Every finding on record at Oneida County Hospital & Long Term Care Facility

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure the residents and their representatives received assistance to exercise their right to formulate an Advanced Directive. This was true for 2 of 12 residents (Resident #4 and #19) 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 Resident Rights Regarding Treatment and Advance Directives policy, review date 6/5/25, documented: - On admission the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. - The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. - Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including stroke and malignant melanoma of the skin (serious form of skin cancer). Resident #4's Idaho Physician Order For Scope of Treat (POST) form documented under Section D- Advanced Directives: The following documents also exist: DPA (Durable Power of Attorney) and DPAHC (Durable Power of Attorney for Healthcare). Resident #4's record did not include a copy of her DPAHC. On 5/11/26 at 3:06 PM, the DON stated Resident #4's paper chart had a form stating she had an advanced directive, but her medical record did not have a copy of her advanced directive and should have had one. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (a rapid, chaotic, and irregular heartbeat) and major depression. Resident #19's Advanced Directive Questionnaire, under Section II documented - I have an Advanced Directive and Durable Power of Attorney for Health Care. Review of Resident #19's medical record contained an Idaho Statutory Form Power of Attorney. This form stated this power of attorney did not authorize the agent to make healthcare decisions. On 5/12/26 at 12:32 PM, the DON stated that the facility did not realize Resident #19's POA form was for financial and not healthcare power of attorney and was not sure if Resident #19 realized that he did not have a POA for healthcare.

Based on policy review, record review, and staff interviews it was determined the facility failed to ensure appropriate discharge planning was documented in the resident's medical record and appropriate resident information was communicated to the resident's representative for 1 of 1 resident (Resident #27) reviewed for discharge. This deficient practice had the potential to result in adverse outcomes or harm if the resident did not receive appropriate care after discharge. Findings include: The facility's Discharge Summary policy approved date 4/22/25, documented it is the policy of the facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including dementia and Parkinsonism. A progress note dated 3/31/26 at 11:06 AM, documented staff reported Resident #27 had a fever (101.4 F) without other associated symptoms. Fever of unclear source. Plan: Obtain urinalysis and urine culture. Monitor closely for development of additional symptoms (respiratory, urinary, skin). A progress note dated 3/31/26 at 5:30 PM, documented Resident #27 was picked up by his wife. She grabbed all his belongings and all his medications. Resident #27's vital signs were within normal limits and he was very excited to be going home. Resident's wife signed paperwork for discharge and walked resident out. On 5/12/26 at 2:11 PM, the DON provided the Discharge Instruction form that family had signed on discharge for Resident #27 dated 3/31/26. The form documented the following:-Regular diet-Activity: Resume as normal-Shower: YDriving Restrictions: N/ADisposition: Home and Home Care NurseWound Care: N/ASpecial Instructions: Follow HHMedication: As Prescribed Resident #27 care plan did not document his discharge plan or goals. Resident #27's medical record did not document discharge planning was discussed with resident or family. No discharge summary completed. On 5/12/26 at 1:33 PM, the DON stated she was not sure if there was a discharge summary or charting done for Resident #27. On 5/12/26 at 2:14 PM, the DON stated Resident #27 did not have the proper discharge documentation in his medical record and they could improve on this process.

Based on record review, staff interviews, and policy review it was determined the facility failed to refer residents for recommended further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 2 residents (Resident #2) reviewed for Pre-admission Screening and Resident Review (PASRR) Level II evaluations. This deficient practice had the potential to cause harm if residents' PASRR Level II recommendations for specialized services needs were not referred for evaluation and incorporated in the resident's care. Findings include:The facility's Resident Assessment - Coordination with PASRR Program policy, dated 8/18/25, documents 7. Recommendations, such as any specialized services, from a PASRR Level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses which included alcohol dependence with alcohol-induced persisting dementia and diabetes.Resident #2's comprehensive care plan, initiated on 4/14/26, documented Resident #2 was prescribed antipsychotic medication and thiamine related to her diagnosis of alcohol-induced persisting dementia.Resident #2's medical record documented she had a completed PASRR Level I and Level II screening evaluation from the state-designated authority. However, the PASRR Level II's recommended substance use evaluation was not followed up on and Resident #2's medical record had not documented a reason for failure to follow the state-designated authority's recommendation.On 5/12/26 at 2:58 PM, the LCSW stated the facility did not have a substance use evaluation for Resident #2 or had documented why it was not obtained.On 5/12/26 at 4:17 PM, the DON stated Resident #2 had not been referred for the substance use evaluation as recommended on the PASRR Level II and should have been.

Based on record review, interviews, and policy review it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 2 residents (Resident #1) reviewed for Pre-admission Screening and Resident Review (PASRR) Level I and Level II evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: The facility's Resident Assessment - Coordination with PASRR Program policy, dated 8/18/25, documents 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions.a. PASRR Level I - initial pre-screening that is completed prior to admission.2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses which included dementia and Post-Traumatic Stress Disorder (PTSD). Resident #1's care plan, created on 12/5/23, documented Resident #1's diagnosis of dementia and PTSD. Resident #1's admission MDS (Minimum Data Set - an assessment used to identify the resident's clinical condition, cognitive and functional status, and use of services), completed on 12/13/23, documented PTSD. Resident #1's medical record documented her PTSD diagnosis (major mental illness). On 5/11/26 at 3:07 PM, Resident #1's PASARR Level I had not documented her diagnosis of PTSD (major mental illness). Therefore, Resident #1's medical record had not documented the completion of PASRR Level II. On 5/12/26 at 3:08 PM, the LCSW stated the facility should have completed Resident #1's PASRR Level I with her PTSD diagnosis and submitted a PASRR Level II to the state-designated authority but had not.

Based on record review, observation, staff interviews, and policy review it was determined the facility failed to ensure that prior to the placement of bed rails, a resident assessment was completed that included alternatives to bed rail use were attempted and how the alternatives failed to meet the resident's assessed needs.This was true for 1 of 12 residents (Resident #3) reviewed for bed rails.This failure created the potential for harm due to the risk for injury, entrapment and/or death. Findings include:The facility's Proper Use of Bed Rails policy, reviewed date 6/5/25, documented.Policy Explanation and Compliance Guidelines: Resident Assessment 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and the use of bed rails. 8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses which included Schizophrenia (a mental disorder characterized by disturbances of thinking, mood, and behavior) and depression.On 5/11/26 and 5/12/26, observed Resident #3 with one upper bed rail on his bed and in the up position.On 5/12/26 at 10:05 AM, review of Resident #3's medical record had not documented the resident assessment, evaluation of the alternatives attempted or documentation of the purpose of the intended use of the bed rails, a physician order for bed rails, or documented discussion of risks and benefits with a signed consent for use of bed rails.On 5/12/26 at 1:42 PM, the DON stated Resident #3 had not been assessed for the use of bed rails and should not have had the bed rail in use but had. The DON confirmed the policy was not followed.

Based on staff interview and review of employee personnel files, it was determined the facility failed to ensure each CNA's annual performance review was completed at least once every 12 months for 2 of 2 CNAs (#1and #2) whose personnel records were reviewed for sufficient and competent staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility. Findings include:On 5/13/26 at 10:17 AM, review of CNA #1's employee file documented her initial hire date was 10/18/23.CNA #1's employee file did not have documentation that an annual performance review had been done.On 5/13/26 at 10:25 AM, review of CNA #2's employee file documented her initial hire date was 4/24/09.CNA #2's employee file did not have documentation that an annual performance review had been done.On 5/13/26 at 10:48 AM, the HR Director stated the CNAs annual performance reviews had not been provided to her to include in the personnel files.On 5/13/26 at 10:52 AM, the DON stated the CNAs annual performance reviews had not been completed but should have been.

Based on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate, posted daily for each shift, and included scheduled and actual hours. This failed practice had the potential to affect the 23 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:State Operations Manual, Appendix PP revised on 7/23/25, documents.the facility posts the following information on a daily basis: facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census. On 5/12/26 at 1:40 PM, the daily posted staffing sheets were reviewed for the months of November 2025 - May 2026, the following was observed:-No facility resident census included on the sheets for the 7 months reviewed -No weekend (Saturday and Sunday) daily posted staffing sheets completed for the 7 months reviewed -No actual licensed and unlicensed staff hours documented on the sheets for the 7 months reviewed On 5/12/26 at 2:41 PM, the DON stated the facility had not documented the resident census and the actual licensed and unlicensed staff hours on the daily posted staffing sheets prior to her arrival as the DON and the practice had continued but should not have.On 5/12/26 at 2:45 PM, the DON stated the facility had not completed weekend daily posted staffing sheets prior to her arrival as the DON and the practice had continued but should not have.

Based on record review, observation, staff interview, and policy review it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 5 residents (Resident #15) observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include: The facility's Oxygen Administration and Monitoring policy dated 9/29/25, documented Policy Interpretation and Implementation 5. Keep delivery devices covered in plastic bag when not in use.Resident #15 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses which included chronic obstructive pulmonary disease (disease process which causes decreased ability of the lungs to perform their function) and heart failure. A physician order dated 3/11/25, documented Resident #15 was to wear her CPAP machine (provides positive airway pressure to help breathing) every night related to her obstructive sleep apnea. On 5/11/26 at 10:58 AM, and 5/12/26 at 9:46 AM, Resident #15's CPAP mask and tubing were observed to be placed in her bed on top of the bed linen. The equipment was not bagged. On 5/12/26 at 1:38 PM, the DON stated the CPAP equipment should not have been in the bed and should have been stored appropriately and placed in a plastic bag when not in use.

Based on record review and staff interview, it was determined the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) was accurately completed prior to admission for 1 of 3 residents (Resident #15), and when a new mental health diagnosis was identified for 2 of 3 residents (#10 and #11), whose records wer reviewed for PASARR screenings. These failures created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: Appendix PP of the State Operation Manual, revised on 8/8/24, documented the PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders or intellectual disabilities and related conditions prior to admission to a nursing facility. A negative Level 1 screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as Level 2 PASARR, which must be conducted prior to admission to a nursing facility. Appendix PP of the State Operations Manual, revised 8/8/24, documented any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. 1. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes, and post-traumatic stress disorder (PTSD). On 11/4/24, The CMS Form-802, Matrix for Providers documented Resident #15 had a diagnosis of PTSD. Resident #15's Level 1 PASARR was completed and signed on 8/11/22 by the Licensed Clinical Social Worker (LCSW) employed by both the hospital and the long-term care facility. The Level 1 PASARR documented Resident #15 did not have any serious mental disorders, including PTSD. On 11/6/24 at 4:49 PM, the Administrator confirmed Resident #15 had the diagnosis of PTSD when she transferred from the hospital to the long-term care facility. On 11/6/24 4:53 PM, the LCSW stated he completed Resident #15's Level 1 PASARR when she transferred from the hospital to the long-term care facility and was not sure why her diagnosis of PTSD was not identified. He added he may have looked at her medication list to see what she was being treated for and may not have looked at her diagnoses list. The LCSW confirmed Resident #15's Level 1 PASSAR was not accurate, and it should have indicated her diagnosis of PTSD. 2. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction, major depressive disorder, and anxiety disorder. Resident #10's medical record documented her diagnoses of major depression and anxiety on a completed Level 1 PASARR, dated 9/23/13, and Level 2 PASARR, dated 9/24/13. Resident #10's medical record documented a new mental health diagnosis of delusional disorder on 12/17/14. Resident #10's medical record was reviewed and did not include an updated Level 1 PASARR for the new diagnosis. On 11/6/24 at 11:50 AM , the LCSW confirmed he did not complete an updated Level 1 PASARR for Resident #10's new serious mental disorder diagnosis because he was not aware he was supposed to. 3. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses of diabetes, osteoarthritis, and chronic pain. Resident #11's medical record included a completed Level 1 PASARR, dated 2/28/18. The Level 1 PASARR did not identifiy any serious mental disorders diagnoses. Resident #11's medical record included a new serious mental disorder diagnosis of major depressive disorder on 6/19/19 and paranoid schizophrenia on 7/30/20. Resident #11's medical record was reviewed and did not include an updated Level 1 PASARR for the either of the new serious mental disorder diagnoses. On 11/6/24 at 11:50 AM, the LCSW confirmed he did not complete a Level 1 PASARR for Resident #11's new serious mental disorder diagnoses because he did not know he was supposed to.

