Every finding on record at Owyhee Health & Rehabilitation Center

Based on observation and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents and ensure medication were prepared following standards of practice. This was true for 3 of 3 medications carts observed. This failed practice created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include: 1. On 8/19/25 at 11:44 AM, the middle medication cart was observed outside the dining room left unlocked. The CMA assigned to the medication cart was not present. On 8/19/25 at 11:46 AM, the DON stated the medication cart should not have been left unlocked. 2. On 8/18/25 at 1:25 PM, A medication cart was observed in the 200 hall across from the nurse's station against the wall and unlocked. On 8/18/25 at 1:30 PM, LPN #2 stated she was called into room [ROOM NUMBER] and forgot to lock her medication cart before she walked away. 3. On 8/18/25 at 11:46 AM, during a dining room observation LPN #1 was observed administering medications in the dining room and returning to her medication cart. She then proceeded to unlock her medication cart, open the top drawer, and remove a medication cup with multiple white tablets in it out of the right corner compartment. During the observation additional medication cups with medications in them were observed in the compartment. Upon inspection of the top drawer 5 medication cups were observed with multiple medication tablets. Next to the 5 medication cups was a Lantus insulin pen primed with 18 units and noted to have a safety needle tip. On 8/18/25 at 11:48 AM, LPN #1 stated 2 out of the 5 medication cups contained narcotics (opioid medication). LPN #1 stated she had already signed them out of the narcotic log. When asked if this was standard practice LPN#1 stated no she should prepare the medication as she is ready to administer. She also stated she did not see a concern with keeping the insulin pen uncapped and primed in the top drawer.

Based on observation, staff interview, and record review, and the FDA Food Code, the facility failed to ensure food was maintained at appropriate temperatures, sanitation practices were followed, and expired food was discarded from the dry storage unit. This deficient practice had the potential to affect 55 of 56 residents who consumed food prepared by the facility, creating the potential for adverse outcomes including foodborne illness. Findings include:1.The FDA Food Code Section 3-501.16(A)(2) states that Except during preparation, cooking, or cooling, potentially hazardous food (time/temperature control for safety food) shall be maintained at a temperature of 41 degrees Fahrenheit or below. a. On 8/18/25 at 11:39 AM, during a lunch observation, refrigerator #1 in the dining room contained Boost Breeze and multiple Mighty Shakes. A thermometer on the second shelf read 50 degrees Fahrenheit. A review of refrigerator #1's temperature log dated June 2025 to August 2025, showed temperatures within proper range. On 8/20/25 at 7:21 AM, the Certified Dietary Manager confirmed the 50-degree Fahrenheit reading and began discarding the Mighty Shakes.On 8/20/25 at 7:23 AM, the Administrator requested temperature checks. The following was observed:One drink located at the front of refrigerator #1 measured 50 degrees FahrenheitOne drink located at the back of refrigerator #1 measured 38 degrees Fahrenheit The Administrator stated that only Boost Breeze (which does not require refrigeration) should remain in refrigerator #1, and all other dairy products should be stored in refrigerator #2. b. On 8/18/25 at 1:31 PM, during a kitchen inspection, refrigerator #2 in the main kitchen was noted to be at 48 degrees Fahrenheit. On 8/20/25, temperature readings fluctuated: 7:10 AM: 32 degrees Fahrenheit 10:30 AM: 42 degrees Fahrenheit On 8/20/25 at 10:30 AM, [NAME] #1 stated she needed to discard all items in refrigerator #2 because 42 degrees Fahrenheit was in the danger zone.On 8/18/25 at 1:56 PM, the Certified Dietary Manager stated she was not concerned with a fluctuating temperature of 48 degrees Fahrenheit. On 8/20/25 at 5:11 PM, the Administrator stated after close monitoring of refrigerator #2 they believe it was having issues. All items in refrigerator #2 were discarded, and the unit was replaced. 2. The FDA Food Code Section 4-601.11 (C) Cleaning of Equipment and Utensils, documented nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, food residue, and other debris. On 8/20/25 at 10:30 AM, during a kitchen inspection, steam tray containers were observed in a cabinet with yellow residue, and baking sheets had thick brown residue. On 8/20/25 at 10:33 AM, [NAME] #1 stated the steam tray containers were dirty and the baking sheets were no longer in use, and they should have been removed from the kitchen. 3. On 8/18/25 at 1:31 PM, the following expired items were found in the dry pantry:White Vinegar Worcestershire sauceApple Cider Vinegar On 8/18/25 at 1:45 PM, [NAME] #1 stated the items were expired and they should have been removed.

