Every finding on record at Monte Vista Hills Healthcare Center

Based on the facility bowel care standing orders, record review, and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 5 of 14 residents (#6, #11, #20, #24, and #57) 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 Provider's Standing Orders-PRN documented the following:- When using standing PRN orders, please place end date no longer than 3 days. Please notify provider if symptoms occur for more than 24 hours- Constipation: Encourage fluids and monitor for dehydration- Peri Colace 8.6/50 mg 2 Tablets BID - MiraLAX 17 grams PO QD or BID- Milk of Magnesium 30 mL QHS (use with caution with renal insufficiency)- [NAME] Cow- Milk of Magnesium 30 mL, 6 oz Prune Juice (use with caution with renal insufficiency)- Bisacodyl 5-10 mg PO or suppository- Lactulose 15 mL QD-BIDa. Resident #6 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including respiratory failure and morbid obesity. Resident #6 had a documented bowel movement on 11/17/25 at 5:02 PM, and not again until 11/21/25 at 8:01 PM, over 96 hours with no documented bowel movement or documented nursing intervention. Resident #6 had a documented bowel movement on 12/5/25 at 9:16 PM, and not again until 12/10/25 at 12:56 PM, over 96 hours with no documented bowel movement or documented nursing intervention. b. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (chronic mental illness) and cancer. Resident #11's physician orders for bowel care management were documented as: Miralax oral powder 17 Gm/scoop – give 17 gram by mouth in the morning for constipation, mix in 6-8 oz fluid of choice – order date 7/31/25 Bisacodyl EC oral tablet delayed release 5 mg – give 1 tablet by mouth every 6 hrs as needed for constipation for 3 days – order date 11/5/25 Resident #11 had a documented bowel movement on 11/18/25 at 9:41 PM and not again until 11/23/25 at 9:34 AM, over 106 hours with no documented bowel movement. No documentation of Resident #11 receiving the physician ordered Bisacodyl EC medication for constipation management. Resident #11's physician orders, dated 12/7/25, for bowel care management were documented as: Milk of Magnesia – give 30 ml by mouth as needed for bowel care **if no bowel movement in 3 days Bisacodyl suppository 10 mg – insert 1 suppository rectally as needed for bowel care **if no bowel movement within 6-12 hrs of Milk of Magnesia administration Enema Disposable Enema – insert 1 dose rectally as needed for bowel care **if no bowel movement within 2-6 hrs of Bisacodyl suppository administration Resident #11 had a documented bowel movement on 12/2/25 at 8:10 PM and not again until 12/10/25 at 1:59 PM, over 185 hours with no documented bowel movement. No documentation of Resident #11 receiving the physician ordered medications for constipation management. On 12/16/25 at 2:45 PM, the DON stated the nurse had not documented bowel medication interventions on the medication administration record as ordered by the provider for Resident #11 and should have. c. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including osteolysis (the destruction or breakdown of bone tissue, essentially bone loss due to excessive resorption (removal) of calcium and minerals, often leading to weakened, soft, or porous bones) and malnutrition. Resident #20 had a documented bowel movement on 11/28/25 at 11:51 AM, and not again until 12/2/25 at 7:49 PM, over 96 hours with no documented bowel movement or documented nursing intervention. Resident #20 had a documented bowel movement on 12/2/25 at 7:49 PM, and not again until 12/6/25 at 9:29 AM, over 96 hours with no documented bowel movement. Resident #20's medical record documented she was given MiraLax Oral Powder 17 GM on 12/3/25 not resulting in a BM until 12/6/25. Resident #20 had a documented bowel movement on 12/7/25 at 11:24 AM, and not again until 12/11/25 at 11:24 AM, over 96 hours with no documented bowel movement or documented nursing intervention. d. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including fracture of right femur, diabetes, and cancer of the uterus. Resident #24 had a documented bowel movement on 12/6/25 at 1:35 PM, and not again until 12/11/25 at 11:02 AM, over 117 hours with no documented bowel movement or documented nursing intervention. e. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a chronic autoimmune disease affecting the brain, spinal cord, and optic nerves) and quadriplegia (a severe medical condition involving the partial or total loss of movement and sensation in all four limbs and the torso). Resident #57 had a documented bowel movement on 11/26/25 at 8:05 PM, and not again until 12/6/25 at 8:55 PM, over 240 hours with no documented bowel movement or documented nursing intervention. Resident #57 had a documented bowel movement on 12/8/25 at 5:47 AM, and not again until 12/14/25 at 9:59 PM, over 144 hours with no documented bowel movement or documented nursing intervention. On 12/16/25 at 2:45 PM, the DON stated the nurses assigned to Residents #6, #20, #24, and #57 had not documented any bowel medication interventions during the times noted and should have.

Based on observation and staff interview, it was determined the facility failed to ensure resident's privacy was maintained during personal cares. This was true for 1 of 1 resident (Resident #39), when staff were providing personal cares in resident rooms. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth. Findings include: Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including Ataxic Cerebral Palsy (caused by injury to the brain controlling balance and coordination), schizoaffective disorder (hallucinations/delusions mixed with mood episodes like depression or bipolar mania), and PTSD (Post Traumatic Stress Disorder).On 12/16/25 at 9:46 AM, surveyor observed from the hallway, Resident #39's door open and 2 staff members assisting Resident #39 with personal cares. Resident #39's room was across from the nurse station in a high traffic area. Surveyor knocked on Resident #39's open door and heard staff call out cares.On 12/16/25 at 9:47 AM, surveyor asked LPN #3, who was standing at the nurse station, if resident cares should be done with a resident's door open. LPN #3, stated no, the door should have been shut and walked to Resident #39's door and closed it.On 12/16/25 at 11:55 AM, the DON stated the staff should not have had the door open when doing resident cares.

Based on review of the State Operations Manual, observation, and staff interview, it was determined the facility failed to ensure residents were free from accident hazards for 1 of 1 resident (Resident #55) whose room was observed for environmental safety. This deficient practice had the potential to cause physical harm if portable oxygen cylinders were not properly secured from falling over. Findings include: Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a progressive lung disease making breathing difficult), and diabetes.On 12/15/25 at 2:43 PM, observed the following in Resident #55's room:- 2 portable oxygen cylinders propped up, unsecured in the corner- 1 portable oxygen concentrator that Resident #55 was currently using- 1 portable liquid oxygen tank hanging on Resident #55's wheelchairResident #55 stated she brought the portable oxygen cylinders from home but was not using them.On 12/15/25 at 3:14 PM, the DON stated she was not aware Resident #55 had portable oxygen cylinders in her room and stated she would go check on it.On 12/15/25 4:00 PM, the DON stated they secured the portable oxygen cylinders in a cart. She stated they should have been secured or put in the oxygen room and was not.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 4 residents (#6 and #20) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:a. Resident #6 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including respiratory failure and morbid obesity.On 12/15/25 at 2:55 PM, observed Resident #6's oxygen concentrator was set at 3.5 lpm. On 12/16/25 at 10:20 AM, observed Resident #6's oxygen concentrator was set at 3.5 lpm. Resident #6's physician oxygen order documented O2 per N/C at 1 to 2 lpm to keep SATs equal to or greater than 88%. b. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including osteolysis (the destruction or breakdown of bone tissue, essentially bone loss due to excessive resorption (removal) of calcium and minerals, often leading to weakened, soft, or porous bones) and malnutrition. On 12/15/25 at 2:30 PM, observed Resident #20's oxygen concentrator was set at 3.5 lpm. Resident #20's physician oxygen order documented 2 lpm N/C to keep SAT greater than 90%. On 12/16/25 at 3:00 PM, the DON stated Resident #6 and Resident #20's oxygen concentrators were set at 3.5 lpm and should not have been.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 12/15/25 at 3:40 PM, during the 200 Hall medication cart audit, observed the narcotic accountability sheets, dated 12/1/25 to 12/15/25, with 1 licensed nurse signature not documented on 12/7/25. On 12/15/25 at 3:42 PM, CMA #1 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 12/17/25 at 1:10 PM, the DON stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart.

Based on observations, record review, and staff interviews it was determined the facility failed to ensure medications were stored in locked compartment, and medications and biologicals were not expired. This was true for 1 of 2 medication carts reviewed and 1 of 1 resident (Resident #55) room observed for medication storage. This failure created the potential for undetected misuse of medication, residents to receive expired medications with decreased efficacy, and use of expired biologicals. Findings include:Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a progressive lung disease making breathing difficult), and diabetes. On 12/15/25 at 2:43 PM, observed 2 medication cups on Resident #55's nightstand with Nystatin cream (antifungal medication) in each cup. Resident #55 stated she does not know why they are there; it is probably old, and the nurse must have left it. On 12/15/25 at 4:00 PM, the DON stated the Nystatin cream should not have been left in Resident #55's room. She stated she removed the Nystatin cream and told the nurses they could not leave medications at bedside. A.The following was observed during the medication cart audits. On 12/16/25 at 11:02 AM, the 100 Hall medication cart was audited with RN #1 present. Observed the following: - one bottle of fiber supplement with an expiration date of 7/24 printed on the bottle - one tube of muscle rub with a written expiration date of 12/12, unable to determine if month and year or month and day as it was not fully dated On 12/16/25 at 11:13 AM, RN #1 stated, the medications were expired and should have been discarded and had not been. On 12/17/25 at 1:35 PM, the DON stated the expired medications should have been removed from the medication cart and had not been. B. The following was observed for biologicals. On 12/16/25 at 11:15 AM, observed one set of glucose test solutions with an expiration date of 10/10/25 printed on the bottles, and one set of glucose test solutions with an expiration date of 10/12/25 printed on the bottles. RN #1 stated the test solutions were expired and should have been discarded and had not been. On 12/17/25 at 1:40 PM, the DON stated the glucose test solutions should have been removed from the cart and had not been.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.The facility's Food Storage policy, undated, documented food items will be stored on shelves. Food should be dated when placed on shelves.food should be stored a minimum of 6 inches above the floor.date markings should be visible.leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. On 12/15/25 at 12:30 PM, observed in the dining room the following issues.- a squeeze bottle containing white liquid (CDM stated it was ranch dressing) without contents label and no dates. - one container labeled as milk without a date poured or expired date. (CDM stated, they pour out the milk and ranch dressing after each meal).On 12/15/25 at 12:32 PM, observed in the walk-in refrigerator the following.- a small zip lock type bag with diced tomatoes not labeled with dates.- a small zip lock type bag with diced cucumbers not labeled with dates.- a plastic container with sliced cheese not labeled with dates.- a plastic container with barbeque sauce not labeled with dates.On 12/15/25 at 12:37 PM, observed with the CDM, a case of food stored on the ground in the dry food storage room. On 12/15/25 at 12:40 PM, the CDM stated the food in the dry food storage area should not be stored on the floor and all food items should be labeled and dated and were not.

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:U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. 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.On 12/15/25 at 12:25 PM, observed in the kitchen area the following.- Two garbage cans not in continuous use in the food prep area without lids.On 12/17/25 at 10:30 AM, the CDM stated she thought the garbage cans could have the lids off when in use but the cans were not in use and should have had the lids on.

Based on interview and record review, the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect 61 of 62 residents who received meals prepared in the facility's kitchen. Findings include: A printout of the Dietary Manager certification training program stated the Dietary Supervisor (DS) had completed 34% of the course since it was started 1/4/24. On 7/23/24 at 4:06 PM, the DS was asked if she was certified as a Dietary Manager. She stated she was not, but she had been working as the Dietary Manager at the facility since April of 2023. The DS stated she had ten years of food service experience in restaurants but none in healthcare. She stated she had her food handler's certification and had not completed other courses in food safety and management. During an interview on 7/25/24 at 3:15 PM, the Administrator and RD confirmed the DS was currently enrolled in a qualifying course which would provide the DS with the credentials she needed to meet the regulation after completion of the course.

Based on observation, interview, policy review, and review of the Idaho and FDA Food Codes, the facility failed to appropriately store, distribute, and label foods; clean ovens; and perform appropriate hand hygiene. This deficient practice had the potential to affect 61 of 62 residents who received meals prepared in the facility's kitchen. Findings include: 1. The Idaho Food Code, revised February 2021, stated ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The facility policy titled Food Labeling and Storage, undated, stated All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered and dated when stored and When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. The facility policy titled Food Storage, undated, stated 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated, f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded, and c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. A. On [DATE] at 10:44 AM and on [DATE] at 4:20 PM, the walk-in refrigerator was observed with the DS. Open containers were found that included: - a bottle of salad dressing with an expired use by date of [DATE]. - a bottle of Italian dressing with an open date of [DATE] and a use by date of [DATE] with an open/exposed spout. - a bottle of Italian dressing with an open date of [DATE] and a use by date of [DATE] with an open/exposed spout. - a bottle of Ranch dressing with an open date of [DATE] and a use by date of [DATE] with an open/exposed spout. On [DATE] at 12:42 PM, the DS stated the salad dressings were homemade except the Ranch dressing and the Ranch dressing was removed from the original container. The DS stated she thought the USDA [United States Department of Agriculture] rule applied, keeping salad dressings up to 30 days. On [DATE] at 3:05 PM, the RD was asked about kitchen labeling, storing, cleaning the ovens, and handwashing practices. The RD confirmed the items in the walk-in refrigerator and mini freezer should have been protected from freezer burn and should have been labeled and dated. B. On [DATE] at 4:20 PM, the walk-in refrigerator was observed with the DS. An undated open/exposed bag of whipped cream was found. The DS stated staff should have placed it in a zip lock bag. C. On [DATE] at 10:44 AM, the mini freezer in the kitchen was observed with the DS. The freezer contained food products that were loosely wrapped/covered and did not contain a date or a label. These included a package of pancakes, two packages of French toast, two packages of hash browns, a package of onions/pepper mix, a double layer of trays with multiple single size servings of ice cream, a package of chicken cordon bleu, a package of chicken nuggets, a pizza, a package of biscuits covered in ice, and a package of chicken strips. The DS acknowledged the frozen items did not contain a date or label but felt the items wrapped in a plastic film was sufficient to prevent freezer burn. On [DATE] at 4:28 PM, the mini freezer in the kitchen was observed with the DS. The freezer contained an undated package of loosely wrapped chicken strips and ravioli. The DS acknowledged the frozen items did not contain a date or label and the items were only wrapped in plastic film. During an interview on [DATE] at 3:05 PM, the RD was asked about kitchen labeling, storing, cleaning the ovens, and handwashing practices. The RD confirmed the items in the walk-in refrigerator and mini freezer should have been protected from freezer burn and should have been labeled and dated. The RD stated she observed the trays of single servings of ice cream in the mini freezer and made recommendations to the DS. 2. FDA Food Code Section ,d+[DATE].11 stated, EQUIPMENT, FOOD-CONTACT SURFACES, NONFOOD-CONTACT SURFACES, AND UTENSILS (A) (B) (C) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The facility's General Food Preparation and Handling policy, undated, stated: - The kitchen surfaces and equipment will be cleaned and sanitized as appropriate - Prepared food will be transported to other areas in covered containers - Bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash their hands prior to putting gloves on and after removing gloves. A. On [DATE] at 10:44 AM, the two standard ovens and stoves were observed with the DS. The bottom of the inside of both ovens contained a white dried residue and the two grease trays, below the stoves, contained food drainage. On [DATE] at 4:06 PM, the two standard ovens were observed to have the same white residue and both stove grease trays contained the same food drainage from the day before. On [DATE] at 4:06 PM, the DS stated the ovens and grease trays should be cleaned daily but she was not sure what the white residue was. B. On [DATE] at 10:55 AM and [DATE] at 4:11 PM, multiple clean trays, tubs, silverware, multiple plate bases and lids sitting on a back table were observed with the DS. These items were noted to be covered in a white residue. On [DATE] at 4:11 PM, DS stated the white residue was due to hard water. DS stated, the water softer machine had been down for one week and the last time the dishes were de-limed was one and a half months ago. C. On [DATE] at 4:46 PM, the refrigerator in the nutrition room on the south nurse station was observed with the DS and to contain an open container of frozen fruit, undated, and a container of fruit, with an expired date of [DATE]. The DS confirmed the frozen fruit should have been disposed of on [DATE]. D. On [DATE] at 7:31 AM, the [NAME] did not wash his hands between glove changes while plating breakfast foods on the steamtable. On [DATE] at 7:39 AM, the Dietary Aide did not wash her hands before donning gloves while assembling the breakfast trays. On [DATE] at 7:41 AM, the DS was observed handling the lid of the large trash can to discard her gloves and did not wash her hands prior to donning another pair of gloves at 7:42 AM, and handling toast while preparing for breakfast. The DS was asked about not washing her hands and the DS confirmed she should have washed her hands before donning the gloves. On [DATE] at 9:28 AM, the Dietary Aide touched the sink faucet with her bare hands after washing her hands and then proceeded to unload clean dishes from the dishwasher. During a follow up interview on [DATE] at 8:26 AM, the RD was asked about her expectation for sealing open foods, labeling foods, and handwashing. RD stated to follow their state food code which was to securely seal and label foods and wash hands when indicated.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure continuity of care by not providing pertinent health information to the receiving hospital. This was true for 4 of 6 residents (#19, #33, #34, and #55) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to the lack of information provided upon transfer. Findings include: The facility's Criteria for Transfer and Discharge policy, dated December 2023, documented, information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information including contact information. c. Advance Directive information. d. All special instructions or precautions for ongoing care, as appropriate, to include but is not limited to treatments and devices, transmission-based precautions, and special risks (e.g., falls, elopement, aspiration, or pressure injury). e. Comprehensive care plan goals; and f. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The following resident records did not include documentation that pertinent resident health information had been sent to the hospital upon their transfer: 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy (a chemical imbalance in the blood that damages the brain), sepsis, urinary tract infection, diabetes, severe protein-calorie malnutrition, and acute kidney failure. LPN #1 noted on 7/16/24 at 10:13 AM, due to lab work results, Resident #19 was transferred to the hospital and admitted for hyponatremia and abnormal renal function. A nurses note, dated 7/16/24 at 6:14 PM, documented Resident #19's daughter was notified of the hospital transfer and admit. Resident #19's medical record did not include documentation that her advance directive, comprehensive care plan, or other pertinent resident health information had been sent to the hospital. On 7/26/24 at 9:45 AM, the DON stated there was no documentation of what information was sent with Resident #19 to the hospital. 2. Resident #34 was admitted to the facility on [DATE], with multiple diagnoses including gastrointestinal hemorrhage, severe protein-calorie malnutrition, COPD, and diabetes. A Nursing Home to Hospital Transfer form, dated 5/28/24, documented Resident #34 was transferred to hospital for gastrointestinal bleeding. A nurses note, dated 5/28/24, documented, resident left facility with POST form, admission form, and med list. Resident #34's medical record did not include documentation that her advance directive, comprehensive care plan, or other pertinent resident health information had been sent to the hospital. On 7/25/24 at 3:54 PM, the DON confirmed that the care plan and advanced directives were not sent to the hospital. 3. Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including acute osteomyelitis of the left ankle and foot, sepsis, chronic ulcer on part of left foot, diabetes, and morbid obesity. A nurses note, dated 5/27/24, documented Resident #55 was transferred to the hospital with new onset, foul drainage from his left foot ulcer. A nurses note, dated 5/27/24 at 2:06 PM, noted Resident #55's brother was notified of his transfer to the hospital. On 7/25/24 at 5:05 PM, the DON stated there was no documentation in Resident #55's record of what information was sent to the hospital. Additionally, the DON confirmed there was no physician's order for his transfer to the hospital. 50983 4. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, sepsis, and pneumonia. Resident #33's record documented she was transported and admitted to the hospital on 2/29/24, with a diagnosis of pneumonia and again on 5/25/24, with a diagnoses of acute chronic respiratory failure and sepsis secondary to pneumonia. Resident #33's record did not include documentation of the information that was provided to the hospital upon Resident #33's transfer. On 7/26/24 at 11:58 AM, the SSD, who is responsible for transfer and discharge documentation and notification, stated he was not aware of what documentation was needed for a hospital transfer.

Based on observation, policy review, and staff interview, it was determined the facility failed to secure and label unidentified loose pills in 1 of 1 medication cart (North side medication cart), audited for labeling and storage of medication. This failure created the potential for residents to miss doses of medication. Findings include: The facility's Medication Access and Storage policy, revision date May 2023, documented: - The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. - Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. - Medication storage areas are kept clean, well lit, and free of clutter. On 7/24/24 at 2:39 PM, a North side medication cart audit was completed with LPN #1 present. The following was found: - 4 unidentified pink pills loose in the second drawer. - 3 unidentified blue pills loose in the second drawer. - 1 unidentified half of a brown tablet loose in the second drawer. - 10 unidentified white pills, different sizes, loose in the second drawer. On 7/24/24 at 2:44 PM, LPN #1 stated she did not know why the pills were on the bottom of the drawer and she was not sure whose job it was to check the medication cart for loose pills. On 7/25/24 at 11:09 AM, the DON stated the nurses should check the medication cart throughout their shift and destroy loose medication in the drug buster bottle. If it is a narcotic it is destroyed by 2 nurses. She also stated she was not sure if pharmacy checks the carts when they are in the facility. The DON stated the medication cart audits are done by the DON but, there is not documentation of the audit being done, what they are looking for, or what they found.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an advanced directive. This was true for 1 of 16 residents (Resident #25) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include: The facility's Advanced Directives and Associated Documentation policy, revision date December 2023, documented it is the policy of this facility that a resident's choice about advance directives will be recognized and respected. It is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advanced directive. The facility will obtain a copy of the advanced directive documents and place the documents in the resident health record. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including stroke and dementia. A Medical Treatment Decisions form, dated 8/3/21, documented Resident #25 had an advanced directive and had presented her advanced directive to the Admissions Coordinator. Resident #25's care plan, dated 8/3/21, did not include an advanced directive decision. On 7/25/24 at 4:01 PM, the DON stated Resident #25 did not have an advanced directive but did have a POST and a DPOA. She also stated Resident #25's advanced directive decisions should have been included in her care plan.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice and comprehensive care plans were followed for 2 of 16 residents (Residents #17 and #41) reviewed for quality of care. Resident #17 was at risk of wound infection when her wound care was not performed as directed by her care plan. Resident #41 was at risk for adverse outcomes when his urinary catheter tubing was not secured as directed by his care plan. Findings include: 1. Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including orthopedic aftercare following surgical amputation of lower right extremity and morbid obesity. Resident #17's MAR included the following wound care interventions which were not completed as ordered by her physician and care plan: - Monitor wound vac each shift to ensure properly functioning, do not change dressing. If issues are noted, then reinforce dressing only and notify physician. Dressing will be completed in the orthopedic office. Order start date 1/18/23. Order discontinued date 2/12/23. The wound monitoring was not documented as completed for the dayshift on 1/19/23, 1/20/23, 1/21/23, 1/26/23, and 1/27/23. - Wound care RLE (right lower extremity). Clean with wound cleanser or NS (normal saline). Cover with a dry dressing. Change daily and as needed for wound care. Order start date 1/26/23. Order discontinued date 1/29/23. The wound care was not documented as completed on 1/26/23 and 1/27/23. - Leave incision to right leg open to air every shift. Order start date 11/28/22. Order discontinued date 1/12/23. The wound care was not documented as completed for the dayshift on 12/2/23, 12/4/23, 12/8/23, 12/22/23, 12/31/23, and for nightshift on 12/17/23 and 12/23/23. During an interview on 7/26/24 at 11:35 AM, the DON reviewed Resident #17's record and confirmed her wound care was not performed as directed by physician orders and the care plan, and there was no further documentation as to why the wound care was not completed. 49552 2. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including traumatic subdural hemorrhage, diabetes, malnutrition, and respiratory failure. Resident #41's physician's order, dated 7/28/22, documented every shift staff were to ensure the catheter is secured to facilitate flow of urine, prevent kinking of tubing, and accidental removal. Resident #41's care plan, directed staff to secure catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. On 7/24/24 at 9:36 AM, Resident #41's foley catheter tubing was observed, with CNA #2 present, and found not to be secured. On 7/25/24 at 5:06 PM, Resident #41's foley catheter tubing was observed, with the DON present, and found not to be secured. On 7/25/24 at 5:08 PM, the DON stated Resident #41 should have had his catheter tubing secured to his leg to prevent it from being pulled out.