Based on observation, record review, policy review, professional standards, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently maintained to provide a safe and sanitary environment. This failure directly impacted 8 of 8 residents (Residents #1 - #8) observed to receive meal service and had the potential to impact all residents, staff and visitors entering the facility by placing them at risk of infection due to cross-contamination of infectious agents, including COVID-19. 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. Findings include: 1. The facility's policy for Infection Prevention and Control, effective 10/4/18, documented the nurses supervised direct care staff during daily activities to ensure appropriate precautions and techniques were observed, resident isolation needs were assessed, and appropriate precautions were initiated in accordance with the facility's policies and current CDC guidelines. The CDC website Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20 (accessed on 12/21/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) stated Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. The facility's policy for Facility Wide COVID-19 Pandemic Containment and Employee Directional Workflow Processes to Prevent Cross-Contamination, effective 4/23/20, stated meals for residents with a confirmed case of COVID-19 were to be placed on an open rolling cart after the enclosed serving cart was sent over and emptied. The open cart for residents who had COVID-19 were to be served on disposable tableware. Personnel were not to utilize the Long-Term Care entrances/hallways to retrieve supplies, meals, or condiments or for any other reason. The facility's policies and CDC guidance were not followed. On 12/14/20 at 6:12 PM, the food cart was brought outside the kitchen to the first set of dining room double doors, which opened to a corridor that accessed the rest of the facility. One of the doors was propped opened by the cart, and the food cart was parked at the threshold of the doors. The other door was closed with the latch edge resting on the side of the food cart, leaving an opening above the food cart. Across the dining room, which was immediately adjacent and opened to the COVID-19 positive unit, another set of double doors was open into the hallway of the COVID-19 positive unit. CNA #1 and NA #1 repeatedly walked across the dining room to the meal cart outside the kitchen, picked up the meal trays from the cart, and walked back through the empty dining room to the COVID-19 positive unit to distribute meal trays. One of the doors remained propped open by the meal cart during the meal service. On 12/15/20 at 7:40 AM, the MDS nurse loaded the food cart with meal trays at the kitchen door and moved it into the hallway outside the dining room double doors. The MDS nurse said the cart was placed outside the COVID-19 positive unit, and the dining room was considered part of the COVID-19 positive unit. On 12/15/20 at 7:45 AM, the food cart was positioned outside the kitchen in a similar manner to the night before. One of the dining room doors was propped open by the food cart, the food cart was pulled to the threshold of the doors, and 1 door was closed with the latch edge resting on the wheel of the food cart, leaving a 4-inch gap along the food cart and an opening above the food cart. The other set of double doors across the dining room remained open to the COVID-19 positive unit. A female staff member walked across the empty dining room from the COVID-19 positive unit, retrieved a meal tray from the food cart, and carried the tray back across the dining room to the COVID-19 positive unit. On 12/15/20 at 9:55 AM, the DON, with the IP present, said that the previous day was the first day they opened the dining room to the COVID-19 positive unit to allow those residents to use the dining room. The DON and IP said they were unaware the doors were being propped open with the cart, and the cart should be pushed into the dining room and the doors closed. 2. The CDC website Hand Hygiene in Healthcare Settings, reviewed 3/15/16 (accessed on 12/21/20 from https://www.cdc.gov/handhygiene/patients/index.html) documented patients should clean their hands at the following times: * Before preparing or eating food. * Before touching their eyes, nose, or mouth. * Before and after changing wound dressings or bandages. * After using the restroom. * After blowing their nose, coughing, or sneezing. * After touching surfaces such as bed rails, bedside tables, doorknobs, remote controls, or telephones. This guidance was not followed. Examples include: a. On 12/14/20 from 6:15 PM to 6:21 PM, CNA #1 delivered and set up meal trays to Residents #1, #2, #3, #4, and #5 in the COVID-19 positive unit. CNA #1 did not offer/provide hand hygiene to any of the residents, and no staff were observed offering or reminding the residents to perform hand hygiene prior to the meal. On 12/14/20 at 6:23 PM, CNA #1 said she had not offered hand hygiene to the residents before they ate, and she said, I skipped a step. b. On 12/14/20 from 6:12 PM to 6:20 PM, NA #1 delivered and set up meal trays for Residents #6, #7, and #8. NA #1 did not offer/provide hand hygiene to any of the residents, and no staff were observed offering or reminding the residents to perform hand hygiene prior to the meal. On 12/14/20 at 6:20 PM, NA #1 said staff usually offered hand hygiene to the residents prior to meals, and she did not offer hand hygiene to the residents prior to their meal, due to forgetfulness. On 12/14/20 at 6:25 PM, RN #1 said staff were to offer hand hygiene to residents before they ate and after toileting. RN #1 said whoever delivered the meal tray should offer hand hygiene to the resident. On 12/15/20 at 9:00 AM, the DON said the CNAs were to offer hand hygiene to the residents before meals. On 12/15/20 at 4:48 PM, the DON said the facility did not have a policy for resident hand hygiene. 3. The CDC website Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20 (accessed 12/21/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) documented the following regarding Eye Protection: * Put on eye protection (goggles or a face shield that covers the front and sides of the face) upon entering the patient's room or care area. * Protective eyewear (safety glasses, trauma glasses) with space between the glasses and face likely do not protect eyes from all splashes and sprays. The CDC website also documented HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. The CDC website documented for staff to Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. The Data.CMS.gov website, accessed on 12/29/20 at https://data.cms.gov/stories/s/q5r5-gjyu, documented the positivity rate for the county the facility was located in was at 15.8% for the week ending 12/16/20. Greater than 10% is considered high or substantial community spread. The professional guidance was not followed. Examples include: a. On 12/14/20 at 2:40 PM, the DON was wearing an N95 mask and eyeglasses with small plastic detachable side guards in the Family Room. Approximately 5 minutes later, the IP entered the room wearing an N95 mask and clear safety glasses with louvered side panels. b. On 12/14/20 at 3:24 PM, the Housekeeping Manager was supervising room cleaning on the COVID-19 negative unit, and he was wearing eyeglasses with added side guards. He said he wore an N95 mask and side guards on his personal eyeglasses when he was on the COVID-19 negative and positive units. c. On 12/14/20 at 4:27 PM, the IP was observed on the COVID-19 positive unit, and she was wearing an N95 mask and clear safety glasses with louvered side panels. On 12/14/20 at 4:45 PM, the DON said staff who worked in the COVID-19 negative area were to wear an N95 mask and eye protection, which could include goggles or side guards attached to eyeglasses. She said regular eye glasses don't cut it. The DON said staff were to wear full PPE when performing aerosolized procedures and at all times when in the COVID positive unit. The DON was asked to provide manufacturer's information or other documentation regarding the detachable side guards on her eyeglasses. The facility did not provide any documentation regarding the detachable side guards for eyeglasses. On 12/15/20 at 10:10 AM, the IP said staff working on the COVID-19 negative unit should wear an N95 mask and eye protection, which included goggles or a face shield. The IP said regular eyeglasses were not acceptable, but regular glasses with side guards were acceptable. The IP said staff working on the COVID-19 positive unit must wear full PPE at all times, including eye protection. The IP said the eye protection options were the same for both COVID-19 negative and positive units. The IP was wearing clear safety glasses with louvered side panels during the interview. When asked about the safety glasses she was wearing, the IP said the facility obtained them from a medical supply company. The IP said the clear safety glasses with louvered side panels and personal eyeglasses with side guards were acceptable to wear on the COVID-19 positive unit. However, the facility's Personal Protective Equipment policy, dated 4/24/20, directed staff to wear goggles or face shield as added face/eye protection. Personal eyeglasses were not a substitute for goggles. The policy did not include information related to the clear safety glasses with louvered side panels and personal eyeglasses with side guards.

