia. She is being tracked (every) shift for behaviors. Her behaviors include physical assault, verbal assault, wandering, trespassing, noncompliance, undressing in public areas.... Her behaviors do seem to escalate in the evening hours... She does require verbal reminders for activities and often escort also. She usually wanders in and out of them...." The residents' documented history of behaviors, especially her wandering and trespassing, included: Wandering: July 2013= 227, August 2013= 17,327, September 2013 = 521, October 2013 = 453, November 2013 = 10, and December 2013 = 89. Trespassing: July 2013 = 43, August 2013 = 17,269, September 2013 = 91, October 2013 = 99, November 2013 = 0, and December 2013 = 128. The residents' behavior management plan documented a goal of 2 episodes of wandering for 3 consecutive months and 4 episodes of trespassing for 4 consecutive months. There has not been a change in the behavior plan, and the resident continues to wander and trespass. There was evidence of a lack of supervision found in the residents' NN and there was a potential the resident would be injured if she were to wander into a resident's room who was violent. The DON and RSD were interviewed 1/30/13 at 9:00 a.m. There was discussion about the large amount of behaviors. The behavior care plan was provided. No other information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure the environment in a resident room remained free of accident hazards. This was true for 1 of 1 residents (#2) reviewed for falls. Resident #2 was harmed when he tripped over a cord in his room when ambulating to the bathroom resulting in a fractured hip requiring surgery. Findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2 fell in the facility on 5/26/12 and was transferred to the hospital for repair of a left hip intertrochanteric fracture. The resident was readmitted to the facility on [DATE] and developed a Stage III pressure ulcer on his right heel and a Stage I and Stage II pressure ulcer on his left and right buttocks, respectively. (See F314) Resident #2's evaluation in the emergency room , dated 5/26/12, documented, "...X-ray of the hip shows a comminuted closed intertrochanteric fracture." His discharge summary from the hospital, dated 5/30/12, documented, "Procedures Performed: ...nailing of left intertrochanteric hip fracture...He will be discharged back to his skilled nursing facility with continuation of physical therapy..." Resident #2's quarterly MDS assessment, dated 3/20/12, coded: * BIMS of 13 indicating he was cognitively intact * Required limited assistance of one person for bed mobility, transfer, walking in the room or corridor, and locomotion on or off the unit * Does not use any mobility devices * When walking or turning around he was not steady, but able to stabilize without human assistance * Had 2 non-injury falls since the last assessment Resident #2's Fall Risk Assessment, dated 4/10/12, documented a score of 13 indicating he was at moderate risk for falls. Resident #2's PN, dated 5/26/12 at 6:15 pm, documented, "At approximately 0710 (7:10 am) this AM (Resident #2) was walking back from the bathroom in his room to his bed when his right foot got caught on the remote electrical cord from another bed. This caused him to fall onto his left knee with all of his weight...I went into the room to assess him and he told me that he trip in (sic)the cord in the walk way and that his knee hurt...He was sent for x-rays and found that his left hip was fractured..." On 9/14/12 at 8:30 am, the Administrator was asked for the I/A regarding Resident #2's fall. She stated, "I think we called that one in (to the Bureau of Facility Standards). I'll bet that's where it is." The Administrator provided the I/A and did not provide any other information regarding the fall. The Fall Scene Investigation Report, dated 5/26/12 at 7:10 am, documented Resident #2, "tripped on the remote cord from the middle bed. He was coming back from the bathroom to his bed & his R(ight) foot got caught on the remote cord then he fell on to his L(eft) knee." The initial interventions was to, "removed cord from walking path." The resident said, "He got done going to the bathroom then was going back to bed and tripped on the remote cord." The CRNA (Certified restorative nurse aide) documented, "...He said he had went to the bathroom and was coming by the empty middle bed when he fell . When I looked, the cord for the bed control was at the foot of the bed on the floor where it was easy for his foot to get caught. ...I...moved the cord from where it was to under the bed out of the way." The resident's revised care plan, dated 9/12/12, included the intervention, "Ensure I have has (sic) unobstructed path to the bathroom," under the problem, "...risk for falls..." On 9/14/12 at 8:40 am, Resident #2's room was observed and there were no apparent cords or hazards in the resident's pathway at this time. On 9/14/12 at 3:30 pm, the Administrator and the DON were informed of the issue. The facility provided no other information or documentation that resolved the concern.

Based on a complaint from the public received by the Bureau of Facility Standards on 6/19/12, observation, staff interview, and record review, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop avoidable pressure ulcers. This was true for 3 of 7 residents (#s 1-3) reviewed for pressure ulcer prevention and treatment. 1. Resident #2 was harmed when he developed a Stage III pressure ulcer on his right heel resulting in non-weight bearing on that heel delaying his physical therapy treatments. In addition, he developed a Stage II pressure ulcer on his right buttock and a Stage I pressure ulcer on his left buttock. 2. Resident #1 was harmed when he developed two Stage II pressure ulcers, one on the right heel and one on the left heel, resulting in non-weight bearing on the heels delaying his physical therapy treatments. 3. Resident #3 was harmed when she developed Stage II pressure ulcers described as "two lines of blisters" on her right thigh from the catheter tubing/strap rubbing on that area. Finding included: The complainant said an identified resident had a bedsore developing on the tailbone. The complainant said the skin on the tailbone was open. The complainant said the staff were putting a prescription ointment on that area twice daily. 1. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2 fell in the facility on 5/26/12 and was transferred to the hospital for repair of a left hip intertrochanteric fracture. (See F323) The resident was readmitted to the facility on [DATE]. Lippencott's Manual of Nursing Practice, 8th Edition, page 1080, documented nursing considerations under the heading, "Fractures for specific sites: Hip...provide constant monitoring and nursing care to reduce the risk of complications, such as...pressure sores. Provide meticulous skin care to prevent breakdown - ...inspect heels daily and use heel protection measures..." The resident's significant change MDS, dated [DATE], coded: * BIMS of 7 indicating severely impaired cognitive skills for daily decision making * Required extensive assistance of 2 persons for bed mobility and transfer * At risk for the development of pressure ulcers, no pressure ulcers present at this time Resident #2's Care Area Assessment (CAA) Summary identified Pressure Ulcer as a triggered care area. The CAA Worksheet, under the Care Area Pressure Ulcer, dated 6/12/12, identified the resident's risk factors for developing pressure ulcers including: pressure-requires regular schedule of turning, immobility, altered mental status, cognitive loss, poor nutrition, sedatives, antipsychotic and antidepressant medication and pain. The Care Plan Considerations area documented, "Res(ident) does not have pressure ulcer in this assessment. Has decreased with mobility since s/post (status after) surgical repair of hip. Care plan will not be implemented at this time." This was signed by a Staff Development nurse. Resident #2's admission Resident Assessment-Data Collection Form, dated 5/30/12, did not document any pressure ulcers on either heel. The resident's Braden Scale for Predicting Pressure Sore Risk, dated 5/31/12, was scored at 18 indicating the resident was at low risk for pressure ulcers. NOTE: The Braden Scale and the MDS/CAA Worksheet documented different assessments of the resident in three areas: * Mobility: CAA-immobile, MDS-required extensive assistance of 2 or more persons for bed mobility, Braden-slightly limited * Nutrition: CAA-poor nutrition, Braden-adequate nutrition * Friction & Shear: CAA-immobile, MDS-required extensive assistance of 2 or more persons for bed mobility, Braden-Potential Problem: Moves feebly or requires minimum assistance. Pressure Ulcer Development An Incident & Accident Report (I/A), dated 6/8/12, documented Resident #2 developed a 4.5 cm x 3 cm area of "skin slough" on his buttocks to the "right of (his) coccyx... Color normal sans (without) discharge, or discoloration, blances (sic)...1 layer of skin removed...RT (resident) spending increased amount of time in bed post hip fx (fracture)...barrier cream applied repositioned off Rt (right) side." The I/A Investigation documented, "...Q 2 hr (every 2 hour) repositioning..." An I/A, dated 6/29/12 at 10:15 pm, documented Resident #2 developed "red discoloration (with) open area to center on to R heel, L buttocks red discoloration...1. 7 cm x 7 cm red discoloration to R heel ... (with) open area to center that is 2 cm x 1.5 cm. 2. L buttocks has red area that is 2 cm x 1.5 cm. Noticed by LN during tx (treatment)...heels not being kept of (sic) mattress to relief (sic) pressure...Float bilat(eral) heels when in bed @ all times, Allevyn boot wrapped (with) kerlix to R heel along (with) padding boot..." The predisposing factor was identified as "limited mobility (secondary) [MEDICAL CONDITION]." On 9/14/12 at 9:00 am, the Administrator was asked for Resident #2's care plans since admission on 5/30/12. The care plan provided by the Administrator did not identify any problem areas or interventions related to pressure ulcers from admission on 5/30/12 until a temporary care plan, dated 6/30/12, after the development of 3 pressure ulcers, documented the problem, "New skin issues. R(ight) heel red disc & open area, L buttocks red area. Intervention: ...