Based on observation, interview, and record review, the facility failed to ensure positioning devices were in place to prevent further contractures for 1 of 1 resident (Resident #6) reviewed for range of motion. This deficient practice could result in further contractures and pain for Resident #6. Findings include: A facility policy for range of motion was requested and not provided. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including traumatic brain dysfunction, quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Resident #6's annual MDS, dated [DATE], documented Resident #6's cognition was severely impaired and her upper extremity (shoulder, elbow, wrist, hand) had impairment on both sides. A physician order, dated 5/27/22, documented, Encourage use of carrots [a positioning device] or rolled up washcloth in bilateral hands as she will accept to assist with contracture prevention. Resident #6's care plan, revised 7/23/24, directed staff to, Encourage (carrots) or rolled up washcloths to bilateral hands as she will accept/tolerate (does often refuse and remove) to assist with prevention of further contractures and ROM limitations. A TAR, dated July 2024, documented Resident #6 had the carrots or rolled up washcloths in place during the dayshift on 7/22/24, 7/23/24, and 7/24/24. On 7/22/24 at 11:45 AM, Resident #6 was observed sitting in her wheelchair in the hallway. Resident #6's hands were contracted as she held them against her chest. No positioning devices were in her hands. On 7/23/24 at 2:50 PM, Resident #6 was observed awake in bed and holding her contracted hands against her chest. No positioning devices were in her hands. On 7/24/24 at 10:27 AM, Resident #6 was observed asleep in bed and holding her contracted hands against her chest. No positioning devices were in her hands. On 7/24/24 at 2:37 PM, Resident #6 was observed asleep in bed and holding her hands against her chest. No positioning devices in her hands. Progress notes, dated 7/22/24, 7/23/24, and 7/24/24, did not include documentation of Resident #6 refusing the positioning devices in her hands. During an interview on 7/24/24 at 3:03 PM, LPN #2 was asked about Resident #6's positioning devices. LPN #2 confirmed Resident #6 did not have the positioning devices in her hands stating, she has them but will refuse to use them. LPN #2 looked in Resident #6's room for the positioning devices and came out of the room stating she could not find them. LPN #2 then stated, the laundry may have it. LPN #2 stated sometimes Resident #6 will get the positioning devices soiled during breakfast when RNA #1 feeds her and RNA #1 may have put it in the laundry. On 7/25/24 at 11:52 AM, RNA #1 was asked if Resident #6 had positioning devices in her hands during this week and RNA #1 said, No. On 7/25/24 at 4:51 PM, CNA #6 was asked if Resident #6 used positioning devices for her contractures and CNA #6 stated, No, she's never seen any carrots or wash cloths for her hands. On 7/26/24 at 9:57 AM, the DON stated she was not aware the TAR documented Resident #6 had the positioning devices in her hands, but Resident #6's refusals were not documented. On 7/26/24 at 10:24 AM, the PTA was asked about Resident #6's carrots for her hands. The PTA stated he had provided Resident #6 with positioning devices about two months ago, and they should be in her room and should be used.

Based on interview, record review, and policy review, it was determined the facility failed to ensure staff used a gait belt per the policy during a transfer that resulted in a potential for more than minimal harm for 1 of 5 residents (Resident #116) reviewed for accidents. Findings include: Resident #116 was admitted to the facility on [DATE], with multiple diagnoses including status-post left hip fracture, osteoporosis, Parkinson's disease, and arthritis. Resident #116's admission MDS, dated [DATE], stated Resident #116 was cognitively intact; height was 63 inches and weight was 202 pounds and required substantial/maximal assistance with chair/bed-to-chair transfer. A care plan, dated 11/6/23, stated, ADL Self Care Performance Deficit r/t [related to] acute illness, Parkinson's disease, S/P [status post] left hip fracture. An intervention included, Transfer (chair/bed to chair transfer, toilet transfer): Requires dependent assist, 2 person mechanical lift, dated 11/16/23. A fall risk evaluation, dated 11/8/23 stated Resident #116 was a high risk for falls, had a history of falls, and had balance problems while standing/walking. A nursing note, dated 12/8/24, stated Resident #116 was assisted by COTA #1 resulting in a complaint of pain in her left hip and a skin tear to her left hand. Resident #116 was transferred to the hospital for assessment. Physician progress notes, dated 12/29/24, stated Resident #116 was admitted to the hospital on 12/08/23 with a left femoral fracture (periprosthetic [close to implant], both distal and proximal). The facility investigation, dated 12/8/23, documented the following: Resident #116 lost her balance and was assisted to the floor by COTA #1 during a transfer from a wheelchair to a recliner. Resident #116 was taken to the hospital and a left periprosthetic femoral fracture was found and surgical repair was performed. COTA #1's statement documented, I was helping resident transfer from wheelchair to recliner. I placed the walker in front of the resident and put a hand under her right arm to give her a boost up, because she has been transferring well lately. Resident lost her balance and had a moderate fall backwards, more to her left side. She was mostly on her left buttock when she was on the floor. I immediately notified nursing while I supported resident upper body in sitting position on the floor. The facility investigation conclusion documented staff were trained on 12/8/23 regarding ensuring residents are wearing non skid footwear during transfers, locking wheelchair brakes, and using a gait belt during transfers. On 7/25/24 at 6:40 PM, COTA #1 was asked if she used a gait belt during Resident #116's transfer. She stated she normally used a gait belt, but could not remember if she used a gait belt during Resident #116's transfer on 12/8/23. COTA #1 confirmed Resident #116 was a two-person transfer for the CNAs, but she did not use a second person because therapy listed Resident #116 as a moderate assist, requiring one person. On 7/26/24 at 10:15 AM, the PTA stated COTA #1 should have used two-persons to transfer Resident #116 on 12/8/23, and confirmed COTA #1 did not utilize a second person. The PTA was asked if it was their policy to use a gait belt for Resident #116 and was a gait belt used when Resident #116 fell . He stated it was their policy and confirmed it was not documented that COTA #1 used a gait belt during resident #116's transfer on 12/8/23. On 7/26/24 at 1:52 PM, the Administrator stated for all staff, including therapy staff, are expected to follow the care plan and use a gait belt for transfers.

Based on observation, policy review, and staff interview, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment, when staff did not clean resident's equipment, perform hand hygiene properly, and follow proper protocol when checking blood sugars, and administering insulin. These failures had the potential to impact 1 of 7 resident's (Resident #27) equipment observed for cleanliness, 1 of 1 resident (Resident #41) for catheter drainage bag care, and 2 of 4 residents (Resident #14 & #41) who have their blood sugar checked and are on insulin. These deficient practices placed them at risk for cross-contamination and infection. Findings include: The facility's Hand Hygiene policy, revised December 2023, directs staff to use alcohol-based hand rub prior to donning gloves, removing gloves, before moving from a contaminated body site to a clean body site during resident care, and before and after handling urinary catheters. The U.S. Centers for Disease Control and Prevention, (CDC), Clinical Safety: Hand Hygiene for Healthcare Workers, (https://www.cdc.gov/clean-hands/hcp/clinical-safety/), dated February 27, 2024, documents to change gloves and clean hands, when moving from a soiled body site to a clean body site on the same patient. The facility's Glucometer Cleaning and Decontamination policy, revised December 2020, directed staff to disinfect the exterior surface of the glucometer after each use, following the manufacturer's directions, using either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim. The Sani-Cloth guideline for use documented: - unfold a clean wipe and thoroughly wet surface. - allow treated surface to remain wet for 2 minutes. - let it air dry. The facility's Administering Insulin policy, revised March 2023, directed staff to swab rubber cap with alcohol sponge, when preparing the insulin syringe and needle. 1. On 7/22/24 at 12:31 PM, CNA #6 delivered Resident #25's meal to her. CNA #6 did not offer hand hygiene to Resident #25. On 7/22/24 at 12:33 PM, CNA #6 stated I do wash their hands, but I must have spaced that one. On 7/22/24 at 12:36 PM, CNA #1 was observed passing meal trays to residents eating in their room. She did not offer to wash the resident's hands before setting up their meals. On 7/22/24 at 12:40 PM, CNA #1 stated, she did not offer to wash her hands and should have. We should be asking if they want their hands washed. 2. On 7/23/24 at 2:30 PM, CNA #3 and CNA #4 were observed transferring Resident #27 using the Hoyer lift (an assistive device that allows resident to be transferred by the use of electrical power). The Hoyer lift was observed with a dry gray substance on the base of the machine. After Resident #27 was transferred, CNA #4 took the Hoyer lift down the hall to the storage room. CNA #4 did not clean the Hoyer lift after transferring Resident #27. On 7/23/24 at 2:43 PM, CNA #4 stated she was not sure when the Hoyer lifts were cleaned. On 7/23/24 at 2:44 PM, Housekeeper #1 stated Hoyer lifts should be cleaned after every use. On 7/23/24 at 2:46 PM, CNA #3 stated the Hoyer lift should have been cleaned after transferring Resident #27. On 7/26/24 at 11:53 AM, the DON stated Hoyer lifts should be cleaned by the CNAs between residents. 3. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including traumatic subdural hemorrhage, diabetes, malnutrition, and respiratory failure. On 7/24/24 at 9:36 AM, observed CNA #2 provide Resident #41 with foley catheter care. CNA #2 donned gloves and cleaned Resident #41's urinary meatus (the opening in the penis where the urine comes out) and then cleaned a small amount of stool from his rectum. CNA #2 did not change soiled gloves before placing a clean brief on Resident #41. On 7/24/24 at 9:38 AM, observed CNA #2 donning a new pair of gloves without performing hand hygiene, to drain Resident #41's foley drainage bag. On 7/24/24 at 9:43 AM, CNA #2 stated she should have changed her gloves after providing catheter care to Resident #41 and she did not know she needed to wash her hands when changing her gloves. 4. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and COPD. On 7/24/24 at 11:34 AM, LPN #2 used the glucometer (a device used to measure the amount of glucose in your blood) to check Resident #49's blood sugar. LPN #2 brought the glucometer to the medication cart and was observed wiping the glucometer off with a Sani-cloth (disinfecting wipe) and then placed the glucometer on a tissue, on top of the medication cart. LPN #2 did not follow recommended dry time of 2 minutes as listed on the Sani-cloth container. On 7/24/24 at 11:39 AM, LPN #2 removed Resident #49's insulin pen from the top drawer of the medication cart. She then placed the needle on the tip of the insulin pen. LPN #2 did not clean rubber cap of the insulin pen prior to applying the needle. On 7/24/24 at 11: 43 AM, LPN #2 stated the needle was still covered so she did not think she had to clean the insulin pen stopper. She also stated she thought the dry time for the Sani-cloth was 2 minutes, but she would have to check, and she did not know it had to be kept wet for the 2 minutes. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and hypertension. On 7/24/24 at 11:49 AM, LPN #1 used the glucometer to check Resident #10's blood sugar. LPN #1 brought the glucometer to the medication cart and was observed wiping the glucometer off with a Sani-cloth and then placed the glucometer on a tissue, on top of the medication cart. LPN #1 did not follow recommended dry time of 2 minutes as listed on the Sani-cloth container. On 7/24/24 at 11:57 AM, LPN #1 stated the dry time for the Sani-cloth was 2 minutes, but she did not realize it had to stay on the glucometer for 2 minutes. On 7/26/24 at 8:50 AM, the DON stated the facility did not have an Insulin pen use/cleaning policy. They just follow the regular insulin policy. 50983 The facility's Oxygen Use policy with a revision/review dated January 2024, documented the filter on the concentrator should be checked at least every month and cleaned as needed. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy, chronic respiratory failure, and diabetes. Resident #14's physician order documented to change tubing, clean filter, and change oxygen water bottle every Sunday on the night shift, starting 12/19/21. On 7/22/24 at 11:22 AM, surveyor observed the filter on Resident #14's oxygen concentrator to have a thick layer of dust. On 7/26/24 at 8:48 AM, the IP stated the night shift nurse is responsible for cleaning the filters on the side of the oxygen concentrators. Additionally, the IP stated the oxygen concentrators should be cleaned monthly and PRN.

Based on policy review, facility grievance review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with baths or showers consistent with their preferences and needs. This was true for 5 of 15 residents (#1, #3, #6, #7, and #8) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being due to a lack of bathing. Findings include: The facility's policy for Baths and Showers revised 5/2007, documented staff were to assist ambulatory and dependent residents with bathing or shower needs to promote cleanliness, stimulate circulation, and aid in relaxation. This policy was not followed. a. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 6/10/21, documented Resident #1 was moderately cognitively impaired and required one person to do all her bathing needs for her. Resident #1's care plan related to bathing, initiated on 2/5/21, documented Resident #1 wanted to have a bath or shower once a week and a bed bath once a week, for a total of two baths weekly. Resident #1's ADL record for bathing documented the following: * Resident #1 received a shower on 5/8/21 and received her next shower on 5/17/21, eight days after her last shower. She refused a shower or bath on 5/14/21. Resident #1's record did not include documentation bathing was re-offered or refused at other times. * Resident #1 received a shower on 5/17/21 and received her next shower on 5/27/21, nine days after her last shower. She refused bathing on 5/20/21 and 5/24/21. Resident #1's record did not include documentation bathing was re-offered or refused after 5/20/21 or 5/24/21, at other times. * Resident #1 received a shower on 6/1/21 and received her next shower on 6/10/21, eight days after her last shower. She refused a shower or bath on 6/4/21 and 6/9/21. Resident #1's record did not include documentation that bathing was re-offered or refused between 6/2/21 to 6/3/21 and 6/5/21 to 6/8/21. * Resident #1 received a shower on 6/17/21 and received her next shower on 6/23/21, six days after her last shower. Resident #1's record documented that she refused a shower on 6/22/21. There was no documentation that bathing was re-offered or refused between 6/17/21 to 6/21/21. * Resident #1 received a shower on 6/28/21 and received a sponge bath on 7/14/21, 15 days after her last shower. Resident #1's record documented that she refused a shower on 7/2/21, 7/8/21, and 7/13/21. There was no documentation that bathing was re-offered or refused between 6/29/21 to 7/1/21, 7/3/21 to 7/7/21, or 7/9/21 to 7/12/21. * Resident #1 received a sponge bath on 7/14/21 and received her next sponge bath on 7/21/21, six days after her last bath. Resident #1's record did not include documentation that bathing was re-offered or refused between 7/15/21 and 7/20/21. * Resident #1 received a sponge bath on 7/21/21 and received her next bath on 7/28/21, six days after her last bath. Resident #1's record did not include documentation bathing was re-offered or refused between 7/22/21 to 7/27/21. b. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment, dated 7/23/21, documented Resident #8 was moderately cognitively impaired and she required one-person total assistance for bathing. Resident #8's care plan related to bathing, initiated on 5/12/18, documented that Resident #8 preferred a shower 2 -3 times a week on Wednesday, Friday, and any other day. Resident #8's ADL record for bathing documented the following: * Resident #8 received a shower on 5/12/21 and received her next shower on 5/19/21, six days after her last shower. Resident #8's record documented she refused a shower on 5/14/21. Resident #8's record did not include documentation bathing was re-offered or refused on 5/13/21 and between 5/15/21 to 5/18/21. * Resident #8 received a shower on 5/20/21 and received a sponge bath on 5/26/21, six days after her last bath. Resident #8's record did not include documentation bathing was re-offered or refused on 5/20/21 and between 5/22/21 to 5/25/21. * Resident #8 received a shower on 5/26/21 and received her next shower on 6/2/21, six days after her last sponge bath. Resident #8's record did not include documentation bathing was re-offered or refused between 5/27/21 to 6/1/21. * Resident #8 received a shower on 6/9/21 and received her next shower on 6/16/21, six days after her last shower. Resident #8's record did not include documentation bathing was re-offered or refused between 6/10/21 to 6/15/21. * Resident #8 received a shower on 7/9/21 and received her next shower on 7/16/21, six days after her last shower. Resident #8's record did not include documentation bathing was re-offered or refused between 7/10/21 to 7/15/21. * Resident #8 received a shower on 7/23/21 and received her next shower on 7/30/21, six days after her last shower. Resident #8's record documented that she refused a shower on 7/27/21. Resident #8's record did not include documentation bathing was re-offered or refused between 7/24/21 to 7/26/21 and 7/28/21 to 7/29/21. c. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan documented that he preferred a shower twice a week and had no preference regarding what days of the week his shower occurred. Resident #3's ADL record for bathing documented the following: * Resident #3 received a shower on 6/10/21 and his next shower on 6/17/21, six days after his last shower. Resident #3's record did not include documentation bathing was re-offered or refused. * Resident #3 received a shower on 7/6/21 and received his next shower on 7/12/21, six days after his last shower. * Resident #3 received a shower on 7/20/21 and received his next shower on 7/27/21, six days after his last shower. He did refuse one bath during this time. There was no documentation that he was re-approached or re-offered a shower after the refusal. * Resident #3 received a shower on 7/27/21 and received his next shower on 8/5/21, eight days after his last shower. Resident #3's record did not include documentation a shower was re-offered or refused. d. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including urinary tract infections, diabetes, and a right foot fracture. A quarterly MDS assessment, dated 6/29/21, documented Resident #6 had long-term and short-term memory impairment and required one-person supervision for bathing. Resident #6's care plan related to bathing, initiated on 1/28/21, documented Resident #6 wanted 1-2 showers per week. Resident #6's ADL record for bathing documented the following: * Resident #6 received a shower on 5/11/21 and received his next shower on 5/29/21, 16 days from his last shower. Resident #6's record did not include documentation a shower was re-offered or refused between 5/12/21 to 5/18/21, on 5/20/21, and 5/22/21 to 5/28/21. e. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MDS assessment dated [DATE] documented that she needed one person to physically assist her with bathing and stabilize her when moving from a seated position to a standing position. Resident #7's care plan for bathing, initiated on 11/18/20, documented Resident #7 was to be showered twice weekly and as needed. Resident #7's ADL record for bathing documented she received her first shower on 11/21/20, eleven days after admission to the facility. On 8/19/21 at 7:15 AM, CNA #1 stated she currently worked as a bath aide. She stated there were days when residents did not receive showers as scheduled on their care plan due to short staffing. She stated CNAs gave baths on evening and night shifts due to a lack of staff.