Based on contract review, policy review, observation, and staff interview, it was determined the facility failed to ensure infection control surveillance was maintained for the contracted laundry services which processed residents' personal laundry. This deficient practice had the potential to impact 18 of 21 residents who had personal laundry services provided by the facility. This deficient practice placed residents at risk of infection from cross contamination. Findings include: The facility's contract with the off-site personal laundry vendor, dated 5/1/13, documented the service provided laundry pick-up, wash, dry, fold, steam press and delivery of laundry items. The laundry was hygienically cleaned and handled to prevent recontamination for dust and dirt during transport. Provided with the personal laundry vendor's contract was a copy of the vendor's equipment information, dated (YEAR), which documented a Whirlpool Front-Loading Automatic Washer, Use and Care Guide, noted to be designed to use only HE High Efficiency detergents. The facility's Handling of Soiled Linen policy, dated 10/4/18, did not include a policy or procedure for personal laundry services. A Laundry policy, dated (MONTH) 2019, was attached to the facility's contract with the off-site personal laundry vendor and documented the following: * The facility laundered linens and clothing in accordance with current CDC (Center for Disease Control) guidelines to prevent transmission of pathogens. * Soiled laundry was handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. * Sorting of laundry occurred after washing. * Laundry was processed with the following hot or low-temperature processes: Hot-water cycle: Washed with detergent in a water temperature of 160 degrees or above for at least 25 minutes. Low-temperature cycle: Washed with chemicals suitable for a low-temperature washing (less than 160 degrees) at the proper concentration. * If laundry was sent off to be cleaned, the facility maintained an agreement with the laundry service that stipulated the laundry was hygienically clean and handled to prevent recontamination for dust and dirt during transport. * Laundry staff were in-serviced on handling linens and laundry on a regular basis. On 2/6/20 at 11:22 AM, the Administrator said the facility's linen and personal laundry were sent out for laundering. He said the linen went to a professional linen service and the personal laundry went to a local residence for processing. He said the personal laundry vendor performed laundry at her home in her shop, and it was not likely she would be able to provide a policy for Infection Control or personal laundry, but he would attempt to obtain the information. Some time later, the Administrator provided the Laundry policy, as described above. On 2/6/20 at 1:54 PM, the MDS Coordinator said 3 residents in the facility opted to have their laundry done privately, and all the other residents had their personal laundry needs met by the facility. The MDS Coordinator said the CNAs placed the residents' dirty clothes in a blue bag in the dirty laundry closet, the clothes were rinsed out in the hopper if needed, and then the blue bag was placed at the back door for the laundry vendor to pick up every Thursday. On 2/6/20 at 1:58 PM, the Housekeeping Manager said the bags of clean personal laundry arrived at the back door, then they were taken to the housekeeping room, placed on hanger carts, covered with a sheet, and distributed. The Housekeeping Manager said the laundry vendor had a copy of the facility's Infection Control laundry policy and procedures, but he had never seen the laundry vendor's facility so he did not know if she followed it. The dirty clothing closet was observed as well as the hopper and blue bags for dirty laundry. The Housekeeping Manager said the laundry vendor came to the facility to pick up the blue bags, and if there were too many to fit in the closet they were placed on the ground at the back door. On 2/6/20 at 3:49 PM, the Administrator said he had not toured the off-site laundry facilities, and the facility trusted the vendor as they had been outstanding in the area for as long as the facility had been in business. The Administrator said he had not confirmed that the laundry vendor fulfilled the contract she signed. On 2/7/20 at 8:50 AM, the laundry vendor said she processed the facility's laundry in her own washing machine and dryer. She said she picked up the dirty laundry by the facility's back door at 9:00 [NAME]M. every morning, and the dirty laundry was in clear plastic bags and blue bags with the tops closed. The laundry vendor said she transported the laundry in the trunk of her car and in the back seat of her car if needed. She placed a mat beneath the dirty clothes in the trunk and removed the mat for clean clothes. She used Clorox wipes on her car seats after transporting dirty clothes . The laundry vendor said the laundry room was 16 by 20 feet, and it was in the basement of her home with an entry directly from the outside. The laundry vendor said the washer and dryer were next to each other on pedestals, and they were on the opposite side of the room from the clean laundry and folding table. She said she sorted the facility's clothes on the floor in front of the washing machine before she placed them into the machine, and she mopped the laundry room floor twice a week. She said she washed urine soaked items on the 80 minute hot temperature cycle, and items such as blouses on the 47 minute warm cycle. She said she had no way to measure the water temperatures. She said she only took in laundry from the mentioned facility, and she washed her own laundry only if no or very little laundry from the facility was in the room. She said she kept her personal laundry separate from the facility's, but she used the same machine to process all the laundry. The laundry vendor said she sanitized the washing machine between her personal laundry and the facility's laundry through a complete cycle using a sanitizer made by the machine's manufacturer. She said if she found fecal matter in the facility laundry, she placed the laundry in a red bag, immediately returned it to the facility, and placed it in the dirty laundry room where the CNAs rinsed it. The laundry vendor said she wore scrubs while she sorted and washed the dirty clothes, and she wore the same scrubs when she transferred the clean clothes to the dryer and while folding them. The laundry vendor said she kept the facility's laundry separated with each resident's clothes in their own labeled laundry basket, and she delivered the laundry to the facility on Tuesdays and Fridays by transporting it in the trunk of her car. The facility's laundry vendor failed to ensure residents' personal laundry was not cross contaminated when she transported dirty and clean clothes in the trunk of her car, sorted dirty clothing on the floor, did not ensure proper washing temperatures, and did not change into clean scrubs after handling dirty clothes and before processing clean clothes.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the resident's pulse was monitored appropriately for residents who received blood pressure medication. This was true for 1 of 5 residents (Resident #21) who were reviewed for unnecessary medications. This failure created the potential for harm if residents experienced adverse effects from blood pressure medication. Findings include: The facility's policy for Vital Signs, dated 11/5/19, documented the following: * Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. * An acceptable range for pulse was 60 to 100 beats per minute. * Vital signs were obtained by the nurse as indicated, when administering certain medications, or for monitoring the effectiveness of medications or therapies. * Certain cardiac drugs are given only when a resident's pulse or blood pressure is within a certain range. Resident #21 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #21's physician orders [REDACTED].>* Apical pulse to be monitored every shift. The order started on 3/14/19. Resident #21's MARs for (MONTH) and (MONTH) 2020 documented [MEDICATION NAME] (blood pressure medication) was administered each day from (MONTH) 1 through (MONTH) 5, 2020. Resident #21's Weights and Vitals Summary documented his pulse was monitored as follows: * 1/6/20 at 10:29 AM = 70 * 1/7/20 at 4:55 AM = 66 * 1/13/20 at 7:05 PM = 70 * 1/19/20 at 11:32 PM = 47 * 1//20/20 at 9:36 AM = 65 * 1/27/20 at 3:54 PM = 70 * 2/5/20 at 12:38 AM = 69 Resident #21's Weights and Vitals Summary did not document his pulse was monitored each shift as ordered by the physician. On 2/6/20 at 10:06 AM, the DNS said did not find documentation Resident #21's pulse was checked every shift.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with the level of supervision necessary to prevent falls. This was true for 1 of 2 residents (Resident #14) reviewed for falls. This failure placed Resident #14 at risk of pain, bone fractures, brain damage, and other life changing injuries, as a result of falls. Findings include: The CMS State Operations Manual, Appendix PP, the Long Term Care Facility federal regulations and guidance to surveyors, describes a fall as unintentionally coming to rest on the ground, or other lower level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person, or if he or she had not caught him/herself, is considered a fall. The facility's policy for Fall Risk Assessment, dated 1/7/20, documented the following: * The facility provided an environment free from accident hazards over which the facility has control, and the facility provided supervision and assistive devices to each resident as needed to prevent avoidable accidents. * Nursing staff and the medical provider reviewed a resident's record for previous falls, especially falls that occurred in the past 90 days, and recurrent falls over time. * Staff attempted to determine if the falls were related to recent changes in condition or new/changed medications. * The provider and nursing staff evaluated the resident for conditions that may predispose them to falls and identified underlying medical conditions that may increase the risk of injury from falling. * Facility staff identified environmental factors that may contribute to falling. * Facility staff and the medical provider collaborated to identify and address fall risk factors that could be changed. * The facility monitored the effectiveness of the care plan interventions, and modified the interventions as needed in accordance with current standards of practice. The facility's policy for Falls and Fall Risk, dated 5/11/16, documented the following: * Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes and try to prevent the resident from falling and try to minimize complications from falling. * Staff, with contribution of the physician, identified appropriate interventions to reduce the risk of falls. * If falls continued despite the primary interventions, staff implemented additional or different interventions, or indicated why the current intervention was appropriate. * If underlying causes of the falls could not be identified or resolved, staff tried various interventions until falling was reduced or stopped, or the cause of continued falling was identified as unavoidable. * Staff, in collaboration with the physician, identified and implemented relevant fall interventions to minimize serious consequences of falling. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/4/19 he was admitted to a hospital for pneumonia and was readmitted to the facility on [DATE]. On 12/17/19 he was admitted to a hospital for pneumonia [MEDICAL CONDITION] (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death) and was readmitted to the facility on [DATE]. Resident #14's quarterly MDS assessments, dated 3/26/19 and 6/25/19, documented he was unable to complete the interview to assess his cognitive status. The MDS assessment documented he required extensive 1 person assistance for ambulating in his room and the corridor, and was totally dependent on the assistance of 1 person for locomotion in other locations in the facility. The MDS assessments also documented he required extensive assistance of 2+ persons for transfers. The assessments documented he was not steady, however, could stabilize himself without human assistance. Both assessments documented Resident #14 used a wheelchair and had experienced 2 or more falls since the last MDS assessment. Both assessments documented Resident #14 experienced shortness of breath or trouble breathing upon exertion, such as while walking and during transfers. Resident #14's annual MDS assessment, dated 9/24/19, documented the same information noted above on the prior two MDS assessments, with the following exceptions. The 9/24/19 MDS assessment documented Resident #14: *Required extensive assistance from 1 person for transfers. The prior two assessments documented he required extensive assistance of 2+ staff for transfers. *Required extensive assistance of 2+ persons for ambulating in his room or in the corridor. The prior two assessments documented he required extensive assistance of 1 person for ambulating in his room and the corridor. *Was not steady and was only able to stabilize with human assistance during transitions and walking. The two prior assessments documented he was unsteady, however, could stabilize without human assistance. The 9/24/19 MDS assessment also documented Resident #14 had 2 or more falls since the prior MDS assessment. Resident #14's MDS assessment, dated 1/7/20, completed following his discharge from the hospital on [DATE], documented Resident #14 required extensive assistance of 2+ persons for transfers. The 9/24/19 MDS assessment documented he required extensive assistance from 1 person for transfers. The 1/7/20 MDS assessment documented Resident #14 required extensive assistance of 2+ persons for ambulating in his room or in the corridor, and was totally dependent on physical assistance from 1 staff for locomotion in other areas of the facility. The MDS assessment documented Resident #14 was not steady but was able to stabilize with human assistance during moving from a seated to a standing position, during walking, and during surface to surface transfers. The MDS assessment documented Resident #14 experienced shortness of breath or trouble breathing upon exertion, such as while walking and during transfers. The MDS assessment documented Resident #14 used a wheelchair and had 1 fall resulting in injury since readmission to the facility on [DATE]. Resident #14's Morse Fall Scale assessments, used to determine a person's risk for falls, dated 5/22/19, 6/20/19, 7/5/19, 7/8/19, 8/13/19, 9/19/19, 10/29/19, 12/8/19, 12/27/19, 1/4/20, and 1/7/20, documented he was at high risk for falls. Resident #14's care plan documented he fell often. The care plan was initiated on 3/28/18. Interventions included the following: *Follow the facility's fall protocol. The intervention was initiated on 3/28/18. * Educate Resident #14/family/caregivers about safety reminders and action to take if a fall occurs. The intervention was initiated on 3/28/18. * Ensure Resident #14 is wearing non-skid socks when he is ambulating. This intervention was initiated on 3/28/18. * Encourage safe choices. Cue and redirect with 1:1 as needed . The intervention was initiated on 3/30/18. * Encourage Resident #14 to sit in a recliner, not a rocking chair or swivel chair, in the day room. The intervention was initiated on 9/17/18. * He may choose to sit on the floor. Offer alternatives and encourage safe choices. Assist him to the floor for safety, if he chooses. (He has a history of sitting down unexpectedly from prior to admit. Move at (Resident #14's) pace. (Wheelchair) for increased mobility when elder chooses not to ambulate. Observe for unsafe behavior and intervene before a fall occurs. The intervention was initiated on 8/31/18 and revised on 9/20/19. * Low risk interventions included: Orient to surroundings, use a colored call light, keep call light, water, and personal items within reach, remind him to ask for assistance, answer the call light promptly, keep the room uncluttered, maintain the bed at an appropriate height and the brakes locked, maintain adequate lighting, encourage him to wear shoes/slippers with non-skid soles or gripper socks, keep assistive devices in reach, educate resident/representative, monitor for changes in condition, complete the fall risk assessment every quarter, annually, with significant changes, and with falls. The intervention was initiated on 10/24/19. * Moderate risk interventions included: Close supervision and frequent monitoring, obtain orthostatic blood pressures at least quarterly (blood pressure when laying down, sitting, and standing), request a medication review with falls, educate resident to change position slowly, obtain an