(change) dressings & float heels, encourage res(ident) to reposition when in bed..." On 6/28/12, Resident #2's physical therapy (PT) note documented, "Gait Pattern: Patient was able to ambulate further today..." On 6/29/12, a PT note documented, "He (Resident #2) is slowly improving gait and independence in transfers. Plan is to continue PT and progress gait and transfers per patient tolerance to help patient return to previous LOF (level of functioning)." The next PT note, dated 7/2/12, documented, "Additional Comments: Patient is cooperative with PT although we were not able to perform gait training due to wound on right LE (lower extremity). Wound is due to patient spending most of his time in bed..." On 7/4/12, the PT note documented, "...PT (patient) continues to not perform weight bearing activities due to wound on right LE. Plan to continue PT and advance to weight bearing when wound is healed." On 6/28/12, Resident #2's occupational therapy (OT) note documented, "...Patient completed sit to stand activities... Patient completed functional transfers..." On 7/2/12, the OT note documented, "...Patient has a pressure sore on the right foot and per nursing they would like him to stay off of the foot..." On 7/3/12, the OT note documented, "...Instructed CNA staff as to correct position for heels. Resident moving better overall but heels are sore." Resident #2 returned to the facility after a surgical repair of a [MEDICAL CONDITION]. The resident's CAAs triggered the area pressure ulcer. The facility failed to care plan pressure ulcer prevention interventions despite the nature of the resident's surgery and the risk factors the facility identified on the CAA worksheet. Subsequently, the resident developed a pressure ulcer on the right heel and the right and left buttocks. Pressure Ulcer Monitoring and Treatment a. Right Heel Pressure Ulcer 6/30/12: The right heel pressure ulcer was found on 6/30/12 and described in the nurses Progress Notes (PN) at 6:47 am as, "red discoloration that is 7 cm X 7 cm to right heel with open area to center of heel that is 2 cm x 1.5 cm...heel was cleansed an (sic) allevyn heel applied an (sic) wrapped with kerlix gauze to keep allevyn heel in place. Heels were floated on top of a pillow, right heel had padded boot applied to keep pressure off..." 7/1/12: A LN filled out a form documenting, "Problem Resident has a closed blister on R heel. May we apply zinc oxide and cover (with) allevyn heel. (Change) QD (every day) until resolved." The physician replied on 7/2/12 with, "OK as above." This treatment was documented as done daily on the resident's July 2012 TAR until 7/23/12. 7/3/12 at 8:31 am in PNs: The Wound Nurse documented in the PNs, "Resident has a closed blister with a 1 cm skin tear on right foot, area rederssed (sic) and kept floated at all times will monitor." The Wound Nurse also documented the presence of the right heel ulcer in a "Skin Binder." This binder contained the names of numerous residents with skin issues. The line item for Resident #2 contained an area to document his name, location of the ulcer, assessment date, Stage of ulcer, other (information), size, depth, drainage and response to treatment. The information contained in these areas documented the assessment was done on Resident #2 on 7/3/12. The location was a "blood blister to R heel." No staging was documented. Under "other" was "blister." The size of the wound was not documented. Response to treatment documented "Improved." Note: The Wound Nurse determined the right heel blister was "improved" but there were no measurements of the wound documented to indicate the wound was improving. 7/12/12 at 8:20 am in PNs: The Wound Nurse documented, "Areas to feet slowly improving, 3 cm area where skin sloughed off present, new dressing applied, will monitor closely." There was no documentation in the Skin Binder regarding Resident #2's right heel. Note: The Wound Nurse did not identify which foot the wound was on, did not measure the wound, identify if there was drainage, odor, color, tunneling, what stage the wound was, and the condition of the skin around the ulcer. Note: The Wound Nurse determined the wound was "slowly improving," but there was no condition of the wound or measurements of the wound documented to support the determination that the wound was improving. 7/14/12 at 4:25 pm in PNs: "...continues with dressing to feet. Were changed today per skin nurse..." Note: There was no documentation by the Wound Nurse in either the PNs or the Skin Binder regarding this dressing change and the condition of the wound. 7/16/12 on a facility form: A LN documented, "Problem: May we (change) order for Allevyn 3 x 3 apply zinc oxide and cover (with) allevyn 3 x 3 change QD and prn." The physician responded on 7/16/12 with, "OK as above." Note: There was no documentation of where the zinc oxide and allevyn was to be applied. 7/16/12 at 1:15 pm in PNs: Wound Nurse documented, "Dressing to foot changed, area clean and dry, measures 3 cm in diameter, red center... New order obtained to apply silvadine to heal (sic) and cover with an allevyn dressing. Change daily..." Note: There was no documentation of the location of the foot dressing - right or left. There was no documentation in the physician orders [REDACTED]. 7/16/12 in Skin Binder: Wound Nurse documented the wound was on the "L Heel," was a blister, was 3 cm, depth of 0.5 cm with serosanguinous drainage and was the "same." Note: The wound was identified on previous notes that it was on the right heel not the left heel. The note regarding the "L heel" documented the wound was now draining, was not staged, no documentation of odor of drainage, tunneling, or skin around the wound. 7/19/12 at 7:47 pm in PNs: A RN documented, "Res skin issues heels are continuing to heal; rt (right) heel is draining clear yellow fluid no odor..." NOTE: This note documented "heels" were continuing to heal. The PNs from 7/22/12 to 7/24/12 referenced below, documented the wound was to the left heel. The facility Wound Nurse documented, in the Skin Binder, that the wound was to the left heel beginning on 7/16/12 and continuing to 9/5/12. There was no other documentation in the physician progress notes [REDACTED]. 7/22/12 at 4:23 pm in PNs: A LN documented, "...Does continue with left heel open area. Allevyn dsg (dressing) in place..." 7/22/12 on facility form: A LN documented, "Problem: As per skin nurse: Can we (change) to dsg to L heel to: Monitor L heel site QD, (change) allevyn 3 x 3 Q 3 days and prn (as needed) (if soiled or missing) to L heel. Cleanse site (with) NS (normal saline) and apply skin prep peri (around)wound then place thin layer or duoderm paste to wound bed (with) dsg. (Change) Q 3 days & prn?" The physician response was, "OK." 7/23/12 at 6:00 pm in PNs: A LN documented, "...monitor L heel..." 7/24/12 at 11:10 am in PNs: A LN documented, "...continues to have open area to left heel..." 7/25/12 at 4:48 pm in PNs: A LN documented, "Wound dressing changed to right heel. Moderate amount of serosangous (sic) drainage noted to wound. Wound bed pink. Edges white...." 7/26/12 at 8:27 am in PNs: The Wound Nurse documented, "Area to heel cleansed and new dressing applied. Large amount of serosangneous (sic) drainage present, slightly foul smell present...request a wound consult..." 7/26/12 in facility Skin Book: The Wound Nurse documented, site, "L heel, Blister, 3 cm, 0.5 cm depth, serosanguineous drainage, ...will ask for wound consult." Note: The wound was on the right heel not the left heel. The wound was no longer a "blister." There were no measurements to define the actual size of the wound with length and width. There was no description of the peri-wound area or if there was tunneling. 7/27/12 on physician progress notes [REDACTED]. 8/2/12 in Doctor's Progress Notes: The Wound Nurse Consultant documented, "Pt (patient) has a Stage 3 ulcer R heel from (,) it is thought (,) following a [MEDICAL CONDITION]. He is diabetic, has a charcot foot and his ankle is fused. This area appears to have been a blister but has more depth now. 4 cm x 3 cm x .5 cm deepest. Debrided extra tissue & cleansed wound (with) sterile conservative sharp debridment. Plan is to use duoderm paste & foam dsg q 3 days. May be up for therapy as long as wound is progressing..." Resident #2's PNs and notes in the Skin Binder documented the right heel ulcer was healing. On 9/5/12 at 2:22 am, the PN documented the right heel was left open to the air. On 9/14/12 at 8:40 am, Resident #2's right heel ulcer was observed by 2 surveyors along with the facility Wound Nurse. The right protective boot was removed. The skin along the heel was scaly. There was no dressing present. The base of the heel had a 3 cm x 1.0 cm wound area. The area was mostly dry with scar tissue. The center, approximately 0.5 cm circular was also dry. There was no scab and no drainage from the wound. The wound was less than 0.5 cm deep and pale pink at the base. The surrounding tissue had no redness. The left heel was intact, without redness or any evidence of previous injury. b. Right Buttock Skin Slough An Incident & Accident Report (I/A), dated 6/8/12, documented Resident #2 developed a "4.5 cm x 3 cm area of "skin slough" on his buttocks to the "right of (his) coccyx... Color normal sans (without) discharge, or discoloration, blances (sic)...1 layer of skin removed...RT (resident) spending increased amount of time in bed post hip fx (fracture)...barrier cream applied repositioned off Rt (right) side." The I/A Investigation documented, "...Q 2 hr (every 2 hour) repositioning..." The PNs and Skin Binder contained no documentation that staff monitored this wound. The TAR documented that day and night shift were to "apply barrier cream (with) each brief change to R buttox (sic)." This treatment was started on 6/9/12. There was no documentation that this wound was healed. c. Left Buttock An I/A, dated 6/29/12 at 10:15 pm, documented Resident #2's, "L buttocks red discoloration... L buttocks has red area that is 2 cm x 1.5 cm. The predisposing factor was identified as "limited mobility (secondary) [MEDICAL CONDITION]." 6/30/12 at 6:47 am in a PN: LN documented, "...L buttocks has red area that is non-bleachable (sic) and 2 cm x 1.5 cm in size..." 7/1/12 at 7:03 am in a PN: LN documented, "...L buttock with non-blanchable red area..." Note: The PNs after 7/1/12 did not refer to either the left or right buttock areas, but refer to "buttocks." There was no documentation in any of the PNs nor in the Skin Binder regarding the measurements of either the right or left buttock areas and no description of the areas regarding color, drainage, odor, or tunneling. 7/3/12 in physician orders: "[MEDICATION NAME] ointment to peri area & buttocks BID and PRN R/T (twice a day and as needed related to) maintain skin integrity..." The resident's TAR documented this treatment was started on 7/4/12 and continued through August and September. 7/16/12 at 4:39 am in PN: LN documented, "...Continues to have reddened are (sic) to buttocks but area improving with tx (treatment)..." 7/17/12 at 2:09 am, 7/21/12 at 6:41 am, 7/25/12 at 5:50 am in PN: LN documented, "...Skin WDI (warm, dry, intact) with bandages intact on heel and buttox..." Note: There was no documentation that a bandage was placed on the buttocks and no documentation that a bandage on the buttocks was changed. 8/13/12 at 3:33 pm in PN: LN documented, "...Buttocks are clear and intact..." 