Based on review of Resident Council Minutes, review of Facility Assessment, policy review, review of facility grievances, review of staffing schedules, record review, and resident and staff interview, it was determined the facility failed to ensure there was sufficient numbers of competent staff to administer medications per resident preference, answer call lights in a timely manner, and provide baths or showers to residents as needed. This was true for 8 of 15 residents (#1, #3, #5, #8, #9, #10, #11, and #12) who were reviewed. This deficient practice created the potential for Resident #11 to receive inaccurate medications or experience nausea when he was made to take his medications all at one time, residents to experience physical or psychological harm due to long call light response times (#5, #8, and #9), for Resident #10 to experience anxiety when her physical therapy was not provided at the scheduled time, and for residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being when residents did not receive showers or baths per their preference and as scheduled (#1, #3, #6, #7, #8, and #12). This deficient practice also had the potential to affect the other 44 residents residing in the facility. Findings include: a. Resident Council meeting minutes and grievances were reviewed and documented the following staffing concerns from residents: * Resident Council Meeting minutes, dated 5/20/21, documented a concern that weekend staffing was insufficient to meet resident needs. *A grievance, dated 7/19/21, documented a nurse made Resident #11 take his medications all at once and delegated a CNA to apply his topical medications. *A grievance, dated 5/30/21, documented Resident #12 had a strong body odor and was not receiving his scheduled showers. b. Residents and a staff member expressed concerns during interviews about adequate staffing, as follows: * On 8/18/21 at 8:40 AM, Resident #8 stated the facility did not have enough CNAs to meet residents' needs, and the night shift was always short on staffing. She stated when LNs or CNAs take time off, there was no coverage or replacement staff, and residents went without care. * On 8/18/21 at 9:15 AM, Resident #9 stated night shift care was poor. He stated staff put him to bed in the evening, and that was the last time he saw anyone until the following day. He stated he had to wait 40 minutes to an hour before his call light was answered. * On 8/18/21 at 9:25 AM, Resident #1 stated there were long wait times for call lights to be answered daily from 6:00 PM through 8:00 PM. She stated the wait was two hours for her call light to be answered during the night shift on 8/17/21. * On 8/18/21 at 11:20 AM, Resident #5 stated there was not enough staff to answer call lights quickly during the night. He stated it took between 2-3 hours for his call light to be answered at night. He also stated he could tell when the facility did not have enough staff because his meals were delivered cold. * On 8/18/21 at 9:30 AM, Resident #10 stated physical therapy staff was usually late to pick her up for therapy because the therapy technician worked on the floor as a CNA. * On 8/19/21 at 9:48 AM, Physical Therapy Technician #1 stated he was not a CNA, but he answered call lights, assisted residents with transfers, and helped residents to the bathroom as needed. He stated the CNAs called him to help them usually 5-6 times a shift. He stated residents' call lights were usually on when he picked them up for therapy, and he helped them with their needs, then took them to physical therapy. c. Residents did not receive baths/showers consistent with their needs and bathing schedules. The facility's bath and shower policy, revised 5/2007, documented the facility bathed residents to promote cleanliness, stimulate circulation, and assist in relaxation. This policy was not followed. Examples include: i. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 6/10/21, documented Resident #1 was moderately cognitively impaired and required one person to do all her bathing needs for her. Resident #1's care plan related to bathing, initiated on 2/5/21, documented Resident #1 wanted to have a bath or shower once a week and a bed bath once a week, for a total of two baths weekly. Resident #1's ADL record for bathing documented the following: * Resident #1 received a shower on 5/8/21 and received her next shower on 5/17/21, eight days after her last shower. She refused a shower or bath on 5/14/21. Resident #1's record did not include documentation bathing was re-offered or refused at other times. * Resident #1 received a shower on 5/17/21 and received her next shower on 5/27/21, nine days after her last shower. She refused bathing on 5/20/21 and 5/24/21. Resident #1's record did not include documentation bathing was re-offered or refused after 5/20/21 or 5/24/21, at other times. * Resident #1 received a shower on 6/1/21 and received her next shower on 6/10/21, eight days after her last shower. She refused a shower or bath on 6/4/21 and 6/9/21. Resident #1's record did not include documentation that bathing was re-offered or refused between 6/2/21 to 6/3/21 and 6/5/21 to 6/8/21. * Resident #1 received a shower on 6/17/21 and received her next shower on 6/23/21, six days after her last shower. Resident #1's record documented that she refused a shower on 6/22/21. There was no documentation that bathing was re-offered or refused between 6/17/21 to 6/21/21. * Resident #1 received a shower on 6/28/21 and received a sponge bath on 7/14/21, 15 days after her last shower. Resident #1's record documented that she refused a shower on 7/2/21, 7/8/21, and 7/13/21. There was no documentation that bathing was re-offered or refused between 6/29/21 to 7/1/21, 7/3/21 to 7/7/21, or 7/9/21 to 7/12/21. * Resident #1 received a sponge bath on 7/14/21 and received her next sponge bath on 7/21/21, six days after her last bath. Resident #1's record did not include documentation that bathing was re-offered or refused between 7/15/21 and 7/20/21. * Resident #1 received a sponge bath on 7/21/21 and received her next bath on 7/28/21, six days after her last bath. Resident #1's record did not include documentation bathing was re-offered or refused between 7/22/21 to 7/27/21. ii. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment, dated 7/23/21, documented Resident #8 was moderately cognitively impaired and she required one-person total assistance for bathing. Resident #8's care plan related to bathing, initiated on 5/12/18, documented that Resident #8 preferred a shower 2 -3 times a week on Wednesday, Friday, and any other day. Resident #8's ADL record for bathing documented the following: * Resident #8 received a shower on 5/12/21 and received her next shower on 5/19/21, six days after her last shower. Resident #8's record documented she refused a shower on 5/14/21. Resident #8's record did not include documentation bathing was re-offered or refused on 5/13/21 and between 5/15/21 to 5/18/21. * Resident #8 received a shower on 5/20/21 and received a sponge bath on 5/26/21, six days after her last bath. Resident #8's record did not include documentation bathing was re-offered or refused on 5/20/21 and between 5/22/21 to 5/25/21. * Resident #8 received a shower on 5/26/21 and received her next shower on 6/2/21, six days after her last sponge bath. Resident #8's record did not include documentation bathing was re-offered or refused between 5/27/21 to 6/1/21. * Resident #8 received a shower on 6/9/21 and received her next shower on 6/16/21, six days after her last shower. Resident #8's record did not include documentation bathing was re-offered or refused between 6/10/21 to 6/15/21. * Resident #8 received a shower on 7/9/21 and received her next shower on 7/16/21, six days after her last shower. Resident #8's record did not include documentation bathing was re-offered or refused between 7/10/21 to 7/15/21. * Resident #8 received a shower on 7/23/21 and received her next shower on 7/30/21, six days after her last shower. Resident #8's record documented that she refused a shower on 7/27/21. Resident #8's record did not include documentation bathing was re-offered or refused between 7/24/21 to 7/26/21 and 7/28/21 to 7/29/21. iii. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan documented that he preferred a shower twice a week and had no preference regarding what days of the week his shower occurred. Resident #3's ADL record for bathing documented the following: * Resident #3 received a shower on 6/10/21 and his next shower on 6/17/21, six days after his last shower. Resident #3's record did not include documentation bathing was re-offered or refused. * Resident #3 received a shower on 7/6/21 and received his next shower on 7/12/21, six days after his last shower. * Resident #3 received a shower on 7/20/21 and received his next shower on 7/27/21, six days after his last shower. He did refuse one bath during this time. There was no documentation that he was re-approached or re-offered a shower after the refusal. * Resident #3 received a shower on 7/27/21 and received his next shower on 8/5/21, eight days after his last shower. Resident #3's record did not include documentation a shower was re-offered or refused. iv. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including urinary tract infections, diabetes, and a right foot fracture. A quarterly MDS assessment, dated 6/29/21, documented Resident #6 had long-term and short-term memory impairment and required one-person supervision for bathing. Resident #6's care plan related to bathing, initiated on 1/28/21, documented Resident #6 wanted 1-2 showers per week. Resident #6's ADL record for bathing documented the following: * Resident #6 received a shower on 5/11/21 and received his next shower on 5/29/21, 16 days from his last shower. Resident #6's record did not include documentation a shower was re-offered or refused between 5/12/21 to 5/18/21, on 5/20/21, and 5/22/21 to 5/28/21. v. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MDS assessment dated [DATE] documented that she needed one person to physically assist her with bathing and stabilize her when moving from a seated position to a standing position. Resident #7's care plan for bathing, initiated on 11/18/20, documented Resident #7 was to be showered twice weekly and as needed. Resident #7's ADL record for bathing documented she received her first shower on 11/21/20, eleven days after admission to the facility. On 8/19/21 at 7:15 AM, CNA #1 stated she currently worked as a bath aide. She stated there were days when residents did not receive showers as scheduled on their care plan due to short staffing. She stated CNAs gave baths on evening and night shifts due to a lack of staff. d. The facility assessment tool, updated 4/28/21, and last reviewed by the QAPI Committee on 5/13/21, documented on average, the facility had 43 residents, 28 of whom needed the assistance of 1-2 staff for bathing, eating, and toileting. It documented 15 residents were totally dependent on staff to provide bathing for them, 12 required complete assistance with transferring, and 13 were entirely dependent on staff for toileting needs. The facility's CNA work schedule for June 2021, documented two CNAs worked the night shift from 6/8/21 to 6/16/21, and one CNA worked the night shift on 6/21/21 and 6/28/21. The facility's CNA work schedule for July 2021, documented two CNAs worked during the night shift on 7/23/21 and 7/24/21. The facility's CNA work schedule for August 2021, documented two CNAs worked during the night shift on 8/2/21, 8/10/21, and 8/20/21. The CNA work schedule also documented two CNAs were scheduled to work on the night shift on 8/21/21, 8/26/21, and 8/27/21. On 8/20/21 at 7:54 AM, the Administrator stated the facility census was 52. He stated the facility staffed two LNs and two CNAs at night to care for residents, and they could always use more staff.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not wear appropriate PPE for droplet precautions, clean and disinfect shared use equipment between each use, and correctly secure a urinary catheter so it did not touch the floor. This failure was true for 4 of 15 residents (#6, #13, #14, and #15) who were observed and whose records were reviewed, and had the potential to affect the other 48 residents residing in the facility. This deficient practice created the potential for spreading infectious organisms, including, but not limited to COVID-19 from cross contamination. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. These failures placed all staff and residents at increased risk of infections. Findings include: 1. The facility's policy Emerging Infectious Disease COVID-19 Surveillance, revised 12/2/20, documented all new admissions would be placed on isolation/transmission-based precautions in a single-person room. It documented staff would wear an N95 mask, gown, gloves, and eye protection when entering the resident's room. This policy was not followed. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 8/18/21 at 4:17 PM, documented Resident #13 was not vaccinated against COVID-19, and he required contact and droplet precautions. Resident #13's door had the following signs: * A sign for contact precautions which included instructions to put on gloves and a gown before entering the room and to discard, clean, and disinfect reusable equipment before exiting the room. * A sign for droplet precautions which included instructions to clean hands, make sure eyes, nose, and mouth were fully covered before entering the room, and to remove face protection and clean hands before exiting the room. * A sign from the CDC website with detailed instructions of the steps for putting on and taking off PPE. The sign also stated an N95 mask, a face shield or goggles were to be worn if entering the room. A storage cabinet filled with new face shields, N95 masks, and disposable gowns was in the hallway on the right side of Resident #13's room. On 8/20/21 at 7:40 AM, CNA #1 performed hand hygiene, put on gloves and a disposable gown. She tied the gown at her neck but did not tie the gown at her waist. She walked into Resident #13's room to deliver a breakfast tray wearing her surgical mask and eye protection instead of putting on an N95 respirator and face shield as required. On 8/20/21 at 7:43 AM, CNA #1 exited Resident #13's room. She did not use hand sanitizer to clean her hands after exiting the room. She did not change her mask or clean her goggles when she exited the room. She walked past rooms 110, 112, 114, 116, and 118 to the nurses' station in front of room [ROOM NUMBER] and washed her hands at the sink in the nurse's station. On 8/20/21 at 7:45 AM, CNA #1 stated she thought she should change her surgical mask when exiting the room. On 8/20/21 at 8:30 AM, the ADON stated staff were required to wear an N95 mask, gown, gloves, and face shield to enter a quarantine room and isolation gowns should be tied at the waist covering the staff's uniform. 2. The CDC's website, accessed on 8/24/21, included a section for Catheter-Associated Urinary Tract Infections, which documented proper techniques for urinary catheter maintenance. The website stated to keep the urine collection bag below the level of the bladder and not resting the drainage tube and collection bag on the floor. This was not followed. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's record documented he had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) inserted related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's care plan for his catheter, initiated 1/28/21, included interventions as follows: * Position catheter bag and tubing below the level of the bladder. * Secure catheter to facilitate the flow of urine, prevent kinking of tubing, and accidental removal. * Use leg bag for urinary catheter during the day and change to larger bedside drainage bag during the night. On 8/19/21 at 3:02 PM, Resident #6 was observed sitting in his wheelchair, wheeling himself from the nurse station to his room. He had a large urinary drainage bag hanging on the interior side of his wheelchair near his right leg. Resident #6's catheter tubing was dragging on the floor under his wheelchair while he wheeled from the nurse station to his room. On 8/20/21 at 8:20 AM, Resident #6 sat in the group dining room in his wheelchair. He had a large urinary drainage bag hanging on the interior side of the wheelchair near his right leg. His catheter tubing was tangled and rested on the floor under his wheelchair. On 8/20/21 at 8:23 AM, LPN #3 stated a CNA should have changed Resident #6's large urinary bag to a small leg bag in the morning to avoid the catheter tubing and bag from resting on the floor. She stated she should have double-checked that it was changed. On 8/19/21 at 6:00 PM, the ADON stated Resident #6's catheter tubing and drainage bag touching the floor did not meet facility infection control requirements. 3. The facility's policy Infection Prevention and Control Program, revised on 9/29/17, documented the requirement for cleaning and disinfecting shared resident equipment. The policy stated equipment that was shared between residents was to be cleaned and disinfected daily, and before and after use to prevent the spread of infectious diseases and microorganisms. This policy was not followed. On 8/18/21 at 9:45 AM, 2 CNAs were observed entering Resident #14's room with a Hoyer lift (a mechanical lift used to assist with transferring residents). On 8/18/21 at 9:50 AM, CNA #2 pushed the Hoyer lift out of Resident #14's room. CNA #2 parked the Hoyer lift in the storage room without cleaning or disinfecting it after use. On 8/18/21 at 9:52 AM, CNA #2 stated a CNA usually cleaned the Hoyer lift at the beginning and end of each shift. On 8/18/21 at 9:55 AM, NA #1 was observed pushing the Hoyer lift out of Resident #15's room and parking it in the storage room without cleaning or disinfecting it after use. On 8/18/21 at 9:57 PM, NA #1 said she did not clean the Hoyer lift after using it. She stated she usually cleaned it at the end of her shift. On 8/20/21 at 8:30 AM, the ADON said the Hoyer lift should be cleaned between each use.

Based on observation, record review, and resident and staff interview, it was determined the facility did not ensure a fall care plan and a physician order [REDACTED].#3) sampled for falls. Resident #3 was harmed when she reached for a water bottle placed out of her reach, fell from bed which did not have the appropriate sized side rails as ordered by the physician, and the fall resulted in the resident sustaining femur fractures to both of her legs. Findings included: Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 7/30/14 annual MDS assessment documented the following: *Required extensive assistance with two staff members for bed mobility; *Required total dependence with two staff members to transfer in/out of bed; and, *Was moderately cognitively impaired, BIMS=11. The resident's September 2014 Order Summary Report documented an order dated 7/24/12, "2 1/2 Length Side Rails to Bed for safety, bed mobility R/T (related to) seizure disorder." Refer to F154 regarding informed health status regarding the use of side rails The resident's care plan dated 1/30/14, documented a focus of: "Has high risk for injury and fracture r/t severe Osteoporosis, osteopenia, [DIAGNOSES REDACTED] and Seizure disorder with involuntary movement at times..." With an intervention of, "Protect from injury. Avoid sudden bumps..." The resident's ADL care plan, dated 1/30/14, documented an intervention of: "Side Rails: 2 half rails up as per Dr.s (physician) order for safety while in bed due to seizure disorder, to assist with bed mobility..." The resident's fall care plan, dated 1/30/14, documented a focus of: "At risk for falls r/t Poor communication/comprehension, Deconditioning, Psychoactive drug use, Incontinence." With interventions of, "Keep needed items, water, etc. in reach on bedside table/tray...Four 1/2 length side rails while in bed to provide safety r/t seizure disorder." Note: The care plan was not consistent on how many side rails were to be applied to the bed. The resident's Progress Notes dated 9/6/14 and 9/7/14, documented the resident had fallen from bed, was found in the praying position, and was assessed , monitored, and given medication for pain. When leg pain was found, the facility transported the resident to a local emergency room (ER). A local hospital physician's note dated 9/7/14, documented, "Bilateral distal femur fractures...At this time, I believe nonoperative care is warranted. Our plan is a hinged knee brace for protection..." A facility "Fall Scene Investigation" dated 9/6/14 at 1:00 PM indicated the resident fell on [DATE] at 10:25 AM. The investigation documented the following: The "Fall Description Details" section documented, "Resident on knees beside bed with head on bed...reach for her pop (sic)." The "Root Cause of this Fall" section documented, "Resident was reaching for pop and table was out of reach...Staff educated on checking all before leaving." A facility investigation dated 9/10/14, documented the following: The "Investigation" section documented, "Res(ident) stated she was reaching for her drink when she fell ...Interventions put in place immediately included floor mats on both sides and bed in lowered position. Two additional quarter rails were added as well as bilateral bolsters inside the rails." The "Summary" section documented, "Resident at high risk for fracture due to medical conditions...Resident did not complain of leg pain until later in the night. Upon return from hospital, has bilateral knee braces to prevent knee flexion; as surgical intervention is not recommended." The resident's September 2014 MAR, documented the resident experienced no pain to mild pain from 9/1/14 to 9/5/14 and had not taken any PRN pain medications. However, after the fall from 9/6/14 to 9/8/14 the resident experienced moderate to severe pain and had taken PRN pain medications with effective results. After the fall, the resident's care plan was updated and contained the following interventions: -9/6/14, "Bed in lowest position." -9/8/14, "1/2 Side Rails x(times) 4 for bed mobility and padded bolster mattress for seizure precautions." -9/8/14, "Mats at bedside." -9/8/14, "Keep bedside table close to bed." The following observations were made of the resident's room: -On 9/8/14 at 4:10 PM, the bed had four quarter rails attached to the bed (two upper and two lower on each side of the bed) with the padding extending the length of the bed. The pads had bed bolsters attached to the inside portion. The resident was in bed watching a movie and had a pink water bottle in the bed with her. There was also a water mug on the over bed tray table. The tray table was one and a half feet away from the bed and was resting partially on top of one of the padded fall mats placed on each side of the bed. The bed was raised in the normal position. -On 9/9/14 at 7:35 AM, the resident was asleep in bed with a pink water bottle at her side. The bed was in the low position. The tray table was one and a half feet away from the bed, raised above the bed level and was resting partially on top of one of the padded fall mats with a water mug and Sprite bottle on top of the table. A staff member was seen going into the room, took the water mug away and walked out of the room with the mug. -At 7:43 AM, a CNA was observed in the room. She adjusted the tray table down to the level of the bed and moved it closer to the bed. The table was still 6 to 8 inches away from the edge of the bed. -At 9:53 AM, the tray table was observed sitting directly on the fall mat with the table top overlapping the bed by 2 inches. On 9/11/14 at 8:12 AM, CNA #3 was interviewed regarding the resident's fall. She stated she found the resident half on and half off the bed with her face and head looking over the bed. She stated the bed had a quarter side rail to each side of the bed toward the top half. On 9/11/14 at 8:40 AM, LPN #4 was interviewed regarding the fall. She stated the resident was found in the 'praying position' with her knees toward the ground and her head facing the bed. She stated she interviewed the resident who told her she was reaching for her pop which was in the pink water bottle, when she fell out of bed. When LPN #4 asked the resident where the pop was located, the resident said it was on the bedside table next to the head her bed. Note: The bedside table was located 18 inches diagonally away from the head of the resident's bed. On 9/11/14 at 9:00 AM, Resident #3 was interviewed regarding the fall. Holding up her pink water bottle she said she was reaching for it. When asked which side of the bed it was located at the time of the fall, she pointed to her left (window side). When asked where on that side, she stated, "table." When asked if it was the tray table (to her right) or the bedside table (to her left), she motioned her head left and said, "There." On the table were stuffed animals and the surveyor asked, "With the animals?" and she stated, "Yeah." On 9/11/14 at 9:40 AM, CNA #5 was interviewed regarding the fall. She stated the resident was found on her knees with her upper body on the bed right next to the lower portion of the quarter side rail. She said there were no lower side rails attached to the bed at the time. On 9/11/14 at 10:35 AM, the DON was interviewed with a Clinical Partner present. When asked for the conclusion of the investigation he stated, "The patient was reaching for a pop and fell off the bed." When asked to review the care plan regarding keeping items within reach, he reviewed and stated, "I understand." When asked about what type of side rails the resident had at the time of the fall he stated, "She had two quarter at the top." The DON was not sure why the resident did not have two half-length side rails as ordered. He was also informed of the surveyor's observations of the bed in the normal position and the tray table out of reach of the resident, where upon he stated, "I did not know about that." On 9/11/14 at 5:50 PM, the Administrator and DON were informed of the issue. No further information was provided.