order for [REDACTED]. * High risk interventions included: Place a fall risk indicator on the resident's name plate, increase frequent monitoring, assess for need of increased supervision (room close to the nurses' station), and offer toileting at least every 2 hours and as needed. The intervention was initiated on 10/24/19. * Wheelchair for increased mobility as needed to prevent falls. The intervention was initiated on 11/14/19. * When in the activity room (day room), assist with transferring from the wheelchair to recliner with the Prevalon-Seated Positioning System (a device used to reduce friction and shearing during transfers). The intervention was initiated on 1/8/20. Resident #14's Incident and Accident Reports documented he fell 6 times from 5/22/19 to 1/7/20 as follows: * On 5/22/19 at 11:15 AM, Resident #14 was in the day room, he stood up from the recliner, attempted to sit down in another chair, missed the chair, and fell on his bottom. Resident #14 complained of pain in his right hip. A witness statement documented Resident #14 stood up, ambulated, misjudged where the other chair was, and fell . An x-ray was obtained of the right hip, and there was no evidence of a fracture. The intervention included removing the other chair from the day room. * On 6/8/19 at 4:00 PM, a CNA was with Resident #14 when he attempted to sit in the recliner, misjudged the distance to the recliner and sat on the floor. The investigation report documented Resident #14 had gripper socks on at the time of the fall. The intervention documented on the investigation report included ordering two-sided gripper socks to prevent slipping. The report did not describe how the two sided gripper socks related to the documented reason for the fall. The need for Resident #14 to wear non-skid socks when ambulating was previously added to his care plan on 3/28/18. * On 7/5/19 at 2:25 PM, Resident #14 attempted to sit on the lap of another resident who was seated in a recliner in the day room, he missed the area and sat on the floor. A CNA witness statement included in the investigation report documented the CNA was playing a game with other residents and watching Resident #14 at the same time. The CNA documented Resident #14 was standing up walking prior to attempting to sit in the recliner occupied by another resident. The other resident moved her knee and he fell slowly to the floor. The CNA helped lower him to the floor. There were no documented interventions to prevent future falls. The investigation report did not address the need for Resident #14 to have extensive assistance from 1 person while ambulating, which did not occur prior to the fall. * On 7/8/19 at 3:25 PM, Resident #14 was walking in the day room and sat on the floor. There were no new interventions as he frequently chooses to sit on the floor. A witness statement documented Resident #14 stood up from the chair, took 3 or 4 steps, and sat down on the floor. The investigation report did not address the need for Resident #14 to have extensive assistance from 1 person while ambulating, which did not occur prior to the fall. * On 8/13/19 at 12:45 PM, Resident #14 was assisted to a chair by a CNA, and he slid off the chair onto the floor with assistance from the CN[NAME] There were no documented interventions put in place. A witness statement documented Resident #14 was being assisted from the wheelchair to the chair in the day room, the chair slid and the CNAs lifted him to the floor. * On 10/29/19 at 9:25 AM, Resident #14 was ambulating with assistance in the day room, and he sat on the floor with assistance from staff. The investigation documented Resident #14 was placed in a chair after breakfast, and he stood up and started walking. The intervention was using a mechanical lift to transfer Resident #14 to the chair. The witness statements were contradictory. One witness statement documented Resident #14 started to stumble, and a staff member helped lower him to the floor. Another witness statement documented Resident #14 was ambulating and tried to sit, so the staff member assisted him to the floor. Another witness statement documented Resident #14 got out of his chair, walked away, and started to stumble. Another staff member lowered him to the floor. * On 1/7/20 at 11:55 AM, Resident #14 stood up from his wheelchair in the day room, fell forward, and struck the floor. He was under watch of staff at (the) time of fall, and was lying face down on the floor when he was found. Injuries included an open wound on his forehead near the left eye, measuring approximately 1.2 centimeters, and redness on the bridge of his nose, forehead, and around his left eye. Interventions included closer monitoring by staff and limited education to elder on asking for help. A witness statement documented Resident #14 tried to stand up from his wheelchair, and he lost his balance and fell . Interventions included closer supervision by the aide in the day room. A hospital diagnostic report, dated 1/7/20, documented a CT scan (a type of x-ray image) was performed after Resident #14 fell , and there was no acute [MEDICAL CONDITION] spine (neck area) or head. The hospital diagnostic report also documented Resident #14 did not have an intercranial hemorrhage (bleeding inside the skull). He did sustain bruising and swelling to the area of his left eye and a soft tissue injury to his left forehead. On 2/3/20 at 5:10 PM, Resident #14 was sitting in a recliner in the day room. Staff were intermittently coming in and out of the day room to interact with other residents, and an activity staff member was present and intermittently interacting with residents. There was not a staff member within reach of Resident #14, and it was not apparent Resident #14 was being monitored by a particular staff member. On 2/4/20 at 3:52 PM, the DNS said Resident #14 fell on [DATE] when he stood up and lost his balance. The DNS said Resident #14 was not independent with transfers or ambulation at that time, he had been ill and had declined, necessitating use of a wheelchair. The DNS said a staff member was in the room when Resident #14 fell , he was by the couch and she was across the room when he stood up and fell just as fast as he stood up. The DNS said Resident #14 was not being monitored at any particular time intervals during that time. The DNS said she did not document closer monitoring by staff, and what was meant was to find things to keep him occupied in the day room. The DNS said Resident #14 also had falls between 5/22/19 and 10/2919 where he would sit on the floor, and he previously did that at home. The DNS said Resident #14 would miss the chair and sit on the floor, and it was not really a fall, but the facility completed all the paperwork. The DNS said increased supervision meant knowing where Resident #14 was. The DNS said Resident #14 was previously more ambulatory, and his room was not close to the nurse's station anymore. On 2/7/20 at 10:22 AM, the DNS said that to prevent falls, staff tried to help Resident #14 sit down. The DNS said Resident #14 would not remember if staff reminded him to ask for assistance. When reviewing the Fall Prevention Care Plans dated 5/22/19, 6/8/19, 7/5/19, 7/8/19, 10/29/19, and 1/7/20, which were attached to each Incident and Accident Report, the DNS said Monitor in day room meant staff was always there from 8:00 AM to 8:00 PM, and she did not know if it was documented how staff monitored Resident #14. The DNS said not all of the interventions marked on Resident #14's Fall Prevention Care Plans were reasonable for him, and there was not a specified time interval for frequent monitoring. Each of Resident #14's six falls occurred in the facility's day room between 9:25 AM and 4:00 PM and all were witnessed by staff. Staff were not within proximity and/or sufficient in numbers to prevent the falls. Resident #14's ability to ambulate declined. The 9/24/19 and 1/7/20 MDS assessments documented he required extensive assistance of 2+ persons for ambulating in his room or in the corridor. The 3/26/19 and 6/25/19 MDS assessments document he required extensive assistance of 1 staff for the same activity. The 9/24/19 and 1/7/20 MDS assessments documented Resident #14 was not steady and was only able to stabilize with human assistance during transitions and walking. The 3/26/19 and 6/25/19 MDS assessments documented he was unsteady but was able to stabilize without staff assistance. Resident #14 was hospitalized twice in (MONTH) 2019 for pneumonia. The facility failed to ensure Resident #14 received the level of supervision necessary to protect him from falls.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure appropriate behavior and side effect monitoring was documented for residents receiving [MEDICAL CONDITION] medications. This was true for 2 of 5 residents (#5 and #21) reviewed for unnecessary medications and created the potential for harm if residents experienced adverse side effects or behaviors from unnecessary [MEDICAL CONDITION] medications. Findings include: The facility's policy for [MEDICAL CONDITION] Medications, dated 11/5/19, documented the following: * Residents are not given [MEDICAL CONDITION] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). * The effects of the [MEDICAL CONDITION] medications, including the resident's physical, mental, and psychosocial well-being were evaluated on an ongoing basis, including in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. * The resident's response to the medication, including progress towards goals and any adverse effects, were documented the resident's record. This policy was not followed. 1. Resident #5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5's physician orders [REDACTED]. * [MEDICATION NAME] (antidepressant medication) 30 mg at bedtime related to major [MEDICAL CONDITION]. The order started on 7/29/19. * [MEDICATION NAME] (antidepressant medication) 50 mg at bedtime, related to major [MEDICAL CONDITION]. The order started on 9/10/19. * [MEDICATION NAME] (antidepressant medication) 50 mg once per day, related to major [MEDICAL CONDITION]. The order started on 2/1/20. Resident #5's MARs for (MONTH) and (MONTH) 2020 documented the [MEDICATION NAME], and [MEDICATION NAME] were administered as ordered. Resident #5's care plan documented he had situational depression, initiated on 8/5/19. Staff were directed to administer medications as ordered and monitor/document for side effects and effectiveness. The care plan directed staff to monitor efficacy and adverse side effects of the medication during medication administration and pharmacy/behavior meeting, monitor behavior every shift, and monitor for symptoms addressed in the Black Box Warning information. The care plan directed staff to monitor/record the incidence of target behavior symptoms and document per the facility's protocol. There was no documentation found in Resident #5's record regarding monitoring for side effects of [MEDICATION NAME], or [MEDICATION NAME]. On 2/7/20 at 10:15 AM, the DNS said there should be documentation of side effect monitoring for Resident #5's [MEDICATION NAME], and [MEDICATION NAME], and she could not find any documentation that it was done. 2. Resident #21 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #21's physician orders [REDACTED]. The order started on 5/7/19. Resident #21's MARS for (MONTH) and (MONTH) 2020 documented the [MEDICATION NAME] was administered as ordered. Resident #21's care plan documented the following: * Staff were directed to administer [MEDICAL CONDITION] medications as ordered by the physician and monitor for side effects and efficacy. Staff were directed to monitor for symptoms addressed in the Black Box Warning information. The intervention was initiated on 2/9/19 and revised on 2/22/19. * The care plan directed staff to monitor efficacy and adverse side effects of medications through medication administration and pharmacy/behavior meetings, and to monitor behaviors every shift. The intervention was initiated on 2/9/19. There was no documentation in Resident #21's record of behavior monitoring related to anxiety . On 2/7/20 at 10:14 AM, the DNS said there should be documentation of behavior monitoring for Resident #21's [MEDICATION NAME]. The DNS said she talked to the Licensed Clinical Social Worker, and the facility did not have documentation of behavior monitoring for Resident #21's [MEDICATION NAME]

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure privacy during a medical examination for 3 of 12 residents (#7, #21, and #22) who were observed for privacy. This failure created the potential for residents to be embarrassed when a medical examination was provided in a common area. Findings include: The facility's dignity policy, dated 2/13/17, directed staff to protect resident privacy during treatment procedures. a. On 10/23/18 at 11:38 AM, a PA performed an examination of Resident #21's ears with an otoscope (a lighted instrument used to visualize the middle ear) while Resident #21 was seated in the day room with other residents and visitors present. b. On 10/23/18 at 11:43 AM, the PA performed an examination of Resident #22's ears while seated in the day room with other residents and visitors present. c. On 10/23/18 at 11:20 AM, Resident #7 was awake and lying in a recliner in the activity day room. Directly across from Resident #7 was another resident and the Licensed Clinical Social Worker (LCSW). There was also 3 other residents present in the activity room. The PA and CNA #1 were next to Resident #7. The PA inspected her ears with an otoscope and cleaned wax out of her ears. On 10/23/18 at 11:25 AM, the DON said residents should not be examined in a public area. On 10/23/18 at 11:45 AM, the PA said it would have taken too long to take the residents into an exam room or into their own rooms. On 10/23/18 at 11:32 AM, the LCSW said he saw the PA examine Resident #7's ears but was engaged in conversation with the resident sitting next to him. The LCSW said the PA's examination was not appropriate. On 10/23/18 at 11:44 AM, CNA #1 said she was assisting the PA to identify where the residents were. CNA #1 said she did not attempt to move Resident #7 to a private room to be examined because it would have been too much work to move her out of the recliner.

Based on observation and staff interview, it was determined the facility failed to ensure exam equipment was appropriately cleaned and disinfected between residents for 2 of 12 residents (#21 and #22) who were observed for infection control. This failure created the potential for harm by exposing residents to the risk of infection and cross-contamination. Findings include: On 10/23/18 at 11:38 AM, a PA performed an examination of Resident #21's ears while he was seated in the day room. The PA examined his ears with an otoscope. Upon completion of the examination, the PA placed the instrument in his back pocket and completed a conversation with Resident #21. On 10/23/18 at 11:43 AM, the PA removed the otoscope from his back pocket and performed an ear examination of Resident #22's ears. This was the same otoscope used for the exam on Resident #21. The otoscope was not disinfected before use on Resident #22. On 10/23/18 at 11:45 AM, the PA said he did not disinfect the otoscope between the residents' examinations. The PA said he should have cleaned the otoscope before and after each resident's examination.

Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure an order was in place for an indwelling urinary catheter for 1 of 1 resident (Resident #1) reviewed for indwelling catheter use. The failure created the potential for harm if the resident developed a urinary tract infection due to unnecessary catheter use. Findings include: The facility's Indwelling Catheter policy, dated 10/4/18, directed catheters should have a physician order [REDACTED]. Resident #1 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's hospital History and Physical, dated 5/9/18, documented he had an indwelling catheter. Resident #1's 5/16/18, readmission orders [REDACTED] Resident #1's (MONTH) (YEAR) physician recapitulation orders and treatment administration record, directed staff to change the catheter as clinically indicated and to provide catheter care each shift by a licensed nurse. The orders did not include the [DIAGNOSES REDACTED]. Resident #1's current care plan directed staff to provide catheter care each shift along with other essential infection control measures. The care plan did not include documentation of the size of the catheter or the balloon size. On 10/22/18 at 3:04 PM, Resident #1 said he was not sure why he had a catheter. On 10/24/18 at 11:31 AM, LPN #1 said if the catheter needed to be changed she would check the physician's orders [REDACTED]. On 10/24/18 at 11:44 AM, the DON said Resident #1's clinical record should have had an order and a [DIAGNOSES REDACTED].