7/12/12 in the Skin Binder: The Wound Nurse documented, "Hip/peri area, excoriation, size-peri area and buttocks, Improved." This exact same information was repeated in the Skin Binder documentation for Resident #2 on 7/16, 7/26, and 8/3. There was no further documentation in the Skin Binder regarding the buttocks after 8/3/12. On 9/14/12 at 8:40 am, Resident #2's buttocks were observed by 1 surveyor along with the facility Wound Nurse. The buttocks, coccyx and sacral region were observed to have intact skin. No scar tissue was noted. The right inner buttock was reddened. The Wound Nurse checked 3 right inner buttock areas and each area blanched. On 9/14/12 at 10:35 am to 11:08 am, the facility Wound Nurse was interviewed regarding pressure ulcers and Resident #2. The Wound Nurse said she was an LPN, had a certificate in another state, but was not certified by a national program as a wound nurse. She said she was not consulted regarding pressure ulcer prevention for Resident #2, but was called once the pressure ulcer on the right heel was discovered - "I get it once a problem develops." She said that Resident #2's heels should have been floated/off-loaded due to the [MEDICAL CONDITION] prior to the development of the right heel pressure ulcer. The Wound Nurse said that she has had good results healing pressure ulcers on other residents using zinc oxide on the heels. She said she did not have a reference that recommended this treatment as a standard of practice, "Just previous experience with previous doctors. No other resources." She said she recommended this treatment because, "I had a previous similar wound on another resident and it worked really well. As a rule it works if it's not an open area." She was asked about her PN and Skin Binder documentation. She said, "I need to write more detail on there. I agree." She stated that the assessment written in the Skin Binder from the week before, automatically populated the skin assessment areas for the current assessment and that she needed to change each area individually for the current assessment or the old information would remain in the assessment areas. When asked why she did not stage the wounds, she replied, "I was told by the nurse that did this prior to me that we weren't supposed to stage (the wounds)." She was asked about the boots that were used for Resident #2's heels and why they were selected. She said, "They were a sample (that a vendor had given the facility). They are better than heel protectors." Resident #2 developed 3 pressure ulcers when the facility failed to implement preventative measures to relieve pressure on the resident's buttocks and heels. The facility failed to consistently and accurately monitor each ulcer for size, drainage, odor, tunneling, appearance, and improvement with treatment. The facility failed to provide treatments for the ulcers based on current standards of practice and based on the resident's specific needs. 2. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 6/8/12, coded: * BIMS score of 6 indicating severely impaired cognitive skills for daily decision making * Required limited assistance of 1 person for bed mobility and transfer * No pressure ulcers present The CAA for pressure ulcers, dated 6/12/12, documented, "He will be care planned that he will not develop any avoidable pressure ulcers..." The resident's 14-day PPS scheduled MDS assessment, dated 7/5/12, coded: * BIMS score of 5 indicating severely impaired cognitive skills for daily decision making * Required extensive assistance of 2 or more persons for bed mobility and transfer * At risk of developing pressure ulcers, but no pressure ulcers present Note: Resident #1 developed pressure ulcers on his bilateral heels on 6/28/12. Resident #1's Admit/Readmit Screener form, dated 6/21/12, documented the resident had a "right heel bruise." Note: There were no measurements of the bruise or description of the bruise. The Wound Nurse was not notified to help evaluate the bruise. A description of a deep tissue injury was present on the Screener form as, "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue." Resident #1's admission Braden Scale for Predicting Pressure Sore Risk score was 16 indicating he was a low risk for pressure ulcers. The resident's care plan documented the problem, dated 6/13/12, "...potential for developing pressure ulcers..." Interventions included, "...Follow facility policies/protocols for the prevention/treatment of [REDACTED]. NOTE: The facility policies/protocols for skin breakdown, dated 7/11/11, included 2 pages. The first page was entitled, "Stage I" and included interventions for Stage I pressure ulcers. The second page was entitled, "Stage II, Stage III and Stage IV" and included interventions for those pressure ulcers. Under the problem, dated 6/13/12, "...Self Care Performance...," interventions were, "...Bed Mobility: He requires limited assist of one caregiver to reposition and turn in bed..." The resident's admission PN, dated 6/21/12 at 5:15 pm, documented, "...Noted 2+ [MEDICAL CONDITION] to pedal areas. Pitting with no c/o (complaints of) tenderness. Enc. (encouraged) to be kept elevated while in recliner. Shin very fragile and tissue paper thin (see skin sheet for more details)... Res(ident) requires assist with ADL's as related to confusion and [MEDICAL CONDITION] PNs documented the following: - 6/22/12 at 12:43 pm: "Resident has sent (sic) in recliner in am...Resident has dementia and is very confused at times..." - 6/24/12 at 3:22 am: "...Resident was encouraged throughout evening to sit in recliner in room to relive (sic) pressure from bottom with no success resident was increasing confused an (sic) wanted to sit in w/c (wheelchair)...assisted to bed at hs (bedtime). Resident had feet elevated, [MEDICAL CONDITION] 2+ [MEDICAL CONDITION] was noted..." - 6/26/12 at 1:46 pm: "Resident remained in bed for breakfast..." An I/A, dated 6/28/12 at 10:30 am, documented Resident #1 had, "white nonblanchable areas bilateral heels. R heel 3 cm x 2 1/2 cm, 1/2 cm purple area to inner medial heel, L heel 1 1/2 cm x 1 cm non blanchable area..." Predisposing factors were described as "...decline in condition..." Care initiated or treatment provided was, "float heels, heel protection." A 6/28/12 PN note at 2:35 pm documented, "Resident was found to have white non blanchable areas to bilateral heels. Right heel 3 cm x 1 cm with 1/2 purple area to medial heel area. Left heel 3 1/2 cm x 1 1/2 cm non blanchable area..." On 6/29/12 a LN informed the physician of the condition of the bilateral heels. The physician responded on 6/29/12 with, "Cover (with) foam pads & change every 3 days & heel protection." On 7/1/12 at 5:00 am, an I/A documented Resident #1 had, "fluid filled areas to bilat(eral) heels...Resident has been refusing out of bed, not eating well." The heels were described as, "dark fluid filled blisters. L heel 6 cm, R heel 8 cm circular." The plan of care was documented as, "Zinc oxide to bilat heels, cover with kerlix, heel protectors in place, float heels while in bed." A request was sent to the physician on 7/1/12 by a LN, "Resident has closed blisters bilateral heels. May we apply zinc oxide to heels and cover (with) allevyn heel and kirlex (sic) (change) QD until resolved." The order was signed by the Physician Assistant on 7/2/12. (Please see F274 for failure to conduct a significant change MDS assessment.) Resident #1's PNs, dated 7/1/12 at 3:15 pm, documented, "...BLE (bilateral lower extremity) +2 [MEDICAL CONDITION]. Dark filled blisters measuring 6 cm on left heel and 8 cm on right heel...Legs elevated and floated while in bed, when in w/c heel protectors in place..." The Wound Nurse documented the condition of Resident #1's heels as follows: - 7/3/12 at 8:28 am in PN: "Resident has multiple skin issues this week, bilateral heels and arms, closed blisters on bilateral heels, intact except a 1 cm skin tear, new dressing applied... - 7/3/12 in Skin Binder: "Heels/Arms, Feet and arms, initial assessment this week." No size was recorded. The wounds were not staged. - 7/12/12 at 8:17 am in PN: "Treatments done this am, areas to bilateral heels improving slowly, new skin forming and old sloughing off..." - 7/12/12 in Skin Binder: "Heels/Arms, Feet and arms, 8 cm, 6 cm, Improvement slow." Note: The documentation from 7/12 does not document the size of the heels with length or width and does not identify if the heels or arms are "8 cm" and "6 cm." There was no documentation of the color of the wounds, if the blisters were still present, if there was any odor, tunneling, condition of the skin around the wounds, or the stage of the wounds. - 7/16/12 in Skin Binder: "Heels/Arms, Feet and arms, 8 cm, 6 cm, Improvement slow." Note: The documentation from 7/16 does not document the size of the heels with length or width and does not identify if the heels or arms are "8 cm" and "6 cm." There was no documentation of the color of the wounds, if the blisters were still present, if there was any odor, tunneling, condition of the skin around the wounds or the stage of the wounds. Note: The documentation in the Skin Binder for 7/16/12 was identical to the documentation on 7/12/12 - 7/17/12 at 9:58 am in PN: "...Bilateral heels improving, dressings reapplied as ordered..." There was no documentation of the color of the wounds, if the blisters were still present, if there was any odor, tunneling, condition of the skin surrounding the wounds, or the stage of the wounds. - 7/26/12 in Skin Binder: "Heels/Arms, Feet and arms, 8 cm, 6 cm, Improvement slow." NOTE: The resident was discharged to the hospital on [DATE] and was not in the facility on 7/26. - 8/3/12 in Skin Binder: "Heels/Arms, Feet and arms, 8 cm, 6 cm, Improvement slow." NOTE: The resident was discharged to the hospital on [DATE] and was not in the facility on 8/3. (See F514) A PT note, dated 6/28/12 at 8:45 pm, documented, "Noted red areas on bilateral heels with a blister on the left noted. Nursing was notified and we evaluated the wounds together. Due to this I did not perform gait training with this patient or any weight bearing activities. I placed padded booties on feet and placed a pillow under his feet to deweight his ankles." PT notes continued to document from 6/28/12 to 7/18/12 that weight bearing activities were not performed with the resident. On 7/19/12 at 3:19 pm, a PT note documented, "Patient continues to have wounds on bilateral feet which wound (sic) become irritated with weight bearing activities. Plan is to d/c (discontinue) PT (physical therapy) today. May resume PT (physical therapy) when wounds are healed and patient is able to participate in weight bearing activities." On 9/14/12 at 10:35 am to 11:08 am, the facility Wound Nurse was interviewed regarding Resident #1's bilateral heel pressure ulcers. She was asked about the initial assessment on 6/21/12 that documented a "bruise" on the resident's right heel. She stated that she did not think the "bruise" was indicative of a deep tissue injury, but she was not called to evaluate the area until the blisters were found on the heels. When asked what precautions should be taken when a resident was admitted with this type of "heel bruise," was in a recliner, and had [MEDICAL CONDITION] in the legs. She said, "The feet should have been uploaded (off-loaded) at all times, heel protectors as he allows, pillows to off-load feet and heel protectors when in the recliner and pressure relieving such as use the wheelchair, not let him ambulate as much." When asked about the same incomplete documentation in the Skin Binder for numerous days, she said, "The (electronic) system automatically prints the same information each week unless I change it." She stated, "I need to write more detail on there. I agree." Resident #1 was admitted to the facility with a bruise on his right heel and 2+ [MEDICAL CONDITION] to the lower extremities. He required 2 persons to move in bed, but the care plan said he only needed cueing for bed mobility. He sat in a recliner with his feet elevated and was encouraged to do so by the nursing staff. The facility failed to implement any precautions to prevent pressure ulcers to his heels until after he developed Stage II pressure ulcers to his feet and possibly deep tissue injury preventing him from continuing his physical therapy treatments. On 9/14/12 at 3:30 pm, the Administrator and the DON were informed of the issues. The facility provided no other information or documentation that resolved the concern. 