Based on observation, record review, staff and resident interviews, it was determined the facility failed to ensure: - Residents did not develop pressure sores, - Residents' healed pressures sores did not reoccur, - Pressure sore prevention was implemented, - Care plans were revised and changed as needed, - Treatments were adjusted to provide prevention and healing, and - Moisture and refusals for care were addressed where needed. These issues in part were found for 7 of 12 (#s 1, 2, 3, 5, 7, 11, and 12) sampled residents. Resident #11 was harmed when a Stage II pressure sore healed and returned within 5 days. Resident #1 was harmed when he had multiple moisture associated skin disease (MASD) Stage II sores on his buttocks and a pressure sore on his heel. 1. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident went to the hospital and was readmitted on [DATE] with a stage II pressure sore on the sacrum. The significant change MDS, dated [DATE], documented the resident: - had short and long term memory issues, -was moderately impaired for decision making skills, - required extensive assistance of one to two staff for transfers, dressing, eating, personal hygiene and bathing. - had a stage II and Stage III pressure sore. (Note: The facility classified a wound to the abdomen that resulted from a misplaced peg tube as a Stage III pressure sore.) The resident's care plan, dated 2/5/13, documented a focus of: "At risk for skin breakdown r/t: nutritional status, incontinence, impaired mobility, terminal illness. Decreased sensation on skin, [MEDICAL CONDITION]." The interventions were: "- Assess changes in skin status - Notify MD if indicated. - Blue quilted boots to be worn at all times. - Complete Braden Scale to assess risk factors. - Complete skin alteration report weekly and PRN. - Dietitian to review and document nutritional status monthly and PRN. - Encourage weight shifting when in wheelchair. - Moisture barrier cream applied after incontinent episode. - Obtain lab/diagnostics as ordered by MD. - Provide diet as ordered by MD. - Supplements per orders. - Tx as ordered to area(s) per order. Reevaluate/notify MD for modifications as needed to slow healing/non-healing/changes in wound." The Stage II sore was on the coccyx area. The sore healed on 4/17/13. The wound reopened on 4/22/13. The documentation was: The 4/17/13 at 7:26 p.m."LN - Skin Pressure Ulcer Weekly: Sacrum, Pressure 0 cm X 0 cm X 0 cm. Wound resolved - skin intact and blanchable." The 4/22/12 at 6:27 p.m. "LN - Skin Assessment Evaluation - PRN/Weekly: Sacrum, Pressure 1.5 cm X 1.0 cm X 0.1 cm. Previously healed has re-opened due to area already fragile and at risk with contributing factors including: incontinent, moisture possible shearing/friction, immobility and inadequate nutrition." The 5/1/13 Braden Scale Assessment for predicting pressure sore risk scored the resident as a 15 = High Risk. The 5/8/13 "LN - Skin Assessment Evaluation - PRN/Weekly: Sacrum, Stage II = 2.5 x 2 x 0.1 cm. Resident continues with tx and dressing per SKIN TAR." The 5/17/13 "LN - Skin Pressure Ulcer Weekly: Sacrum, 0 x 0 x 0, Appears that pressure ulcer to sacrum has been resolved while in hospital new area to coccyx now." The DON and ADON were interviewed, on 6/20/13 at 11:30 a.m., about the return of the pressure sore on the sacrum. They indicated they would "look into it." The staff did not address or provide any additional information about the sore. Resident #11 was harmed when the facility resolved a Stage II pressure sore on the sacrum and 5 days later it returned as a Stage II sore. The documentation in the record focused on the abdominal wound after the sacrum sore healed. The facility failed to ensure the resident's fragile skin on the sacrum area was monitored and preventative measures continued to be implemented. The resident continued at risk due to moisture issues, poor caloric intake and being restrained in a wheelchair with a pommel cushion and lap buddy. 2. Resident #1 was admitted to the facility, on 4/19/10 and readmitted on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS, dated [DATE], documented the resident: - was cognitively intact with a BIMS = 15 - required extensive assistance of one to two staff for bed mobility, dressing, toilet use, personal hygiene and bathing. - only transferred one time in the look back period. - had a Stage II pressure sore. The resident's care plan had several areas that had information about skin issues and prevention. The "ADL- Self Care Deficit...(initiated 4/9/12)" had intervention for "Two person assist with bed mobility." The "Impaired physical mobility r/t pain...(initiated 3/25/13)" had interventions of, "ABD pillow/brace at all times., -turn q (every) 2 mattress in addition to turning by staff., - Maintain good body alignment., - pressure reducing mattress." The care plan specific to skin documented: "Alterations in skin R/T: Nutritional Status, Impaired mobility, Non-compliance with turning position, admitted with calloused skin on bilateral buttocks and MAID (sic) on buttocks and upper thigh, STD(suspected deep tissue) injuries to bottom of bilateral feet, wounds are chronic and likely to not fully heal. MD Orders written stating wounds are unavoidable due to unreliable diet, pt condition and noncompliance. resident refuses to use air mattress to lay in bed (HX). MD order signed that skin tears and wounds are unavoidable dated 5/15/12. (initiated: 4/9/12)" The interventions were: "- Assess changes in skin status - Notify MD if indicated. - Assist resident to turn and reposition with cares and as requested/allowed-does frequently refuse. -Blue boots on with heel floating. - Complete skin alteration report weekly and PRN. - Educate Resident/Family about: pressure ulcer etiology, Primary risk factors, Treatment, Prevention, Non-compliance issues. - Lotion skin with daily cares. - Moisture Barrier Cream applied after every incontinent episode and PRN, NURSE to put moisture barrier cream when skin tear present. - Monitor tolerance dressing changes for wound care and offer PRN pain med prior to wound care to improve compliance. - Moisture barrier cream applied to buttocks each time resident is up in sit to stand for transfers or toileting. - Pressure guard, APM, (alternating pressure mattress) encourage compliance with bed rest to help promote wound healing. Two side rails, 1/4 length, for safety r/t alternating pressure mattress. - Provide diet as ordered by MD. - Resident has specific nurses that he prefers to do wound care, if resident refuses wound care and preferred nurses are not on shift, document refusals and reattempt the next shift/day. - Supplements per orders. - Turn/reposition every 2 hours, two person assistance. - Tx as ordered to area(s) as needed slow healing/non-healing/changes in wound." The resident's care plan documented focus of, "Resident has condition which requires contact precautions-MRSA to wound. (initiated: 4/3/13)" The interventions were: "- Contact precautions for wound..., - Hand washing after resident contact, - Use gloves when touching or coming into contact with blood, body fluids, secretions or excretions." The resident had two plans for resisting care, the first documented, "Resident exhibits episodes of resisting care/treatment. Can be manipulative of staff (will refuse cares and then tell other staff that they were not offered, etc.) (initiated: 4/9/12) The interventions were: "- Assess for possible causes of resisting care and intervene accordingly. - Coordinate care to permit staff person for whom resident demonstrates preference to deliver care. - Listen to all concerns, complaints that resident may bring up but investigate to determine fact of the issue due to history of manipulative behaviors, telling different stories to different staff. - Try to redirect undesirable behavior. - Allow for flexibility in ADL routine to accommodate residents mood. - Praise/reward resident for demonstrating consistent desired/acceptable behavior. - Discuss with resident implications of not adhering with therapeutic regime. - If resident resisting care, leave resident and return in 5-10 minutes. - Discuss approaches and times of least resistance that might be more successful." The second plan for resisting cares documented, "Does not adhere with: \ Medication administration \ Treatment \ Daily care needs \ Hygiene needs noncompliant with treatments, wound care. refuses use of pressure relieving devices including roho, mosaic cushions, air mattress. history of refusal to lay in bed or reposition on regular schedule. \ denial of risk factors, Cognitive Impairment, Mental/emotional illness." (initiated 5/29/12) The interventions were: "- Accept resident's right to refuse/decline and show respect for resident's decision. Provide education as he will accept to assist him with making informed choices concerning own cares and health issues. - Discuss with resident his/her objections, reasons, fears, ideas. - Do not argue when giving care when dealing with episodes of refusals/non-adherence, offer education as needed. - Encourage independence: encourage resident to complete as many ADLs as possible. - Establish a daily routine based on input from the resident. - Give positive feedback and reinforcement for resident's adherence. - Have a different care-giver attempt procedure. - Inform resident about risks and consequences of choice. - Offer as many alternatives/choices as possible for resident to choose from. - Provide non-threatening and non-judgmental environment." The resident has had multiple areas of skin breakdown since 4/19/10, his original admitted . There were six areas documented of tissue breakdown. Only one, a sore on the heel was classified as a pressure sore. The others were related to moisture associated skin problems. The areas with skin breakdown were, Right buttock (found 4/19/12), Right Gluteal Fold (found 4/15/13), Right lateral ankle (found 4/25/13), Left gluteal fold (found 2/8/13), Left thigh (found 5/8/13) and the right heel pressure sore (found 12/3/12). The resident had skin issues to the right buttock starting on 4/19/12. The LN -Skin Ulcer Non pressure weekly documented area was resolved on 3/6/13. The resident had a pressure sore on the right heel that was found on 12/3/12. The nursing notes documented starting in January 2013 the resident was cooperative and the sores were healing. Some examples were: 1/22/13 at 8:20 p.m., "Tx to feet and buttocks per Skin TAR orders. Overall wounds appear to be healing as resident is cooperative and complaint (sic) with orders including bed rest and repositioning to keep off buttocks...Educated resident that it is largely due to his compliance with bed rest that his wounds are healing and he agreed to lay back down in bed after he got up to smoke." 2/8/13 at 1:51 p.m. the IDT documented, "Discussed in skin meeting today, SDTI to left foot, numerous areas to buttocks (MAID). He does use air mattress in bed, is repositioned frequently by staff - does have fragile skin and long history of skin issues/poor healing. At this time, current treatments appear effective as wounds are improving and resident has had better compliance with treatments and repositioning." 3/8/13 at 1:20 p.m. the IDT documented, "Discussed in skin committee- MAID to buttocks, Right heel - previous SDTI has now opened and is stage II ulcer. Current treatment and interventions effective with areas showing improvement in size and appearance. Will continue current treatment/interventions and continue to monitor." On 3/15/13 at 10:15 a.m. the resident fell out of bed while assisting the aide with repositioning as she was making his bed. The resident was transported to the hospital and was found to have a left fractured femur. The resident was admitted to the hospital. The physician History and Physical, dated 3/21/13, documented an assessment of: "Nonambulatory patient with significant cardiac problems, who already has decubitus and a past history of [MEDICAL CONDITION] and Escherichia coli....If possible, he is still is (sic) going to need very vigilant decubitus precautions, so we will get him into a bed that minimize the chance of the decubitus occurring, have the wound nurse work with him and do vigorous decubitus precautions..." On 3/23/13 the resident was readmitted to the facility. The resident's left fractured femur was not repaired so the resident would have to be on bed rest. The resident's fragile skin was at increased risk for breakdown and there was no revisions to the care plan to reflect that. When the resident returned from the hospital he still had a pressure sore on the right heel and open areas to the left gluteal fold. THE RESIDENT'S SKIN PROBLEMS FOR APRIL 2013: On 4/3/13 the LN - Skin pressure ulcer weekly documented the right heel open area was, "2.6 x 2.8 x 0.1 cm, has serosanguinous drainage, small amount of exudate and wound bed was pink / beefy red." The sore on the heel was healed on 5/28/13. On 4/3/13 the LN -Skin Ulcer Non Pressure Weekly documented the left gluteal fold open area was, "4.8 x 1.8 x 0.1 cm, had serosanguinous drainage and small amount of exudate." The documentation was, "Due to fx femur resident no longer tolerates scheduled turning - foley cath in place to reduce any incontinent/moisture from breaking down skin and prompt peri-care after BM with moisture barrier cream applied as needed. Resident also on Q turn mattress." On 4/15/13 the LN- Skin Ulcer Non Pressure Weekly documented the right gluteal fold had an open area that was "2.5 x 2.1 x 0.1 cm, had serosanguinous drainage and small amount of exudate." The documentation was, "Skin tear r/t to incontinence, immobility, fragile skin." On 4/25/13 the LN- Skin Ulcer Non Pressure Weekly documented the Right Lateral Ankle had an open area that was, "3.5 x 3.0 x 0.1 cm with serosanguinous drainage and scant amount of exudate." The documentation was, "Velcro straps from brace for femur fracture caused open area to ankle from digging into skin." Review of the "Behavioral Monthly Flow Sheet" for April 2013 documented the facility was monitoring the resident for "Uncooperative." The documentation showed the resident had no episodes of not cooperating with staff. THE RESIDENT'S SKIN PROBLEMS FOR MAY 2013. On 5/2/13 the LN - Skin pressure ulcer weekly documented the right heel open area was, "1.7 x 1.5 x 0.1 cm, had serosanguinous drainage, scant amount of exudate and wound bed had granulation tissue." On 5/15/13 the LN -Skin Ulcer Non Pressure Weekly documented the left gluteal fold open area was 6 x 2 x 0.1 cm, with serosanguinous drainage, scant amount of exudate and granulation in the wound bed." The documentation was, "resident continues to cooperate with tx plan...SKIN TAR." On 5/9/13 the LN- Skin Ulcer Non Pressure Weekly documented the right gluteal fold had an open area that was, "2.2 x 10 x 0.1 cm, with serosanguinous drainage, slight odor, small amount of exudate, and granulation tissue of the wound bed." The documentation was, "Due to ffmur(sic) fx and splint in place resident was not tolerating Q turns and appears to have caused wound decline. Called MD notified and order to d/c brace and continue with strict Q turns to keep off of buttocks." On 5/9/13 the LN- Skin Ulcer Non Pressure Weekly documented the Right Lateral Ankle had an open area that was "2.5 x 3.0 x 0.1 cm with serosanguinous drainage and scant amount of exudate." The documentation was, "Resident continues to be cooperative with treatment plan with no complaints of pain or discomfort." Review of the "Behavioral Monthly Flow Sheet" for May 2013 documented the facility was monitoring the resident for "Uncooperative." The documentation showed the resident had no episodes of not cooperating with staff. THE RESIDENT'S SKIN PROBLEMS FOR JUNE 2013 On 6/11/13 the LN -Skin Ulcer Non Pressure Weekly documented the left gluteal fold open area was, "3.0 x 1.6 x 0.1 cm, had serosanguinous drainage and scant amount of exudate." The documentation was, "Moisture associated skin damage r/t immobility, incontinence, fragile skin r/t history of skin issues including pressure ulcers. Resident continues to be cooperative with tx plan in place per MD orders." (Note: The resident had a foley catheter.) On 6/11/13 the LN- Skin Ulcer Non Pressure Weekly documented the right gluteal fold had an open area that was, "1.0 x 1.0 x 0.1 cm, with serosanguinous drainage, scant amount of exudate, and granulation tissue of the wound bed." The documentation was, "Moisture associated skin damage to right gluteal r/t immobility, incontinence and fragile skin with long standing history of pressure ulcers and skin issues. 100% pink granulation tissue with scant amount of drainage. Resident is compliant and cooperative with tx plan; including repositioning to off load pressure." On 6/11/13 the LN- Skin Ulcer Non Pressure Weekly documented the Right Lateral Ankle had an open area that was, "0.6 x 0.8 x 0.1 cm with serous drainage and small amount of exudate." The documentation was, "Measurements to wound continue to decrease - appears to be healing with tx plan in place per MD orders. Resident is cooperative and compliant with tx plan. Review of the "ADL Flow Sheet" for June 2013 the facility documented from 6/1/ to 6/18/13, 31 refusals out of 213 times he was approached for repositioning every 2 hours. Resident #1 was interviewed on 6/18/13 at 10:50 a.m. he indicated he has had sores since before he was admitted to the facility. He now also has a fractured left femur and he is pretty much bed bound. He has his favorite aides and felt he was cooperative with positioning and care of his sores. He has a lot of pain associated with the fractured femur and even had two pain patches. RN#1, the skin nurse, was observed on 6/19/13 at 10:20 a.m. doing a treatment on the right anterior ankle. The right anterior ankle had 2 small .5 to 1.0 cm open areas and were covered with a dressing. The resident was positioned on the left side to look at his buttock/gluteal area there was 3 sores on the right side that were about 3.5 to 4 cm in diameter. The wound nurse did not measure them. All of the buttock area both left and right sides were red and emaciated looking. Two of the three sores were bleeding. RN #1 indicated there were some new sores present. The Bedding was wrinkled and had dried food particles in it. The condition of the skin, according to RN#1, was such that the facility could not use dressing material on the sores. The cream was applied to the three sores and left open to air. The resident layed back down onto the clean sheet that was placed on the bed. The DON and ADON were interviewed on 6/20/13 at 11:30 a.m. about the resident's sores. They stated Resident #1 was not very cooperative about turning and repositioning. The interview focused around the lack of documentation. They stated the resident was refusing cares and that was why the skin condition deteriorated. There was a lack of documentation to show he was uncooperative or refusing cares and the education the nursing staff was to do according to the care plan. The June 2013 "Behavioral Monthly Flow Sheet" was requested but was never provided. No further information was obtained. Resident #1 was harmed when: - The resident had a history of [REDACTED]. - The resident received a pressure sore from a strap on a brace that rubbed the skin on the ankle, - The care plan was not revised when the resident returned from the hospital at increased risk for skin breakdown related to fractured femur, - The sores on the right gluteal, when observed, were three sores, which is more than documented on skin reports, and - There was no documentation of interventions used by staff for refusals. 3. Resident #2 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent 5/23/13 Quarterly MDS documented in part: -Short and Long Term memory problem -Severely impaired for daily decisions -Behavior constant for inattention -Rejection of Care not exhibited -Was at risk of developing a pressure ulcer -Had a unhealed St II pressure ulcer -Had a pressure relieving device on her bed and chair -Received ulcer care -Application of a dressing to her feet Resident #2's May 21-29, 2013 Treatment Record documented: "TX order for left heel blister: Apply skin prep and cover with foam dressing everyday & PRN. Order Date: 5/20/13 QD Everyday." Resident #2's May 30-June 5, 2013 TAR documented: "TX order for left heel blister: Apply hydrogel daily to heel and continue to offload pressure with boots. Order Date: 5/20/13, QD Everyday." Resident #2's June 6, 2013 TAR documented: "TX order for left heel blister: Apply A&D ointment daily to heel and continue to offload pressure with boots. Order Date: 5/20/2013 Q day." Resident #2's Care Plan documented in part: "Potential for skin breakdown related to: immobility/incontinence/dementia." Interventions included: -"A&D ointment to heel as preventative measure as ordered, -Blue heel floaters at all times when up as preventative measure to assist with prevention of pressure areas. Float heels when in bed, -Provide measures to decrease pressure/irritation to skin:fleece pad, reducing mattress, heel protectors as appropriate, -Assist resident to turn and reposition with cares/PRN, -Inspect skin status with cares, baths, weekly assessments." NOTE: The care plan did not specify how to float heels when in bed, nor did it direct how often repositioning was to occur. Resident #2's Kardex (CNA Care Plan) documented in part: "Blue heel floaters at all times when up, as preventative measure to assist with prevention of pressure areas. Float heels when in bed." Resident #2's 4/9/13 Braden Scale Assessment for predicting Pressure Sore Risk determined the resident was at high risk for developing a pressure ulcer. Resident #2's 5/24/13 Braden Scale Assessment for predicting Pressure Sore Risk determined the resident was at moderate risk of developing a pressure ulcer. Resident #2's Skin Pressure Ulcer Weekly Reports documented as follows: 5/20/13-A left heel, stage II pressure ulcer was found on 5/20/13. This wound was not present on admission and had no tunneling, undermining, or depth. The size of the pressure ulcer was 0 x 0cm (centimeters), and the resident did not experience any pain from the wound. The report also contained, "Comments: Blister is now dried-skin remains intact and is blanchable with surrounding skin dry, intact and normal skin color. Area appears to be healed; will continue to monitor as skin remains at risk." NOTE: A stage II pressure ulcer cannot be 0 x 0 cm. See Skin Assessment notes below. 6/6/13- Documents the same information as above with the exception of the following: "Comments: Previously filled blister r/t pressure; skin intact, remains blanchable, normal in color per resident. Skin to heel now appears dry calloused with orders to apply A&D ointment and monitor daily. Resident tolerates well without any c/o (complaints)." 6/11/13 - Documents the same information as above with the exception of the following: "Comments: Resident continues with dry calloused skin to left heel where previously fluid filled blister that appears to have dried up; skin intact, no drainage, no pain no odor noted. Continues with daily tx plan in place, including pressure off loading boots and monitoring skin as remains at risk." Resident #2's Skin Assessment/Evaluation-PRN/Weekly Reports document the following: 5/20/13-Resident #2 had a left heel blister with a length of 4.0 cm. "Comments: Blister 4.0 cm in diameter. Skin still intact. Dressing applied." 5/26/13-The site, type, and length was not documented. "Comments: No knew (sic) skin issues noted at this time will continue to observe for any changes." 6/11/13-Resident #2 had a left heel pressure with a length of 0. "Comments: Upon head to toes skin assessment no new skin issues noted-left heel continues to heal with skin intact and normal in color for resident." On 6/18/13 at 7:45 am, Resident #2 was observed sitting in her wheelchair at the dining room table in the SCU, with blue boots on her feet. Her boots/feet were on the floor. NOTE: Resident #2's blue boots appeared thick and padded as though they cushioned the resident's feet. The blue boots did not appear to off load the heels. On 6/19/13 at 7:45 am, Resident #2 was observed sitting in her wheelchair at the dining room table on the SCU. She had white tennis shoes on her feet. Her feet were on the floor. On 6/19/13, at 9:10 am, Resident #2 was observed sitting in the recliner in the SCU. Her legs were reclined up, she had socks on but no blue boots were on her feet and her heels were in direct contact with the recliner. At 9:15 am, the same day, the blue boots were observed lying on Resident #2's bed. On 6/20/13 at 8:30 am, Resident #2 was observed sitting in her wheelchair at the dining room table on the SCU. She had tan colored non-skid socks on her feet and her feet were on the floor. No boots were on her feet. On 6/20/13 at 10:15 am, Resident #2 was observed sitting in the recliner in the SCU day room. Her legs were reclined up and a blanket was over Resident #2's legs and feet. The surveyor asked CNA#4 if Resident #2 had the blue boots on. CNA#4 lifted the blanket exposing Resident #2's feet. Resident #2 had the blue boots on over the tan non-skid socks on her feet. CNA #4 stated, "She got that (the pressure ulcer) on her heel from having her shoes on and rubbing that foot part where her heel was. Sure enough when we put the booties on, it went away." The surveyor asked CNA #4 what the staff does with Resident #2's heels when she is in bed. CNA #4 said, "We just use the booties. We can't float the heels like it says on the Kardex, she moves the pillow and her feet. It needs to be reworded. We just use the booties in bed too." On 6/19/13 at 10:00 am, RN #1 was observed while providing treatment to Resident #2's left heel. Resident #2's left heel appeared boggy with dried and peeling skin around the edges. RN#1 said, "Her skin is fragile and that's why we keep the boots on. It's in the order now to keep the booties on, it's on the Kardex for the aides, they have to sign off that she was wearing her boots." Resident #2 sustained a Stage II pressure ulcer to her left heel in the facility on 5/20/13. Resident #2 was observed without her physician ordered blue boots on on her feet on 6/19/13 and 6/20/13. The cushioned type blue boots did not appear to off load the resident's heels when they were on the resident's feet. Further, CNA #4 stated staff did not follow the Kardex (CNA Care Plan) when Resident #2 was in bed for floating the resident's heels. On 6/20/13 at 12:20 pm, the DON and RN #3 were informed of the pressure ulcer concern on Resident #2's left heel. No information or documentation was provided which resolved the issue. 4. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12's 3/30/13 Braden Scale for Predicting Pressure Sore Risk documents the resident has no apparent problem and Resident #12 is at low risk for developing pressure sore. Resident #12's April 2013 TAR documented, "TX order for left heel SDTI: apply sure prep daily order date: 4/19/2013 QD Everyday." Resident #12's May 2013 TAR documented, "TX order for left heel SDTI: apply sure prep daily order date: 4/19/2013 QD Everyday" NOTE: The TAR was not initialed on May 5 & 13. It could not be determined that the treatment was done on those days. Resident #12's June 2013 Physician Orders did not document any specific skin treatments but documented "Skin Care protocol." Resident #12's Kardex (CNA Care Plan) documented: "-Have feet raised on pillows when laying in bed, and have heel protectors on when in wheelchair, -Needs pressure relieving/reducing mattress, pillows, w/c cushion to protect the skin while up in chair, -Apply heel floaters to minimize pressure. Float heels in bed." Resident #12's Care Plan documented in part: "-Has potential impairment to skin integrity r/t [MEDICAL CONDITION], fragile skin, impaired mobility, suspected deep tissue injury left heel. date initiated 5/31/2013" Interventions included: "- Apply heel floaters to minimize pressure. Float heels in bed, -Identify/document potential causative factors and eliminate/resolve where possible, -Monitor/document location, size and treatment of [REDACTED]. -Needs pressure relieving/reducing mattress, pillows, w/c cushion to protect the skin while up in chair, -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface." Resident #12's Skin Assessment/Evaluation-PRN/Weekly Report documented as follows: 3/30/13-Resident #12 had no pressure related issues. "Comments: Upon full head to toe no skin issues noted-other than steri-strips to left hip from surgical incision." 4/19/13-Resident #12 has a SDTI on her left heel measuring 1.0 x 1.5 cm. "Comments: SDTI to left heel-dark purple in color; skin intact; boggy bilateral heels." 5/5/13-Resident had no skin issues noted. "Comments: head to toe skin assessment done no knew (sic) issues noted at this time." 5/22/13, 6/9/13, and 6/16/13-Resident #12 had no pressure related issues. Resident #12's Skin Pressure Ulcer Weekly Report documented as follows: 4/24/2013- On 4/24/2013 a SDTI was found on Resident #12's left heel. The SDTI was not present on admission and it had no depth or tunneling. It was 1.0 x 1.5 cm in size and the resident experienced no pain from the wound. 5/2/2013-The same information as above with the exception of the size of the SDTI. The size was 1.0 x 1.0 cm. 5/15/2013-The same information as above with the exception of, "Comments: SDTI to left heel brown; skin remains intact with measurements decreasing in size. Resident continues to tolerate and is compliant with tx plan as long as explained before hand in simple terms." 5/29/2013-The same information as above with the exception of the size of the SDTI. The size was .5 [MEDICAL CONDITION] cm. "Comments: Measurements continue to decrease, skin intact with surrounding skin blanchable and normal color for resident. No pain or discomfort as verbalized by resident." Resident #12's Interdisciplinary Progress Notes first documented an issue with the resident's heel on 5/23/2013 at 2:36 pm by the Registered Dietitian, "Skin review, skin continues to heal slowly. Currently with stage 1 left heel..." On 6/8/2013 at 2:03 pm, Resident #12's Nursing Progress Notes documented, "LN to assess and treat left heel per MD orders; noted that skin is intact, blanchable and normal in color for resident; no evidence of SDTI or bruising noted. Will continue to monitor as remains at risk as skin is fragile as r/t hx (history) of SDTI. No other skin issues noted at this time." NOTE: The SDTI was found on 4/19/13. The first Nursing Progress Notes documented the treatment of [REDACTED]." On 6/19/13 at 10:40, RN # 1, was interviewed regarding the mattresses in the facility. RN#1 escorted the surveyor to Resident #12's room and was asked if Resident #12's mattress was a pressure relieving mattress. RN #1 stated, "No, this is not a pressure relieving mattress, she had booties on so no pressure relieving mattress was needed." When asked if Resident #12 was at risk for pressure sores, RN #1 stated, "Well yes it is on the care plan. I have to check if this mattress is a pressure relieving mattress or not." At 11:30 the same day, RN #1 stated, "I checked and all our mattresses are considered pressure reducing/relieving mattresses." On 6/19/13 at 10:50, Resident #12 was observed sitting up in her wh