Based on observation, record review, and staff interview, it was determined the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months. This was true for 25 of 25 residents living in the facility (#1-#25), their family members, and/or visitors who wanted to know facility staffing levels. Findings include: On 10/23/18 at 10:43 AM, the facility's daily nurse staffing hours were documented on a white dry erase board at the nurses' station. The dry erase board documented a census of 25 residents (#1-#25) with licensed staff for each shift on that day. The Ward Clerk said she had been updating the daily postings for several years and had not kept the information she posted. On 10/23/18 at 11:53 AM, the DON said the facility should have kept staff posting information.

Based on observation, staff interview and resident interview, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers (PUs.) This was true for 1 of 1 residents (#1) reviewed for PUs and resulted in harm when Resident #1 developed two Stage III PUs on the right hip. Findings include: Resident #1 was readmitted to the facility on [DATE] with multiple diagnoses, including multiple unstageable PU's, [MEDICAL CONDITIONS], malnutrition, and contractures of the left knee. Resident #1's 11/15/16 quarterly Minimum Data Set (MDS) assessment documented significant cognitive impairment, 3 Stage III PUs present on admission, repositioning schedule in place, and extensive assistance of two or more staff required for transfers and bed mobility. Resident #1's 2/14/17 quarterly- and 6/6/17 significant change MDS assessments documented: * 5 PUs, 3 of which were present upon admission * Repositioning schedule in place * Extensive assistance of two or more staff required for transfers and bed mobility (quarterly only) The 6/6/17 significant change MDS assessment also documented: * 5 Stage III PUs, 3 of which were present on admission * Total dependence on staff for bed mobility A PU Care Plan, dated 11/24/16, documented Resident #1 was provided a pressure reducing mattress to protect his skin, and staff were directed to turn and reposition the resident at least every two hours and as needed (PRN), encourage Resident #1 to change positions while in a wheelchair, and document non-adherence to interventions. A Skilled Charting Assessment, dated 1/28/17, documented Resident #1's skin was warm, pink, and dry. The assessment did not document concerns with Resident #1 refusing to reposition either in bed or while sitting in a chair/wheelchair. The facility's Hourly Rounding form instructed staff to monitor Resident #1's positioning by identifying current positioning, position changes with new position noted, and amount of assistance required with repositioning. The Hourly Rounding did not provide space to document whether Resident #1 was repositioned every two hours and/or whether the resident refused. Examples included: * The Hourly Rounding form, dated 2/1/17 from 3:00 pm to 10:59 pm, documented Resident #1 was in a wheelchair from 3:00 pm to 8:00 pm with no documentation of encouragement or refusals to reposition. The Hourly Rounding documented from 9:00 pm to 10:59 pm documented Resident #1 was in bed; it did not document Resident #1's position while in bed, whether there was a position change, or the level of assistance Resident #1 required. * The Hourly Rounding form, dated 2/1/17 11:00 pm to 6:59 am and 2/2/17 from 11 pm to 6:59 am, documented Resident #1 was in bed from 11:00 pm to 6:59 am with no documentation of encouragement or refusals to reposition. The Hourly Rounding for did not document Resident #1's position while in bed, whether there was a position change, or the level of assistance Resident #1 required. * The Hourly Rounding form, dated 2/3/17 from 11:00 pm to 6:59 am, documented Resident #1 was in bed on his right side from 11:00 pm to 3:59 am with no documentation of encouragement or refusals to reposition. From 4:00 am to 5:00 am, Resident #1 was documented as being on his back, and from 5:00 am to 6:59 am, the form documented Resident #1 was on his right side. The Hourly Rounding form did not consistently document whether the resident's position was changed, new positioning, or the level of assistance Resident #1 required if he was repositioned. * The Hourly Rounding form, dated 2/4/17 from 7:00 am to 2:59 pm, documented Resident #1 was in bed from 7:00 am to 11:59 am with one documented refusal to get out of bed, and no documented encouragement or refusals to reposition. From 12:00 pm to 2:59 pm, the form documented Resident #1 was in a wheelchair with no documentation that staff encouraged repositioning. The Hourly Rounding form did not document Resident #1's positioning, whether positioning was changed, or the level of assistance Resident #1 required. * The Hourly Rounding form, dated 2/4/17 from 3:00 pm to 10:59 pm, documented Resident #1 was in bed with a one hour exception from 5:00 pm to 6:00 pm. The Hourly Rounding form documented an R without specifying whether the resident refused to get out of bed, repositioning, or if he was positioned on his right side. * The Hourly Rounding form, dated 2/4/17 from 11:00 pm to 6:59 am, documented Resident #1 was in bed on his right side from 11:00 pm to 3:59 am with no documentation of encouragement or refusals to reposition. From 4:00 am to 5:00 am, the form documented Resident #1 was on his left side, and on his right side from 5:00 am to 6:59 am. The Hourly Rounding form did not consistently document Resident #1's position, position changes, or the level of assistance Resident #1 required. Wound documentation was as follows: * A Wound Weekly Observation Tool, dated 2/3/17, documented Resident #1 acquired a Stage III PU (measuring 10 millimeters (mm) by 4 mm by 1 mm) to his posterior right hip on 2/3/17. The observation tool documented Resident #1 was on a pressure reducing mattress, as well as a turning and repositioning schedule of at least every two hours. * A Wound Weekly Observation Tool, dated 2/3/17, documented Resident #1 acquired a Stage III PU (10 mm by 10 mm by 1 mm) to his anterior right hip on 2/3/17. The observation tool documented Resident #1 was on a pressure reducing mattress, as well as a turning and repositioning schedule of at least every two hours. On 6/16/17 at 10:50 am, the Director of Nursing Services (DNS) stated the two hip PUs were discovered on 2/4/17 by a night nurse and not on 2/3/17 as documented on the Wound Observation Tools. The DNS stated on 2/3/17 she measured other PU's that were present upon the resident's admission to the facility, however she did not chart the results before leaving for the weekend. She stated she was notified on 2/4/17 about an additional two new PUs to Resident #1's right hip. The DNS stated the Incident and Accident report was completed on 2/6/17 and she completed the Wound Weekly Observation Tool for all wounds and back-dated those measurements to 2/3/17. * A Skilled Charting Assessment, dated 2/4/17, documented Resident #1's skin was warm, pink, dry, and intact. The assessment did not document concerns with Resident #1 refusing to reposition in bed and chairs. * A Nurse's Note, dated 2/4/17 at 5:49 am, documented Resident #1 was incontinent and that . two open wounds: one (3 x 3 cm) and the second (1.5 cm) were noted on right hip. The Note documented the RN notified the DNS, but did not document Resident #1's physician or family was notified of the newly discovered pressure ulcers. * A Facility Incident Report, dated 2/6/17, documented staff discovered two Stage III PUs to Resident #1's right hip measuring 1 cm by 1 cm by 0.1 cm, and 1 cm by 0.4 cm by 0.1 cm. The Incident Report documented the PUs to the right hip were caused by decreased circulation, smoking, decreased mobility, and weight loss. The Incident Report documented staff were to reposition Resident #1 to his back and left side only every two hours and PRN. The Incident report documented Resident #1's mattress was changed to a Low Air Loss Mattress on 2/7/16. The Incident report documented the physician and family was notified of the newly discovered pressure ulcers on 2/6/17. * A PU Care Plan revision, dated 2/7/17, documented Resident #1 used a low loss air mattress to protect his skin. The care plan documented staff was to turn and reposition at least every two hours and PRN, encourage Resident #1 to change positions while in his wheelchair, and to document non-adherence to interventions. A Skilled Charting Assessment, dated 2/11/17, documented Resident #1's had multiple open wounds to the right hip, and was swearing during bed checks, repositioning, catheter/peri care and wound care. The assessment documented Resident #1 experienced increased pain with movement and repositioned himself back onto his right side. On 6/13/17 from 2:31 pm to 4:23 pm, Resident #1 was observed in a wheelchair in a common area near his room. There were no staff offers to reposition during the nearly two-hour observation despite interaction with two staff during this time. On 6/15/17 at 9:05 am, the DNS stated Certified Nursing Assistants should reposition residents every two hours when care planned. The documentation prior to the discovery of the two Stage III PU wounds did not record he was consistently repositioned every two hours or that he refused to reposition. On 6/15/17 at 9:05 am, the DNS stated Resident #1 had three different mattresses and when the hip PUs were discovered she thinks he was placed on an air mattress (ArroAIR MAX Pump & [MEDICATION NAME] Air Mattress System). She stated when the hip PU worsened the facility purchased a True Low Loss Air Mattress (Moxi Fusion 2K Convertible Air Mattress) and placed it on his bed. The DNS stated another resident who tried the first ArroAIR MAX Mattress told her it was not comfortable. The DNS was not exactly sure when the first air mattress was placed on Resident #1's bed. A PU Care Plan version, dated 6/16/16, 8/9/16, 11/24/16, and 2/2/17, documented Resident #1 used a pressure reducing mattress to protect his skin. An Invoice from a supplier, dated 7/19/16, documented an ArroAIR MAX Pump & [MEDICATION NAME] Air Mattress System was ordered for the facility. The invoice did not document which resident received the air mattress or when it was initiated. A Wound Weekly Observation Tool, dated 2/3/17, documented Resident #1's Stage III PU measured 10 mm x 10 mm x 1 mm to his anterior right hip. The Observation Tool documented Resident #1 was on a pressure reducing mattress. A Wound Weekly Observation Tool, dated 2/3/17, documented Resident #1's Stage III PU was 10 mm x 4 mm x 1 mm to his posterior right hip. The Observation Tool documented Resident #1 was on a pressure reducing mattress. A Facility Incident Report, dated 2/6/17, documented staff discovered two Stage III PU's to Resident #1's right hip. The Incident report documented Resident #1's mattress was changed to a low air loss mattress. A PU Care Plan version, revised 2/7/17, documented Resident #1 used a low loss air mattress to protect his skin. Wound Weekly Observation Tools documented the following: * 2/10/17 - Resident #1's Stage III PU measured 10 mm x 16 mm x 1 mm to his anterior right hip. A Stage III PU on the posterior hip measured 10 mm x 4 mm x 1 mm. The observation tool documented Resident #1 slept on a low air loss mattress. * 2/17/17 - Resident #1's Stage III PU measured 5 mm x 13 mm x 1 mm to his anterior right hip and slept on a pressure reducing mattress. A Stage III PU to the posterior right hip measured 3 mm x 3 mm x 1 mm, and the resident slept on a low air loss mattress. * 2/20/17 - Resident #1's Stage III PU measured 10 mm x 14 mm x 1 mm to his anterior right hip, and the resident slept on a pressure reducing mattress. A Stage III PU to the posterior right hip measured 5 mm x 5 mm x 1 mm, and Resident #1 slept on a low air loss mattress. An invoice from a supplier, dated 3/1/17, documented a Moxi Fusion 2K Convertible Air Mattress was delivered to the facility. A Wound Weekly Observation Tool, dated 3/2/17, documented Resident #1's Stage III PU was 5 mm x 10 mm x 1 mm to his anterior right hip. The Observation Tool documented Resident #1 was on a True Low Loss Air Mattress. A Wound Weekly Observation Tool, dated 3/2/17, documented Resident #1's Stage III PU healed to his posterior right hip. The observation tool documented Resident #1 was on a low air loss mattress. A Wound Weekly Observation Tool, dated 3/10/17, documented Resident #1's Stage III PU was 10 mm x 10 mm x 1 mm to his anterior right hip. The Observation Tool documented Resident #1 was on a True Low Loss Air Mattress. A Wound Weekly Observation Tool, dated 3/17/17, documented Resident #1's Stage III PU was 10 mm x 15 mm x 1 mm to his anterior right hip. The Observation Tool documented Resident #1 was on a True Low Loss Air Mattress. Resident #1's clinical records included other Wound Weekly Observation Tool between 3/23/17 and 6/13/17 for the anterior right hip wound which documented he was on a True Low Loss Air Mattress and the PU wound size worsened to 15 mm x 15 mm x 1 mm on 4/21/17 and then improved. The facility failed to ensure protective interventions were implemented prior to the discovery of two new PUs involving a resident who had other PUs and disease factors which placed him at higher risk for skin impairment.

Based on observation and staff interview, it was determined the facility failed to ensure residents were provided with a homelike environment. This was true for 2 doors in the dining room, a wall in the private dining room, floor tiles in one of 3 hallways and in the nurses' station, and walls in the rooms of 2 of 9 sample residents (#'s 1 & 8). The failure created the potential for Resident #1 and #8 and all other residents who utilized the dining room, the private dining room and the hallway between rooms 101 and 107, and the hallways by the nurses' station, to experience a negative effect on their sense of comfort and self-esteem. Findings include: 1. The following environmental issues were observed during each day of the 5-day survey: a. A line of eight floor tiles across the hallway between rooms 101 and 133 were cracked. Neither of the rooms were occupied. b. A 1 1/4 inch long by 1/2 inch wide hole in one wall in the private dining room. c. A 1/2 inch wide scrape across one of the double doors in the dining room by the kitchen and a 2-inch wide deep scrape across the door into the kitchen from the dining room. d. Black paint over-spray on 10 floor tiles in the nurses' station that were visible from 2 resident hallways. e. A 6-foot long by 6-inch wide scrape on the longest wall in Resident #1's room. 2. On 6/15/17 at 9:25 am, the wall corner molding was observed to be broken or missing by Resident #8's sink, the baseboard under the sink was dingy, and the corners of 3 floor tiles were curled. On 6/15/17 at 4:30 pm, the Plant Operations Manager said that over time he had replaced many floor tiles throughout the facility. He stated the cracked tiles in the hallway and those in the nurses' station also needed to be replaced. The Plant Operations Manager said he would repair the hole in the private dining room, the sink area in Resident #8's room, the scrape on the double door, as well as replace the door into the kitchen, and paint Resident #1's damaged wall.