3. Resident #3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 5/17/2012, coded: * BIMS score of 3, indicating severely impaired cognitive skills for decision making. * Had an indwelling catheter. * At risk for pressure ulcers. Resident #3's care plan documented the problem, dated 6/6/2012, "(Resident #3) has the potential for developing pressure ulcers." The interventions for this problem included a weekly skin assessment. Resident #3's care plan also documented the problem, dated 6/6/2012, "(Resident #3) has a Foley catheter ..." The goals included, "I will be/remain free from catheter related trauma..." Interventions included, "CATHETER: ...Leg strap to secure the catheter tubing which is to be checked every shift. Change drain bag every 2 weeks and prn. Routine catheter care every shift. (use a non-latex cath) Date initiated 6/6/2012. Revision on 8/29/2012." The temporary care plan documented: * 8/2/2012: "4 reddened areas to back of (R) (right) and (L) (left) leg." Interventions were, "1. Cath (catheter) strap replaced. 2. Observe until resolved." Goal was "healing." * 8/10/2012: "Cath tube irritation caused blisters on (R) thigh." Interventions were, "1. (check) leg cath strap Q (every) tube flush. 2.Tighten and readjust as needed." The goal was to, "(decrease) skin irritation." Resident #3's "Active Orders from 8/1/2012 to 8/31/2012 form included an order for [REDACTED]." Resident #3 's TAR for July 2012 documented, "Cath strap to cath and leg at all times. Check placement every shift." This form was blank for day shift and night shift on 7/30/2012, and for day shift on 7/31/2012. Resident #3's TAR for August 2012 documented, "Weekly skin assessments (-) = No new skin issues, (+) = New skin issues - proceed to alert ch

Based on observation, staff interview, and record review, it was determined the facility did not prevent a resident from developing pressure ulcers. This was true for 1 of 3 residents (#3) sampled for the pressure ulcers. This failed practice had the the potential to cause harm due to an alteration in skin integrity which could lead to further skin breakdown and possibly infection. Findings included: On 11/20/12, an on-site follow-up survey was conducted at the facility. The facility's plan of correction for F314 included new skin risk assessments for all residents and resident care plans updated with interventions for residents at risk for skin breakdown. Despite these measures the following occurred: Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's Quarterly MDS assessment, dated 11/9/12, documented severely impaired cognitive abilities, no rejection of care, was totally dependent on staff for ADL's and mobility, had a history of [REDACTED]. The MDS documented pressure reducing devices to her chair and bed. Resident #3's CNA care guide documented under the "Skin" area a checkmark for, "Routine." The back of the form documented further instructions, including an intervention dated 10/20/12 for, "Shoes and socks on while up in geri chair." NOTE: There was no mention of this measure on Resident #3's care plan. On 11/12/12, a facility I/A form documented the following: - In the "Description of what happened" area, "CNA noted a blister on left inner aspect of heel (with) some redness around it." -In the "Predisposing Factors" area, "Resident has been seen rubbing her feet on the geri chair and putting them between the foot rests." -In the "Change in Plan of Care" area, "Areas to be kept floated at all times and apply heel protectors." On 11/12/12, a "Condition Change Form" documented, "Resident aquired (sic) a 3cm X 3cm white fluid filled area on the inner part of her left heel. Heel protectors applied and feet floated." A "Care Plan Update" form on 11/12/12 documented "Float heels. Apply heel protectors." Resident #3's "Skin Impairment" sheet documented: -11/12/12, "3cm X 3cm white fluid filled area intact skin." -11/19/12, "heel protectors applied area dry skin intact left open to observe heel protectors on." The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities for F314 defines Stage II pressure ulcers as, "Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister." On 11/20/12 at 10:45 AM, Resident #3 was observed by a surveyor to be sitting in her geri-chair without shoes on. No heel protectors were in place. On 11/20/12 at 11:10 AM the facility's wound care nurse was asked about the development of Resident #3's blister. The wound care nurse stated Resident #3 was prone to rubbing her heels on the foot rests of her chair and was supposed to wear socks and shoes when in her geri-chair. The wound nurse stated the blister developed because Resident #3 did not have her shoes on as directed on her care guide, and "her heels rubbed on the chair." The wound nurse stated, "Her heels had been off-loaded in bed, but not in the chair." The wound nurse stated Resident #3's new care plan was to float her heels in bed and provide heel protectors when in her geri-chair. The facility failed to implement measures to prevent Resident #3 from developing a pressure area after they had identified she was at risk for skin breakdown. Once skin breakdown occurred, the facility failed to ensure measures were in place to prevent further breakdown. On 11/20/12 at 2:45 PM the administrator and the DON were informed of these findings. The facility offered no further information.

Based on record review and staff interview, it was determined the facility failed to ensure Resident #10 was not harmed when he had a history of [REDACTED]. This was true for 1 of 5 ( #10) sampled residents. Findings include: Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 10/28/12, documented the resident: * Was severely cognitively impaired, * Had verbal and physical behaviors, rejected cares, which worsened since admission, * Required extensive assistance of one for transfer, dressing, eating, toileting, personal hygene and bathing, * Required extensive assistance of two staff for ambulation, and * Had a fall with fracture prior to admission. The resident's "24 Hour Initial Healthcare Maintenance Care Plan," dated 10/22/12, documented: * Problem: 2 person assist with transfers, Interventions: none listed, * Problem: Alert and Confused; Intervention: Interact and redirect as needed for safety, * Problem: Mood/Behavior, Angry loud, Vocals, Kick/Spit/Hit, Incontinence in inappropriate areas; Interventions: Observe and chart any target behaviors, redirect and chart behaviors. The initial care plan failed to address the resident's history of falls with injury. On 10/25/12 at 6:00 p.m. a "Care Plan Update" documented a problem: Poor safety awareness and confusion - assisted fall with ST (skin tear) to 5 x 3 cm to Left hand with steri strips (sic). The interventions were: 1) Monitor for s/s (sign and symptoms) injury further x 72 hours. 2) Monitor while in lobby, resident getting up. A "Fall Risk Assessment" was completed on 10/25/12 at 6:10 p.m. and documented that the resident had "multiple falls" under History of Falls within last six months. The resident's "Gait Analysis" documented: 1) Unable to independently come to a standing position, 2) Exhibits loss of balance while standing, 3) Strays off the straight path of walking, 4) Requires hands-on assistance to move from place to place, 5a) Uses short discontinuous steps and/or shuffling steps, 6) Has lurching, swaying or slapping gait, 7) Exhibits jerking or instability when making turns, 8) Uses an assistive device, e.g. cane, walker etc. The resident scored a 35.0 on the tool which classified him at "High Risk" for falls. The resident had multiple nursing "Progress Notes" (PN) of non-compliance and attempting to ambulate without assistance. They documented: *On 10/24/12 at 12:38 a.m., "...Was with the hall monitor during the evening and remained in the lobby. Self transferred from W/C to chair several times. Assigned floor staff to remain with resident during night shift until 12:30 a.m. when resident finally went to sleep. Resident had aggressive behaviors toward staff punched at staff and hit wall while staff was assisting resident to ambulate. Resident refused to remain in W/C...." * On 10/24/12 at 7:06 p.m., "....Soft collar is worn at all times r/t (related to) broken neck..." * On 10/25/12 at 2:20 a.m.,"....During evening, resident required constant monitoring by hall monitor and staff. Attempts self transfer, and unaware of safety issues.... Resident self ambulated to lobby in attends and gown during the night, sat on chair..." * On 10/26/12 at 12:45 a.m., "Resident has been up most of the evening. Has been aggressive with staff when providing cares...When resident has been assisted to bed, has gotten back up and transferred self without cares.(sic) Has attempted self transfer x 9 times. Staff has monitored closely and prevented falls...." * On 10/26/12 at 6:05 p.m., "Resident has not attempted any further self-transferring..." * On 10/27/12 at 6:18 a.m., "Resident made numerous attempts to ambulate during evening, use loud vocals...LN and staff heard loud stomps coming form (sic) room resident found ambulating in middle of room...Resident was noted to be awake through the night talking to self." The resident fell on [DATE] at 1:30 a.m. and sustained a fracture of the left hip. The was no documentation in the progress note until the resident returned to the facility on [DATE] then an LPN made a late entry note. The PN documented,"...Resident made numerous attempts to stand up in dining room...Resident made several attempt to ambulate with no assistance, resident was encouraged to stay in lobby for increased supervision....On 10-28-12 about 0100 (1:00 a.m.) resident was noted to be awake; staff asked resident if he needed to use the restroom and the resident stated ?no?. (sic) Approx(imately) at 0115 (1:15 a.m.) and 0120 (1:20 a.m.) resident was noted to be in bed resting with respirations even an (sic) unlabored. At approx 0120-0130 (1:20 - 1:30 a.m.) loud foot stomping was heard coming from room, LN, and staff members rushed in to room, before LN and staff could get to room loud bang noise was heard. Resident was noted to be lying on floor as staff entered room....When he moved resident would c/o (complain of) increased pain to left hip...." The administrator and DON were interviewed 11/20/12 at 2:30 p.m. about the fall. They stated that the resident did have a one to one for the first 24 hours after admission, but that level of supervision was discontinued after the first 24 hours. They were aware that the reasident was a high risk with previous injury falls. They did indicate that the resident was not happy about having increased supervision. No further information was provided.