Based on a public complaint received by the BFS on [DATE], review of the facility's investigation for allegation of abuse, incident/accident reports, record review, observation and staff and family interview, it was determined the facility failed to ensure residents were provided with adequate supervision and/or assistive devices to prevent falls and that all incidents were thoroughly investigated to rule out abuse or neglect. This was true for 4 of 5 residents reviewed for falls (#1, #4, #7 & #8). Resident #1 was harmed when she sustained a fractured femur as the result of a one-person transfer rather than the use of a "sit-to-stand" mechanical lift as outlined in the resident's care plan. Resident #4, who had multiple falls, was harmed when he sustained lacerations to his head and left hand necessitating a resulting ER visit and stitches in his hand and staples in his head. Resident's #7 and #8 had multiple falls and/or attempts to walk on their own, even though they were unsafe to do so. Findings include: A complaint from the public stated that residents did not receive adequate supervision to prevent falls with injury. 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's [DATE] quarterly MDS assessment coded cognitively intact, two person extensive assistance with transfers, functional limitation in range of motion on lower extremeties both sides, and surface to surface transfer was not steady, only able to stand with human assistance. Resident #1's undated Care Plan identified the problems of: *ADL Self-Care deficit. One of the interventions was transfer with "sit to stand (mechanical lift)" - Date initiated: [DATE] *At risk for fracture/injury related to Osteoporosis - Date initiated: [DATE] *Risk for falls characterized by history of falls/injury - Date initiated: [DATE] The facility's Allegation of Abuse investigation dated [DATE] documented, in part, "Res (resident) complaint of pain to L (left) hip on evening of ,[DATE] ([DATE]). LPN assessed and received orders...for x-ray. Informed of fracture at 9 pm and upon investigation of potential cause...noted that the resident was transferred to bed the previous evening (,[DATE] at 2015 (8:15 pm)) by (CNA #4) and she (Resident #1) slipped and was lowered to the ground. (CNA #4) called for assistance from (CNA #5), to be placed back in bed and (CNA #5) states that he assisted but was unaware that the nurse was not notified of the incident. Statement from both (CNA #4 and #5) match and confirm that this resident was on the ground on ,[DATE]. After interview, both CNA's were placed on suspension related to potential neglect exhibited by failure to provide cares as outlined in the care plan and failure to notify the nurse of the fall." Investigation: "(CNA #4) states that she transferred (Resident #1) with one person assist (care planned for a sit to stand). As (Resident #1) was picked up from the w/c (wheelchair) she slipped and was lowered to the ground...no complain of pain at the time...nurse was not made aware... (Resident #1) began complaining of pain on the day shift on ,[DATE]... orders... obtained to get an x-ray. Results ...in... Conclusion: ...sustained a fracture to...femur specifically related to the fact that the care plan was not followed and she was placed on the floor. (CNA #4) was terminated..." The report indicated the DNS interviewed CNA #4 on [DATE]. According to the interview the CNA stated that while putting the resident to bed on the evening of [DATE] after dinner she lowered the resident to the floor because Resident #1 was not able to bear weight. CNA #4 demonstrated the transfer of putting the w/c next to the bed and lifting the resident under the arms. She said she performed a one person transfer without a gait belt. CNA #4 said that after she lowered Resident #1 to the floor, she positioned the resident comfortably with a pillow then asked CNA #5 for assistance in getting the resident to bed. CNA #4 stated she did not report to the nurse that she had lowered the resident to the floor because she did not consider it to be a fall. The resident's physician progress notes [REDACTED]. - [DATE], left distal femur fracture - again with no known trauma...seizure disorder...[DIAGNOSES REDACTED] - severe...severe osteoporosis with severe kyphosis and (history of) recurrent fractures with no reported trauma with any...left leg in splint to protect it as nondisplaced Anticipate slow healing over next 3 months. -[DATE], "...left femur fracture - well aligned now 4 weeks (after) fx (fracture)...abnormal weight loss since fracture...seizures - none reported...DON and dietician trying to work on encouraging...to eat better...will use splint/support to left leg x (times) 3 months then repeat x-ray..." Resident #1, who was totally dependent on staff for care and had a [DIAGNOSES REDACTED]. She sustained a fractured femur as a result of the fall. 2. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. He expired on [DATE]. A review of Resident #4's Incident Reports and NPN documented the facility failed to take adequate steps to prevent falls, as follows: a. Resident #4's NPN documented the following falls: - [DATE] at 9:08 a.m.: Resident #4 was found sitting on the floor leaning back against his bed. The note documented the family and MD were notified of the fall. - [DATE] at 7:36 a.m.: Resident #4 was found sitting on the floor in front of his bed. The note documented Resident #4 stated "he was getting up from his chair and went down; small lump on forehead, beginning to bruise and small bruise on left side of head..." - [DATE] at 3:56 a.m.: Resident #4 was noted at 3:45 a.m. to be sitting on the floor between his recliner and his bed. The note documented "when asked what happened said (sic) he fell /slide (sic) out of his chair." - [DATE] at 4:41 p.m.: Resident #4 had fallen in the dining room and had no apparent injuries. The note stated the fall was witnessed by a family member. However, none of the falls included documentation an Incident Report or an Incident/Accident Committee Review form had been completed. Therefore, the falls did not include documentation they had been reviewed, assessed, or appropriate corrective action taken to prevent future falls. b. Resident #4's Incident Reports documented unwitnessed falls as follows: - [DATE] at 2:30 p.m.: Resident #4 had an unwitnessed fall in the bathroom which resulted in a bump to the back of his head. The attached Incident/Accident Committee Review form stated Resident #4 was "confused et (and) attempts to be independent. Balance is not good when standing up @ times. Unaware of safety needs @ times." The "Plan to Prevent Reoccurrence" section stated "Continue to educate resident to use rails...With residents independence he will occasionally acquire minor skin issues/falls." However, the plan did not explain how education would assist when the resident was confused. Additionally, the plan did not include any increased supervision or monitoring of Resident #4. - [DATE] at 1:30 p.m.: Resident #4 had an unwitnessed fall in his bedroom. The attached Incident/Accident Committee Review form stated Resident #4 was "Confused and resistive (with) cares from staff and with his independence he falls." The "Plan to Prevent Reoccurrence" section stated "Continue with resident education and attempt to make resident more aware of safety issues...therapy screen." No additional corrective action, such as increased monitoring or supervision, was documented. - [DATE] at 8:30 p.m.: Resident #4 had an unwitnessed fall in his bedroom resulting in a laceration to his forehead and a skin tear to his right hand. The attached Incident/Accident Committee Review form stated Resident #4 "is confused and not always aware of safety issues but continues to attempt to be independent." The "Plan to Prevent Reoccurrence" section stated "Staff need to frequently ensure resident's environment is safe and no hazards are noted to trip resident. Res needs to be continuously monitored and educated about safety." However, the plan did not indicate what "frequently ensure resident's environment is safe" meant, did not identify what trip hazards had been noted (the Incident Report did not document that Resident #4 had tripped over an object), or how Resident #4 was to be "continuously" monitored. - [DATE] at 8:45 p.m.: Resident #4 had an unwitnessed fall in his bedroom resulting in a laceration/skin tear to the back of his right hand. The attached Incident/Accident Committee Review stated "Resident removed his shoes and when he stood up he fell landing on buttocks." The "Plan to Prevent Reoccurrence" section stated "non-skid socks provided." No additional corrective action was documented. - [DATE] at 7:00 a.m.: Resident #4 had an unwitnessed fall in his bedroom resulting in a "lump" and a "bruise" to his head. The attached Incident/Accident Committee Review form stated "Res restless et (and) getting out of chair frequently. Resident cont (continues) to be independent but (with increase) confusion et unsteady gait resident does have frequent falls." The "Plan to Prevent Reoccurrence" section stated "Cont to attempt to assist resident et attempt to redirect him to make appropriate decisions. Monitor so when restless staff are attempting to keep res near them to redirect him." However, the plan did not indicate how staff were to monitor or how staff were attempting to keep Resident #4 near them (i.e., plans/documentation of frequent checks, one-on-one staffing, etc.). - [DATE] at 6:30 a.m.: Resident #4 had an unwitnessed fall in his bedroom resulting in a laceration to his head and left hand. A corresponding NPN, entered at 9:38 a.m., stated Resident #4 was sent to the ER and received stitches to his left hand. An additional NPN, dated [DATE] at 5:22 a.m., stated "Staples to head intact..." The attached Incident/Accident Committee Review form stated "Resident is confused and not aware of safety issues. He attempts to be independent but is not steady." The "Plan to Prevent Reoccurrence" section stated "Keep environment free from clutter and make sure safe...Do q15 min checks." However, the plan did not indicate how the every 15 minute checks differed from the monitoring that was to "continuously" take place in previous plans, how staff were to document the checks, etc. Additionally, given the repeated unwitnessed falls, it was not clear how the plan was sufficient to keep Resident #4 safe. - [DATE] at 3:45 a.m.: Resident #4 had an unwitnessed fall in his bedroom. The attached Incident/Accident Committee Review form stated he was "Confused et (and) unaware of safety issues. Makes unsafe inappropriate decisions." The "Plan to Prevent Reoccurrence" section stated "Res has impulse behaviors so is able to have falls quickly so staff check him each time they pass room and q 15 mins." No additional corrective action was documented. It was not clear how the plan was sufficient to keep Resident #4 safe. - [DATE] at 7:30 a.m.: Resident #4 had an unwitnessed fall in his bedroom resulting in a skin tear to his right arm. The attached Incident/Accident Committee Review form stated he was "Very confused. Does not realize safety issues and does have frequent falls as not able to make safe decisions." The "Plan to Prevent Reoccurrence" section stated "Cont to monitor resident et (and) attempt to redirect when inappropriate decisions made." No additional corrective action was documented. It was not clear how the plan was sufficient to keep Resident #4 safe. - [DATE] at 11:45 p.m.: Resident #4 had an unwitnessed fall in the hallway. The attached Incident/Accident Committee Review form stated "Res got self out of recliner and ambulated alone (with) unsteady gait and fell in hallway. Confused et (and) unaware of safety issues." The "Plan to Prevent Reoccurrence" section stated "Cont (with) 1:1 supervision to attempt to keep resident safe. Attempt to keep him safe when getting out of chair..." However, the plan did not address when the one-on-one was implemented, what one-on-one meant, or how Resident #4 was able to have an unwitnessed fall with a one-on-one staff. - [DATE] at 11:15 a.m.: Resident #4 had an unwitnessed fall in his bedroom. The attached Incident/Accident Committee Review form stated "Res observed sitting on floor in front of bathroom door. Res takes self to (bathroom and with) unsteady gait so does frequently fall." The "Plan to Prevent Reoccurrence" section stated "Observe resident when in room and attempt to assist him to bathroom. Take to bathroom (every 2 hours and as needed). Provide fluids/snacks. Ask frequently if has any needs." However, the plan did not address the one-on-one staff mentioned in the previously, and did not include any additional corrective action. It was not clear how the plan was sufficient to keep Resident #4 safe. - [DATE] at 1:15 a.m.: Resident #4 had an unwitnessed fall in his bedroom. The attached Incident/Accident Committee Review form stated "Very confused (with) no awareness of safety issues. Attempts to be independent and not capable of making safe appropriate decisions." The "Plan to Prevent Reoccurrence" section stated "Staff continues to monitor resident's moving around in room/halls. Assure environment is safe. Offer (bathroom every 2 hours and as needed). Provide snacks." However, the plan did not include any additional or new corrective action. It was not clear how the plan was sufficient to keep Resident #4 safe. - [DATE] at 5:00 p.m.: Resident #4 had an unwitnessed fall in his bedroom resulting in a laceration to his forehead. The attached Incident/Accident Committee Review form stated "Resident observed @ sink in room washing blood off forehead. Cont to be very confused (with) strong desire to be independent and has poor balance/gait." The "Plan to Prevent Reoccurrence" section stated "Cont (with) plan approaches as written." However, it was not clear how the plan was sufficient to keep Resident #4 safe. A review of Resident #4's NPN documented he was placed on "1:1 supervision when ambulating for increase (sic) safety at this time." One-on-one supervision was documented in NPN as follows: - [DATE] at 1:23 p.m. - [DATE] at 2:29 a.m. and 6:17 p.m. - [DATE] at 7:21 p.m. However, no additional documentation related to the one-on-one supervision (i.e., description, if continuous or only at certain times, who the assigned staff was, documentation of implementation, etc.) could be found in Resident #4's record. Additionally, it was not clear why the one-on-one supervision was not implemented sooner, or why the one-on-one supervision was not continued [DATE] given that Resident #4's record did not document any falls taking place between [DATE] and [DATE]. Resident #4's Care Plan included a Focus are for "Risk for falls characterized by history of falls/injury, multiple risk factors..." which was initiated on [DATE]. The Interventions were listed as follows: - Have commonly used articles within easy reach - Resident to wear proper and non slip footwear - Encourage resident to use handrails or assistive devices properly - Ensure environment is free of clutter - Analyze previous resident falls to determine whether pattern/trend can be addressed - Orient resident to environment each time changes are made However, the interventions were similar to those implemented as a result of Resident #4's Incident/Accident Committee Review forms related to falls. Resident #4's Care Plan did not indicate if the interventions had been revised since the [DATE] initiation date. Additionally, based on information documented in his record, it was not clear how the interventions were sufficient to keep Resident #4 safe. During an interview on [DATE] from 2:20 - 3:30 p.m., the DON stated the facility tried to address all issues related to Resident #4's falls and take corrective action to prevent. According to NPN and Incident/Accident reports, Resident #4 had at least 16 falls between ,[DATE] and [DATE]. He sustained "lumps/bumps" to the head, bruises, skin tears, and lacerations. This resulted in harm to resident when on [DATE] the resident sustained [REDACTED]. The resident fell 8 times after that incident. The facility failed to ensure corrective action sufficient to protect Resident #4 for falls was implemented and followed. 3. Resident #7 was admitted to the facility on [DATE] following the surgical repair of a fractured right hip on [DATE]. Other [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. an order for [REDACTED]. NPN documented the following regarding Resident #7: *[DATE] at 8:35 PM, "...yelling, screaming, attempting to get out of bed telling staff she will fall and will be all their fault." *[DATE] at 12:45 PM, "..attempting to get out of wheelchair, grabbing doors, and refusing any assistance from staff." *[DATE] at 1:22 AM, slid out of her wheelchair. *[DATE] at 7:29 PM, slid to the floor twice on the day shift. *[DATE] at 3:19 AM, "...attempted and succeeded in getting up out of recliner and walking by herself several times. She needs a constant eye on her. She is unsteady on her feet." *[DATE] at 3:44 AM, "several attempts to get out of her W/C...Several attempts she stood up but her balance was off and she almost fell ." *[DATE] at 6:10 AM, had "episodes" of behaviors and "attempting to stand up." *[DATE] at 6:35 PM, the resident was walking in her room, lost her balance, and was lowered to the floor. The same note also stated she was found sitting on the floor at 2:00 PM. *[DATE] at 1:23 AM, remained unsteady on her feet wandered (walking) into the hallway. The note stated she required a 1 person assist. *[DATE] at 4:26 AM, walked into another resident's room. *[DATE] at 4:22 PM, the resident was seen up walking in her room. *[DATE] at 5:56 PM, "...forgets and tries to ambulate independently." *[DATE] at 9:26 PM, "...continues to get up on own wandering in the hallway holding onto the railing. She is unsteady on her feet. *[DATE] at 1:32 PM, "...forgets that she is not to ambulate without help." *[DATE] at 2:03 PM, the resident was often found walking in her room. *[DATE] at 6:53 PM, the resident had been walking on her own. *[DATE] at 2:08 PM, the resident had an unwitnessed fall without apparent injury. *[DATE] at 11:35 PM, the resident #7 was found walking in her room and was unsteady on her feet. "Fall Scene Investigation Reports" documented Resident #7 fell 3 times on [DATE], 3 times on [DATE], and once on [DATE]. Resident #7's daughter was interviewed with the resident on [DATE] beginning at 2:30 PM. The daughter stated she visited Resident #7 several times a week and was very involved in her care. She stated screws had been placed in Resident #7's hip and premature weight bearing could cause the dislocation of those screws. The daughter stated the resident frequently forgot and ambulated on her own without regard to weight bearing status. The daughter stated Resident #7 only ambulated with a walker with the physical therapist. Resident #7's care plan, dated [DATE], stated she had a "Self Care Deficit" and required "Toe touch (weight) bearing right leg." The care plan stated she had wandering behaviors and cognitive impairment. It directed staff to "Monitor frequently for safety." The care plan also stated Resident #7 was at risk for falls. It directed staff to provide "1:1 when resident is agitated/aggressive or delusional...Have resident sit within sight of staff to monitor her...Monitor closely for safety and provide increased supervision...be aware of positioning of resident in wheelchair so resident does not sit too far forward and slide out of wheelchair." The plan did not specifically address ways to prevent Resident #7 from ambulating and bearing weight on her right leg. In addition, the care plan did not provide specific direction to staff as to when Resident #7 required 1:1 staffing, line of sight staffing, etc. The DON was interviewed on [DATE] beginning at 4:20 PM. She reviewed Resident #7's medical record. She stated she could not tell what level of staff supervision had been provided to Resident #7 to prevent weight bearing and falls. The facility did not have documented evidence of She confirmed the care did not provide specific direction to staff in order to keep Resident #7 safe. The facility did not take steps to prevent Resident #7 from weight bearing and to prevent falls. 4. Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. a) "Fall Scene Investigation Reports" documented Resident #8 fell from her bed 15 times between [DATE] and [DATE]. Falls from bed were documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], twice on [DATE], [DATE], [DATE], [DATE], twice on [DATE], [DATE], and [DATE]. NPN also documented Resident #8 fell from bed on [DATE] at 1:31 AM and [DATE] at 8:30 PM. In addition, incident reports documented Resident #8 fell 2 times from a wheelchair on [DATE] and [DATE]. Resident #8's care plan was initiated on [DATE]. Resident #8 had 15 reports of falling from bed. The care plan did not include direction to staff to keep her from falling out of bed. The only item listed to prevent falls from bed was to "Reposition resident in center of bed and ensure proper placement of resident to decrease chance of rolling out of bed." The care plan did not include a plan for increased and/or assistive devices to prevent falls. The DON was interviewed on [DATE] beginning at 2:30 PM. She reviewed Resident #8's medical record and incident reports. She confirmed the falls and confirmed the care plan did not address the prevention of falls from bed. She stated the facility could not prevent Resident #8 from falling. She said the facility had instead focused on preventing injuries to the resident when she did fall. The facility did not take steps to prevent Resident #8 from falls. b) Resident #8's "Fall Scene Investigation Reports" did not match the incidents documented in her medical record. Incident reports documented Resident #8 fell on [DATE], [DATE], [DATE], and [DATE]. Corresponding NPN were not present in the medical record. NPN also documented Resident #8 fell from bed on [DATE] at 8:30 PM and [DATE] at 1:31 AM. Corresponding incident reports were not documented. The facility's s Incident/Accident Committee Review forms, for falls occurring to Resident #8 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], did not include ways to prevent future falls. Five of the incident reports, dated [DATE], [DATE], [DATE], and 2 incident reports dated [DATE], stated to continue the current care plan. Five of the incident reports, dated [DATE], [DATE], [DATE], [DATE], and [DATE], stated to position the resident in the middle of the bed. An incident report for a fall, dated [DATE], did not include a plan. It stated "...will (continue) to allow freedom of movement, anticipate needs, and attempt to prevent injury." The DON was interviewed on [DATE] beginning at 2:30 PM. She confirmed the incident reports and nursing documentation. She stated the nurses did not always complete incident reports and did not always document incidents in NPN. She stated the facility compiled data on the number of falls that occurred. She acknowledged the data was not correct because incident reports were not generated for all falls. She confirmed measures beyond placing Resident #8 in the center of the bed and adjusting the room temperature had not been recommended to prevent falls from the bed through the performance improvement program .