Based on observation, record review, and staff, resident, and family interviews, it was determined the facility failed to ensure residents at risk of falls had sufficiently developed interventions in place to prevent future falls. This was true for 4 of 6 sampled residents reviewed for falls. The deficient practice resulted in a hip fracture for Resident #10 and multiple falls with minor injuries for Residents' #7, #8 and #9. Findings include: The facility's Fall Risk Managing policy dated 10/1/08, documented, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. * Prioritizing approaches to managing falls included: If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. *Monitoring subsequent falls and fall risk included: If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. *Post Fall 72 hour monitoring included: neurological check protocol and visual checks every 15 minutes for the first day; every 30 minutes the second day; and every 45 minutes for the third day. The Fall Scene Investigation Report policy included: i. Licensed nurse will complete initial assessment. ii. Obtain vital signs and provide appropriate first aid to any noted injuries. iii. Check blood sugar. iv. Start neurological checks with all unwitnessed falls or with evidence of head injury. v. Obtain orthostatic blood pressures. 1. Resident #10 was admitted with [DIAGNOSES REDACTED]. Resident #10's care plan, dated 12/11/15, identified he was at risk for falls. Interventions to prevent falls included: encourage to slow down and pick up feet; cue and redirect with one on one to make safe choices; encourage to sit on the edge of the bed a few minutes before getting up; and supervise/remind to walk slower to increase balance when ambulating. A revision of Resident #10's care plan for falls, dated 7/1/15, included the following interventions: transfer with supervision/cueing reminders to slow down; walk to/from meals, dining room, dayroom with supervision/reminders to walk slower to increase balance; encourage to keep pants pulled up until in bathroom when ready to sit on the toilet; restorative program for strengthening/gait transfer and improved mobility; encourage to sit at the edge of the bed for a few minutes before getting up; review information on past falls; attempt to determine cause of falls; and remove potential causes if possible. Resident #10's Quarterly MDS assessment, dated 12/29/15, documented Resident #10 was severely cognitively impaired, required staff supervision for transfer activities and ambulation. Resident #10 was occasionally incontinent of bladder function, always incontinent of bowel function, and required extensive staff assistance with toileting. The MDS assessment documented he had fallen 3 times since his last MDS assessment. On 9/29/15, a Restorative Note documented Resident #10 required supervision with bed mobility, transfers, walking in room and corridor, and extensive assistance with toileting. On 10/30/15, a Morse Fall Scale assessment, documented Resident #10 was a high risk for falls. Review of Facility Incident Reports documented the following 5 falls: *On 10/30/15 at 7:00 pm, Resident #10 was found on the floor with the bedside table turned over. The report documented he used the table for support when getting ready for bed. *On 11/9/15 at 1:40 pm, Resident #10 stood up in the dayroom, stepped on his pants and fell . Resident #10 sustained a 2 cm x 2 cm abrasion to his right knee. Measures to prevent future falls included, assuring his pants were tied or pulled up, and RSA gait training. * On 12/9/15 at 3:10 pm, Resident #10 was walking in his room when he tripped over a chair, lost his balance and fell . The report documented Resident #10 shuffled his feet when walking. Resident #10's care plan was updated with the interventions to encourage him to slow down, pick up his feet and staff to cue, and redirect with one to one to make safe choices. *On 1/5/16 at 1:50 pm, Resident #10 was walking in the dayroom, lost his balance and fell on his knee. The report documented Resident #10 shuffled and did not pick up his feet. Resident #10's care plan was updated with the interventions of continue balance and gait training, and encourage resident to slow down and pick up feet. *On 1/19/16 at 10:32 pm, Resident #10's MAR documented he received a Dulcolax suppository. On 1/20/16 at 1:30 am, Resident #10 was found in the hallway, lying on his side crying out for help complaining of left hip pain. On 1/20/16, Nursing Progress Notes documented the CNA heard a noise and found Resident #10 lying on the floor in the hall. Resident #10 had a left ankle abrasion and was crying out for help and complaining of left hip pain. Resident #10 stated he was going to the bathroom. The resident was transferred to the emergency room . On 1/20/16, a X-ray report documented, Resident #10 had an acute intertrochanteric fracture of the left femoral neck. On 5/12/16 at 2:45 pm, CNA #7 stated Resident #10 required supervision with transfer activities and ambulation related to his fast pace of walking, leaning forward when ambulating, history of tripping over his/her feet, and need for continual cues to slow down. CNA #7 stated she assisted Resident #10 with toileting every two hours during the evening shift. She stated Resident #10 was usually in bed resting by 10:00 pm. and asleep by 11:00 pm. She stated on 1/19/16 when she left at 11:00 pm Resident #10 was asleep and was not aware he had been given a suppository. During interviews with LN #6 on 5/11/16 at 8:40 am, and CNA #5 on 5/12/16 at 1:30 pm, the CNA's confirmed Resident #10 slept from 11:00 pm to 5:00 am. LN #6 and CNA #5 stated that when Resident #10 awoke in the morning, the nurse aides assisted him to the bathroom and provided personal cares. LN #6 and CNA #5 stated Resident #10 never used the call light. LN #6 stated that although she had never given Resident #10 a suppository, she would have administered the suppository between 3:30 am-4:00 am to allow the resident to sleep per his routine. CNA #5 stated when Resident #10 awoke in the morning, he was a little shaky, and had gait and balance issue and needed assistance to the bathroom. On 5/12/16 LN #8 stated she was busy during the evening shift on 1/19/16. She stated she had reviewed Resident #10's bowel record and noted he had not had a BM for 4 days and had not received a suppository on day 3 per the bowel protocol. LN #8 stated that at approximately 11:30 pm, she administered a suppository to Resident #10 in bed and reported the information to the oncoming nurse. LN #8 stated she was not aware Resident #10 usually slept to 5:00 am. On 5/12/16 at 1:30 pm, CNA #5 stated that on 1/19/16, the night nurse told her Resident #10 had received a suppository. She stated when she checked on Resident #10 during first rounds, the resident was asleep. CNA#5 stated she was going to awaken Resident #10 and assist him to the bathroom when the resident across the hall activated the call light. CNA #5 stated she answered the call light, came out of the room within a few minutes, observed Resident #10 on the floor and yelled for help. On 5/13/16 at 9:30 am, the DNS stated she did not know a reason that suppositories would be given at night when residents slept other than the residents were laying down. The DNS further stated a suppository at a time when Resident #10 usually slept, may have contributed to his fall on 1/20/16. 2. Resident #7 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7's Admission MDS assessment, dated 12/15/15, and Quarterly MDS, dated [DATE], documented his cognition was intact and he required limited the assistance of one person for mobility and transfers. Morse fall scale assessments dated: 11/14/15; 11/21/15; 11/26/15; 12/8/15; 12/10/15; 12/29/15; 1/2/16; 1/8/16; 2/14/16; 3/9/16; 4/9/16; and 5/5/16 identified Resident #7 as at high risk for falls. Resident #7's care plan, dated 12/15/15, identified him as at risk for injury from falls related to decreased mobility and balance, Parkinson's, urinary incontinence and benign prostate hypertrophy. Interventions included: *One person assist with gait belt/walker when up at all times; *Anticipate and meet resident's needs; *Balance training, pivot turning training. Cue and redirect with one to one to make safe choices and to call/wait for assistance; *Call light within reach and encourage resident to use call light for assistance as needed. Resident needs prompt response to all requests for assistance. *Restorative program to promote activities and exercise for strengthening and improved mobility; *Encourage safe choices. Cue and redirect with one to one as needed; * Appropriate foot wear when ambulating. Resident wears left leg brace during day; *Follow facility fall protocol; *Needs activities to minimize potential for falls; *Provide safe environment; even floors free from spills and clutter, call light within reach, bed at correct height, and personal items within reach. Review of Facility Incident Reports documented the following 11 falls: *On 4/1/15 at 9:00 pm, Resident #7 was found kneeling on the floor, resident was attempting to be independent. The resident stated he was trying to get his shoe from under the bed. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, frequently review safe choices, calling and waiting for assistance and cue to redirect to safe choices with one to one. *On 7/16/15 at 7:30 am, Resident #7 was found lying on the floor; resident was attempting to be independent. The resident stated he was trying to get to the bathroom. The root cause was documented as toileting status and loss of balance while opening the door. The resident was documented toileted at 7:00 pm. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, fall assessment updated and use of walker, gait belt, with one assist at all times. *On 7/31/15 at 10:45 am, Resident #7 was found sitting on floor with his fishing pole line wrapped around his leg, he was attempting to be independent. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, re-educated to use call light, fall assessment updated use of walker, gait belt, with one assist at all times, and place fishing poles in closet. *On 11/16/15 at 3:15 pm, Resident #7 was found on the floor lying on his back, resident was attempting to be independent. Resident #7 stated he was getting in his wheel chair. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, fall and skin assessment updated and remind resident to wait for assistance. *On 11/26/15 at 4:55 pm, Resident #7 was found sitting on the floor with the call light within reach; he was attempting to be independent. Resident #7 slid out of his chair while attempting to transfer self to bathroom. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, re-educate resident on safe choices, fall and skin assessment updated and medication review by pharmacy and physician. *On 12/29/15 at 2:45 pm, Resident #7 lost his balance during a pivot transfer after using the toilet and landed on his bottom, he is determined to be independent. Measures to prevent future falls include: fall protocol, frequent checks, LN assessment x 3 days, and restorative aide to work with Resident #7 on balance a pivot turns. *On 1/2/16 at 11:00 am, Resident #7 was up without assistance, lost balance and found sitting on floor, resident wants to be independent. The resident stated he had to go to the bathroom. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, re-educate Resident #7 on safe choices, fall and skin assessment updated and restorative aide to work with him on balance. *On 1/8/16 at 3:30 am, Resident #7 lost his balance, found sitting on floor, resident wants to be independent. Resident stated he was trying to get to the bathroom. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, remind resident to use call light, fall and skin assessments updated, medications reviewed and PT evaluation ordered. Resident #7 bit his lip with the fall, 1 mm cut with bump. *On 2/14/16 at 11:35 am, Resident #7 was found sitting on floor. The resident stated he got up to hang a calendar on the wall. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, review safe choices, with return demonstration, and balance training, and fall and skin assessments done. *On 4/9/16 at 1:40 pm, Resident #7 was in the shower chair with CNA, the CNA turned to get clothes from sink and Resident #7 stood up to walk out of stall and fell to floor falling on buttocks. Resident #7 wants to be independent. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, fall and skin assessments updated, review safe choices-cue and redirect with one to one, gather all supplies and keep them close by, do not turn your back with cares. *On 5/5/16 at 6:45 am, Resident #7 was found on floor after trying to ambulate independently. The resident stated he was trying to get to the bathroom. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, review safe choices, fall and skin assessments updated, and RSA balance training. Resident #7 sustained a 4 cm x 4 cm reddened area on left knee. On 5/11/16 at 8:00 am, the Administrator stated the facility was progressive in not using any interventions that could be construed as a restraint such as, alarms or low beds. He stated Resident #7 was cognitively intact, but often non-compliant in using his call light or asking for help. On 5/11/16 at 8:30 am, CNA #6 stated residents who were incontinent were assisted to the bathroom every 2 hours or checked and changed. Residents who were continent notified staff when they needed to use the bathroom. CNA #6 stated Resident #7 notified staff when he needed to be toileted. She stated Resident #7 did not always use his call light, but often yelled out for help. On 5/11/16 at 10:10 am, Resident #7 stated he had fallen several times and staff did not always respond to call lights. Resident #7 stated he usually fell trying to get up to go to the bathroom. He stated 4 people used the same bathroom and sometimes when he needed to use the toilet it was occupied. He stated he could use the hall bathroom, but it was too far. Resident #7 stated he had difficulty turning because his left ankle did not move, but he wanted to do as much for himself as possible. He stated he did not want to ask to do everything. At this time, family members stated Resident #7 had fallen at home. Family members stated Resident #7 did have a brace for his left ankle, but the brace had caused problems. Resident #7 stated the brace did not keep him from falling. On 5/12/16 at 6:40 am, LN #3 stated Resident #7 had not accepted his [DIAGNOSES REDACTED]. LN #3 stated she was unaware of any ankle issues. She stated Resident #7 got up and fell even when someone was with him. LN #3 stated re-educating or reminding Resident #7 to call for help did not work. She stated Resident #7 was very independent and if he had an alarm on, he would just take it off. On 5/12/16 at 7:12 am, CNA #8 stated Resident #7 was in the restorative program. She stated Resident #7 was in denial about his Parkinson's, and often was non-compliant in calling for help. She stated Resident #7 always participated in the restorative program. On 5/12/16 at 9:15 am, LN #6 stated Resident #7 had an unsteady gait and was working with RSA on balancing. LN #6 stated Resident #7 got himself up to either go to the bathroom or get in his wheelchair. She stated reminding him to use his call light or redirecting him did not work. On 5/12/16 at 3:00 pm, CNA #7 stated Resident #7 used his call light sometimes, but was often non-compliant even with reminders. She stated he usually fell trying to go to the bathroom. She stated Resident #7 was not assisted to the bathroom every 2 hours, but as he needed. She stated Resident #7 sometimes wanted to go to the bathroom right after he had just gone. She stated she was unaware he had prostate problems that caused him to feel like he needed to go to the bathroom all the time. She stated that assisting Resident #7 to the bathroom every hour would probably help. On 5/13/16 at 8:30 am, PT stated he had evaluated Resident #7 and determined he did not have rehabilitation potential. On 5/13/16 at 9:30 am, the DNS stated Resident #7 was in denial about his Parkinson's. She indicated Resident #7 was determined to be independent and wanted to go home, but he had been falling at home. The DNS stated the facility was restraint free and she was concerned that implementation of alarms would lead to more falls. She stated residents were placed on frequent checks for 72 hours after a fall. The DNS agreed Resident #7 did not have reoccurring falls during the frequent check times. The DNS stated Resident #7 was non-compliant in using his call light and confirmed reminding or redirecting him had not worked. She stated hourly rounds had been implemented on all residents, but could not provide the documentation of hourly rounds for Resident #7. The DNS confirmed that implementing the same interventions after each fall had not prevented subsequent falls. 3. Resident #8 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's MDS assessment, dated 2/9/16, documented she was severely cognitively impaired, incontinent and required limited assistance of one person for mobility. Resident #8's Morse Fall assessments dated: 1/2/15; 11/4/15; 12/11/15; 2/6/16; 2/9/16; 4/14/16; 4/16/16; 4/20/16; 4/22/16; and 5/9/16 documented Resident #8 as at a high risk for falls. Resident #8's care plan, dated 11/4/15, identified her at risk for injury from falls related to decreased mobility, fractures, dementia, depression, anxiety, urinary incontinence and muscle weakness. Interventions to prevent falls included: *Encourage safe choices, cue and redirect one to one as needed. No obstacles in resident's room; *Call light in reach and encourage resident to use as needed; *Introduce yourself with every interaction, make eye contact and keep statements simple; *LN assessments weekly and as needed; *Check position of bed; do not leave in high/low positions; *Room by nurse's station, resident makes poor safety choices. Frequently cue and redirect to use call light/wait for help; *Up with walker, gait belt and assistance for transfers; and *Encourage resident to slow down and take her time. Remind resident of hush no rush. Review of Facility Incident Reports documented the following 9 falls: *On 11/15/15 at 11:45 am, Resident #8 turned with walker while going to the bathroom, lost her balance, reached for the nurse's hand, and fell landing on her buttocks. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, review safe choices, calling for help and, fall assessment and care plan updated. *On 12/11/15 at 2:40 pm, Resident #8 was found on the floor without pants. She had a loose stool and took off her pants and attempted to walk without using her walker. Resident #8 was anxious and did not use call light. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, review safe choices, walker/gait belt/ assist added and RSA to work on balance and strength. *On 2/6/16 at 7:45 pm, Resident #8 was on the toilet in the bathroom when the CNA left to get supplies. She stood, turned and started to fall. The CNA assisted her to the floor. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, review safe choices, stay with resident during toileting, use call light to get items, get up slowly, medication review by pharmacy and doctor, and fall, skin assessments, and care plan updated. *On 3/13/16 at 6:10 pm, Resident #8 was at the dining table with staff and other residents. She stood up to get something, became orthostatic and fell hitting her head on the table. Resident #8 sustained a bump on the back of her head. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, physician review of fall/vital signs/medications, and re-educate resident on getting up slowly and not to bend over. *On 4/14/16 at 3:35 am, Resident #8 was attempting to walk without her walker, became weak and was assisted to the floor. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, medication review, and physician review. *On 4/16/16 at 10:50 pm, Resident #8 was found on the floor with back against bathroom door. Resident #8 did not use her walker or call light. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, and review safe choices frequently with resident. *On 4/20/16 at 4:19 am, Resident #8 was in the day room with CNA because Resident #8 was agitated. Resident #8 stood up from her wheelchair and fell forward face down. The CNA was behind her and could not reach her to keep her from falling. Resident #8 sustained a 2 cm discolored area to forehead. Resident #8 was sent to emergency room . Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, and medication review by pharmacy and physician with medication changes. *On 4/27/16 at 2:00 am, Resident #8 was found on the floor after walking without a walker or assistance. Resident #8 was upset and yelling. She sustained a skin tear to right hand and reddened area to her right posterior back. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, and transfer to facility that can evaluate behaviors and adjust medications. Resident #8 was discharged , on 4/27/16 at 4:20 pm, for a psychiatric evaluation and readmitted on [DATE] at 1:50 pm. *On 5/9/16 at 10:18 pm, Resident #8 was found on the floor after attempting to transfer to her recliner. Measures to prevent future falls included: fall protocol, frequent checks, LN assessment x 3 days, fall and skin assessments and care plan updated, medication review by pharmacy and physician, and sitter from 10 pm-7 am. On 5/9/16 at 4:00 pm, Resident #8 was observed singing while ambulating with her walker assisted by 2 staff using a gait belt. On 5/11/16 at 8:30 am, CNA #6 stated incontinent residents were assisted with toileting every 2 hours or checked and changed. Residents who were continent notified staff when they needed to be assistance with toileting. She stated Resident #8 was assisted with toileting every 2 hours. On 5/12/16 at 11:52 am, the Administrator stated Resident #8's family was willing to sit with her when her behaviors became an issue. He stated he had sat with Resident #8 several times when her family could not be there. The Administrator agreed reminding Resident #8 to use her call light or re-educating her to make safe choices did not work. On 5/12/16 at 9:15 am, LN #6 stated Resident #8 had fallen her first night back. She stated Resident #8 woke up confused, tried to walk and fell . LN #6 stated she had just been in the room with her. She stated Resident #8 had orthostatic hypotension and her blood pressure medication order had been discontinued. LN #6 stated Resident #8 could not remember to use her call light or walker. She stated when Resident #8 was having a psychotic episode; she got up abruptly and acted out. She stated Resident #8 had refused the use of gait belts initially, but new orders now required the use of gait belts for ambulation and transfers. She stated Resident #8 needed closer observation and 24/7 supervision. On 5/13/16 at 9:30 am, the DNS stated Resident #8's behaviors affected her falls. She stated Resident #8 often yelled, acted out and became agitated. She stated when Resident #8's behaviors escalated, Resident #8 was sent for a psychiatric evaluation to adjust her medications. The DNS confirmed Resident #8 could not remember to use her call light or make safe choices due to her cognitive impairment. The DNS stated she was aware 5 of the 9 falls had occurred with staff present and 3 of the 9 falls had documented behaviors at the time. She stated she thought an alarm would increase Resident #8's behaviors and was unsure what would work, but had implemented a sitter after she fall on 5/9/16. She stated when Resident #8 was initially admitted , a gait belt could not be used because she had broken ribs from a car accident, but now staff used a gait belt. 4. Resident #9 was admitted with [DIAGNOSES REDACTED]. Resident #9's care plan, dated 12/12/15, identified Resident #9 at a high risk for falls. The related interventions included: encourage resident to sit up and stand slowly to allow the resident to get his balance; supervision with transfers in and out of bed; assist with toileting every 2 hours; review information on past falls; attempt to determine cause of falls; and remove potential causes if possible. On 2/5/16, a Morse Fall Scale assessment documented Resident #9 was a high risk for falls. The assessment documented Resident #9 used a wheelchair with assistance; had an impaired gain; had difficulty getting up; bounced to rise; kept head down when walking; grasped furniture, persons or aides when ambulating; and could not walk unassisted. Review of Facility Incident Reports documented the following 3 falls: *On 1/8/16 at 10:15 am, Resident #9 was found on the floor in his room. He sustained a 1 cm x 1.2 cm skin tear to his left elbow. Resident #9 stated I tried to put myself to bed again. *On 2/5/16 at 1:30 am, Resident #9 was found on the bathroom floor. Resident #9 had swelling on the left side of his head and small skin tears to his elbows. Resident #9 stated he was reaching for the bar by the toilet when he lost his balance and hit his head and arms. The report documented Resident #9 was normally ambulatory, but not able to make safe choices. Resident #9 did not have gripper socks on and did not use the walker. Measures to prevent future falls included usage of gait belt with walker and assistance. However, usage of a gait belt with walker and assistance was already an intervention. *On 4/8/16 at 3:20 am, Resident #9 was found on the floor at the foot of his bed. Resident #9 stated he was trying to get in bed and lost his balance. Measures to prevent future falls included the intervention of staff monitoring Resident #9 when he walked. On 5/13/16 at 9:30 am, the DNS stated new interventions had not been implemented other than the standard post fall protocol for Resident #9 after his 2/5/16 fall.