Based on observation, staff interview, and record review, it was determined the facility failed to provide necessary care to prevent aspiration for residents at risk of aspiration and aspiration pneumonia. This was true for 3 of 5 (#s 1, 2, and 6) residents sampled for tube feeding. The necessary aspiration precaution for elevating the head of the bed at least 30 degrees during all tube feedings, as ordered by the physicians and documented in the Care Plans, was not implemented, placing the residents at risk for injury or death. This constituted immediate jeopardy (IJ) to Residents #s 1, 2, and 6's health and safety. In addition, based on observation, staff interview, and record review, it was determined the facility failed to ensure physician orders [REDACTED]. Resident #5 was harmed because of a delay in treatment for [REDACTED]. Resident #s 2 and 3 were not provided with assistive devices ordered to protect the residents' fragile skin. The facility was informed verbally and in writing of the immediate danger to Residents #s 1, 2, and 6 on 10/19/11 at 9:30am. On 10/19/11, at 12:40 pm, the facility provided an acceptable plan of correction to protect residents and the IJ was abated. This abatement plan included identifying all residents receiving enteral nutrition and the risk for aspiration; the measurement and marking of all beds with purple tape to clearly indicate 30 degrees; a protractor diagram on the wall above the beds of all identified residents; staff education on the protractor diagram and the markings on the beds; and audits to verify correct HOB elevation. Findings included: According to the American [MEDICATION NAME] Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition, (http://www3.us.elsevierhealth.com/ gastro/policy/v108n4p1280.html), the following guidelines should be followed with all enteral nutrition: "To limit the risk of aspiration with [MEDICAL CONDITION] feeding, the following precautions should be taken: raise the head of the patient's bed 30?-45? during feeding and for 1 hour after, use intermittent or continuous feeding regimens rather than the rapid [MEDICATION NAME] method, [MEDICAL CONDITION] residuals should be checked regularly, and all patients should be watched for signs of feeding intolerance." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent significant change MDS assessment, dated 8/19/11, documented the following: * Severely impaired cognitive skills * Extensive assist requiring two persons for bed mobility, transfers, walking in the room and corridor, dressing, toilet use, and personal hygiene * Total dependence requiring two persons for eating * Swallowing disorder with loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals * Feeding tube * 51 percent or more of total calories received through feeding tube * 501 cc (cubic centimeters)/day or more of average fluid intake received through feeding tube The resident's Physician order [REDACTED]. a. Order dated 9/2/11, Fiber Source HN 110ml/hr x 12 hrs (110 milliliters per hour for 12 hours), continuous 9pm-9am (Nocturnal) per [DEVICE] continuously. (HOB elevated 30-45 degrees) Provides: 1320 ml formula, 70 g (grams) protein and 1069 ml free H20 (water). b. Order dated 9/2/11, Ensure 237 ml [MEDICATION NAME] per [DEVICE] three times a day related to Supplement. (Noon, 3pm, 6pm) Provides 711 ml formula, 754 kcals (kilocalories), 26 g protein, 597 ml H20. The resident's Care Plan for ADL, under the problem, "...risk for Self Care Deficit...," was the plan of approach, "Hi/Low bed at 45 degree angle, in lowest position and unplugged 9/2/10." Additionally, the resident's Care Plan for "Needs tube feeding due to medical conditions [MEDICAL CONDITIONS] secondary to Meningitis," was the plan of approach, "Keep head of bed elevated 45 degrees during infusion of feeding." On 10/18/11 at 7:30 am, Resident #1 was observed asleep in her room, receiving enteral nutrition through a [DEVICE]. The head of the bed was observed to be at no more than 10 degrees elevation. ADON #1 was asked to come to the resident's room and observe the position of the resident. When asked what the elevation of the resident's bed appeared to be, ADON #1 stated, "Not 30 degrees." There were no markings on the bed to indicate the degree of elevation. ADON #1 attempted to raise the bed but the bed control was not functioning. After examining the bed, ADON #1 stated the bed control had been "squished" in the frame of the bed and would have to have Maintenance come fix the bed. ADON #1 stated the resident would need to be out of the bed and the bed swapped out for a different bed that functioned properly. The resident was left in ADON #1's care and supervision. The surveyor asked ADON #1 what the toileting schedule was for Resident #1 and he stated the resident was checked every two hours. CNA #2 was interviewed on 10/18/11 at 11:15 am. CNA #2 stated she came on duty at 6 am and had not changed Resident #1 this morning. When asked whether she was aware the resident's bed was not functioning properly, she stated the night shift would have done rounds at 5:30 am and they would have reported the bed as being broken. CNA #2 stated the bed was in the same position the surveyor and ADON #1 observed, that being the head of the bed at approximately 10 degrees. CNA #1 stated she was unaware the HOB was supposed to be at 30 degrees minimum elevation. Since Resident #1 received continuous enteral feedings at night, the survey team made the decision to enter the facility that night to observe all residents receiving continuous enteral feedings, in order to ensure the correct administration of such feedings and to further assess the scope of any deficient practice in the facility. On 10/18/11 at 11:50 pm, the surveyor entered Resident #1's room and observed the resident receiving enteral nutrition through her [DEVICE]. The HOB was at approximately 20 degrees elevation, not at the physician ordered mininum of 30 degrees. The surveyor obtained two other surveyors to witness the elevation of the bed, as well as LN #1 who was on duty in that hallway. When asked what the elevation of the HOB was for Resident #1 at that time, LN #1 stated he thought it might be close to 30 degrees. The surveyor discussed this with LN #1 who then conceded it was not at 30 degrees. LN #1 then stated he had worked two days prior and had found the resident's bed control to be broken and that the HOB could not be raised. He stated he had reported this issue to Maintenance on Monday morning (10/17/11) to be fixed. As referenced earlier, the bed was found by the surveyor to be broken that morning, another 24 hours after LN #1 stated he had reported the issue. This meant the resident had been receiving enteral feedings through her [DEVICE] for 3 days without intervention for safe administration. This placed the resident at risk for aspiration, aspiration pneumonia and possible death. LN #1, as the charge nurse on duty, was advised to immediately place the resident in the safe, physician ordered minimum elevation of 30 degrees for her HOB and to ensure the safe administration of any enteral nutrition for any other residents in the facility, with documentation of such actions, before the surveyors left the building. The surveyors left the building on 10/19/11 at 12:15 am with this assurance from LN #1. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's record included a telephone order from the physician, dated 10/12/11, which documented the resident's [DEVICE] feeding as [MEDICATION NAME] 1.5, 250 mg (milligrams) every 6 hours, flush with 50 ml (milliliters) before and after. Head of the bed at 30 degrees. Check residuals and call physician if residual 30 cc or greater. Resident #6 was observed on 10/18/11 at 10:30 am, receiving a [MEDICATION NAME] enteral nutrition feeding through his [DEVICE]. The resident was laying supine in his bed, with the HOB at approximately 10 degrees. The resident was observed to receive a [MEDICATION NAME] feeding of 250 ml of enteral nutrition through his [DEVICE], with his HOB at less than 30 degrees. After the procedure, the surveyor immediately asked LN #3 what the elevation of the resident's bed was and she stated she thought it might be at 20 degrees elevation. Again, the bed did not have any markings to indicate elevation of the head of bed. The surveyor advised LN #3 the HOB had to be at least 30 degrees and to raise the head of bed immediately to avoid aspiration risk for the resident, which the LN was observed to correct after it was brought to her attention. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent significant change MDS assessment, dated 9/2/11, documented the following: * Moderately impaired cognitive skills for daily decision making * Usually understood others, usually understood by others * Received nutrition via PEG (percutaneous endoscopic gastrostomy) tube * Total dependence on one staff member to meet nutritional needs * Extensive assistance of at least two staff members required for bed mobility, transfers, ambulation, dressing, personal hygiene, and toileting Resident #2's recapitulated physician's orders [REDACTED]. * "Boost Glucose Control 1185 ml (five, 8 (ounce) boxes) continuous X 8 hrs (hours) (overnight) (at) 150 mlhr (milliliters per hour) per [DEVICE]. Every day. (Head of bed 30 degrees) ...." The resident's Nutritional Needs Care Plan, dated 9/6/11, documented the following: * "Problem: Needs tube feeding due to medical conditions of dysphagia aspiration." * "Intervention/s: Keep head of bed elevated 45 degrees during infusion of feeding." NOTE: The resident's recapitulated physician's orders [REDACTED]. On 10/18/11, at 11:50 p.m., Resident #2 was observed asleep in bed with a container of Boost Glucose Control formula infusing at 150 ml/hr through the resident's PEG tube. No markings were in place to indicate the HOB angle of the resident's bed at the time of the observation, however two surveyors in the room determined the resident's HOB was less than 20-degrees. LN #4, who was in the room at the time of the observation, was asked to describe the resident's HOB angle. LN #4 stated the HOB was at 30-degrees. When surveyors questioned the accuracy of that measurement and how LN #4 determined that the HOB was at 30-degrees, LN #4 adjusted the HOB to a higher angle. Nursing Interventions & Clinical Skills, 3rd ed., by Elkin, Perry, and Potter, documented, "Implementation for Administering Tube Feedings: Elevate head of bed to high-Fowler's, at least 30 degrees ... Reduces risk of aspiration during feeding with head higher than stomach." 4. Facility Incident and Accident Reports documented that Resident #2 was assessed with [REDACTED]. Resident #2's Skin Care Plan, dated 9/7/11, documented, "Geri gloves on at all times except during showers." On 10/19/11, at 3:50 p.m. the RN Consultant provided an Individual Plan Report (Care Tracker) for Resident #2 and stated the Care Tracker had the most up-to-date information on the resident and that the Care Plan for Resident #2 may not be accurate, implying the geri-gloves were no longer in use. The Care Tracker for Resident #2 that was described by the facility's RN Consultant as a condensed version of the Care Plan accessible to CNA staff for reference was dated 9/30/11 and documented, "Observe arm placement prior to going through doorways. Geri gloves daily except during showers. Leave open to air at night. Elbow protectors bilater(ally) at all times except for showers." Resident #2 was not observed with geri-gloves and/or elbow protectors at any time during the facility's annual recertification and state licensure survey, from 10/17/11 at 2:47 p.m. through 10/20/11 at 3:45 p.m. On 10/20/11, at approximately 11:30 a.m., the facility's Administrator and RN Consultant were apprised of the findings. No further information was provided by the facility. 5. Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 7/19/11, documented the following: * Severely impaired cognitive skills for daily decision making * Resisted cares * Extensive assistance of at least two staff members required for bed mobility, transfers, locomotion (wheelchair), dressing, and toileting * Total dependence on at least two staff members for eating * Always incontinent of bowel and bladder Resident #4's Skin Protection Care Plan, dated 7/20/11, documented the following: * "Problems: (Resident #4 is) at risk for bruising, ecchymoses or skin tears r/t (related to) [MEDICAL CONDITIONS], TBI ([MEDICAL CONDITION]), OBS, meds (medications) which may cause increase in bruising, crawls around on floor mat." * "Plan of Approach: Geri gloves to arms." On 10/19/11, at 3:50 p.m. the RN Consultant provided an Individual Plan Report (Care Tracker) for Resident #4 and stated the Care Tracker had the most up-to-date information on the resident and that the Care Plan for Resident #4 may not be accurate, implying the geri-gloves were no longer in use. The Care Tracker for Resident #4 that was described by the facility's RN Consultant as a condensed version of the Care Plan accessible to CNA staff for reference was dated 10/19/11 and documented, "Geri gloves to arms ... Geri-gloves." Resident #4 was not observed with geri-gloves at any time during the facility's annual recertification and state licensure survey, from 10/17/11 at 2:47 p.m. through 10/20/11 at 3:45 p.m. On 10/20/11, at approximately 11:30 a.m., the facility's Administrator and RN Consultant were apprised of the findings. No further information was provided by the facility. 6. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent quarterly MDS assessment, dated 9/13/11, documented there had been no rejection of cares, such as medication, laboratory draws, etc. In addition, the resident was assessed as requiring extensive assistance of 1 person for personal hygiene, dressing, transfers and bed mobility. Under the Oral/Dental section of the assessment, the resident was checked for obvious or likely cavity or broken natural teeth. The resident's 9/14/11 Care Plan for Nutrition identified problems of intake of less than 75% at most meals and need for therapeutic diet. Though "Mouth Pain" was a category under the problem column, it was not checked as an issue for the resident. The ADL Care Plan included an approach of oral care every a.m. and p.m. and as needed. No other instruction for oral care was present in the plan. Review of Nurse's Notes from 7/17/11 through 10/7/11 revealed the following entries: 7/17/11 - 1:10 p.m. Resident #5 refused to eat lunch. Resident was asked if his mouth hurt and he answered, "yes." Offered [MEDICATION NAME] which was accepted. 7/18/11 - 3:00 p.m. Refused lunch. 8/2/11 - 7:00 p.m. Swollen area over right jaw line. Went to dentist and [MEDICATION NAME] 500 mg by mouth 3 times daily for 10 days was ordered for abscess. Note stated, "Will set up return appt(appointment) to have tooth extracted." Guardian was notified. 8/4/11 - 1:15 p.m. Did not eat breakfast or lunch. When offered food the resident reportedly just pointed to his tooth. Liquids offered at room temperature due to the discomfort. Tooth described as "abscessed." 8/5/11- 12:50 a.m. Ate only cake for dinner. Complained of tooth pain. Pain medication given with yogurt. 8/5/11 - 1:35 p.m. Physical behaviors occurred when staff attempted to give him food or get him out of bed. 8/8/11 - 12:35 a.m. Complained of tooth pain. Medicated with relief. 8/8/11 - 8:30 a.m. Swelling appeared to be gone. Note: Nurse's Notes referred to the tooth as "abscessed" until 8/9/11. 9/4/11 - 1:30 a.m. Complained of tooth pain. Medicated with relief. 9/6/11 - 3:12 a.m. Refused to go to bed. Complained of tooth pain. Medicated with [MEDICATION NAME]. 9/12/11 - 1:25 p.m. Complained of tooth pain. Medicated with relief. 9/12/11 - 10:00 p.m. Order for antibiotic treatment for 10 days for left hip wound. 9/24/11 - 10:35 a.m. Complained of tooth pain. Medicated with relief. 9/25/11 - 12:45 a.m. Complained of tooth pain. Medicated with relief. 9/30/11 - 6:40 p.m. Complained of tooth pain. Medicated with relief. 10/1/11 - 2:40 a.m. Complained of tooth pain. Medicated with relief. Physician's Progress Notes for dental visits were reviewed and the following documents noted: 2/5/09 11:30 a.m. Resident seen for pre-operative visit. [MEDICAL CONDITION] present in right foot. Recommendation against dental surgery at that time. 8/2/11 Dentist documents they are not equipped to provide restorative treatment in the office. (Care giver in attendance with the resident) remarked that he was scheduled to be put under (sedation) and have treatment done in a local hospital with a dentist from a major city over a year ago, but a foot infection prevented that from happening. The dentist stated they would attempt a referral again. 10/19/11 Report with pictures of teeth indicating 3 areas of the resident's mouth needing work. No progress note or other information present. The 9/13/11 quarterly Social Service Progress Note documented the resident was having tooth pain at the time, and that the guardian was working with Indian Affairs to get some funds released to do the dental work. A 9/22/11 Social Services Progress Note documented again that the guardian was working with Indian Affairs for funds for dental work, and that he continued to experience dental pain. On 10/18/11 at 9:50 a.m. the social services designee was interviewed about the dental care issues. She stated the resident had seen a dentist, (no date mentioned) and the guardian was trying to obtain funds. On 10/19/11 at 11:20 a.m. the RN consultant and Unit Manager were interviewed in regard to the resident's dental issues. They stated a referral was made in 5/11, but the resident had to be sedated for the procedure, which was difficult to arrange. A conversation ensued about the foot infection preventing him from receiving the care some time in 2010, and that the facility did not need to wait for money from Indian Affairs to schedule the procedure. No further information was provided. On 10/20/11 at 8:30 a.m. the social services designee was again interviewed about the dental care issues. She confirmed at that time that the dental issues had not been resolved, and there was no information available on progress with a referral to obtain the needed care. Resident #5 was harmed when the facility failed to ensure timely treatment for [REDACTED]. The resident experienced the inability to eat regular foods during periods of pain, which had the further potential to impact his overall well being.

Based on observation, staff and resident interviews, record review and a complaint received from the general public, it was determined the facility failed to ensure that 2 of 4 sampled residents (#2 and #4) identified with swallowing deficits, received thickened liquids as ordered by their physicians. Resident #2 was at serious risk for aspiration when she received water in her room that was not thickened to honey consistency, as ordered by her physician. This was also the case for Resident #4 who had a physician order [REDACTED].#2 and #4 who were at risk for aspiration and choking from thin liquids, which could result in serious illness or death. Additionally, the facility failed to ensure that one of one resident (#1) who had been hospitalized was accurately and completely assessed by evaluating results of interventions related to treatment for [REDACTED]. The resident was harmed when he suffered extreme pain and his medical condition deteriorated rapidly. The facility did not call the resident's physician when a rapid decline in the resident's condition was observed. (Refer to F157 as it relates to the immediate notification requirement). The facility's failed practice was brought to the attention of the facility's Administrator and Director of Nursing Services on April 28, 2011 at 2:20 pm, when the facility was provided with specific details of the failure to ensure residents at risk for choking or aspiration received fluids as ordered by their physician. On April 28, 2011 at 4:00 pm, the facility provided the survey team with an acceptable plan of correction and the immediate jeopardy was abated. The plan of correction was as follows: "1. DON removed thin liquids from resident 2 and 4. 2. ADON audited Care Tracker (care plan software) to ensure all orders for thickened liquids were correctly noted. 3. An order was written for resident 2 to change fluids to nectar thick (call was placed to MD who wrote progress note and we are awaiting his return call to clarify the order as it was only written in progress note versus given as an actual order). 4. All nursing staff on shift at the time this concern was noted have been in-serviced as to the need to follow orders as written in Care Tracker and also to consult the 'Dietary Binder' when passing fluids or providing an activity with fluids or snacks. (Clarification requested on 5/2/11. Administrator provided the following:) All staff have been inserviced regarding the need to follow orders as written in Care Tracker and also to consult 'Dietary Binder' as it pertains to passing fluids (This includes all staff who have worked in the facility since the time the citation was given and will continue until all staff have completed the in-service. This has also been added to the facility new employee orientation process). This plan has been implemented as of evening shift on 4/28/11. 5. All physician progress notes [REDACTED]. All orders received will be noted by a nurse and countersigned by another nurse and any dietary orders will be placed in the 'dietary binder'. 6. All clinicians to be inserviced regarding the need to give all changes in orders to the nurse on duty (who will then follow number 4 above). 7. A 'Dietary Binder' has been created to reflect current diet consistency to include fluids and this binder will be used when passing fluids or providing snacks (including med pass and activities), that are not given for a specific resident from the dietary department. 8. All orders will be reviewed in the daily 'stand-up' meeting to ensure they are noted properly and compared to the 'dietary binder' as a second check. 9. The MDS nurses will audit the 'care tracker' software as often as dietary orders are written to ensure they reflect what is in the residents chart." Findings were as follows: A complaint was received by the survey agency on April 25, 2011. The complaint alleged that residents did not received appropriate fluids to prevent dehydration. 1. Resident #2 was admitted to the facility 3/26/11 with [DIAGNOSES REDACTED]. The most recent significant change MDS assessment, dated 4/5/11, documented the resident: * had severe cognitive impairment, * had mild depression, * required extensive assistance of two staff for transfers, ambulation, dressing, eating, personal hygiene and bathing. * was frequently incontinent of bowel and bladder, * had loss of fluids from mouth when eating or drinking, and * had a mechanically altered diet. The resident's physician saw the resident on 3/30/11 and documented in a progress note,"Dysphagia: Chokes on thin fluids, thick fluid diet. Is high risk for further aspiration..." The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]." The resident returned to the facility on [DATE]. The resident's physician recapitulation order signed by the physician on 4/11/11 had a diet order that stated, "Enhanced Meals nectar thick. Drinkable puree." The resident's care plan, dated 4/6/11, documented for "Altered Nutritional Status" an approach of "Drinkable pureed no thicker than nectar." On 4/28/11 at 9:25 a.m. Resident #2's room was observed to have thin water available in the room on the end table about 4 feet from the bed. At 11:35 a.m. the resident's bedside table still had an insulated mug with unthickened water and ice. CNA 1, 2 and 3 were in the room providing cares to the resident. They were asked if the water belonged to the resident, to which they all replied, "yes." When asked if they knew the resident was on thickened liquids, all appeared surprised and indicated they did not know. One staff indicated they had provided unthickened fluids via a straw and the resident, "drinks with a straw well." On 4/28/11 at 12:45 p.m. the resident was observed in the dining room with an aide providing a liquified diet. The resident was receiving nectar thick fluids and the resident's diet card reflected the physician's orders [REDACTED]. On 4/28/11 at 1:10 p.m. the DON was asked about the thin liquids and how staff were informed about the resident's restriction. She indicated that the information was in the facility computer system. At 1:15 the ADON logged into the "Care Tracker" computer system and the resident's information was brought up on the screen. The resident's fluid restrictions were not in the system; the CNAs would not have known about the resident's restrictions. On 4/28/11 at 2:20 p.m. the administrator and DON were informed of the Immediate Jeopardy situation. 2. Resident #4 was admitted to the facility 1/3/11 with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * was severely cognitively impaired, * did not have any behaviors, * required extensive assistance of one to two staff for transfers, dressing, eating, personal hygiene and bathing. * was always incontinent of bowel and bladder, * holds food in his mouth or cheeks or has residual food in his mouth after meals, and * receives a mechanically altered therapeutic diet. The resident's physician recapitulation orders, dated 4/13/11, documented the resident's diet to be "Regular diet - Pureed honey thick, with small portions and Nutritionally Enhanced Meals." The resident's care plan, dated 4/25/11, for "Altered hydration status" documented an approach of "honey thick liquids." On 1/4/11 the facility conducted a "Group Inservice" with staff about the resident for, "Diet: Pureed (with) honey - thick liquids and small portions, 2 (ounce) boost...." On 4/28/11 at 9:35 a.m. Resident #4's room was observed to have thin water available in the room on the bedside table about 6 feet from the resident. On 4/28/11 at 12:45 p.m. the resident was observed in the dining room with an aide providing honey thick fluids. At 1:15p.m. the ADON logged into the "Care Tracker" computer system and the resident's information for "Honey thick liquids" was available. The resident still, at 1:15, had thin liquids available in his room and this was shown to the DON. She indicated that he was not supposed to have thin liquids. On 4/28/11 at 2:20 p.m. the administrator and DON were informed of the Immediate Jeopardy situation. 3. A complaint was received by the survey agency on April 25, 2011. The complaint alleged that on April 22, 2011 an identified resident was observed screaming in pain. The staff indicated the resident had been in that condition all day. The physician or family had not been notified. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had been discharged to the hospital three times since the date of admission. The admission MDS, dated [DATE], documented the resident was severely cognitively impaired, required extensive assistance by 2 staff for ADL care and had no behavioral symptoms. The resident was discharged to the hospital on on 2/19/11. A history and physical report from the hospital was dated 2/20/11 and documented the following: "...Apparently he developed a fever up to 103 and then showed decreased responsiveness and his blood pressure dropped. He was immediately transported to the emergency department were he was evaluated by (physician name) and found to have some decreased level of consciousness. He seemed to improve with [MEDICATION NAME]; however, he was also noted to have a urinary tract infection and possible [MEDICAL CONDITION]. It was felt he should be admitted for treatment of [REDACTED]." The resident was readmitted to the facility on [DATE] with physician orders [REDACTED]. His final [DIAGNOSES REDACTED]." The resident's care plan for nutrition was dated 3/3/11 and included a plan for hydration. Approaches included: *Nursing to monitor skin turgor *Extra fluids with med pass *Request updated lab prn (as needed) The care plan also identified the resident required assistance with meals. The nurse progress note for admission, dated 3/2/11, documented: "Arrived (at 3:50 pm) ...brought into facility per Geri chair...Resident states happy to be home. Smiling and waving (at) staff... Has contractures to both arms and hands and feet... He is two person assist for transfer. Geri chair for comfort and positioning. admitted (with) Foley cath(eter) ...Yellow urine draining to BSU (bed side urine) bag... Denies pain..." *Nurse progress note for 3/3/11, (2:00 pm) indicated the resident's Foley catheter was intact and had clear yellow urine draining. The resident denied pain. *On 3/5/11 a nurse progress note documented the resident was not having nausea, vomiting or loose stools related to the medication Keflex. *Documented nurse note on 3/6/11, the resident was not having ADR (adverse drug reaction) to the Keflex. *On 3/8/11, (9:30 am) the nurse note documented clear yellow urine and was not having drug reactions from the Keflex. (NOTE: This was the first documentation in 5 days that described his urine. The resident was treated for [REDACTED]. This was again noted on 3/9/11. *The next note was dated 3/16/11 and indicated the physician had been in and ordered lab work for the resident. *A monthly nursing summary was dated 3/17/11. The summary was a form with several areas that required a check mark if they applied to the resident. The form checked the resident had a Foley Catheter. For skin turgor a check mark indicated, "fair" with dry fragile skin. There were no other progress notes in this closed portion of Resident #1's record until 4/10/11. Nurse progress notes from 4/10/11 documented: *4/10/11, (10:00 am)- "Resident having episodes of nausea with vomiting. PRN [MEDICATION NAME] given with Tylenol for discomfort with little results. Noted blood in the urien (sic) and discomfert (sic), MD (Medical Doctor) notified order for transport to (hospital identified) for eval (uation)...family aware. 1300 (1:00 pm) Resident returned from (hospital identified) per facility vehicle. NO (New order) [MEDICATION NAME] mg (by mouth, two times a day for 10 days)... family notified." *4/11/11, (12:55 pm)- "Resident has been noted to crying out in pain. (As documented). Res was administered Tylenol with no noted relief. Res(ident) continued to yell out in pain given [MEDICATION NAME] (2) and noted to be (illegible) effective for awhile. Noted cloudy, dark urine, with sediment. (No) ADR noted ABX (antibiotic) therapy...Will cont. to observe." (NOTE: The resident was continually having pain and then worsening symptoms related to a change in his urine. Staff still document they would continue to observe). *4/12/11, (12:20 am)- "Res c/o (complains of) pain. Given Tylenol 650 mg. Some leaking from around cath(eter). Balloon was deflated, cath adjusted and balloon inflated with 10 cc (cubic centimeters) of water. Will monitor for further leakage." *4/12/11, (not timed)- "Res has transported to (hospital) via facility transport at (2:30 pm) per family request. I educated family on pharmacology [MEDICATION NAME] explained process of UTI. (Three nurses identified) all provided education to family about res condition and about possible avenues we could take in facility. Did call (physician) and left message for him about families request for new pain med r/t nausea. Family did not want to wait for Dr. to call back and insisted he be sent to (hospital emergency room ). Res VS (vital signs) are BP (blood pressure) 106/67, (T) temperature 99.2, (P) pulse 98, (R) respirations 22, O2 (oxygen saturation level) 93% at RA (room air). Res has been admitted to (hospital) for urosepsis. Did call and give report to (name) nurse in ER at (hospital) before I sent res..." A history and physical report from the hospital indicated he was admitted on [DATE]. The report indicated the resident had a urine culture done when he went to theER on [DATE] and the results were returned with positive [MEDICAL CONDITIONS]. The physician indicated [MEDICAL CONDITION] was resistant to [MEDICATION NAME] resident had been prescribed on 4/10/11. The resident was in the hospital for five days and returned to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. The resident's care plan for nutrition was dated 4/18/11 and included a plan for hydration. Approaches included: *Nursing to monitor skin turgor *Extra fluids with med pass *Request updated lab prn (as needed) *Cranberry juice with meals The care plan also identified the resident required assistance with meals. The facility documented I & O ( fluid intake and urine output) from the 4/17/11 admission to discharge on 4/22/11, for each day as follows: * 4/17- I- 480 cc, O- 1000 cc (Resident readmitted that day). * 4/18- I- 1020 cc, O- 1900 cc * 4/19- I- 1820 cc, O- 2474 cc * 4/20- I- 1320 cc, O- 1550 cc * 4/21- I- 1920 cc, O- 1675 cc * 4/22- I- 240 cc, O- 800 cc (Resident discharged to hospital). (NOTE: There was no documentation that this information was used for assessment purposes or reported to the physician. The resident had more output of fluids than he took in on all but one day. This could have been indicative of a renal or dehydration issue). Nurse progress notes documented the following: *4/17/11, (2:00 PM)- "pt. (patient) admitted from (hospital via facility van transfer), pt. calm, pleasant, appeared happy (and) cheerful with staff...urine golden and clear... A little agitated (sic) when opened hands and looked into axilla, staff noted that pt. usually responds this way when manipulating hands and arms..." *4/17/11, (9:00 am)- "Resident C/O (complains of) pain all over. N.O. (New Order) obtained for [MEDICATION NAME] 50 mg. (4 times a day as needed). [MEDICATION NAME] given with little results. PRN Tylenol given for (increased) temperature (101.2 degrees). Results pending resident cont(inues) to cry out. Unable to make needs known- currently resting in bed. Phone call made to MD in place will monitor. (10:30 am)- Per MD N.O. for [MEDICATION NAME] 5/325, 1-2 tablets (every 6 hours as needed). Family notified. (5:00 pm)- Per MD (doctor named) to assume care of resident family aware." *4/18/11, (1:30 am)- "Res returned from dinner. Had some crying out, whimpering. Was given pudding and drinks of juice. Res quieted down somewhat. When taken to bed, Res would cry out. Offered water and Res would calm down only to start crying out ten minutes later. Tylenol has been given (two times every four hours). No relief from crying out. Aides changed and repositioned the Res. Results are pending." (NOTE: There was no further documentation on this day). *4/19/11, (9:30 am)- "Resident currently rests in bed. Ate 50 % of meal assisted by one, decreased crying out and moaning- family here to visit. Currently on abx for UTI- no C/O GI (gastro-intestinal) upset or loose stools. No C/O bladder spasms R/T UTI will continue to monitor. (3:00 pm)- MD order- [MEDICATION NAME] 25 mg (by mouth, every 8 hours, as needed). Family notified. *4/21/11, (illegible time)- "No urinary symptoms noted or reported. Res is afebrile. Urine is clear, golden color. No sediment noted...Res cont. on contact precaution due [MEDICAL CONDITION] in urine." *4/22/11, (5:30 am)- "Since change of shift , Res huffing, puffing, and crying out.. Medicated with (two) [MEDICATION NAME] and [MEDICATION NAME] d/t (due to) C/O pain and nausea which seemed to have no effect as behaviors continued. (Family member) visited last NOC (night) and pointed out an abrasion and blood on inner aspect of navel on left side = 1.5 cm wide x 2 cm long- abrasion has (increased) during NOC. Res is putting his left middle finger in the naval and raking it across the side of the naval. Res also observed trying to dig his nails into his skin on his torso. Nails are trimmed short...Redirection unsuccessful. Res appeared stressed, but closed window d/t C/O being cold- then too hot- so turned on fan- unable to satisfy residents complaints. Will continue to monitor." *4/22/11, (not timed)- Res had s/s of pain this shift. Given prn [MEDICATION NAME] with some effectiveness. Res would cry out yelling but would calm when approached. Res refused to eat at meal but did take meds with 120 cc of fluid... Family in to see resident. Resident sleeping. Will continue to observe." *4/23/11, (2:30 am)- "At shift change on 4/22 (6:00 pm) Res highly agitated, yelling out, crying, clenching/tensing up, rocking head back and forth- won't respond to questions will not drink or take hs (bedtime) meds. Eyes closed half way and Res relaxes for a moment and begins snoring for a moment- eyes suddenly wide and appear 'wild' and raking and writhing begin again. Res reportedly refused eating or drinking all day. Family insisted he go back to the (Emergency Department), Resident transferred, MD notified. Awaiting word as to condition of resident and when will return." The resident had not returned to the facility as of the survey days of 4/28 and 4/29/11. The survey team obtained records from the hospital the resident had been admitted to on 4/22/11. A history and physical report was dated 4/22/11 and documented the following; "(Resident #1) currently residing at the (facility named) and over the past 24-48 hours has become increasingly agitated. His family has found that with increased agitation this tends to be an indication that he has some sort of infection. ...initial evaluation showed a significant elevation in his potassium, which was 7.2 and he has white count of 19.9, and therefore at this point, we will go ahead and admit him to the hospital and get this potassium under control and see if we can get on top of this infection... Assessment: Increased agitation with change in mental status. Plan: This certainly could be secondary to his acute [MEDICAL CONDITION]. As to why he has acute [MEDICAL CONDITION] I am not quite sure as currently I do not see any signs of urosepsis, but that is certainly one of the possible etiologies. ...for this gentleman to try to get his potassium down over the course of the next few days. We will use fluids to hydrate and with this hydration we will hope that the kidneys improve. Certainly, if at some point, we feel like [MEDICAL TREATMENT] is what is necessary we will need to move him to another facility that offers that service..." The resident was transferred from the local hospital the next day, to another hospital where he could receive [MEDICAL TREATMENT]. The transfer summary was dated 4/23/11 (1:44 pm) and documented: "Admitting complaint: Acute [MEDICAL CONDITION]. ...Initial urine analysis showed no urinary infection, although this has been sent for urine culture. The patient has a periumbilical exudate has been cultured as well. It does not appear to be grossly cellulitic. The patient has some post nasal pharynx mucus that has been sent for culture and requires frequent suctioning in order for the patient's lungs to sound good...." The resident's labs had not improved greatly and his urine out put was 120 mL (milliliters) overnight, even with IV drips. The resident was placed on IV [MEDICATION NAME], a broad spectrum antibiotic. The transfer plan documented communication had occurred with two hospitals' nephrology departments. The resident was transferred by ambulance to the closest hospital, preferred by the resident's family. This report also referred to the history and physical report completed on 4/22/11 for "past medical history, medications, etc." The DON was interviewed on 4/29/11 at 8:25 am. The facility nurse consultant was present. The records were provided to the DON. The nurse note, dated 4/12/11, was brought to the DON's attention. The surveyor asked about the documentation related to, "provided education to family about res condition and about possible avenues we could take in facility." The documentation did not include what these possible interventions were. The DON did not explain the education but said that if the family wanted the resident to go the the ER the facility would send him. The DON stated that on that particular occasion the resident was not that agitated or in a lot of discomfort and was on antibiotics. The surveyor pointed out that he had recently been treated for [REDACTED]. The DON and nurse consultant nodded in agreement and did not have any other comments related to the facility's care of Resident #1. The facility failed to assess the resident who had repeat hospitalization s for urosepsis. There was no daily documentation to indicate the resident's urine was being continually observed for signs and symptoms of infection. When the resident had been receiving antibiotics there was not daily documentation that he was not having adverse reactions to the medication. There was no indication the input and output data was used or conveyed to a physician after his last admission. The facility did not send the resident to the ER when he was in pain most of the time after he was readmitted on [DATE]. The resident showed signs of suffering in pain particularly on the last two days prior to being admitted to the hospital. The documentation acknowledged that on 4/22 the resident had scratched his navel and caused it to bleed. There was no documentation that the wound was cleaned or received a dressing. The pain medications available to him did not provide relief from pain and the facility did not document attempts to obtain medication to relieve his pain or to send him to the emergency room until the family insisted.