Based on observation, staff interview and record review the facility did not ensure that pressure ulcers were prevented for 4 or 4 sampled residents (#'s 1, 2, 4 and 11) reviewed for pressure ulcers. Resident #4 was harmed when she developed two Stage III pressure ulcers in the facility that required wound clinic treatment with debridement. Residents #1 and #11 were harmed when they developed multiple/recurrent avoidable pressure ulcers and experienced pain related to the ulcers. In additon, Resident #2 developed Stage I pressure ulcers to the inner thigh and peri area and a Stage II pressure ulcer to the coccyx. Documentation for these pressure ulcers was incomplete or not provided. Findings include: 1. Resident #4 was admitted to the facility 8/30/11 with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 9/12/11, documented the resident: * Had one Stage II pressure sore. The significant change MDS assessment, dated 11/28/11, documented the resident: *Had three Stage III pressure sores. The quarterly MDS assessment, dated 2/20/12, documented the resident: * Was moderately impaired cognitively, * Had mild depression, * Needed total assistance of one to two staff for transfers, dressing, personal hygiene and bathing, * Had a catheter, * Had one Stage III pressure sore and two healed Stage III pressure sores. The resident's care plan dated 8/30/11 documented a problem, on 10/15/11, of: "Alteration in skin integrity high risk for pressure ulcer development r/t (related to) dementia and confusion, immobility secondary to s/p (status [REDACTED]. Has brace/immobilizer to right leg that can cause pressure. admitted to (sic) pressure ulcer to left heel, high risk for further pressure ulcers, especially to right heel/leg r/t use of brace...." The Goals and Approaches were multiple and there were many hand written additions to the pressure sore care plan. According to RN1, during an interview on 3/15/12 at 2:30 p.m., these hand additions were put on the paper "anywhere there was a space." Some of the additions that could be deciphered were: "10/10/11 - Keen high pressure relief cushion." "10/12/11 - No pillows under knee use roll towel (under) leg." "10/15/11 - Monitor skin condition closely with baths, daily cares." "10/15/11 - Turn every hour in bed, encourage frequent off loading, use pillows for support. Due to right femur fracture can not turn onto right side must keep right leg straight and in line...." "10/15/11 - Monitor bilat(eral) heels (every) shift for any possible pressure from PRAFO (Pressure relieving ankle/foot orthotics) devices - remove (every) shift and (as needed)...." "10/15/11 - PRAFO devices to right and left heels at all times." "10/15/11 - Encourage good nutrition and hydration to assist with promoting healing. Protein supplement three times a day, vitamin c and multiple vitamins supplement, pro stat supplement (three times a day)" "10/15/11 - Preventative skin care with moisture barrier cream every shift. Watch buttock/coccyx (related to) decreased mobility." "10/15/11 - Foley catheter due to chronic incontinence and immobility at this time to assist with keeping skin clean and dry and to promote healing." "10/15/11 - Use care with transfers to avoid any bumps and bruises and to minimize any potential for injury to right leg." "10/15/11 - Encourage (Resident #4) to be up and out of bed several times daily to assist with position change and pressure relief. Encourage her to alternate between wheelchair and recliner when up." "10/15/11 - Ensure that heels are floated at all times and attempt to minimize any potential pressure to areas." "10/15/11 - Pressure relieving devices to bed and chair, low loss air mattress to bed, high level pressure relief keen cushion in chair." "10/26/11 - Keep padding in place on knee immobilizer to relieve pressure." "11/29/11 - Mighty shakes (three times a day)." "12/6/11 - PRAFO boots are absolutely to be used (at) night (and) during the day in or out of bed. Heel floaters not adequate." "1/18/12 - Check integrity of skin, color, temp, intactness, sensation." "1/18/12 - Check integrity of devices frequently for bottom." "1/24/12- Wound care appointment (R) heel, (R) malleolus, -closed. (L) heel-continue PRAFO, leave dressing in place...." "1/24/12 - Keep dressing on heel intact until next (appointment) and wound care clinic...." "2/21/12 - Please be sure PRAFO devices used bilat(erally) at all times (new pressure ulcers)." "2/28/12 - [MEDICATION NAME] 100 mg po bid for another 10 d stop on 3/9/12 (100 milligrams orally twice a day for another 10 days)" "2/28/12 - Must have PRAFO device at all times." There were nine additional approaches that had been deleted; all had the same content in them as above. The "Pressure Ulcer Risk Assessment/Prevention Intervention Protocol" form documented Scores of 34 on 11/29/11 and 2/20/12. Point values of 12 or above documented High Risk. Resident #4 was being followed by the wound clinic. The resident was admitted to the facility with a pressure sore on the left heel. The resident was seen in the wound clinic on 9/29/11, for the pressure sore to the left heel. The facility's documentation related to the pressure sore was difficult to track. The only documentation provided by the facility were the Weekly Wound Clinic notes (WCN) and Comprehensive Skin Assessments (CSA). Besides the initial pressure sore on the left heel, from 9/29/11 until 3/6/12 the resident acquired and resolved three additional pressure sores. These were: a Stage III to the right heel, a Stage III to the right malleolus and a Stage II to the coccyx. * The WCN for 9/29/11 documented: "Wound now 4 x 3.5 x 0.2 cm (centimeters) (improving) no evidence of infection." NOTE: The documentation doesn't specify where the sore is but it is assumed to be the posterior left heel. * The WCN for 10/4/11 documented: "The pressure ulcer on the posterior left heel has been present for approximately 1 month. The pressure ulcer is thought to be related to immobility. The pressure ulcer measures 4.5 cm x 5.1 cm x 0.2 cm.... There is a moderate amount of serous and serosanguinous exudate draining from the pressure sore.... The pressure ulcer located on the posterior right heel....The pressure ulcer is thought to be related to immobility. The pressure ulcer measures 4.1 cm x 3.5 cm x 0.1 cm.... There is no exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous...." * The WCN for 10/11/11 documented: "The pressure ulcer located on the posterior left heel...measures 3.5 cm x 3.8 cm x 0.1 cm.... The pressure ulcer located on the posterior right heel... The pressure ulcer measures 5.5 cm x 4 cm x 0.2 cm. It has increased in size.... There is a moderate amount of serosanguinous exudate draining...The pressure ulcer bed has exposed subcutaneous tissue. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous...The pressure ulcer located on the right medial malleolus has been present for approximately 1 day. The pressure ulcer is thought to be related to immobility. The pressure ulcer measures 1.3 cm x 1 cm x 0.3 cm. There is no exudate draining from the pressure ulcer." * The 10/11/11 physician progress notes [REDACTED].? Stage 4 ? Both (with) dense eschar...." NOTE: PU=Pressure ulcer, L = left and R = right) * The WCN for 10/25/11 documented: "The pressure ulcer located on the left heel... measures 4.5 cm x 3.8 cm x 0.3 cm. There is a minimum amount of serosanguinous exudate draining from the pressure ulcer. The pressure bed has exposed subcutaneous tissue. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous.... The pressure ulcer located on the posterior right heel... measures 5.3 cm x 3.8 cm x 0.3 cm. There is a minimum amount of serosanguinous exudate draining from the pressure ulcer. The pressure ulcer has exposed subcutaneous tissue. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous... The pressure ulcer located on the right medial malleolus... measures 1.5 cm x 1.7 cm x 0.2 cm. It has increased in size... There is moderate amount of serosanguinous exudate draining..." * The 11/1/11 physician progress notes [REDACTED]. We have debrided the remaining eschar. R heel wound 75% eschar, 25% granulated. Debrided as much as tolerated today. R medial ankle is (without) eschar, debrided some residual necrotic fat/ fibrous material... Assessment) Pressure ulcers, Stage 3 L heel, Stage 3 R heel, Stage 3 L ankle...." * The WCN for 11/8/11 documented: "The pressure ulcer located on the posterior left heel... measures 3 cm x 2.7 cm x 0.3 cm. It has decreased in size... The pressure ulcer located on the posterior right heel.. .measures 3.2 cm x 4 cm x 0.2 cm. It has increased in size... There is a moderate amount of serous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue... The pressure ulcer located on the right medial malleolus... measures 1.5 cm x 1.8 cm x 0.3 cm. It has increased in size...There is moderate amount of serous exudate draining... The pressure ulcer bed has exposed subcutaneous tissue. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous...." * The resident was seen in wound clinic on 11/15/12, 11/22/11 and 11/29/11; there were not a lot of changes in the ulcers at these visits. * The CSA for 11/25/11 documented the three sores that the wound clinic was following, but it also documented an additional pressure sore. The documentation was: "R Medical Buttock 0.5 cm x 0.5 cm superficial open area." It was classified as a stage I and had serosanguinous drainage. The area had resolved by the CSA note of 12/2/11. * The WCN for 12/6/11 documented: "The pressure ulcer located on the posterior left heel... measures 2.7 cm x 2 cm x 0.3 cm. There is a moderate amount of serosanguinous exudate draining... ulcer bed has exposed subcutaneous tissue... The pressure ulcer on the posterior right heel... measures 3 cm x 2.8 cm x 0.3 cm.... There is a moderate amount of serosanguinous exudate draining... ulcer bed has exposed subcutaneous tissue... The pressure ulcer located on the right medial malleolus... measures 1.1 cm x 1.2 cm x 0.2 cm.... There is a minimum amount of serosanguinous exudate draining...ulcer bed has exposed subcutaneous tissue...." * The resident was seen in wound clinic on 12/13/11, 12/20/11, 12/27/11 and 1/3/12. *The WCN for 1/10/12 documented: "The Stage III pressure ulcer located on the posterior left heel... measures 0.6 cm x 0.2 cm x 0.1 cm.... There is a minimum amount of serosanguinous exudate draining... The Stage III pressure ulcer on the posterior right heel... was assigned an outcome of resolved.... The Stage III pressure ulcer located on the right medial calcaneous... measures 0.1 cm x 0.2 cm x 0.1 cm.... There is a minimum amount of serosanguinous exudate draining... ulcer bed has exposed subcutaneous tissue...." * The CSA for 1/13/12 documented the three sores that the wound clinic was following but it documented an additional pressure sore. The documentation was: "Sacrum - Stage II. Measures 1.25 cm x .75 cm, resolving, wound bed pink...." NOTE: There was no further documentation about the sacral ulcer. * The WCN for 1/17/12 documented: "The Stage III pressure ulcer located on the posterior left heel.... measures 0.6 cm x 0.2 cm x 0.1 cm.... There is a minimum amount of serosanguinous exudate draining... ulcer bed has exposed subcutaneous tissue... The Stage III pressure ulcer located on the right medial calcaneous... was assigned an outcome of resolved." * The CSA for 2/10/12 documented: "L heel ulceration (open area) 0.2 x 0.1 x 0.1 (cm) wound bed pink, surrounding tissue pink (no) drainage or odor, almost resolved." * The CSA for 2/17/12 documented: "1) L heel 0.2 x 0.1 x 0.1. 2) R medial Malleolus (and) R heel are healed." * The WCN for 2/21/12 documented: "The Stage I pressure ulcer located on the posterior left heel... measures 1.5 cm x 1.5 cm x 0 cm.... The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous... The Stage III ulcer located on the right heel... measures 2.5 cm x 1.9 cm x 0.2 cm.... There is a large amount of serous and serosanguinous exudate draining from the pressure sore. The pressure ulcer bed has exposed subcutaneous tissue. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous...." The physician further documented, "Evaluation of ulcer characteristics was done in detail. There are now new pressure changes on the right heel with a grade 1 pressure ulcer (after a thin eschar was debrided), and the left has worsened dramatically. It is apparent that the PRAFO devices have not been in place...." NOTE: The documentation of the left and right sores were reversed. * The WCN for 2/28/12 documented: "The Stage I pressure ulcer located on the posterior left heel.... was assigned an outcome of resolved.... The Stage III pressure ulcer on the right heel... measures 1.9 cm x 1.1 cm x 0.2 cm. There is minimum amount of serous and serosanguinous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed subcutaneous tissue...." RN1 was interviewed, on 3/15/12 at 2:30 p.m., about the resident and the pressure sores. RN1 indicated that the resident came to the facility after a [MEDICAL CONDITION] femur. The resident was not a good surgical candidate, so the physician applied a hard splint on the leg. RN1 felt that the resident's heel and malleolus broke down due to the pressure from the splint. The sore on the coccyx came from the resident sitting in the wheelchair for long periods of time, which the resident preferred. The physician changed the type of splint; RN1 did not remember when, and the resident was seen in the wound clinic. The clinic made the PRAFO boot recommendation. The resident did not like the boots, so would have the staff remove them. The sores did not improve very quickly, and one sore came back due to the noncompliance. The resident was harmed because the facility failed to ensure: * Interventions were in place when the resident was admitted with the splint on and was documented to be at high risk for skin breakdown, * physician's orders [REDACTED]. * The resident's position in the wheelchair was changed frequently enough to prevent coccyx breakdown. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's initial MDS assessment, dated 1/19/11, documented the resident was at risk for developing pressure sores but did not have any pressure sores at the time of admission. A facility "Nursing Assessment" dated 1/19/11 documented, "...Skin Integrity: intact, Skin Moisture: hydrated, Skin Turgor: fair, Skin Problem: none." The assessment also documented the resident was incontinent of urine. The facility "IDCC Notes" (Interdisciplinary Care Committee), dated 1/17/12 documented, "...His PUR (pressure ulcer risk) score is 26, which does indicate a high risk for skin breakdown... He does currently have area of shearing to his buttocks, is being seen at wound care clinic with recommendations and treatments as ordered..." The facility "Pressure Ulcer Risk Assessment" tool documented the following assessments and scores: 5/3/11 (score 21), 7/26/11 (score 21), 10/21/11 (score 26) and 1/17/12 (score 26). Any score above a 12 was defined as high risk. Facility "Comprehensive Skin Assessment" (CSA) forms and progress notes from a local wound clinic documented the following: * Wound clinic notes in the resident's record dated back to October 19, 2011 and documented for this visit: "...The pressure ulcer located on the buttocks crease has been present for approximately 14 days. The pressure ulcer is thought to be related to immobility. The pressure ulcer measures 0.7 cm (centimeters) x 1.6 cm x 0.1 cm. It has decreased in size from its (sic) original measurement of 2.1 cm x 1.6 cm x 0.1 cm... There is a minimum amount of serous exudate draining from the pressure ulcer. The skin around the pressure ulcer is [DIAGNOSES REDACTED]tous." The note also indicated this was a follow up visit, the resident was not in pain and recommended treatment. In addition, documentation included: "I examined the patient for ulcer/wound that has been resistant to healing despite numerous interventions. The plan now is to examine any underlying characteristics that may impede healing... The exam reveals evidence of a deep tissue injury, consistent with pressure on the buttocks. The ulcer at the buttocks crease is showing improvement. Factors which may be causative or likely contribute to non-healing include: pressure, lack of adequate off-loading when seated, lack of adequate off-loading when supine... to 'off-load' to (sic) ulcer or wound means to remove or decrease the amount of pressure or shear force exerted upon the wound. Off-loading is a critical part of this patient's management... Patient to return to clinic in 1 week." NOTE: The wound clinic did not include a designation for a stage of the wound. This was the case for all notes from the clinic. *A facility CSA, dated 12/12/11, documented the resident had a stage II pressure ulcer to his right buttock crease that measured 1.6 cm x 0.2 cm x 0.2 cm. (length, width and depth consecutively). *CSA, dated 12/19/11, documented, "buttock open area 0.5 x 0.2x 0.2" It was indicated as a stage II with minimum drainage. *CSA, dated 12/22/11, documented, "Open area tip of penis. 0.7 cm x 0.1 cm x 0.1 cm. (No) bleeding or discharge wound bed pink surrounding tissue pink. Denies pain." This was documented as a stage II wound. There was no documentation regarding the buttock wound or if it was resolved. *Wound clinic notes, dated 12/26/11 documented, "The pressure ulcer located on the buttocks crease/left buttocks (converted) has been present for approximately 2 months. The pressure ulcer is thought to be related to immobility...measures 0.3 cm x 0.1 cm x 0.1 cm. It has decreased in size... There is a minimum amount of serous exudate draining from the pressure ulcer..." NOTE: There was no documentation related to the new wound on the resident's penis. *CSA, dated 1/2/12, documented a red buttock crease which measured 0.3 x 0.1 x 0.1 and a 1 cm open area on penis. There was no staging and N/A (for not applicable) was check marked on the form. No drainage was indicated. *Wound clinic notes for 1/2/12 documented the buttocks wound as, "Very nearly resolved." Nothing was documented regarding the penis wound. *CSA, dated 1/9/12 documented the buttock wound was covered with a bandage from the wound clinic. In addition the resident had a 1.0 cm slit open at the end of the penis with no drainage. Origin of the wound was pressure and it was documented as a Stage I. The resident's great toe had a .25 cm scab to the tip of the toe. *CSA, dated 1/16/12, documented the buttock pressure ulcer was resolved but was kept covered with a bandage for preventative measures. The left toe had a .25 cm scab and the penis still had a 1.0 cm slit. *Wound clinic note, dated 1/16/12 documented, "...the buttocks crease/left buttocks (converted)... is thought to be related to immobility... It has decreased in size... There is no exudate... The skin around the pressure ulcer is macerated..." Notes documented a wound to the urinary meatus present for approximately one day and related to incontinence. In addition, a pressure ulcer to the left hallux (toe) had been present for approximately one day and thought to be related to immobility. Measurements were 1 cm x 0.6 cm x 0.1 cm. *Wound clinic note, dated 1/23/12, documented the wound to the buttock area resolved but present for approximately 3 months and was related to immobility. "The wound located on the urinary meatus has been present for approximately 7 days. The wound is thought to be related to incontinence. The wound measures 0.6 cm x 0.4 cm x 0.1 cm." There was minimum serous exudate draining from the wound and the skin around the wound was [DIAGNOSES REDACTED]tous. Documentation of a pressure ulcer indicated, "...left hallux (toe) has been present to approximately 7 days. The pressure ulcer is thought to be related to immobility. The pressure sore measures 0.6 cm x 0.4 cm x 0 cm. It has increased in size..." *CSA, dated 1/30/12, documented a scab on the penis and a new open area to the scrotum which measured 1.5 cm x .5 cm. Origin of wound was check marked on the form as "pressure" but it was not staged. *CSA, dated 2/6/12 documented the penis had healed and a light brown scab had formed on the right side of the scrotum. *Wound clinic note, dated 2/6/12 documented a wound on the urinary meatus present for approximately 2 weeks. It had decreased in size and measured 0.5 cm x 0.5 cm x 0 cm. The patient rated pain related to the wound as a 4 on a scale of 0 to 10. Recommendations were for barrier cream to be applied, "at least three times/day, with five applications even better." *CSA, dated 2/13/12 documented the resident had a "red bottom." No documentation indicated if the reddened area was blanchable. *Wound clinic note, dated 3/6/12 documented the wound to the meatus was resolved, as was the pressure sore to the left hallux. A new pressure ulcer had developed on the buttocks, which was thought to be present for approximately one day. The pressure ulcer measured 0.3 cm x 0.1 cm x 0.1 cm. The resident did not complain of pain, there was a small amount of serous exudate. The skin around the wound was normal. The pressure sore was not staged but described as a "partial thickness pressure ulcer." The resident was observed on 3/14/12 at 7:30 am seated in his wheel chair by a dining room table. He was waiting to be served his breakfast. At 8:06 am, he received his plate. The CNA who served him asked how he was doing. He said that he was in pain that morning and his "butt was hurting." The CNA said she would go ask his nurse if he could have something for pain. In a couple of minutes Resident #1 let out a loud yell. A nurse in the dining room said, "(Resident #1) she is going to get you something for pain." At 8:12 am, a nurse brought the resident some pain medication. The resident's pressure sores were observed on 3/14/12 at 9:45 am. He had a new blister on his penis that was approximately 0.4 cm in diameter. The blister was fluid filled and closed. The resident had a catheter and was lying in bed on a plastic lined pad, without any incontinence brief on. The resident also had a 1.2 cm in diameter pressure sore with slough on his coccyx. The center of the wound was 0.3 cm. On 3/15/12 at 10:15 am, LN-1 (Acting DON) was interviewed regarding pressure ulcers for Resident #1. She was asked to provide additional information regarding the resident's pressure ulcers that would indicate they were unavoidable. LN-1 and the Administrator were advised that information related to onset of pressure ulcers and how the interdisciplinary team had implemented plans to ensure the resident would not break down unless unavoidable had not been provided. The resident was harmed when he developed multiple and recurrent avoidable Stage II pressure ulcers while in the facility. Please refer to F315 as it relates to additional findings for placement of a catheter as a treatment to heal pressure ulcers. 3. Resident #11 was originally admitted on [DATE] and re-admitted to the facility on [DATE] after a short hospital stay. [DIAGNOSES REDACTED]. The resident's initial MDS assessment was dated 10/2/10. The resident required total assistance for bed mobility, transfers, dressing, toilet use and hygiene. He required extensive assistance to walk in his room or in the corridor. He could eat with set up help only. Documentation indicated the resident had one Stage I pressure ulcer and one Stage II pressure ulcer. The Stage II was present on admission. However, the number of current pressure ulcers not present on admission or at a lesser stage, was listed as one Stage II pressure ulcer. The resident's quarterly MDS assessment, dated 8/19/11, documented he had one Stage II pressure ulcer. The date of onset was documented as 3/11/11. The significant change MDS, dated [DATE], documented the resident had three Stage II pressure ulcers, with only one being present upon his last admission, and the onset of the oldest pressure ulcer was 3/11/11. The resident's ADL abilities remained the same with the exception of walking in his room, which he had not done in that assessment period. A facility "Nursing Assessment" was completed on 8/28/11 when the resident returned from the hospital. The portion of the assessment for the resident's skin condition documented, "...Skin Integrity: intact, Skin Moisture: dry, Skin Tugor: No tenting, Skin Problems: #1-DQ (decubitis) on bottom/unable to measure due to (patient) unwillingness." A body diagram had a circle on the buttocks area with #1 documented next to the circle. The following was documented on facility CSA forms: *12/07/11- Multiple scabs on forearms due to scratching self. "Small OK (sic ?) 0.1 cm (illegible) R(ight) buttock." *12/14/11- The resident had scabs on his forearms from scratching, dry scaly skin on his legs and a dry hard area on the buttocks that was not open. *12/21/11- Scabs on forearms from scratching, dry hard skin on buttocks but no open areas, dry skin on legs and ankles. *12/29/11- Pinpoint scabs on right leg related to scratching, a 75 cm open area on R buttock, scabs on arms due to picking. Pressure ulcer not staged. *01/4/12- R buttock 1 x .75 open area, R buttock .75 scab, R buttock 1 cm open area, L(eft) arm .75 scab. Pressure ulcer not staged. *01/11/12- "Dry hard skin on buttock R proximal to coccyx" with no open areas. *01/18/12- No pressure ulcers documented, only scabs from scratching. *02/08/12- Resident had developed an open area to the coccyx that measured 0.8 cm x 0.1 cm x 0.2 cm. The resident also had open areas to the right upper inner thigh that measured 2.0 cm x 1.4 cm x 0.1 cm. Both areas were Stage II and due to pressure. *02/15/12- The resident had scratches on both lower legs and buttocks with scabs that had been picked off. This was the same for the skin report dated 2/22/12. *02/29/12- Scratches still present and open area to right buttock that measured 3 cm x 2 cm, result of pressure, Stage II. *03/02/12- An open area to inner right thigh measured 2.8 x 1.4 x .25 cm. "Abrasion .8 x .2 cm pink bed, pink edges." This was located on the coccyx. "Abrasion 2 cm x (illegible)." This was located on the left posterior thigh close to the buttocks crease. The back of the form which was for documenting other characteristics of wounds, including staging or origin of wound was not completed. An IDCC note, dated 1/24/12, documented the following: "...His PUR score is 31, which indicates he is at high risk for skin breakdown. Head to toe skin assessment is done weekly by LN and his skin condition is monitored daily with cares... He has chronic skin irritation/breakdown to his buttocks, areas continue to heal slowly and he is encouraged to comply with wound care and pressure relief measures...." On 3/15/12 at approximately 6:15 pm, LN-1 (Acting DON) and the Administrator were advised that any additional information that could confirm that Resident #11 had developed pressure sores that were unavoidable should be provided. On 3/16/12 LN-8 (RN consultant) provided the surveyor with additional documentation for Resident #11. LN-8 said the resident scratches a lot and this contributes to his wounds, even though he did develop them at the facility. NOTE: The facility CSA forms documented most of the resident's scratching involved his arms and legs. The facility did not provide evidence that the resident's pressure ulcers were unavoidable. The resident was harmed when he developed recurrent and multiple Stage II pressure ulcers in the facility. Please refer to F315 as it relates to additional findings for placement of a catheter as a treatment to heal pressure ulcers. 4. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 5/13/11 admission MDS assessment documented the resident had 1 Stage II pressure ulcer. The most recent quarterly MDS assessment, dated 2/1/12, documented no pressure ulcers were present. Resident #2's 5/26/11 Care Plan identified the problem of potential skin breakdown, in part due to poor circulation, limited mobility, fragile skin; and stated the resident was admitted with ulceration to the left great toe. NOTE: It was verified during interview with the RN MDS coordinator on 3/15/12 at 12:30 p.m. that the Stage II pressure ulcer documented on the admission MDS referenced the left great toe ulcer. The Care Plan Goal to maintain skin integrity was to heal the toe ulcer within 60 days and to have no other pressure ulcers develop over the next 90 days. The Care Plan for skin integrity had 19 goals/interventions which were handwritten and lined through to indicate discontinuation. Most of the discontinued items were not dated/initialed to indicate when they were no longer in place. Of the interventions remaining on the Care Plan as still in effect, included were: * 5/26/11 Head to toe skin assessment weekly * 11/16/11 Apply heel floats while in bed * 5/26/11 Monitor skin condition with baths, daily cares * 5/26/11 Assist (Resident #2) to turn, reposition at least every two hours, encourage frequent off-loading * 5/26/11 Low loss air mattress * 5/26/11 Gel cushion to Wheelchair Pressure Ulcer Risk Assessments were completed on 8/9/11, 11/11/11 and 1/31/12. All assessments documented the resident was at high risk to develop pressure ulcers, with scores of 32, 29 and 29. The assessment tool indicated a score of 12 or above was considered high risk. Comprehensive Skin Assessment/Weekly Skin Occurrence forms reviewed for 1/7/12 through 3/3/12 revealed the following: 1/7/12 - Peri area red. 1/14/12 - Red on inner thigh, shearing from legs rubbing together. 1/29/12 - No skin issues. 2/4/12 - Peri area red. 2/18/12 - 1. peri area excoriated (yeasty), 2. 1 cm (centimeter) open area in crack of buttocks. The area was further described as a pressure sore, Stage I with a length of 1 cm. (no width or depth recorded). 2/25/12 - Peri area red. 3/3/12 - 1. peri area red, 2. 1 cm open area on coccyx. The area was further described as a pressure sore, Stage I with a length of 1 cm. (no width or depth recorded). NOTE: A Stage I pressure sore is defined as skin intact, a Stage II as open area/break in skin. No further Comprehensive Skin Assessment/Weekly Skin Occurrence forms were present for review. A Nurses Notes entry for 3/4/12 at 9:30 p.m. documented the resident had been turned side to side in bed due to the "skin issue on coccyx." Nurses Notes entry on 3/5/12 at 4:30 p.m. documented the resident was positioned through the shift as tolerated. Nurses Notes entries for 3/7/12 (2) and 3/8/12 (2) contained no mention of the coccyx wound. No Nurses Notes were documented after the 3/8/12 date. On 3/14/12 observations of the resident were conducted. From 7:35 a.m. to 8:50 a.m. the resident was seated in the wheelchair in the dining room. The resident was moved to her room and sat in the wheelchair until 12:30 p.m., at which time she was observed in the dining room for the noon meal. She remained there until 1:

Based on observation, staff interview and record review it was determined the facility did not ensure that 2 of 4 sampled residents (#1 and #11) who were catherized had a clinical condition that required this intervention. This resulted in harm for Resident #1 who had developed two recent urinary tract infections [MEDICAL CONDITION] and blisters on his penis, and failed a recent attempt to have his catheter removed because he was unable to urinate and empty his bladder. In addition, Resident #11 did not have assessments that documented clinical indications for the use of a Foley catheter. The facility documented that the catheter was used because of, "Stage II pressure ulcers." Findings include: The following documentation regarding the use of a catheter is documented in Federal guidance at F315: Indwelling Catheter Use - The facility's documented assessment & staff approach to the resident should be based on evidence to support the use of an indwelling catheter. Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include: * [MEDICAL CONDITION] that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible, & which is characterized by: - Documented post void residual (PVR) volumes in a range over 200 milliliters (ml); - Inability to manage the retention/incontinence with intermittent catheterization; and - Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction. * Contamination of Stage III or IV pressure ulcer with urine which has impeded healing, despite appropriate personal care for the incontinence; and * Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 11/18/10, documented the resident was always incontinent of bladder. The MDS assessment completed after the resident was in the hospital was dated 2/1/11. The resident was not coded for use of a catheter, and was coded as frequently incontinent of bladder. This was a small improvement since his admission MDS. The resident was documented to have a catheter on his quarterly MDS, dated [DATE] and on his annual MDS dated [DATE]. A bowel and bladder assessment was completed when the resident was readmitted to the facility on [DATE]. The assessment asked the question, "Does the resident have a history of UTI?" The response was no. A note was added to the assessment that documented a 3 day bowel and bladder monitor was completed. This had resulted in a determination that the resident had frequent episodes of incontinence. The recommendation was for the facility to implement an individual toileting program to offer a urinal or toileting at 6:00 am, 9:30 am, 11:00 am, 1:30 pm, 3:00 pm, 5:00 pm, 8:30 pm, 11:00 pm and as needed. This was to be care planned. His current care plan was dated 11/19/11 and identified a problem dated 2/23/11 that documented, "Alteration in urinary elimination, chronic incontinence, poor bladder control R/T (related to) [MEDICAL CONDITION] (a prostate condition) confusion at times, limited mobility, history of recurrent urinary tract infections. Currently using Foley catheter to promote wound healing."There was no assessment, or other documentation, for clinical need to use a catheter. A physician progress notes [REDACTED].#1) presents with UTI. This was first noted 3 days ago. Associated symptoms include dribbling or intermittent urine stream with urinary incontinence. Medical history is pertinent for [MEDICAL CONDITION] bladder and recurrent UTIs... Exams: ...Skin: no ulcerations, [MEDICAL CONDITION] or rashes." A telephone order, dated 5/4/11 documented a nurse's request to have a Foley catheter for wound healing. It also indicated the catheter could be discontinued after wound healing. The physician signed the note on 5/11/11. NOTE: This request was made only 2 days after the physician had completed a visit to treat the resident for a UTI. The physician documented the resident did not have wounds at that time. A physician progress notes [REDACTED]. No fever or other systemic symptoms. Ulcer culture had light growth but covered with antibiotics guided by culture and sensitivity. Continues to have a foley cath(eter) to try to keep the area clean. Weight has remained stable. This will hopefully aid wound healing...Exams: ...Skin: right greater than left buttock sores with right about 2 cm and grade II." On 3/15/12 at 10:15 am, LN-1 (Acting DON) was interviewed regarding pressure ulcers for Resident #1. She was asked to provide additional information regarding the resident's catheter and to provide a description of the pressure ulcers that necessitated the use of the catheter when it was implemented. On 3/16/12 at approximately 12:30 pm, LN-8 (RN consultant) provided documentation of when the catheter was inserted. However, no corresponding documentation with in-depth description of pressure ulcers at the time was provided. Facility "Comprehensive Skin Assessment" (CSA) forms and progress notes from a local wound clinic documented the following: * Wound clinic notes in the resident's record dated back to October 19, 2011 and documented for this visit: "...The pressure ulcer is thought to be related to immobility. The pressure ulcer measures 0.7 cm (centimeters) x 1.6 cm x 0.1 cm... I examined the patient for ulcer/wound that has been resistant to healing despite numerous interventions. The plan now is to examine any underlying characteristics that may impede healing... The exam reveals evidence of a deep tissue injury, consistent with pressure on the buttocks. The ulcer at the buttocks crease is showing improvement. Factors which may be causative or likely contribute to non-healing include: pressure, lack of adequate off-loading when seated, lack of adequate off-loading when supine... Off-loading is a critical part of this patient's management... " NOTE: The wound clinic did not include staging in the documentation. This was the case for all progress notes from the clinic. *A facility CSA, dated 12/12/11, documented the resident had a stage II pressure ulcer to his right buttock crease that measured 1.6 cm x 0.2 cm x 0.2 cm. (length, width and depth consecutively). *CSA, dated 12/22/11, documented, "Open area tip of penis. 0.7 cm x 0.1 cm x 0.1 cm." This was documented as a stage II wound. There was no documentation regarding the buttock wound or if it was resolved. *CSA, dated 1/2/12, documented a red buttock crease which measured 0.3 x 0.1 x 0.1 and a 1 cm open area on penis. There was no staging. *CSA, dated 1/16/12, documented the buttock pressure ulcer was resolved but was kept covered with a bandage for preventative measures. The penis still had a 1.0 cm slit. *Wound clinic note, dated 1/16/12 documented, "...the buttocks crease/left buttocks (converted)... is thought to be related to immobility... It has decreased in size... The skin around the pressure ulcer is macerated..." Notes documented a wound to the urinary meatus present for approximately one day and related to incontinence. NOTE: The resident had a catheter in place, so the maceration and urinary meatus wound would not have been related to urinary incontinence. *Wound clinic note, dated 1/23/12, documented the wound to the buttock area resolved but present for approximately 3 months was related to immobility. "The wound located on the urinary meatus has been present for approximately 7 days. The wound is thought to be related to incontinence. The wound measures 0.6 cm x 0.4 cm x 0.1 cm." *CSA, dated 1/30/12, documented a scab on the penis and a new open area to the scrotum which measured 1.5 cm x 0.5 cm. Origin of wound was check marked on the form as pressure but it was not staged. *CSA, dated 2/6/12 documented the penis had healed and a light brown scab had formed on the right side of the scrotum. *Wound clinic note, dated 2/6/12 documented a wound on the urinary meatus present for approximately 2 weeks. It had decreased in size and measured 0.5 cm x 0.5 cm x 0 cm. Recommendations were for barrier cream to be applied, "at least three times/day, with five applications even better." *CSA, dated 2/13/12 documented the resident had a "red bottom." No documentation indicated if the reddened area was blanchable or what had caused it. *Wound clinic note, dated 3/6/12 documented the wound to the meatus was resolved. A new pressure ulcer had developed on the buttocks, which was thought to be present for approximately one day. The pressure ulcer measured 0.3 cm x 0.1 cm x 0.1 cm. The pressure sore was not staged but described as a "partial thickness pressure ulcer." While the above CSA and wound clinic notes do not indicate the condition of the resident's skin at the time the catheter was inserted, they do indicate the catheter did not resolve the resident's wounds. The wound clinic documentation did not contain a recommendation for a Foley catheter to heal the wounds. The cause for the pressure ulcers were often attributed to immobility, not moisture, and did not exceed a Stage II. The resident's pressure ulcers were observed on 3/14/12 at 9:45 am. He had a new blister on his penis that was approximately 0.4 cm in diameter. The blister was fluid filled and closed. The resident had a catheter and was lying in bed on a plastic lined pad, and not wearing an incontinence brief. The resident also had a 1.2 cm in diameter pressure sore with slough on his coccyx. The center of the wound was 0.3 cm. The resident was already at risk for UTIs and was placed at increased risk for repeat infections with continued use of a catheter. The resident had telephone orders dated 12/12/11and 1/7/12 for antibiotic treatment of [REDACTED]. The facility requested (fax transmission) to remove the catheter on 1/26/12. This was approved, but attempts to remove the catheter failed, as the resident could no longer urinate independently. Nurses' notes for 1/27/12 documented the resident as "very uncomfortable." When straight catheterized, the resident produced bloody urine and when urine began to clear in color an additional 900 cc (cubic centimeters) of urine was obtained. The physician was contacted and recommended bladder retraining with straight catheterization every 6 hours until the resident could void on his own. This process was not successful, and the resident complained of continuous pain. The catheter was reinserted per physician order [REDACTED]. The resident was harmed when he was catherized without a clinical condition to necessitate this intervention. 2. Resident #11 was originally admitted on [DATE] and re-admitted to the facility on [DATE] after a short hospital stay. [DIAGNOSES REDACTED]. The resident's initial MDS assessment was dated 10/2/10. The resident required total assistance for bed mobility, transfers, dressing, toilet use and hygiene. He required extensive assistance to walk in his room or in the corridor. He could eat with set up help only. Documentation indicated the resident had one Stage I pressure ulcer and one Stage II pressure ulcer. The Stage II was present on admission. The resident was frequently incontinent and did not have a catheter. The resident's quarterly MDS assessments, dated 5/27/11 and 8/19/11, documented the resident had a catheter. A facility "Nursing Assessment" was completed on 8/28/11 when the resident returned from the hospital and documented the resident had a catheter. There was no documentation provided regarding the clinical need for a catheter. A telephone order, dated 8/31/11, documented a nursing request for a Foley catheter to promote skin healing related to chronic incontinence. The physician signed the order on 9/6/11. NOTE: Previous documentation indicated the resident had a catheter prior to the request. The resident's care plan, dated 9/21/11, doumented an intervention related to pressure ulcers. The intervention was dated 9/21/11 and indicated the resident was, "currently using a Foley catheter due to chronic incontinence to assist with promoting healing. Is also frequently incontinent of bowel, encourage (Resident #11) to let staff know when he thinks he may need to have bowel movement and to sit up on toilet or commode." There was no care plan to direct staff when to change the catheter, position catheter collection bag and tubing, how often staff should provide catheter care, etc. The following was documented on facility CSA forms: *12/07/11- Multiple scabs on forearms due to scratching self. "Small OK (sic ?) 0.1 cm (illegible) R(ight) buttock." *12/14/11- The resident had scabs on his forearms from scratching, and a dry hard area on the buttocks that was not open. *12/21/11- Scabs on forearms from scratching, dry hard skin on buttocks but no open areas. *12/29/11- Pinpoint scabs on right leg related to scratching, a .75 cm open area on R buttock, scabs on arms due to picking. Pressure ulcer not staged. *01/4/12- R buttock 1 x .75 open area, R buttock .75 scab, R buttock 1 cm open area, L(eft) arm .75 scab. Pressure ulcer not staged. *01/11/12- "Dry hard skin on buttock R proximal to coccyx" with no open areas. *01/18/12- No pressure ulcers documented, only scabs from scratching. *02/08/12- Resident had developed an open area to the coccyx that measured 0.8 cm x 0.1 cm x 0.2 cm. The resident also had open areas to the right upper inner thigh that measured 2.0 cm x 1.4 cm x 0.1 cm. Both areas were Stage II and due to pressure. *02/15/12 and 2/22/12- The resident had scratches on both lower legs and buttocks with scabs that had been picked off. *02/29/12- Scratches still present and open area to right buttock that measured 3 cm x 2 cm, result of pressure, Stage II. *03/02/12- An open area to inner right thigh measured 2.8 x 1.4 x .25 cm. "Abrasion .8 x .2 cm pink bed, pink edges" on the coccyx. "Abrasion 2 cm x (illegible)" on the left posterior thigh close to the buttocks crease. The back of the form, which was for documenting other characteristics of wounds, including staging or origin of wound, was not completed. An IDCC note, dated 1/24/12, documented: "He is using a Foley catheter due to chronic incontinence to promote healing of chronic skin issues; cath care is provided every shift." On 3/15/12 at approximately 6:15 pm, LN-1 (Acting DON) and the Administrator were asked for any additional information that could confirm that Resident #11 had a clinical condition which required a catheter. On 3/16/12 LN-8 (RN consultant) provided additional documentation. LN-8 said the resident scratches a lot, and this contributes to his wounds. The catheter was used to keep him from developing infections in wounds related to incontinence. The documentation included the 8/3/11 telephone order for the Foley catheter, skin assessments for February and March 2012 wich did not document stages for pressure ulcers, and another skin assessment which was a smeared copy without a date. None of the assessments documented any ulcers above a Stage II. NOTE: The facility CSA forms documented most of the resident's scratching involved his arms and legs. The facility did not provide evidence that Resident #11 had a clinical condition which required a Foley catheter.