Based on observation, staff interview, record review and review of the facility's Policy and Procedure for Skin Care, the facility failed to prevent the reoccurrence of a pressure ulcer for 1 of 1 resident sampled for pressure ulcers (#1). The deficient practice caused actual harm to the resident when the facility failed to consistently document on and ensure implementation of care planned interventions to prevent the reoccurrence of an unstageable pressure ulcer to the resident's left heel. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual MDS, dated [DATE], recorded: *BIMS score- 7 severe cognitive impairment *Bed Mobility- Extensive 2 physical assist *Walk in Room- Limited assistance 2 person physical assist *Walk in Corridor- Limited assistance 2 person physical assist *Locomotion on Unit- Total dependence 2 person physical assist *Dressing- Total dependence 1 person physical assist *Toilet Use- Extensive assistance 2 persons physical assist *Personal Hygiene- Limited assistance 1 person physical assist *Risk of Pressure Ulcers- Yes *Unhealed Pressure Ulcer- Stage 1 or Higher- No The resident's Significant Change MDS, dated [DATE], recorded: * BIMS Score -99 Unable to interview *Bed Mobility- Extensive 2 physical assist *Walk in Room- Activity occurred only once or twice 2 person physical assist *Walk in Corridor- Activity did not occur *Locomotion on Unit- Activity occurred only once or twice 2 person physical assist *Dressing- Extensive assistance 2 person physical assist *Toilet Use- Total dependence 2 person physical assist *Personal Hygiene- Extensive assistance 1 person physical assist *Risk of Pressure Ulcer- Yes *Unhealed Pressure Ulcer- Stage 1 or Higher- Yes *Stage and number of pressure ulcers- Stage 2- 1 present. Oldest 8/9/13 The Braden Scale-For Predicting Pressure Sore Risk documented: *Dated 6/4/13 and 6/12/13 Category- "At Risk" *Dated 7/3/13 Category- "Moderate Risk" *Dated 8/1/13, 8/7/13, 8/13/13, 8/15/13, 8/21/13, 8/28/13 Category-"Moderate Risk" (Note: Resident developed a Stage 2 Pressure Ulcer on 8/8/13) *Dated 9/5/13 Category- "Moderate Risk" *Dated 10/23/13 Category- "Moderate Risk" *Dated 11/6/13 Category- "Moderate Risk" *Dated 11/15/13 Category "High Risk" Note: On 11/20/13 a new area was noted on the left heel in the same area as the August Pressure Ulcer. No new interventions were implemented between 11/15/13 when she was assessed as High Risk and 11/20/13 when the new area was found. The resident's Care Plan documented: *Focus: "(Resident) has an ADL self-care performance deficit r/t(related to) Wasting Disease/Depression" Date Initiated: 8/20/13 *Interventions: Bed Mobility: "(Resident) is total assist with bed mobility." -"Only use draw sheet to lift (Resident) in bed and to turn (R&L) (right and left). To be repositioned at least Q (every) 2 hours. Use pillows with positioning. Reposition from side to side using pillows to support back and lower extremities, float heels. On back for meals only. (Resident) has a pressure reducing mattress. Uses a foot cradle to keep covers off of feet." Dated Initiated: 9/16/13 Revision on 10/7/13 *Focus: "(Resident) is at risk for potential for pressure ulcer development, R/T decreased mobility, Dx (diagnosis) of: [MEDICAL CONDITION], wasting disease, [MEDICAL CONDITION], candidiasis." Date Initiated: 9/20/13 Revision on 9/25/13 *Interventions: -"Observe skin with ADL's, LN assessment and prn(as needed). Fill out skin report abnormalities. Notify LN, DON, and physician." Date Initiated: 9/27/13 -"(Resident) needs: monitoring/reminding/assistance to turn/reposition least every 2 hours, more often as needed or requested." Date Initiated: 9/25/13 -"(Resident) requires: Pressure reducing device on bed/WC." Dated Imitated: 9/25/13 Note: This is pressure reducing, as opposed to pressure relieving. -"Teach (Resident)/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes." Date Initiated: 9/25/13 Revision on 9/25/13 * Focus: "(Resident) is at risk for side effects from DX(diagnosis) of: Diabetes Mellitus without complications, glucocorticoid deficient." Date Initiated: 8/20/13 Revision on: 9/25/13 *Interventions: -"Inspect feet with ADL's for open areas, sores, pressure ulcers, blisters, [MEDICAL CONDITION] or redness." Date Initiated 9/20/13 Revision on: 9/25/13 The Interdisciplinary Plan of Care which was implemented on 8/8/13, the date the resident was found to have a Stage 2 pressure ulcer, included: *Problem: Skin Tear or Skin Integrity, Impairment of R/T (checked)Pressure Ulcer (checked) Left heel 1 cm (centimeter) x(by) 1 1/2 cm. *Interventions -(Checked) Assess/record/report to MD prn:Skin tear status, appearance, Healing process, Size, Depth, Length, Width -(Checked)Keep area clean and dry: avoid skin-to-skin contact -(Checked) Protective/preventive measures (checked) heelbows -(Checked) Apply Silvermesh in wound then cover with [MEDICATION NAME] dressing QOD (every other day) The resident's Nurse Assessment Notes documented: On 6/29/13 (Resident) states, "I am too old to get out of bed. I have to stay in bed." Skin assessment documented Integrity: "Red area intact coccyx." The resident's Progress Notes documented: -7/14/13 Type: Skin/Wound Note "While turning and changing depends, noted red areas on bilateral heels. L(left) 2 cm(centimeter) x(by) 2 cm with dry scab. R(right) 1 cm x 1 cm no scab. Heels floated and padded heel protectors applied. Will follow skin protocol." Note: There was no documentation of another heel assessment until 8/8/13 when the facility found the Stage 2 Pressure Ulcer on the left heel. -8/10/13 Type: Skin/Wound Note "open sore on bottom of left heel improving. no drainage, no odor, redness decreased. wound over all improving. wound cleaned and dressed per MD (Medical Doctor) order. elder c/o (complaint of) foot pain while cleaning and dressing. denies pain to site when done. will continue to monitor. fluids encouraged." -8/17/13 Type: Nursing "...Left heel floated on pillow, heel-bo's in place bilateral. Repositioned..." Note: Heel bo and heel bow are use interchangeably throughout facility paperwork. -8/19/13 Type: Nutrition/ Dietary Note "(Resident) triggered a significant change secondary to having developed a stage 2 ulceration on her left heel. Nursing notes that it is healing..." -8/20/13 Type: Nutrition/Dietary Note "...Spoke with nursing staff, notes that pressure ulcer is healed as of 8/19/13. (Resident) does have a decline in mobility per nursing assessment/restorative care...." -8/24/13 Type: Nursing "Elder in bed side to side with meals on back heels floating off bed blankets on cradle so they are off toes. Elder up to the shower dsg (dressing) to L(left) heel came off in shower redressed with [MEDICATION NAME] foam to protect heel made sure heels were floating above mattress while adjusting sheets for cradle elder wiggled her feet so they were touching the bed so we redirected her about the need to float and the CNA's to check every hour to make sure they continue to float and blankets are off toes will continue to observe for any changes." -8/31/13 Type: Nursing "...states her left foot hurts when laying on the bed. elder encouraged to keep foot on pillow to keep it off the bed..." Note: An assessment of the resident's heel was not documented. -10/22/13 Type: Skin/Wound Type "LN reported that Elder had a c/o on (sic) her left heel. Skin assessed no signs of breakdown. skin intact. Skin blanching. No redness noted on physical assessment. skin slightly pink from old wound that has healed nicely. Heelbows on and heels floating..." -10/23/13 Type: Skin/Wound Note "Staff reported that Elder c/o pain on left heel. Area assessed skin blanching, skin intact slight pink from healed wound. Barrier spray applied, heelbows on and heels floating on pillows..." Note: There was no documentation related to the resident's heels between 8/31 and 10/22/13. A Wound-Weekly Observation Tool that was implemented on 8/9/13, the day after the Stage 2 Pressure Ulcer was observed, documented: *A. Communication 3. Special Equipment/Preventative measure (i.e. gel mattress/pad, special bed/Mattress, side rail pads etc.) "Heelbos" *B. Observation/Data -1. Location: "Left heel" -2 b. date acquired: "8/8/2013" -3 a. Type: "Pressure" -4. Pressure Ulcer Stage: 4 a. Original "II" (2) -5. Visible Tissue 5 c. (checked) Granulation tissue present (beefy red) -6. Drainage 6 a. Type: "None" -8. Wound Measurements -8 a. Length(mm)(millimeter) 10 -8 b. Width(mm) 15 -8 c. Depth (mm) 0 *A Wound-Weekly Observation Tool Dated: 8/19/2013 documented: A. Communication -3. Special equipment/Preventive measure "Heelbos, heels off bed" *B. Observations/Data -1. Location: "L Heel" -5. Visible Tissue -5 a. Overall Impression 1. Healed physician's orders [REDACTED]. Apply absorbnt(sic) silver pad to heal(sic)(and)keep covered(with) [MEDICATION NAME] change qod(every other day). keep pressure off heel. On 11/18/13 at 3:55 pm the resident was observed to be lying in bed on her back. There was a foot cradle in place with 2 pillows between her legs and feet resting on the bed. On 11/19/13 at 7:41 am the resident was observed to be lying on her back, foot cradle in place. Right foot, heel was resting directly on the pillow positioned up the lower leg. Left heel floated off the end of the pillow under the lower left leg. Heel bo's in place. On 11/19/13 at 8:24 am the resident observed to have the head of her bed elevated, eating breakfast. Both feet positioned with heels resting on the bed. Cradle over feet. On 11/19/13 at 8:41 am the resident was observed to be lying on her back. Her breakfast had been removed. Both legs and feet were positioned directly on the bed. There was 1 pillow on the lateral side of each leg. On 11/19/13 at 9:15 am the resident was asleep, lying on her back. Both legs and feet were positioned directly on the bed. There was 1 pillow on the lateral side of each leg. On 11/19/13 at 9:50 am the resident remained on her back asleep. On 11/19/13 at 11:40 am resident remained on her back, awake at this time. She had pillows under both legs. The left pillow was positioned with the left heel and foot on the pillow. The right heel was positioned with the heel floated off the pillow and bed. The foot cradle was in place and she had heel bo's on bilateral feet. On 11/19/13 at 2:29 pm the resident was observed to be lying on her back with the head of bed in an upright position. The foot cradle was in place. The right foot and heel were positioned directly on the bed. The left foot, at the ankle, was crossed over the right ankle. There was a pillow behind each leg. On 11/19/13 at 3:05 pm the resident was observed lying on her back with the head of the bed in an upright position. Bilateral heels were resting on the bed, pillows were positioned under the legs. On 11/20/13 at 8:04 am CNA#3 was providing care for the resident. When asked how often the heel protectors were taken off and changed for the resident, the CNA stated, "every other day." The CNA exited the room. The resident was observed with head of the bed in an upright position eating breakfast. Both feet with heel bo's on. The right foot/heel was directly on the bed, with apillow laying to the lateral side of the leg. The left foot was positioned with a pillow under it and the left heel floated off the bed. On 11/20/13 at 8:45 am the resident was observed with head of bed positioned slightly back from upright, and on her back. The right foot and heel remained on the bed. The left foot had the heel barely off the bed. CNA#4 was asked about positioning for the resident. CNA stated, "Every 2 hours we roll her from side to side, put pillows under her feet. When we put her on her side with a pillow behind her back she rolls back over off of it. She likes being on her back the best." On 11/20/13 at 09:50 am the resident was observed lying flat on her back. The foot cradle remained in place. The right foot was positioned off the pillow under her lower leg resting directly on the bed. The left foot and heel were suspended off the pillow. On 11/20/13 at 9:54 am CNA #5 and RN#2 were observed to reposition the resident. The feet were repositioned with both heels off the pillows under the lower legs. A pillow was placed behind the right side of the resident's back. The resident was then offered water, and pulled up in bed by the 2 staff. They then repositioned the head of the bed with the control to an upright position for drinking water. After drinking the water the head of the bed was lowered for comfort. The staff left the room without rechecking the position of the feet after the repositioning. On 11/20/13 at 10:05 am the DON went with surveyor to check the placement of the resident's heels. The right foot and heel were found to be resting on the edge of the pillow. The left foot and heel weres suspended off the pillow. When the DON was asked if the right heel was in an acceptable position for the resident, she placed her hand under the right foot depressing the bed to get the hand under the heel, and questioned it herself. When the surveyor asked the DON about the heel bo's only being removed and changed every 2 days and the skin not being seen for 2 days, the DON stated, "Yeah, that could be a problem. I didn't think about that." The surveyor also asked what type of a mattress was on the resident's bed, pressure reducing or pressure relieving. The DON stated, "that mattress is pressure reducing." The DON was asked what happened that the resident no longer got out of bed. The DON stated, "One day (Resident) said I pay you so you are going to take care of me." The DON further stated, "(Resident) does not want to get up and this is what she likes, being in bed." On 11/21/13 at 8:40 am the DON was interviewed about the care plan and changes that had been made after the resident made the decision to go to bed and not get up. No change in care was identified. The DON and surveyor went into the resident's room to assess position of feet. The right heel was observed to be touching the bed and the left heel was suspended from the pillow. The DON moved the pillow down the right lower leg and the heel was then suspended from touching the bed. The DON stated "Resident is really hard (to keep appropriately positioned)." On 11/21/13 at 9:50 am the DON approached the surveyor and stated the Resident had an area of concern to her left heel that had started again "last night." The DON stated the area was the same as it was in August. The area was found the previous night when the boot was removed for the resident's shower. When the surveyor asked the DON when the skin under the heel bo ad last been seen by staff, the DON stated she was unsure as to when the last time the heel was assessed or actually seen by anyone. The surveyor and the DON observed the area to the left heel. The Resident cried out "OW OW" when the boot and Mipiplex dressing was removed. On the back of the left heel was a raised area, with crusting to the top, it was blackened at the base, with red inflammation surrounding the site. The reddened area blanched with touching by the DON. The resident continued to cry out "OW OW" with touching of the area. On 11/21/13 at 1:35 pm the surveyor asked the DON what was done when the LN found the pressure area the night before. The surveyor was provided the Progress Note written by the LN and the Skin Inspection Report. No measurement was found. When asked where this would be documented,the DON stated "she would have wrote it on this report, but did not (pointing to the Skin Inspection Report)." When asked for the facility's Policy and Procedure on Skin, the DON showed the surveyor a very large book and stated that they "were working on putting it on the computer." The surveyor was provided a six page "Skin Packet and Checklist" that the LN's are to fill out when skin issues were found. When asked for a Policy and Procedure directing the LN how to proceed with filling the paperwork, the facility did not have one. The DON provided a copy of the Physician's Progress Notes from the exam on 11/20/13. The Physician's Progress Notes dated 11/20/13 at 6:30 pm documented: -"Nurse reported area on (left) heel reported by shower aid. Noticed today" -"S/P (secondary problem) history of ulceration same area some time ago that had healed." -"...c/o(complaint of) pain when area on (left) heel examined. circumferential area of [DIAGNOSES REDACTED] (with) core inner area of hardened skin resembling callous" -"AP(acute problem) 1. Callous formation over area of old and healed skin likely secondary to resident insisting on remaining in bed majority of time. No evidence of infection Recommend Mipilex drsg(dressing) for now to see if area can be softened and removed. Re(check) 1-2 days" The resident was harmed when the facility failed to implement interventions to prevent the development of a pressure ulcer to the resident when she had a lifestyle change. The resident developed a pressure ulcer on 8/8/13 that subsequently healed. The facility did not consistently implement interventions to prevent the reocurrence of pressure ulcers and on 11/20/13 an unstagable pressure ulcer was discovered in the same area as the previously documented pressure ulcer in August. On 11/21/13 at 2:30 pm the Administrator and the DON were informed of the findings. No additional information was provided.