Based on observation, staff and resident interviews, record review and a complaint from the general public received on April 25, 2011, it was determined the facility failed to ensure that a physician was consulted for 1 of 5 sampled residents (#1) when the resident had significant changes to his physical condition. This resulted in harm for resident #1 who suffered from extreme pain and had a rapid significant change in his medical condition. In addition, the facility did not contact the family regarding significant changes in the resident's condition prior to his last admission to the hospital. Findings include: The complaint alleged that on April 22, 2011 an identified resident was observed screaming in pain. The staff indicated the resident had been in that condition all day. The physician or family had not been notified. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had been discharged to the hospital three times since the date of admission. The admission MDS, dated [DATE], documented the resident was severely cognitively impaired, required extensive assistance by 2 staff for ADL care and had no behavioral symptoms. The resident was discharged to the hospital on on 2/19/11. A history and physical report from the hospital was dated 2/20/11 and documented the following: "...Apparently he developed a fever up to 103 and then showed decreased responsiveness and his blood pressure dropped. He was immediately transported to the emergency department were he was evaluated by (physician name) and found to have some decreased level of consciousness. He seemed to improve with [MEDICATION NAME]; however, he was also noted to have a urinary tract infection and possible [MEDICAL CONDITION]. It was felt he should be admitted for treatment of [REDACTED]." The resident was readmitted to the facility on [DATE] with physician orders [REDACTED]. His final [DIAGNOSES REDACTED]." The nurse progress note for admission, dated 3/2/11, documented: "Arrived (at 3:50 pm) ...brought into facility per Geri chair...Resident states happy to be home. Smiling and waving (at) staff... Has contractures to both arms and hands and feet... He is two person assist for transfer. Geri chair for comfort and positioning. admitted (with) Foley cath(eter) ...Yellow urine draining to BSU (bed side urine) bag... Denies pain..." *Nurse progress note for 3/3/11 indicated the resident's Foley catheter was intact and had clear yellow urine draining. The resident denied pain. *On 3/5/11 a nurse progress note documented the resident was not having nausea, vomiting or loose stools related to the medication Keflex. Nurse progress notes from 4/10/11 documented: *4/10/11, (10:00 am)- "Resident having episodes of nausea with vomiting. PRN [MEDICATION NAME] given with Tylenol for discomfort with little results. Noted blood in the urien (sic) and discomfert (sic), MD (Medical Doctor) notified order for transport to (hospital identified) for eval (uation)...family aware. 1300 (1:00 pm) Resident returned from (hospital identified) per facility vehicle. NO (New order) [MEDICATION NAME] mg (by mouth, two times a day for 10 days)... family notified." *4/11/11, (12:55 pm)- "Resident has been noted to crying out in pain. (As documented). Res was administered Tylenol with no noted relief. Res(ident) continued to yell out in pain given [MEDICATION NAME] (2) and noted to be (illegible) effective for awhile. Noted cloudy, dark urine, with sediment. (No) ADR noted ABX (antibiotic) therapy...Will cont. to observe." (NOTE: The resident was continually having pain and then worsening symptoms related to a change in his urine. Staff still document they would continue to observe). *4/12/11, (12:20 am)- "Res c/o (complains of) pain. Given Tylenol 650 mg. Some leaking from around cath(eter). Balloon was deflated, cath adjusted and balloon inflated with 10 cc (cubic centimeters) of water. Will monitor for further leakage." *4/12/11, (not timed)- "Res has transported to (hospital) via facility transport at (12:30 pm) per family request. I educated family on pharmacology [MEDICATION NAME] explained process of UTI. (Three nurses identified) all provided education to family about res condition and about possible avenues we could take in facility. Did call (physician) and left message for him about families request for new pain med r/t nausea. Family did not want to wait for Dr. to call back and insisted he be sent to (hospital emergency room ). Res VS (vital signs) are BP (blood pressure) 106/67, (T) temperature 99.2, (P) pulse 98, (R) respirations 22, O2 (oxygen saturation level) 93% at RA (room air). Res has been admitted (sic) to (hospital) for urosepsis. Did call and give report to (name) nurse in ER at (hospital) before I sent res..." (NOTE: As stated in the notes the family requested the facility call the physician related to pain medication. The family also initiated the transfer to the hospital ER). A history and physical report from the hospital indicated he was admitted on [DATE]. The report indicated the resident had a urine culture done when he went to theER on [DATE] and the results were returned with positive [MEDICAL CONDITIONS]. The physician indicated [MEDICAL CONDITION] was resistant to [MEDICATION NAME] on 4/10/11. The resident was in the hospital for five days and returned to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. Nurse progress notes documented the following: *4/17/11, (2:00 PM)- "pt. (patient) admitted from (hospital via facility van transfer), pt. calm, pleasant, appeared happy (and) cheerful with staff...urine golden and clear... A little agitated (sic) when opened hands and looked into axilla, staff noted that pt. usually responds this way when manipulating hands and arms..." *4/17/11, (9:00 am)- "Resident C/O (complains of) pain all over. N.O. (New Order) obtained for [MEDICATION NAME] 50 mg. (4 times a day as needed). [MEDICATION NAME] given with little results. PRN Tylenol given for (increased) temperature (101.2 degrees). Results pending resident cont(inues) to cry out. Unable to make needs known- currently resting in bed. Phone call made to MD in place will monitor. (10:30 am)- Per MD N.O. for [MEDICATION NAME] 5/325, 1-2 tablets (every 6 hours as needed). Family notified. (5:00 pm)- Per MD (doctor named) to assume care of resident family aware." *4/18/11, (1:30 am)- "Res returned from dinner. Had some crying out, whimpering. Was given pudding and drinks of juice. Res quieted down somewhat. When taken to bed, Res would cry out. Offered water and Res would calm down only to start crying out ten minutes later. Tylenol has been given (two times every four hours). No relief from crying out. Aides changed and repositioned the Res. Results are pending." (NOTE: There was no further documentation on this day). *4/19/11, (9:30 am)- "Resident currently rests in bed. Ate 50% of meal assisted by one, decreased crying out and moaning- family here to visit. Currently on abx for UTI- no C/O GI (gastro-intestinal) upset or loose stools. No C/O bladder spasms R/T UTI will continue to monitor. (3:00 pm)- MD order- [MEDICATION NAME] 25 mg (by mouth, every 8 hours, as needed). Family notified. *4/21/11, (illegible time)- "No urinary symptoms noted or reported. Res is afebrile. Urine is clear, golden color. No sediment noted...Res cont. on contact precaution due [MEDICAL CONDITION] in urine." *4/22/11, (5:30 am)- "Since change of shift, Res huffing, puffing, and crying out.. Medicated with (two) [MEDICATION NAME] and [MEDICATION NAME] d/t (due to) C/O pain and nausea which seemed to have no effect as behaviors continued. (Family member) visited last NOC (night) and pointed out an abrasion and blood on inner aspect of navel on left side = 1.5 cm wide x 2 cm long- abrasion has (increased) during NOC. Res is putting his left middle finger in the naval and raking it across the side of the naval. Res also observed trying to dig his nails into his skin on his torso. Nails are trimmed short...Redirection unsuccessful. Res appeared stressed, but closed window d/t C/O being cold- then too hot- so turned on fan- unable to satisfy residents complaints. Will continue to monitor." (NOTE: The physician was not notified. Family not notified that behavior symptoms had intensified, resident with increased agitation and pain). *4/22/11, (not timed)- Res had s/s of pain this shift. Given prn [MEDICATION NAME] with some effectiveness. Res would cry out yelling but would calm when approached. Res refused to eat at meal but did take meds with 120 cc of fluid... Family in to see resident. Resident sleeping. Will continue to observe." (NOTE: No documentation that family was told of prior signs and symptoms of pain with crying and yelling. Also, refused food and fluid). *4/23/11, (2:30 am)- "At shift change on 4/22 (6:00 pm) Res highly agitated, yelling out, crying, clenching/tensing up, rocking head back and forth- won't respond to questions will not drink or take hs (bedtime) meds. Eyes closed half way and Res relaxes for a moment and begins snoring for a moment- eyes suddenly wide and appear 'wild' and raking and writhing begin again. Res reportedly refused eating or drinking all day. Family insisted he go back to the (Emergency Department), Resident transferred, MD notified. Awaiting word as to condition of resident and when will return." The DON was interviewed on 4/29/11 at 8:25 am. The facility nurse consultant was present. The records were provided to the DON. The nurses note, dated 4/12/11, was brought to the DON's attention. The surveyor asked about the documentation related to, "provided education to family about res condition and about possible avenues we could take in facility." The documentation did not include what these possible interventions were. The DON did not explain the education but said that if the family wanted the resident to go the the ER the facility would send him. The DON stated that on that particular occasion the resident was not that agitated or in a lot of discomfort and was on antibiotics. The surveyor pointed out that he had recently been treated for [REDACTED]. The DON and nurse consultant nodded in agreement and did not have any other comments related to the facility's care of Resident #1. The facility failed to assess the resident who had repeat hospitalization s for urosepsis. (Refer to F309 for more findings for Resident #1, related to lack of assessment and interventions for Quality of Care). The facility determined the resident required monitoring when his condition was deteriorating. They did not notify the physician or the family who were very involved with the resident's care.