Based on two complaints from the public, record review, and staff interview it was determined the facility failed to properly assess residents who were demonstrating health care changes including significant declines in health care status which lead to hospitalization , development of a fecal impaction, and need for bowel care. This was true for 5 of 14 sampled residents (#s 2, 4, 5, 13, and 14) reviewed and resulted in harm to residents # 4 and 13: 1) Resident #13 was harmed when she showed significant signs of a decline in her physical and mental health status between 11/22/10 and 11/24/10. No nursing assessments were performed or physician notification occurred for 35 hours after the first documented change. The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. 2) Resident #4, who had a chronic history of constipation, was harmed when the facility nurses failed to comprehensively assess the resident and missed signs and symptoms of fecal impaction. This resulted in the resident being hospitalized with a large fecal impaction and urinary tract infection. Findings include: A complaint received from the public, on 12/8/10, concerned residents not receiving adequate nursing assessment and response when significant changes in health status occurred. 1. Resident #13 was admitted to the facility on [DATE]. She was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Prior to the 1/24/11 discharge, the resident's [DIAGNOSES REDACTED]. The resident returned from the hospital on [DATE] with a new [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 10/27/10, documented the resident scored an 11 on the BIMS and was able to correctly repeat three words, report the correct year, and report the correct month and the correct day of the week. The resident was coded as having no decrease in appetite and no behavioral symptoms. The MDS coded the resident required limited assistance with bed mobility, transfering, walking in her room and corridor, locomotion on or off the unit, dressing, toilet use and personal hygiene. The resident only required set-up assistance with eating. A significant change MDS assessment, dated 12/6/10, coded the resident as a 4 on the BIMS and only able to repeat one word, missed the correct year by 2 - 5 years, and was not able to report the day of the week. In addition, the 12/6/10 MDS coded the resident showed evidence of an acute change in mental status, had a poor appetite and was totally dependent for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. An Investigation of Incident/Accident (I&A) report, dated 11/21/10, documented Resident #13 had an unwitnessed fall on 11/21/10 at 8:15 pm. The resident was found sitting on the floor in her room with her back against a recliner. Following the fall, Resident #13 complained of back pain on a scale of 10 out of 10 and was sent to the hospital on [DATE] at 8:30 pm. A Nurses Note, dated 11/22/10 at 3:30 am, documented the resident returned at 11:30 pm to the facility via the facility van. Nurses Notes, dated 11/22, 11/23, and 11/24/10, following the 11/21/10 fall, documented the resident showed significant signs of altered mental and physical status. There was no documentation of nursing assessment during these changes or physician notification for 35 hours: * 11/22 at 5:00 pm, the resident complained of back pain and refused "meals." * 11/22 at 9:45 pm, "(Resident) would not speak when spoken to. Staring blankly... refusing meals and care." Note: There was no documentation of nursing assessment, neuro checks, physician or family notification. * 11/23 at 5:30 am, "(Nurse) entered room. res(ident) let go of water glass and it dropped on (the) bed. (Nurse) asked her why. All she would do is grunt, will not speak to staff. refusing to assist with transfers... will not help with dressing, just grunts... " Note: There was no documentation of nursing assessment, neuro checks, physician or family notification. * 11/23 at 1:30 pm, "Not speaking with staff... refused all meds (medications)." Note: There was no documentation of nursing assessment, neuro checks, physician or family notification. * 11/23 at 9:50 pm, "Continues to be non-verbal. Took meds, ate a few bites. Only able to grunt." Note: There was no documentation of nursing assessment, neuro checks, physician or family notification. *11/24 at 4:00 am, "No verbal response to staff." Note: There was no documentation of nursing assessment, neuro checks, physician or family notification. *11/24 at 6:00 am, "Refuses to assist in cares, refuses meds, only able to grunt." Note: There was no documentation of nursing assessment, neuro checks, physician or family notification. The resident's Nurses Notes documented the resident's physician was first notified of her "latest behaviors... with not talking" on 11/24 at 8:50 am. The physician visited the resident on 11/24 at 1:20 pm, and sent her to the emergency room (ER) for a CAT (Computerized Axial Tomography) Scan. The physician documented, "If CAT Scan shows nothing send to Safe Haven psychiatric unit." Resident #13 was admitted to the hospital from theER on [DATE]. A History and Physical, dated 11/24/210, documented , "She is admitted today with periods of altered mental status... Patient is extremely noncommunicative, has a flat affect, will not follow simple commands such as opening her mouth... oral mucosa does appear slightly dry... she is not moving her lower extremities whatsoever and not following commands as noted above... CT (CAT Scan) of the head shows a probable new posterior parietal lesion..." The physician's Assessment and Plan included, "Altered mental status likely secondary to a [MEDICAL CONDITION]." On 11/29/10 Resident #13 was readmitted to the facility. The hospital Discharge Summary documented, "(Resident's) medications (upon admission) were initially held due to (resident's) inability to speak or swallow. Speech therapy was consulted and it was determined that she was able to take sips of water but should not take (oral) medications or food... she had an NG (nasal [MEDICAL CONDITION] tube) placed on a feedback protocol for nutrition. Up until her final day in the hospital (resident) could not speak or move to any commands. She would open her eyes and seemed to move her arms spontaneously, but not her legs. However, on the morning of November 29, (resident) seemed to have a remarkable turnaround. She became verbal and was able to state her name and where she was. She also was able to indicate she was thirsty and was beginning to speak more much frequently. She was also able to get up and sit in the chair... Speech therapy was again consulted to see (resident) and it was determined that she was able to eat nectar thick liquids as well as pureed food and would be able to advance as she could tolerate from there. Due to (resident's) turnaround, it was felt that she could safely be discharge home (back to facility). The resident was discharged to the facility with orders for speech therapy, occupational therapy, and physical therapy to help her return to her baseline mobility as well as baseline eating ability." On 2/4/11 at 10:50 am, the DON, MDS Nurse, and LN #2, were interviewed regarding Resident #13's condition change between 11/21/10 and 11/24/10 as well as the lack of nursing assessment and physician notification. The surveyors were told that the resident's "behaviors" of refusing meals, inability to speak, and refusing to assist with transfers and cares, were not observed prior to 11/22/10. The three nurses indicated the resident had demonstrated resistive behaviors to care prior to 11/21/10, but she had not demonstrated the specific types of behaviors documented in the nurses notes between 11/22/10 and 11/24/10. When asked if there was additional documentation regarding nursing assessment and physician notification, between 11/22 and 11/24/10, the DON stated they would review the record and provide copies of what additional information there was. No additional documentation addressing these issues was provided. On 2/4/11 at 11:15 am, the Administrator and DON were notified of the ongoing concerns with lack of nursing assessment and physician notification for Resident #13, between 11/22/10 and 11/24/10, which resulted in harm to the resident who was admitted to the hospital on [DATE] with a new [MEDICAL CONDITION]. 2. Resident #4 was readmitted to the facility on [DATE] after being hospitalized for [REDACTED]. The most current physician orders [REDACTED]. -[MEDICATION NAME] 20 grams/30 milliliter (ml), oral three times per day. Give 30 ml for chronic constipation. -[MEDICATION NAME] 100 milligrams (mg), 1 capsule twice daily for constipation. -Milk of Magnesia (MOM) 30 cubic centimeters, oral, as needed for constipation per facility bowel care protocol. -[MEDICATION NAME] ([MEDICATION NAME]) 5 mg, oral, as needed - 1 to 3 tablets at bedtime as needed. -Ready to use 133 ml, 1 enema rectal, as needed per constipation per facility bowel care protocol. All of these orders were date as of 10/25/10 when the resident was readmitted . Prior to the resident's admission to the hospital on [DATE], the physician's orders [REDACTED]. -[MEDICATION NAME] ([MEDICATION NAME] calcium) 240 mg, oral, twice a day for constipation. Hold for diarrhea. Dated 4/2/10. -[MEDICATION NAME] 527 grams, oral, as needed. Three scoops daily as needed. Dated 5/12/09. (NOTE: The MAR did not document her taking this medication for the month of October 2010.) -The resident also had directives to follow the facility bowel care protocol as above for MOM and enema and the order for [MEDICATION NAME] ([MEDICATION NAME]). The facility "Bowel Care Protocol", dated 1/20/07, documented: "...MOM 30 cc (by mouth) to given (sic) when the resident has not had a bowel movement within 3 days. If MOM is ineffective within 8 hours, then [MEDICATION NAME] suppository 10 mg rectal shall be given. If suppository ineffective within 8 hours, then ready to use enema 133 ml rectal shall be given. If after enema is given the resident still has not had a bowel movement then the LN shall contact the physician to obtain further bowel orders." Treatment records directed bowel movements (BM) be documented daily on each shift. Staff were to indicate XL for extra large, L for large, M for medium, or S for small BM size. There was no indication for consistency of stool, such as; hard, soft, formed or diarrhea. The following documentation of bowel movements was for Resident #4: -August 2010- All days were documented with the exception of days 6, 8, 10 and 20. -September 2010- All days up to days 14 through 20 there was nothing documented. (7 days without documented BM). A large BM was documented on day 21 and then nothing for the rest of the month (9 days no BM documented). -October 2010- Days 1 through 4 had initials and days 5 and 6 had a line drawn across each area for documentation on day shift. Nothing was documented for swing or night shift days 1 through 6. A medium BM was noted on day 7. No BMs on days 8 and 9. Day 10 a medium BM (swing shift) and XL on night shift. Diarrhea on all 3 shifts for day 11. No BM day 12. Diarrhea on day and afternoon shift. No BM on day 14. A medium BM on day 15. No BM days 16 and 17. A small BM on day 18. No BMs on days 19 - 21. This documentation indicated the resident had some type of BM 6 of the 20 days before being sent to the hospital 10/21/10. The DON was interviewed on 2/2/11 at 11:00 am. She was asked what it meant if days on BM records were not documented. She said it meant the resident did not have a BM on that day. The bowel records were reviewed with the DON. She acknowledged the lack of documentation and stated she would look into the matter. In approximately an hour, the DON provided BM records that were kept at the nurses' station. These records were for all the residents and would not have been part of an individual record. Records for September 2010 and October 2010 were provided as follows: -September- The only days not documented for a BM were days 14 and 25. Again, size only was documented and not consistency with the exception of a "d" for diarrhea on days 4 and 9. -October- Days 1-4 that had been initialed on the treatment record documented bowel movements. Days 5 and 6 with a line drawn through them were documented with BMs. No BMs were documented for days 8, 9, 14, 16 and 19. Days with a "d" were 11, 12, 13, 16, 19 and 20. This record documented the resident had some type of BM on 15 of 20 days. The resident was sent to the hospital on day 21. This was a great discrepancy in records with 9 additional days being documented with a BM on the record kept at the nurses' station versus the treatment record in the resident's record. The MAR for October 2010 documented the resident received [MEDICATION NAME] twice daily until day 10 when she refused the medication and continued to refuse it related to diarrhea. She started to take the [MEDICATION NAME] again on day 16. She had one administration on day 21, before being transported to the hospital. MOM was given on days 8 and 19. No [MEDICATION NAME] was given the month of October. The facility received an order for [REDACTED]. Instructions were to give immediately. An additional order was then obtained for [MEDICATION NAME] 1 mg, one tablet, by mouth, QID (four times per day), as needed. The resident took two tablets on the day shift and one tablet on evening shift. There were no other administrations of this medication documented. Nurse progress notes were reviewed and contained the following documentation: -10/9/10, (9:00 pm)- "(Refused) to take bath as needed suppository. To bed early (and suppository) given (and continued) to have 0 results..." (Note: There was no documentation on the MAR for this medication administration). -10/10/10, (11:00 am)- "Resident has remained in bed R/T (related to) having frequent BMs. Wanting us to call MD for something to 'stop my bowels from moving.' Explained to resident that the reason she is going frequently is R/T her having suppository last evening per her request. Refused [MEDICATION NAME] this day..." -10/11/10, (2:00 pm)- "...MD (Medical Doctor) is aware of res(ident) loose stools due to her request of MOM, supp(ository) and enema. MD said to hold [MEDICATION NAME] for a few days and will be in tomorrow..." (Note: The MAR documented she had not taken MOM since 10/8/10, no suppository or enema was documented as given). -10/12/10, (2:00 pm)- "[MEDICATION NAME] held, loose stools cont(inue) x 3, drank tea for breakfast (and) one slice toast. Refused lunch and all a.m. meds c/o (complaints of) discomfort then refuses pain med. On bed most of the shift sleeping on and off." -10/13/10, (2:00 pm)- "Dr. (name) called to notify him of resident continued diarrhea. N.O. (New Order) [MEDICATION NAME] 1 mg, 1 tablet by mouth now and [MEDICATION NAME] 1 mg, QID given x 2, diarrhea subsided. Res states 'I'm feeling better' eating (illegible) donut and tea. In bed all shift. Will continue to monitor." -10/13/10, (9:30 pm)- "Remained in bed. State not feeling well today..." -10/14/10, (3:00 pm)- "Stayed in bed. Refused [MEDICATION NAME]. No C/O pain (illegible). -10/14/10, (9:00 pm)- "Remained in bed this pm stating too sick to get OOB (out of bed). (No) specific symptoms reported. [MEDICATION NAME] not given d/t recent diarrhea. (No) reported diarrhea this pm..." -10/15/10, (2:00 pm)- "No behavior issues. [MEDICATION NAME] held diarrhea last 3 days. (Illegible) this shift ate will. 'I feel better.' Denied pain." -10/15/10, (9:30 pm)- "(Up) in w/c to (dining room. No c/o feeling ill voiced. Res stated 'When you bring my meds bring me some MOM.' Reminded res she has had diarrhea for quite a while (and) yesterday was the first day she had not had loose stools. She stated, 'I haven't gone since then.' and reminded probably bowels are cleaned out." -10/17/10, (9:00 pm)- "Requested MOM as she was 'all bound up from that pill they made me take' Explained we had the bowel protocol and she had a BM 11/16. Medicated (illegible) for C/O pain with good results." -10/18/10, (9:00 pm)- "Res. requests MOM as 'bound up.' Suggested wait until am to see if bowels will move with [MEDICATION NAME]." -10/19/10, (9:15 pm)- "Res very upset with staff. Requested MOM (and) told would give her a dose with her meds and then she became upset when she left desk stating no one would give her any. Res on day 4 so MOM given, results pending." (NOTE: Treatment record indicated small BM on day 18. Nurse station list documented a small BM and illegible documentation on that day for the night shift). -10/20/10, (2:00 am)- "Resident resting quietly at this time, C/O pain at (11:30 pm), medicated per MD orders with no further complaints of pain noted. Will continue to monitor." (NOTE: The location and type of pain not indicated in nurse notes or on MAR). -10/20/11, (2:00 pm)- "C/O (illegible) pain med (with) [MEDICATION NAME] and relief. (Dining room) for (breakfast) and lunch ate well no behaviors." (NOTE: Resident did have an order for [REDACTED]. This administration was not documented on the MAR). -10/20/10, (10:30 pm)- "Stated no BM from MOM last (night). No C/O discomfort. No neg(ative) behaviors." -10/20/10, (10:30 pm)- "Stated no BM from MOM last (night). No C/O discomfort. No negative behaviors." -10/21/10, (3:30 pm)- "Resident complained this am around (10:00 am) that her stomach hurt and she had not been able to go to the bathroom, enema given with no results, attempted twice for manual help but BM was so hard and big manual attempts failed notified Dr. (name) and he ordered resident be sent to ER (emergency room ) for impaction removal resident sent at 11:30 am, no news at this time." (NOTE: The MAR had no record of enema given). -10/21/10, (9:30 pm)- "Call received res is admitted to hospital at (6:00 pm)." The hospital History and Physical notes, dated 10/21/10, contained the following documentation: "...She reports that she has had constipation for at least one week. She notes she has had some diarrhea and was placed on an unspecified antidiarrheal medication, after which she has had significant constipation. She has developed abdominal pain, which she describes as diffuse. she notes that her abdominal pain has been waxing and waning. She notes she has had suppositories and enemas at (facility) without success. The patient also notes that she has had worsening incontinence of urine lately... Abdomen: Full to palpitation but is non tender. There is diffuse discomfort on palpitation, but no surgical tenderness. No peritoneal signs are noted. The patient has bowel sounds, when are somewhat high pitched, but normoactive. The patient has palpable stool in the abdomen, particularly over the [MEDICATION NAME] colon...Laboratory and studies: ....other studies include a CT of the abdomen...a large amount of stool in rectum is noted... Assessment: ...presents today with constipation, abdominal pain, [MEDICAL CONDITION] and is found to have a urinary tract infection with pyuria. The patient has had constipation at least a week or so and has significant fecal retention on CT scan with what appears to be a large ball in the pelvis. ... Does have a significant urinary tract infection with elevated creatinine... Plan: ...The patient was hypotensive. Fluid resuscitation led to normalization of blood pressure... we will attempt manual disimpaction and start the patient with [MEDICATION NAME] as we would for a colonoscopy bowel prep to clean her out...clear liquids while we undergo this...we will be giving fluids judiciously and will follow up on her renal function tomorrow... start the patient on [MEDICATION NAME] 400 mg IV (intervenous) every 12 hours and adjust as necessary based upon urine cultures..." The resident returned to the facility on [DATE]. The DON was interviewed on 2/3/11 at 8:40 am. The surveyor asked what she would have expected a nurse to do regarding assessment of the resident who had a [DIAGNOSES REDACTED]. The DON stated the resident was alert and could tell nursing staff how she felt. The resident was refusing her [MEDICATION NAME] and took [MEDICATION NAME] three times. There was also pain medication given during this time and she was immobile and staying in bed. The MDS LN was also present during the interview and said that the nurses may have thought the bowels were OK as the resident had diarrhea and some movements. MDS LN said there may not have been a big trigger to alert them of a bowel problem. The resident was interviewed on 2/1/11 at 9:00 am. The resident was pleasant and presented as cognitively independent. She indicated many of the staff were very good but a few could be more respectful. She said, "They act like you're just old and don't have anything important to say." She was also complimentary in many areas. She was observed during the interview in her private room to be very capable when maneuvering her power wheel chair. Throughout the survey she was out and about and participated in activities and went to the dining room to eat. The resident's significant change MDS, dated [DATE], documented that she was cognitively independent. The current care plan was dated 11/19/10 and identified the following problem: "Potential for alteration in cognition, mixes up facts at times, is forgetful at times. Gets upset with others when facts are pointed out. Does not realize she forgets things at times. Changes her mind frequently and wants to be totally in charge of her cares..." An approach included, "Allow (Resident #4) to make as many choices as possible. Give her options. Provide education as needed to assist her with making informed decisions." According to the Encyclopedia of Nursing and Allied Health, fecal impaction is the result of extreme constipation. It further states that the possibility that a "patient has a fecal impaction should be considered if he or she shows any or all of the following symptoms: * complaints of inability to have a bowel movement despite frequently feeling the urge to defecate * upon defecation, the stool appears to be either diarrheic or thin and pencil-like * abdominal pain * bloating and a swollen or hard abdomen * anorexia, or lack of appetite; nausea; and vomiting" The documented bowel movements described as "small" and/or "loose" should have been considered as possible indicators of fecal impaction, since in spite of having these bowel movements, the resident continued to report not feeling well and feelings of constipation. Nurses' notes did not indicate the resident was comprehensively assessed. There was no indication that nursing staff palpated the abdomen, listened for bowel sounds, or attempted a manual exam earlier to determine if hard stool was in the rectal vault. There was no indication the nurses ever offered her the [MEDICATION NAME] she could take as needed or educated her on the benefits of taking this medication for constipation. (She was treated with the same medication at the hospital). Nurses did not document specific reasons for administering pain medication ([MEDICATION NAME]) which the 2011 Nursing Drug Handbook indicates for constipation as a side effect. There was no indication that nursing staff had an in depth conversation with the resident to determine what symptoms she was having. The resident was not behaving normally when she preferred to stay in bed and was not eating all of her meals or only eating small snacks, such as tea and toast. The facility missed signs and symptoms and failed to comprehensively assess the resident who had to be hospitalized with a fecal impaction and urinary tract infection. 3. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hosptalized on [DATE] after hitting his head when he fell . He returned to the facility and went back to the hospital a second time that same day and was admitted to the hospital for treatment of [REDACTED]. A facility "Investigation Of Incident/Accident" (I&A report) was reviewed for 11/11/10. The report confirmed the resident had fallen at 9:25 am. Documentation indicated he had a dime sized pink area to the back of his head and he had an altered mental status. NOTE: The I&A report was not provided when incident reports for the last 6 months were requested during the surveyor's entrance to the facility on [DATE] at approximately 1:30 pm. The form was found in the Administrator's office and provided on 2/3/11. A "Neurological Assessment" form was attached to the incident report. It documented a neurological check was done at 9:30 am on 11/11/10. The right and left pupil were both documented for a size of 2 and both reactive. There was no other documentation of neurological checks on the form. An "Alert Charting" nurse progress note was attached to the incident report. Documentation was timed 9:25 am, and as follows: "Alarm sounded and staff immediately responded to find Resident lying on floor on his back. Myself and other LN assessed resident before moving. B/P (Blood Pressure) 138/74, P(ulse)- 82, R(espiration) -16, T(emperature)- 98.2, PERRLA (abbreviation for pupils being round, equal, react to light). Resident had full ROM. Arisen to chair and resident is lethargic and not responding. His eyes opened upon several cues - but not acting usual self. Resident was sent to (name of hospital) via ambulance. Notified Dr. (name) at 9:40 and attempted to notify family via telephone several times but phone number is saying disconnected. Will continue to contact family member to notify of fall. Will continue to monitor." The note was not in the resident's closed record but located in the Administrator's office and provided on 2/3/11. The next nursing note was documented in the nurses notes and dated 11/11/10, (9:00 pm). "(Resident) is being admitted to hospital for dx (diagnosis) of pneumonia." There were no notes located or provided which indicated when the resident returned to the facility after his first evaluation at the hospital emergency department (ED). No notes indicated his condition upon return to the facility. There was no indication of continued neurological checks. The survey team retrieved all documentation of assessments and medical care provided to the resident for the two admissions to the hospital on [DATE]. The ED report dated 11/11/10 documented: "The patient...seen earlier today for altered mental status, evidently had suffered a fall at the nursing home where he lives, struck his head, negative head CT, was discharged . Nursing home then called 911 and sent him back to us with altered mental status, not acting his normal self. No definite history of loss of consciousness, no [MEDICAL CONDITION] activity..." A History and Physical dated 11/11/10 documented: "...resident of (name) nursing home who, according to his (family) who is present at time of interview, had a fall from a standing position...earlier this morning. He was taken to the ED at that time and evaluated by Dr. (name). A CT scan of the head at that time was normal. He was discharged back to (nursing home). According to his (family) when (family) visited him after ER visit in the morning, (family) thought that he had a change from his normal baseline mental status and did not appear well. ... noted that he was shaking and was coughing with productive yellow sputum. He was again brought to the ED for further evaluation." The following was documented on the discharge summary: "discharge date : 11/16/10- ...patient ... presented to the ER (emergency room ) after family members noted worsening a (sic) baseline mental status as well as cough. He also had some fevers and question of productive yellow sputum. CT scan was done in the ER to look for any intracranial processes which was negative. A chest x-ray was suggestive of an early pneumonia...in the ER his temperature rose to 100.6 and oxygen saturation dropped to 88% on 2 liters nasal cannula. The patient was admitted to the hospital and started on baseline antibiotics..." The facility failed to provide ongoing continuous assessment for Resident #14 after he returned from the hospital for evaluation of a blow to his head and deterioration from normal baseline functionality. The resident was also developing pneumonia and was exhibiting signs and symptoms of illness. No records of assessments for these issues were provided. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident physician's orders [REDACTED]. -[MEDICATION NAME] sodium, 100 mg, 2 tablets, oral, daily (order date 6/29/10), [DIAGNOSES REDACTED]. -[MEDICATION NAME], 30 cc, oral daily for constipation (order date 6/29/10). -Senna 8.6 mg, 1 tablet, oral, at bedtime for constipation (order date 6/29/10). -For the 6/29/10 admitted the physician also ordered the facility to follow the bowel program for this resident. The following bowel record was documented for December 2010: No BMs for days 2, 3, 4, 5, 6, 8, 9, 11, 12, 17, 18, 21, 23, 25, 28, 29, 30 and 31. This documentation indicated 18 of 31 days with no BM. The MAR for December 2010 documented: The resident received her daily routine medications as above for constipation. Bowel protocol medications- No MOM was administered. The resident was administered [MEDICATION NAME] suppositories on 12/5, 12/6 and 12/27/10. No enemas were administered. Nurse progress notes for December 2010: -12/6/10, 1:30 pm- "Had X-lg (extra large) results this am from suppository." This was the only nurse progress note regarding BMs. There was no note related to giving this suppository or the other two she received in December. The resident's MDS assessments for the initial on 7/12/10 and quarterly 10/8/10 documented she was moderately cognitively impaired, frequently incontinent of bowel and required extensive assist by 2 for toileting. There was a similar lack of documentation for the month of November 2010. The facility did not indicate comprehensive assessments for providing bowel care to Resident #2 were completed. During a meeting with the Administrator and DON on 2/4/10 at approximately 12:30 pm, the Administrator asked if the facility would have time to send in further documentation. The surveyor said, "Yes." No other documentation related to this resident's bowel care was received. 5. Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident physician's orders [REDACTED]. -[MEDICATION NAME] 100 mg, 1 capsule, oral daily, for constipation (order date 7/27/10). For the 5/27/10 readmitted the physician also ordered the facility to follow the bowel program for this resident. The following bowel record was documented for December 2010: No BMs for days 3, 4, 11, 16, 18, 19, 23, 24, 26, 28, 29, 30 and 31. This documentation indicated 13 of 31 days with no BM. The MAR for December 2010 documented: The resident received his daily routine medications as above for constipation. Bowel protocol medications- MOM was administered on days 1, 20 and 27. The resident was not administered [MEDICATION NAME] suppositories or enemas. The back of the MAR indicated MOM was given by patient request on 12/1/10. No results were documented. On the back o