Based on observation, record review, resident and staff interview, and review of information regarding Sara 3000 mechanical lifts and facility in-service and training records, it was determined the facility failed to ensure the resident environment was free from accident hazards. Resident #7, who was known to have osteoporosis, neuropathy, and long-term anti-coagulant therapy, was at risk for falls, fractures, and/or bleeding related to improper transfers with a Sara 3000 mechanical lift. During the mechanical lift transfers by one staff, Resident #7, who was unable to bear weight or grasp the bars on the mechanical lift, was suspended with a strap around her back and high up under her arms with her body weight supported only by her underarms which constituted immediate jeopardy (IJ) for the resident. On 8/22/12 at 7:00 p.m., the facility Administrator and DNS were informed verbally, and in writing, of the immediate danger to Resident #7. On 8/29/12 at 1:45 p.m., the facility provided an acceptable plan of correction to protect Resident #7, and 4 other residents, who were also identified to have transfers using Sara 3000 mechanical lifts. The plan documented, in part, "...Resident #7 will be transferred in the Sara 3000 lift with two person assist with each transfer...Qualified professional who has been trained in the use of lifts will assess Resident for determination of proper lift device. After assessment by a qualified professional has been carried out on the individual patient, transfer devices will be explored/utilized as indicated by assessment. "Super Users" will be trained by qualified instructor (i.e. Manufacturer representative) to ensure knowledge regarding criteria for use(.) "Super users" will be responsible to orient resident and staff regarding lift choice and use before lift utilization on the resident. "Super Users" will evaluate return demonstration of all staff who works with resident...All staff will follow manufacturer and qualified professional recommendations while taking in to account any physical limitations. * DNS and/or designees will monitor lift utilization to ensure recommendations are followed. * Resident care plan will be specific and individualized to reflect assessment and recommendation of qualified professionals regarding lift utilization..." The Immediate Jeopardy was abated during an onsite visit on 9/12/12. In addition, 3 of 3 random residents (#s 13, 16, and 17) were at risk for falls and/or injury when resident equipment was left unattended in 1 of 3 resident hallways; 2 of 4 sample residents (#s 4 and 5) and 2 of 3 random residents (#s 13 and 14) were at risk for injury when portable oxygen (O2) tanks were not securely attached to their mobility devices; and, 1 of 7 sample residents (# 8), 2 of 8 random residents (#s 16 and 19), and all other cognitively impaired and independently mobile residents who moved about the hallway where the IT (internet technology) room was left open and unattended were at risk for falls and/or injury. Findings included: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's most recent quarterly MDS assessment, dated 6/5/12, coded, in part: * Adequate hearing, and no hearing aid; * No speech; * Usually able to make self understood and usually able to understand others; * Cognitively intact; * No rejection of care; * Total assist of 1 person for transfers and toilet use; * Functional limitation in range of motion (ROM) in 1 upper and 1 lower extremity; * Balance not steady, only able to stabilize with human assistance, during transition from seated to standing position, on/off toilet, and surface-to-surface transfers (transfers between bed and chair or wheelchair); * Wheelchair (w/c) use; and *Restorative nursing with active ROM (AROM) for 15 or more minutes a day for 6 of the last 7 days. Resident #7's 3/13/12 quarterly MDS assessment differed from the 6/5/12 MDS in part, as follows: * Rejection of care occurred 1 to 3 days in the look back period; and * Restorative nursing with passive ROM (PROM) for 15 or more minutes a day for 6 of the last 7 days. Previous MDS assessments, dated 12/20/11 (annual) and 9/20/11 (quarterly) did not include any documentation that Resident #7 rejected care. Resident #7's care plans, dated as last reviewed 6/20/12, documented, in part: * ADL Strengths - Approaches, "Offer to toilet before and after meals and use sit to stand mechanical lift and 1-2 person assist...Use mechanical lift. 3-13-12" * "At risk for contractures and decreased bone density d/t (due to) lower extremity weakness and immobility...neck weakness." Approaches, "3/21/12 Provide neck brace to assist in OT (and) provide support. 4/19 (L) (left) hand orthosis. 03/09/2012 Wrist splint left hand to keep wrist in neutral position, as ordered 2/29/12, to support wrist." * "Potential for skin breakdown D/T immobility R/T Hx of CVA..." Approaches, "Get help to transfer (resident's name) from other staff member until you know her routine well. LIFT for transfers. Encourage...to make safe decisions when transferring." * An Interdisciplinary Plan of Care, dated 7/30/12, documented, "(R)ed rubbed area (L) underarm 2 cm x (centimeters by) 2 cm." Interventions included, "Protective/preventive measures(,) Pad lift." (NOTE: Refer to F314, Pressure Ulcers, as it related to the rubbed area at the resident's underarm.) * "Potential for complications, injury r/t anticoagulant medication..." Approaches, "Protect from injury. Avoid sudden movements...when transferring..." * Problem, "Potential for falls..." Approaches, "07/21/2009 Use lift for all transfers...03/09/2012 Up with lift with 2 assist in AM. Support shoulder not neck. 6/20/12 (Resident's name) may choose to transfer (with) lift in hall. Resident #7's recapitulation of physician's orders [REDACTED]. * 12/16/09 - 1 Aspirin 81 mg PO (by mouth) every morning for long-term anticoagulant therapy; * 10/2/08 and 6/27/12 - Gabapentin 300 mg 2 times a day and 600 mg at bedtime for peripheral polyneuropathy; * 7/13/11 - Mobic 7.5 mg by PO twice daily for osteoporosis; * 3/3/09 - Oyster calcium 500 mg PO twice daily for osteoporosis; * 7/21/12 - Sinemet CR (continuous release) 25-100 mg PO for abnormal involuntary movement; * 3/12/12 - "Please provide resident with neck brace to assist in OT and provide some support." * 4/19/12 - "Day eve(ning) noc (night) Left hand/wrist orthosis. Please check orthosis at least every 2 hours until removed, for redness, blisters, increased edema. Remove orthosis after lunch for 2 hours/day." * 6/30/04 - (Initials of a state university) exercise therapy." On 8/22/12 at approximately 3:43 p.m., Resident #7 was observed in an electric wheelchair (e-w/c) in the Old Farm Lane hallway by room 132 with CNA #8 in attendance. Neither a neck brace nor a left hand orthosis was in place. CNA #8 placed the resident's communication device, which was on a clip board with a non-slip piece of material under the clip board, on the floor next to the wall. (NOTE: Refer to F441, Infection Control, regarding infection control practices). These items were approximately 1 1/2 feet from the left side of the resident's e-w/c. A sling was in place around the resident's chest and the CNA attached the sling straps to a Sara lift. About that time, the MDS nurse walked past and looked at the resident and the CNA in the hallway. Moments later, the DNS walked past the resident and CNA. At about 3:45 p.m., CNA #8 raised Resident #7 off the e-w/c to a standing position using the Sara lift. Once upright, however, the resident's head tilted to the left and extended backward then suddenly fell forward. In addition, the resident's hips shifted backward and her pelvis swayed to the left and stayed there. The resident's body was not in alignment and by this time the sling strap was all the way up under the resident's underarms which raised her shoulders and arms. Neither of the resident's hands were in contact with the patient support grips on the Sara lift at any time during the lift. Resident #7 did not participate in the lift transfer in any way and her body weight was supported only by the strap under her underarms. CNA #8 then moved Resident #7, suspended by the sling strap, down a short hallway to the toilet/shower room. While in the toilet/shower room with the resident, CNA #8 left the resident's e-w/c and the communicator device on the clip board on the non-slip material unattended in the hallway (NOTE: See example #2 below regarding obstructed hallways). At approximately 3:51 p.m., CNA #8 moved Resident #7 out of the toilet/shower room using the Sara lift. The resident was upright; however, her body was not in alignment. Her head was bent forward and tilted to the left, her hips were backward, her pelvis was shifted to the left, and the sling straps were all the way up under her underarms. The resident's shoulders were raised and her arms were up and outward. The resident's body weight was supported only by sling strap under her underarms. CNA #8 was interviewed immediately afterward. When asked about the transfer for Resident #7, the CNA acknowledged that the sling straps were high up under the resident's 3underarms and stated, "She may be small for the sling." He stated the sling was the smallest one the facility had. When asked if Resident #7 had feeling in her arms and lower extremities, the CNA indicated he did not think so. He stated, "That's why I ask her if her feet are okay." When asked how he knew if the resident was okay, CNA #8 stated, "She will blow a kiss to get my attention then mouth words. On 8/22/12 at 4:20 p.m., LN #9 was interviewed. The LN stated she was a charge nurse, usually on the evening shift. When asked about mechanical lift transfers, the LN stated that if she sees an inappropriate transfer she corrects it right then. When asked if she saw all of the mechanical lift transfers, LN #9 stated, "No, I do not." When asked about mechanical lift transfers for Resident #7, LN #9 stated, "The sling she is in is the one recommended for her size." The LN indicated the next size sling was larger. LN #9 stated that Resident #7's "body will lock at the knees and shift on you in the lift. In trying to straighten her out, her body will shift. For her body to be perfectly straight is not achievable. She's a one person assist. Unless a person is about to fall out, usually a one person transfer." When asked how one would know if something was wrong, LN #9 stated, "She (Resident #7) will holler at you or mouth words." When asked if she ever heard Resident #7 holler, LN #9 stated, "Yes I have." On 8/22/12 at 4:45 p.m., CNA #8 was asked about training regarding mechanical lift transfers. The CNA stated, "I was trained by several different CNAs. It was during orientation. Under the direction of a charge nurse." On 8/22/12 at 4:50 p.m., LN #10 was interviewed. The LN stated she was a charge nurse on the evening shift. When asked who trained staff on mechanical lift transfers, LN #10 stated, "The RSA does a lot, and other CNAs." LN #10 added that "nursing management" also provide training. When asked who, however, the LN stated she did not know. On 8/22/12 at approximately 5:00 p.m., the DNS was interviewed by the survey team. When asked, the DNS stated that the RSA (CNA 11), whom she said had worked at the facility for many years, trained staff on mechanical lift transfers. She stated that staff were trained for 1 day during new employee orientation and at yearly skills fairs. She added that the skills fair had not yet occurred in 2012. When asked who checked the RSA's competency on mechanical lift transfers, the DNS stated, "She probably hasn't been in a while. She was trained by a PT (physical therapist). And at skills fairs." The DNS was asked to provide evidence of staff training and proficiency related to mechanical lift transfers. When asked about mechanical lift transfers for Resident #7, the DNS stated, "Did she scream? She will tell you if she feels unsafe. It's her choice to use the Sara lift. If you try to put her in a Hoyer... If she felt unsafe she would let you know. I know it looks horrible. I believe it appears she could slip out of it. She doesn't hold on." When asked about sling sizes, the DNS stated the Sara 3000 slings were small, medium, and large. When asked what criteria was used to determine if a lift was appropriate for a resident, the DNS stated, "(RSA's name) would have that. You would have to ask (RSA's name). I don't believe she has anything written." When asked who provided education and training to staff, the DNS stated the facility did not have anyone designated to do that. On 8/22/12 at 6:00 p.m., the DNS provided a CNA Orientation Checklist for CNA #8 and a blank Mechanical Lifts Skills Check-off Sheet. The DNS also provided a CNA Skills Fair inservice log, dated 7/13/11, with the signatures of 13 staff. The DNS stated, "I can't find the individually signed sheets." CNA #8's Orientation Checklist included 4 columns, titled, "Competency, Self Evaluation, Date & Initial Shown by Staff, (and) Date & initial Demonstrated to Staff." It also contained a section titled "Restorative" which documented CNA #8 was checked off for transfer training on 11/21/11 by the RSA. (NOTE: The Orientation Checklist did not specify if the transfer training included mechanical lift transfers.) On 8/22/12 at approximately 7:00 p.m., the Administrator and the DNS were apprised of the immediate jeopardy for Resident #7 related to unsafe mechanical lift transfers. The DNS stated, "I knew they look bad. That's just (resident's name)." The DNS stated the resident had refused to use a larger sling or the facility's larger mechanical lift, the MaxiMove. The DNS was asked to provide documentation of Resident #7's refusals and that the facility provided education and information to the resident regarding the potential consequences of refusals. The DNS was also asked to provide documentation that the resident was assessed to determine the type of transfer and equipment was appropriate and safe for the resident. The DNS indicated there may not be any documentation but said she would look. On 8/23/12 at 10:35 a.m., the Administrator was asked if the facility had a PT. He stated, "Yes, he's here every day 5 days a week." When asked who oversaw the Restorative Program, the Administrator stated, "It would be the DNS." At that time, a copy of the manual for the Sara 3000 mechanical lift was requested. On 8/23/12 at 12:05 p.m., the PT was interviewed by the survey team. When asked how the PT was involved with residents in the facility, the PT stated he saw new residents, performed evaluations, set-up treatment plans, and provided therapy in the facility. The PT stated he had seen 1 or 2 residents for skilled therapy in the last 6-8 months and "a couple" of residents on part B Medicare in the last year. When asked how often he was in the facility, the PT stated, "If I have a resident, it could be every day." The PT stated that he set-up the restorative program and talked with the RSA by telephone "quite often." The PT stated the RSA would call him anytime if there was a problem or a decline in the functional status of a resident and he would screen or re-evaluate the resident. When asked about Resident #7, the PT stated it was "probably 2 years ago" that he saw Resident #7 professionally. When asked about Resident #7's strength, the PT stated, "She has no strength in her lower extremities, 0/5 (zero out of five)." The PT stated, "She's a tough transfer." The PT stated he had not seen a transfer for Resident #7 in the last year. He also stated, "They haven't contacted me in the last year." When asked about Sara lift transfers for Resident #7, the PT stated, "She needs to hold on. And taking into consideration her lack of trunk and upper body control, with 1 person it's gonna be tough. Her pelvis should not be to the side." The PT added, "Lift transfers would be better with 2 (people). The only way 1 person could do it is from behind her and push up her bum." The PT stated, "To correctly position (Resident #7) in the Sara lift someone would have to stand behind her, wrap their arms around her to keep her arms in place. Someone else would have to operate the lift." When asked about head/neck control, the PT stated the facility had tried a neck brace but the resident did not like it and would not let the staff put it on her. In the morning on 8/24/12, the Administrator informed the survey team the PT would evaluate Resident #7 that day. On 8/24/12 at approximately 11:25 a.m., the PT was interviewed again. The PT stated he evaluated the Sara lift transfer for Resident #7 and the resident's feet were well placed and completely secure. He stated, "She is completely fine with the transfer, she feels safe." When asked about the resident's alignment, the PT stated, "Her pelvis does move to that one side when they move her to take her to the toilet. That's when they need a second person to maintain her pelvis in a neutral position. She is very cognitive and she will let them know if she is not comfortable." The PT stated he had watched 2 CNAs perform the transfer. He stated, "I watched them do it and directed them how to do it." When asked if he had assessed Resident #7, the PT stated, "It was just a transfer assessment." When asked about criteria for mechanical lift transfers, the PT stated, "Body positioning, it starts with the feet, not moving, and correct ergonomics." The PT stated Resident #7 "slightly sagged down" during the transfer. When asked, he stated the sling was placed around the resident's lumbar and thoracic region and the straps were under the residents "armpits" during the transfer. The PT stated that sling straps are always under the arms during transfers for most residents. The PT stated a bucket type sling would be the safest for Resident #7 but, "She absolutely refuses." The PT stated, "She could hold on with one hand, but not much." He demonstrated by flexing his right 3rd, 4th, and 5th fingers slightly. The PT stated the resident's arms were "up and over the bar" and they were held in place "by gravity." The PT stated, "She really doesn't have any grip strength. None. Not really. None." When asked, the PT stated, "I've never been trained on that lift." When asked if he had read the Sara 3000 instruction manual, the PT stated, "No. I look at biomechanics. If they are proper, I don't need to see instructions." On 8/24/12 at 9:00 p.m., the Administrator was asked to provide all therapy documentation for Resident #7 since admission, including the 8/24/12 PT note. On 8/27/12 at 11:22 a.m., the 8/24/12 PT progress note was received from the facility by fascimile (fax). The PT progress note documented, "Transfer evaluation today (with) sara (sic) 3000 lift (with) (resident's name). Transfer is appropriate (and) safe (and) patient is secure in lift. Taught on proper foot placement on pedals (and) proper strap on calf adjustment. (Two) CNAs performed transfer safely. I was needed for minimal assistance to position hips (and) pelvis during transport to toilet." On 8/27/12 at 12:27 p.m., a 14 page fax, including a cover page, was received from the facility. Included in the fax, were 2 therapy documents for Resident #7. One, a PT D/C (discharge) Summary, dated 10/4/04, documented the resident was evaluated on 6/18/04 and D/C on 10/1/04. In addition, it documented the resident's ADL/Functional findings on D/C were, "Functional Activities Overhead Severe Impairment." The other document, an occupational therapy evaluation, was dated 8/15/03. No other therapy documents for Resident #7 were received from the facility. NOTE: The Operating and Product Care Instructions for the Sara 3000 documented, in part, "Safety Instructions Before using...familiarize yourself with the various parts and controls...Then please read this whole manual thoroughly...Information in the manual is crucial to the proper operation...A second attendant may be required with certain patients." And, "Using Your Sara 3000...Patients who can only hold on with one hand, such as those who have suffered a stroke, may still be lifted with the Sara 3000, but their disabled arm should be held down in front of the body during the lift by the attendant (or a second attendant), while their functioning hand holds the patient support arm... ! Caution: Only use this or other methods after a satisfactory professional assessment has been carried out on the individual patient." Residents with a [DIAGNOSES REDACTED]. Poor body alignment and full body weight on the underarms during mechanical lift transfers increased that risk and created the potential for falls as well. The facility failed to evaluate Resident #7 to determine the type of transfer that was appropriate and safe for her; or, to recognize that transfers by 1 staff using the Sara 3000 and the sling in use was unsafe for the resident. The facility also failed to inform and educate the resident regarding the potential risks related to the transfers with the Sara 3000 and/or the sling that was in use. This placed Resident #7 at risk for pathologic fracture(s) and possibly falls, which could result in other fracture(s) and/or other injury. 2. On 8/22/12, at approximately 3:43 p.m., CNA #8 was observed in attendance to Resident #7 who was seated in an electric wheelchair (e-w/c) that was near the middle of the Old Farm Lane hallway by room 132. A Sara 3000 mechanical lift was in front of the resident. About this time, the MDS nurse walked past and looked at the resident and the CNA in the hallway; and, moments later, the DNS walked past the resident and CNA. The resident's communication was placed on the floor next to the wall by room 132. CNA #8 used the Sara lift to transfer the resident from the e-w/c into the toilet/shower room across the hall from beauty shop. For about 7 minutes, the resident's e-w/c and communicator device/clip board/non-slip material were unattended in the hallway. During those 7 minutes, random Resident #16 was observed to ambulate between Resident #7's e-w/c and the communicator device on the floor; and, random Resident #17 was observed as he wheeled his e-w/c between Resident #7's e-w/c and the opposite wall with his animal companion by his side. At 3:51 p.m., CNA #8 was observed as he brought Resident #7 back to her e-w/c in the hallway using the Sara lift. About that time, random Resident #16 ambulated between the opposite wall and Resident #7, CNA #8, and all of the equipment in the hallway. Once past them, random Resident #16 turned around and watched briefly as CNA #8 worked with Resident #7. Moments later, random Resident #13 ambulated with his walker between the opposite wall and CNA #8, Resident #7 on her e-w/c, and the Sara lift. Resident #'s 13, 16, and 17 were at risk for falls and/or injury related to obstructed hallways. On 8/27/12 at approximately 4:20 p.m., the Administrator was informed of the issue. However, no other information was received from the facility. 3. a) On 8/20/12 at 6:05 p.m., Random Resident #13 was observed in his recliner in his room. The resident wore an oxygen (O2) nasal cannula (NC) that was connected to a portable O2 tank. The portable O2 tank was placed on the left front of the platform of the resident's 4 wheeled walker (4WW). A short strap secured the top of the portable O2 tank to the top bar on the 4WW. However, the O2 tank was leaned over approximately 45 degrees and the bottom of tank was not secured. When asked about the portable O2 tank, the resident stated, "I use it that way." The resident denied that the tank had ever fallen or caused balance problems when he walked. Resident #13's most recent quarterly MDS assessment, dated 6/12/12, coded, in part: * BIMS of 15 (cognitively intact); * Independent with all ADLs, except toileting and bathing, without any human assistance; * Balance not stable during walking or turning around and facing the opposite direction while walking, but able to stabilize without human assisance; * No functional limitations in range of motion; and * Use of a walker. b) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 6/12/12, coded, in part: * BIMS of 15 (cognitively intact); * Independent with all ADLs, except dressing and bathing, without any human assistance; * No functional limitations in range of motion; * No balance problems during walking or turning around and facing the opposite direction while walking; and * Use of a walker. On 8/20/12 at 6:10 p.m., Resident #5 was observed seated at the piano in the Activities room. The resident wore an O2 nasal cannula that was connected to a portable O2 tank. The portable O2 tank was placed on the left front of the platform of the resident's 4WW. A short strap secured the top of portable O2 tank to the top bar on the 4WW. However, the tank was leaned over approximately 45 degrees and the bottom was not secured. c) Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/14/12, coded, in part: * BIMS of 7 (severe cognitive impairment); * Limited assistance of 1 person for transfers and to walk in room and corridor; * Balance not steady, only able to stabilize with human assistance while walking (with an assistive device, if used) and when turning around and facing the opposite direction while walking; * Functional limitation in range of motion with impairment on 1 upper and 1 lower extremity; * Use of a walker and a w/c. On 8/20/12 at approximately 6:15 p.m., Resident #4 was observed in the dining room. The resident wore an O2 NC that was connected to a portable O2 tank loosely hung at the back of the resident's wheelchair (w/c). The O2 tank was not in a case. A long strap on the O2 tank was looped several times around the short handles at the back of the w/c; however, the strap did not have any type of latching mechanism to keep it from slipping or falling. d) On 8/20/12 at approximately 6:15 p.m., Random Resident #14 was also observed in the dining room. The resident wore an O2 NC that was connected to a portable O2 tank loosely hung on the front of the resident's front wheel walker (FWW). The O2 tank was not in a case. A long strap on the O2 tank was looped several times on the front of the FWW. However, the strap did not have any type of latching mechanism to keep it from slipping or falling. Resident #14's most recent quarterly MDS assessment, dated 7/24/12, coded, in part: * BIMS of 9 (cognitive impairment); * Extensive assistance of 1 person for transfers; * Limited assistance of 1 person to walk in room and corridor and locomotion on the unit; * Balance not steady, only able to stabilize with human assistance when walking (with an assistive device, if used) and when turning around and facing the opposite direction while walking; * No functional limitation in range of motion; and * Use of a w/c. On 8/20/12 at 7:25 p.m., the survey team informed the Administrator and DNS of concerns that portable O2 tanks were not securely attached to residents' mobility devices; and, that portable O2 tanks on walkers could alter residents' balance. They were asked to provide evidence that portable O2 tanks were safe when hung on walkers and wheelchairs. The DNS indicated that they would put the portable O2 tanks in backpacks (cases) and secure the backpacks onto the mobility devices. On 8/21/12, at 10:45 a.m., 3 documents were found on the table in the room where the survey team worked. The documents stated, in part: * Walkers, "WARNING...DO NOT hang anything other than the manufacturer's recommended accessories on the front of the walker..." * Deluxe Rollator (also called 4WW), "Operating Instructions...Sitting on your rollator...When sitting down on the rollator, DO NOT lean to one side or the other. Be sure to distribute your weight evenly at all times. * Oxygen Cylinder Holder For Adjustable ASBA (unknown acronym), "The Invacare oxygen cylinder holder is designed to be used in conjunction with size D or E oxygen cylinders ONLY." After that, residents' portable O2 tanks were observed in backpacks as follows: * Residents # 5 and 13 - secured in the middle at the front of each of their 4WW; * Resident #4 - secured at the back of the resident's w/c; and * Resident #14 - secured in the middle at the front of the resident's FWW. On 8/21/12 at approximately 3:35 p.m., the DNS was asked about the 3 aforementioned documents. The DNS stated she had tried for 4 hours to find information about portable O2 tanks used with mobility devices. She stated, "That is all there is." On 8/23/12 at 12:05 p.m., the Physical Therapist (PT) was asked about mobility device safety with portable O2 tanks hung on them. Regarding FWW, the PT stated, "It they get too front heavy they can tip over." He suggested that portable O2 tanks should be secured in the center on the inside of FWW. He stated, "If it (O2 tank) is on the outside, it could throw the off balance, depending on the resident." Regarding portable O2 tanks themselves, the PT indicated that tanks filled with liquid O2 "should be vertical but slanted slightly is okay." No other information was received from the facility. 4. On 8/24/12 from 12:50 to 1:05 p.m., Residents #'s 8, 16, and 19 were observed as they ambulated independently from the dining room area and through the hallway where the IT (internet technology) room, next to the Administrator's office, was observed to be wide open. A sign was noted on the IT room door. It read, "Please leave this door open." In the IT room were numerous computer components on the floor to the right of the open doorway. Included in the components on the floor was a hard drive terminal that stood vertical (upright), and, which if bumped, could fall over. A black cabinet, about 4 feet tall, was directly in line with and approximately 4 feet from the open doorway. On the top of the black cabinet, at the edge of the right front corner, was a horizontal hard drive terminal with a flat screen monitor and key board on top of it. If bumped or pulled, the monitor, key board, and possibly the hard drive terminal could fall off the cabinet. To the right of the black cabinet was a shelving system that stood approximately 6 feet tall. This shelving system contained computer components with approximately 100 long wires of various colors (yellow, red, gray, blue, and black) that connected the components together. Should one get tangled up in the wires or pull on the shelving system, it could fall over. During the aforementioned 15 minute time frame, random Resident #16, then Resident #8, and then random Resident #19 were observed to ambulate independently from the dining room area and through the hallway where the open IT room was located. On 8/24/12 at 1:05 p.m., the Plant Operations Manager (POM) was asked about the open IT room. The POM stated, "We are in the process of moving to a better room." He agreed that the open IT room could be hazardous because of the computer equipment and wires. He immediately closed the door. On 8/24/12 at 8:30 p.m., the Administrator and DNS were informed of the potential hazard related to the open IT room. However, no other information was received from the facility.