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop unavoidable ulcers. This was true for 3 of 6 residents sampled for pressure ulcer prevention and treatment (#4, 5, 6). *Resident #6 was harmed when she developed recurrent Stage II pressure ulcers on her coccyx. The facility failed to implement individualized and adequate interventions to prevent further wounds after a previous coccyx Stage II wound was healed 10/30/10. *The facility failed to document descriptions of wounds when Resident #5 did allow pressure ulcer assessment. *Resident #4's progress notes did not address non-compliance and/or education related to non-compliance with dressing changes. In addition, assessments did not include consistent documentation related to staging, measurements, etc. Findings include: 1. Resident #6 was admitted to the facility 2/4/04, with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 12/17/10, documented: *The resident was severely impaired for decision making skills. *The resident required total assistance for bed mobility, transfers, dressing, personal hygiene and bathing. *The resident was frequently incontinent of bowel and bladder. Resident #6's previous quarterly MDS assessment, dated 9/20/10, documented the same information. Additionally, a Stage II pressure ulcer was documented as present. The facility's "Skin Problem Policy and Procedure," dated 8/9/07, documented a pressure ulcer risk assessment (PUR) shall be done on the day of admission, weekly for four weeks after the admission, quarterly and if there was a change of condition. The policy included a "Daily Skin Problem Observation Record" (DSPOR) was to be started when a wound was found. Section "F" of the DSPOR documented if a wound was found, a daily skin problem observation record was to be completed and, "This is to be documented on each at least daily until healed." The next paragraph in section "F" documented "... In other words if we have a SKIN OCCURRENCE" we will do a good comprehensive assessment of it at least once a week." It was unclear if the DSPOR was to be completed daily or weekly. Resident #6's "Pressure Ulcer Risk Assessment/Prevention Intervention Protocol" documented a score of 12 or higher was high risk for pressure ulcers. Resident #6's risk for pressure ulcers was determined to be 16 for the quarters of 3/30/10, 6/30/10, 9/20/10 and 10/16/10 (no documentation an assessment was completed 3 months after 10/16/10). Resident #6's "Comprehensive Skin Assessments" (CSA) included a section for "Skin Problems." On the back of the form was "Weekly Skin Occurrence Form" (WSOF) which had areas to document the "Origin of the Wound" (pressure, vascular, incontinence, surgical, skin tear/laceration, bruise or erosion), "Stage of Wound " (Stage 1 through 4 and N/A), "Size" (Length, depth, width in cm, undermining/Tunneling cm and other), "Drainage" (serous, purulent, serosanguineous, green, yellow/tan, thin, thick, or none), "Drainage Amount" (Minimum, moderate, copious, none), "Surround Tissue" (pink, yellow, black, red, edges) "Wound Bed" (pink, yellow, black, red, % necrosis and N/A), "Odor" (yes, no, describe), "Procedure" (Cleansed with, filled with, secured with, technique, rinsed with and covered with), "Patient's Tolerance" (Well or not well with complaint or no complaint and other), "Signs & Symptoms of Infection" (redness, hot to touch, increased pain, elevated temperature, odor, drainage, none, quality of pain, "Pressure Relieving Device" (Yes or no). The CSAs and the WSOFs were reviewed from 8/14/10 through 10/30/10. All of the WSOFs reviewed were blank. The CSAs contained the following information: 8/14/10 - Skin color pink, skin temperature warm, skin integrity intact, skin moisture dry, skin turgor fair, Skin Problems No skin breakdown" 8/21/10 - "Skin Color pink, Skin Temperature warm, skin integrity blank, skin moisture dry, skin turgor fair, Skin Problems Crease down L (left) buttock .5 x (by) .5 cm (centimeter) red area" 8/23/10 - "Skin color pink, skin temperature warm, skin integrity intact, skin moisture dry, skin turgor poor, Skin Problems L buttock/leg open area 1 cm long 1/2 cm wide" NOTE: Skin integrity was documented as intact however an open area was documented in skin problems 8/28/10 - "Skin color pink, skin temperature warm, skin integrity fair, skin moisture dry, skin turgor fair, Skin Problems L buttock coccyx 1 cm x .5 cm barrier cream applied gel cushion to w/c (wheelchair)" Nurses Note (NN) 8/29/10 - "Dr. notified of open area to L Buttock. POA notified of open area...." 9/4/10 - "Skin color pink, skin temperature warm, skin integrity fair, skin moisture dry, skin turgor fair, Skin problems L buttock 2 cm x .5 cm a cream and a dressing was applied NN - 9/10/11 - "Dsg (dressing) R (right) buttock area Healing slowly" NOTE: It was documented as the "right" buttock on 9/10/11; however it was previously documented as the "left" buttock. 9/11/10 - "Skin color pink, skin temperature warm, skin integrity fair, skin moisture dry, skin turgor fair, Skin Problems L Buttock crease measure 2 cm x .5 cm drsg (dressing) changed" 9/18/10 - "Skin color pink, skin temperature warm, skin integrity fragile, skin moisture dry, skin turgor fair, Skin problems open area to L buttock 2 cm. by .5 cm dressing applied 9/25/10 - "Skin color pink, skin temperature warm, skin integrity fragile, skin moisture dry, skin turgor fair, Skin problems open area to L buttock 2 cm. by .5 cm " Gel cushion to w/c 10/2/10 - "Skin color pink, skin temperature warm, skin integrity fragile, skin moisture dry, skin turgor fair, Skin problems L buttock crease 1.5 cm. by .5 cm " dressing applied 10/9/10 - "Skin color pink, skin temperature warm, skin integrity fragile, skin moisture dry, skin turgor fair, Skin problems 0.5 round open area to L buttock crease" dressing applied NN - 10/13/10 - "Called (physician) regarding shearing to L buttock." 10/16/10 - "Skin color pink, skin temperature warm, skin integrity blank, skin moisture dry, skin turgor fair, Skin problems Buttock crease shearing 1 cm x .5 cm no open areas " NOTE: Investigative Guidelines definitions include: "A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. 10/23/10 - "Skin color pink, skin temperature warm, skin integrity fragile, skin moisture dry, skin turgor fair, Skin problems Shearing L Buttock crease 1 cm x .5 cm [MEDICATION NAME] applied 0 open areas" 10/30/10 - "Skin color pink, skin temperature warm, skin integrity intact, skin moisture dry, skin turgor fair, Skin problems Area to L Buttock healed." The "Physician Notification Form of Occurrence of Wound" for Resident #6 documented the following: 8/23/10 - Wound description - location buttock/leg left, size length 1 cm, width .5 cm, depth 0, open area, the skin turgor was documented as poor 8/26/10 - Wound description - location open L buttock coccyx area size 1" width 1/2 cm Depth was blank. Skin turgor was fair and description of pain was "none noted" The CSAs did not include documentation of the stage, depth or drainage of the wound. The assessments identified an open area on 8/23/10, however the open area was not documented on 8/28/10. The physician was notified of an open area on 8/29/10. On 2/2/11 at 11:25 a.m. the DON was asked for documentation that consistently documented the stage, size, depth, drainage of the wound. The DON stated the information needed to be documented on the WSOF. If the WSOF was not used the information needed to be documented in the narrative on the WSOF. Resident #6's Care Plan, review date 1/12/09, in the "Problem" section documented "Potential for skin breakdown related to decreased mobility, cognitive loss." The "Short - Term Goal" section had a goal date of 4/12/09, and documented "No skin breakdown over the next 90 days." There were two hand written notes in the goal area. The first was dated 1/13/10, and stated, "Monitor skin tears... for s/sx (signs or symptoms) infection until healed." The second hand written statement was dated 1/26/11 and documented "On hospice/comfort care. Keep hospice informed of skin issues." The "Approach" section of the care plan documented the following: 2/5/04 - preventative skin care each shift, encourage good nutrition and hydration, apply lotion each shift and PRN (as needed), reposition every 2 hours and PRN, Monitor skin condition with daily cares, if red area develops, implement facility skin protocol, daily multivitamin. 5/5/04 - canoe mattress 6/29/04 - Geri arms and ted hose 5/30/06 - daily skin assessment by CNA 4/10/07 - Check placement of ted hose each shift. Ensure that they are free of wrinkles, Etc. 12/17/08 - LN check nails weekly and keep nails short to prevent self injuries On 2/3/11 at 2:00 p.m. the DON was asked what revisions had been added to the Care Plan to prevent further pressure ulcers. The DON reviewed the Care Plan and stated the interventions were general precautions and the Care Plan had not been revised to address the pressure ulcer on the coccyx. Resident #6's record included a "Nurse's Note" from the hospice agency, dated 2/2/11, documenting "R (right) medial buttock 2. x 1 cm opening, L upper leg 3.5 x 2.5 cm opening." A "Physician Notification form of skin/wound occurrences", dated 2/2/11, documented a pre-existing condition of [MEDICAL CONDITION] in the legs and thighs. The wound description documented, "1) left lower buttocks thigh crease 1st skin layer off 1.3 cm x 1.3 cm 2) Right down buttocks thigh crease 1 cm x 1 cm. The depth was not documented for the wounds. On 2/3/11 at 2:15 p.m. the hospice CNA and the surveyor viewed the wounds on Resident #6's coccyx. The surveyor observed 2 open areas (denuded). The area under the crevice on the left thigh was 1 cm x 1 cm with a depth of .5 cm, there was a small amount of drainage, the base was pink/glossy. The area of the right inner buttocks was denuded and was 1 cm x 2 cm x .5 depth with a yellow base. On 2/4/11 at 11:15 the Administrator and the DON were informed that due to the lack of monitoring and modifying the impact of the interventions it was not possible to determine the 2 Stage II pressure ulcers were unavoidable. The facility failed to put protective measures in place to prevent the development of two Stage II pressure ulcers and failed to ensure accurate documentation regarding the description of the pressure ulcer. Resident #6's Care Plan for skin breakdown did not document revised interventions for at least 2 years. Resident #6 sustained harm as a result of the development of two Stage II pressure ulcers that were recurrent. 2. Resident #4 was originally admitted on [DATE], and readmitted to the facility on [DATE], after being hospitalized for [REDACTED]. The resident also had [DIAGNOSES REDACTED]. The resident's readmission MDS, dated [DATE], documented she had two Stage II pressure sores. She was assessed with [REDACTED]. She required extensive assistance to transfer and did not ambulate. The most current "Pressure Ulcer Risk Evaluation/Prevention Intervention Protocol" form, dated 11/1/10, documented a score of 39 (12 or above = high risk). The resident's care plan, dated 11/19/10, identified a problem, "Alteration in skin integrity related to poor circulation, limited mobility. Has fragile skin with increased risk for bruising/bleeding due to [MEDICATION NAME] therapy, [MEDICAL CONDITION], chronic ulcers on ankles/feet, deformities to feet...Has diminished pedal pulses, bone protrusions to feet. Is resistance (sic) towards treatment and refuses to cooperate with treatments..." The facility added 18 interventions, including pressure relieving devices, specialized shoes, geri- gloves, lotion for dry skin, peri-care, etc. However, there are no approaches for her non-compliance related to treatments. The care plan also identified behavioral symptoms including resistant to care. One approach indicated education was to be provided about the risk (versus) benefit of refusal of care. Also, "Educate (Resident #4) about the treatments Dr. (name) has recommended. Allow her to choose what she would like to do. Also remind her that although her wounds may heal that without proper treatment to address underlying causes that the wounds will reoccur." This was somewhat out dated as the doctor identified no longer treats the resident. Also, "At this time (Resident #4) is refusing further treatment for [REDACTED]." The facility's "Comprehensive Skin Assessment" forms documented the following: -10/28/10- "B. Scab area to R(ight) inner ankle 1 cm round. (No) redness, no drainage, no [MEDICAL CONDITION] noted." "C. Open area 1 cm round. Pink in (illegible) open area. White scaly skin around edge. No redness, no drainage, no [MEDICAL CONDITION]." NOTE: C. corresponded to a body diagram indicating right inside of foot above arch. "D. Open area pink on wound bed (with) white scaly skin around edge. No drainage, no redness. Open area 1.5 cm x 1 cm." NOTE: D. corresponded to body diagram indicating left inside of foot above arch. "E. Open area 1 cm round pink wound bed. White area around wound. No redness or drainage." (NOTE: E. corresponded to diagram with location in back of large toe joint on left foot). None of the wounds were staged and the depth for them was not indicated with a measurement. -11/4/10- Documentation was for two areas on the resident's feet. The prior area next to the large toe joint appeared to be healed. The other areas were located on the inside of each foot. The pressure sore to the inside of the right foot was the same size. The one on the inside of the left foot was 1.5 cm in diameter. Both wounds had a small amount of serosanguinous fluid. [MEDICATION NAME] dressing was applied. They were not staged and depth was not measured. -11/18/10- Documentation describes wounds to both feet on the medial plantar. The wounds were drawn on the bottoms of the foot diagrams. The one on the right foot was a 1 cm brown scab. The one on the left foot was a one centimeter round open area. There was no staging or depth documented and no indication these were newly developed areas. (NOTE: This was signed as completed by the same nurse who documented the 11/4/10 assessment above). -11/25/10- A right medial plantar brown scab 1 cm round no drainage or redness. Left medial plantar open area 1 cm around no redness or drainage. Bed pink with white scaly skin around it. NOTE: Weekly assessment not done for ten days. -12/5/10- Not essentially different from the 11/25 documentation above. -12/9/10- "Drsg (dressing) to feet intact. Res(ident) ref(used) to have removed. Has drsg change at (5:30 am)." The documentation then indicated the same as for 12/5/10. Nothing indicated on the body diagram. (NOTE: Does not indicate if resident objects to a 5:30 am dressing change). Nurses notes for the same day did not indicate a dressing change was refused or that staff educated her for a refusal. One note documented, "No negative behaviors." -12/16/10-Left medial plantar still had open area 1 cm round. The brown scab on the right medial plantar was less than .5 cm. -12/23/10- Both wounds to plantar right and left foot described same as 12/16/10. New dressing indicated for Allevyn foam dressings to be changed every other day. -12/30/10- Left medial plantar no change. Right medial plantar brown scab then less than .25 cm. -1/6/11- Descriptions the same as 12/20/10. -1/13/11- Descriptions the same with exception of left wound with one cm measurement and then had bloody looking edges with pink bed. -1/20/11- The same description as 1/13/11. -1/27/11- Left essentially the same. "Right medial plantar round open area 1 cm diameter, pinkish red surrounding skin 2 cm diameter, minimal drainage from 1 cm crater open area, no s/sx (signs/symptoms) of infection." (NOTE: this was the first measurement for the size of surrounding area. Still not staged). The DON and Administrator were advised on 2/2/11 at 4:45 pm, that pressure ulcer documentation was incomplete. The next morning the DON provided a physical therapy evaluation that had been completed on 9/5/05. A hand written note on the evaluation documented, "Please note date sent (They sent old notes) Shows long hx (history) of wounds prior to admission." The evaluation described one wound caused by a hematoma to the resident's right calf and the other was on the left plantar talus and had been present for up to 2 years. The plan indicated the right leg ulcer was straightforward to manage. The left foot wound was indicated to be much more troublesome. "Two years of appropriate management have not produced much improvement, but also she has had no deterioration. Normally we would use TCC or custom footwear to offload it. However, the ligamentous laxity of the foot and ankle are so severe that the remainder of the foot will not bear any weight at all...long-term prognosis for healing is not good." The documentation indicated the resident was still walking at the time and was living with a family member who was not usually home. While the resident did have a history of breakdown, her circumstances had changed significantly since her original admission to the nursing home on 10/12/05. The resident no longer walked and used a power wheel chair for mobility. The surveyor did not question the history, but the lack of definitive documentation in assessments and nurse progress notes to support the "unavoidable" aspects of her pressure sores. The progress notes did not indicate there was a lot of non-compliance exhibited by the resident nor education by staff if non-compliance with dressing changes were documented. In addition, weekly assessments did not include staging, changed the location of the wounds on the feet, and did not measure the depth or surrounding area most of the time. The surveyor did not receive documentation of the onset date for the current wounds, possible causes documented, or if the resident's feet had ever been healed since admission. The above records from the physical therapy records did not document a wound on the resident's right foot. 3. Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 12/7/10, documented the resident as independent for cognition, resists care, was totally dependent for transfers by two staff and had two Stage II pressure sores. The care plan, dated last revised on 12/7/10, identified, "Alteration in cognitive function, occasional confusion, forgetful at times, makes poor decisions at times R/T (related to) multiple medical conditions, history of lethargy." Approaches included allowing the resident to make as many choices about his care as possible. Another identified problem for psychosocial well-being included an approach dated 8/12/10: "Educate about pros/cons of choices (repositioning, off loading, etc.) Respect (Resident #5's) wishes if not infringing on rights of peers." The care plan identified a potential for skin breakdown, related to dry skin, limited mobility, poor circulation, incontinent at times, poor nutritional intake, low [MEDICATION NAME] of 2.9, admitted with open areas on thighs and a long history of pressure shear as reported be resident who stated fighting skin problems all the time. A hand written entry, dated 1/7/11, documented, "Skin breakdown wound cultured Proteus. Res has agreed to wound dressing & lying down 2+ hours each shift to promote healing." Approaches included: *Head to toe skin assessment by LN weekly. *Pressure relieving devices to bed/chair. *Assist to reposition frequently. At least every 2 hours. Encourage him to turn side by side while in bed. *Provide peri care after each incontinent episode, moisture barrier. *Keep linens clean, wrinkle free. *Apply lotion every shift. *Encourage long sleeves, geri arms to protect skin. *Encourage good nutrition. *Vitamins as ordered. *Keep MD (Medical Doctor) informed of skin issues. *Approach in positive manner to assist with resident lying down 2 plus hours per shift. The following was documented in facility "Comprehensive Skin Assessment" forms: 10/5/10- "#1 red, excoriated peri area and inner thighs. #2 open area under R(ight) buttock (no) drainage noted wound bed red." (Note: #1 and #2 corresponded to a body diagram). There was no staging or measurements included. 10/13/10- "Excoriation noted to (both) inner thighs." (Note: No statement of above open area under right buttock being healed). 10/19/10- "Resident resistive with skin assessment." 11/2/10- "Resident resistive with total skin assessment-know (sic)open area on buttock is not willing to get out of chair (at) this time." (Note: It had been 14 days since the last attempt to complete a skin assessment). 11/10/10- "Rt (Resident) refused skin assessment. Know (sic) excoriation on inner thighs ans OA (open area) on buttock." Under this entry, in different hand writing, another entry was added, "3 pin size hole on buttock-moisture barrier cream applied." There was no description of the surrounding area. 11/16/10- "Known open area on buttock, unable to assess drsgs (dressings) on BLE (both lower extremities) intact." Nothing was indicated on the body diagram. 12/7/10- "Red area between thighs, no open areas noted. Buttocks red but no OA noted." (Note: 21 days since last assessment attempt noted). 12/14/10- "Red peri area not OA noted." 12/22/11- "1) BLE Una boots (body diagram with both feet circled). 2) R upper posterior thigh 2 open areas, 1cm round each wound bed red other edges pink, OTA (unknown acronym) scant seroseguenous (sic) drainage. 3) L upper posterior thigh red and excoriated." 12/29/10- "#1 several pinpoint open areas on R (lower) buttock and upper medial posterior thigh with minimal seroussaganeous (sic) drainage. #2 unaboot on B(oth) lower exts (extremities)." 1/5/11- "Una boots intact (changed) by PT (Physical Therapy). #2 multiple pinpoint open areas on R (lower) buttocks and posterior medial thigh surrounding area red minimal serous drainage." 1/12/11- "#1 Multiple pinpoint open areas on R (lower) buttocks and medial posterior thigh. #2 Una boot intact (replaced by PT)." 1/19/11- "Moist flaky skin under drg (dressing) no breakdown noted drsg intact." (Note: Location not documented or indicated on body diagram). 1/26/11- The entry was illegible until, "thigh, refused assessment, states 'I let them change it, leave it alone'." On 2/1/11 the DON provided a copy of a "Physical Therapy Progress Report", dated 5/27/10. She said the copy was to show that measurements of the wounds were being done. The report documented, "The patient exhibits closed wounds, except for right dorsal thigh which has a red area about 5 cm x 3 cm which is scabbed over, yet at times may drain sango-serus fluid. Pt. (Patient) refuses to use dressing because he says it is very uncomfortable to sit on. Unaboot application to bilat. LEs weekly post whirlpool bath has decreased dry scaling and seeping leg skin - from status [MEDICAL CONDITION] in legs." The resident was interviewed on 2/1/11 at 7:25 am. The resident stated he spent most of his time in his room and did not use his bed, preferring to sleep in a recliner due to pain when he is lying down in bed. He indicated he had skin problems and felt the dressings were not helpful as when staff changed them they pulled off the scab. He indicated he did not take a shower any more and had a sponge bath in his room. He was very outspoken about directing his care and said he had used paper towels on his buttocks because they pulled scabs off when changing his dressings. He felt this practice had improved the wounds. While there was sufficient evidence of non-compliance for care in the record, the facility failed to document descriptions of wounds when the resident did allow them to assess the areas.