Based on observation, glucometer manual review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The following was observed for hand hygiene:a) On [DATE] at 1:30 PM, Resident #62's meal tray was served to her in her room by CNA #1. Resident #62 was not offered or encouraged to perform hand hygiene before eating.On [DATE] at 1:34 PM, CNA #1 stated she did not offer Resident #62 hand hygiene and had not thought about it.b) On [DATE] at 10:10 AM, CMA #1 entered Resident #10's room with oxygen tubing and humidification bottle. She was observed donning a pair of gloves without performing hand hygiene and before administering Resident #10's oxygen. On [DATE] at 11:00 AM, the DON stated her expectation for all staff was to perform hand hygiene when entering and exiting all residents' rooms.c) On [DATE] at 1:37 PM, Resident #21's meal tray was served to her in her room by the CNA #2. Resident #21 was not offered or encouraged to perform hand hygiene before eating.On [DATE] at 1:43 PM, CNA #2 stated she did not offer Resident #21 hand hygiene, and she should have.The following was observed for proper storage of oxygen supplies:a) On [DATE] at 2:27 PM, observed Resident #21's nebulizer mouthpiece and tubing lying on her nightstand uncovered.b) On [DATE] at 8:10 AM, observed Resident #16's nebulizer mask lying in a chair, next to her bed.On [DATE] at 1:59 PM, the CRN stated the resident's oxygen supplies should have been stored in a bag after use.The following were observed for other infection control concerns:a) On [DATE] at 10:33 AM, CMA #1 was observed checking Resident #14's blood sugar using a glucometer (a device that measures the amount of sugar in the bloodstream at a specific time).After Resident #14's blood sugar was checked, CMA #1 used a Clorox Healthcare bleach wipe and wiped off the glucometer. CMA #1 did not follow the 3-minute dry time.EvenCare G2 glucometer user's guide documented: to disinfect your meter, clean the meter with Clorox Healthcare Bleach Germicidal and disinfectant wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's direction for use.The Clorox Healthcare Bleach Germicidal wipes package documented to disinfect surface, let the surface remain visibly wet for 3-minutes. Air dry.On [DATE] at 10:36 AM, CMA #1 stated she did not know the 3-minute dry time meant the glucometer had to be wet for the 3-minutes.b) On [DATE] at 10:39 AM, CMA #1 was observed cleaning the glucometer with a Clorox Healthcare bleach wipe. The Clorox Bleach wipe had an expiration date of [DATE].On [DATE] at 10:42 AM, the Administrator stated the expired Clorox wipes should not have been on the medication cart and should not have been used.c) On [DATE] at 7:23 AM, observed on the long-term care medication cart, a bottle of hand sanitizer with an expiration date of [DATE], and on the middle hall medication cart a bottle of hand sanitizer with an expiration date of [DATE].On [DATE] at 7:26 AM, the Administrator stated the expired hand sanitizer should not have been used.

Based on record review and staff interview, it was determined the facility failed to ensure the Minimum Data Set assessment accurately reflected resident's status.This was true for 3 of 3 residents (Resident #6, #10, and #33) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include:1.Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a group of lung diseases that block airflow and make it difficult to breathe), psychotic disorder, generalized anxiety disorder, and major depressive disorder. Resident #33's Annual MDS dated [DATE], documented in Section A - A1500 PASRR. Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was checked. On 8/20/25 at 1:42 PM, the MDS Coordinator stated Resident #33's Annual MDS should have been marked as having an MMI. 2. Resident #10 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including stroke with right sided weakness, immunodeficiency, pneumonia, major depressive disorder (MDD), and post-traumatic stress disorder (PTSD). Resident 10's Annual MDS assessment dated [DATE], documented under A1500 in Section A, no for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR level II observed in her electronic medical record, dated 5/2/25. On 8/20/25 at 9:30 AM, the MDS Coordinator stated Resident #10's MDS assessment was coded that the resident did not receive a PASRR Level II, and it should have been coded yes. 3. Resident #6 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including heart failure, diabetes, and long-term use of non-insulin antidiabetic drugs. a. A physician order dated 9/30/24 documented the following order: -Trulicity (an antidiabetic, GLP-1 agonist) Subcutaneous solution injection Pen-Injector 0.75 mg/0.5ml. Inject 0.75 mg subcutaneously one time a day every Wednesday for diabetes. Resident #6's Quarterly MDS assessment dated [DATE], documented under section N, a response of 1 for the question, Insulin injections – Record the number of days that insulin injections were received during the last 7 days. On 8/20/25 at 9:40 AM, the MDS Coordinator stated Resident #6's MDS assessment was coded wrong when she mistakenly thought the Trulicity was a form of insulin when in fact it was a GLP-1 agonist medication. b. A physician's order dated 3/7/25, documented the following: CPAP (continuous positive airway pressure used to treat sleep apnea – a sleep related breathing disorder) at night with 2 liters of oxygen. Resident #6's Quarterly MDS assessment dated [DATE], documented under section O, Yes for the question, Invasive mechanical Ventilator (ventilator or respirator). On 8/20/25 at 9:45 AM, the MDS Coordinator stated Resident #6's MDS assessment was coded that he was on a mechanical ventilator in error when he was actually on a CPAP machine at night.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 14 residents (Resident #10) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed. Findings include:The CMS SOM, Appendix PP, dated 8/8/24, documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including stroke with right sided weakness, immunodeficiency, and pneumonia.Resident #10's physician order dated 8/8/25, documented:-Apply oxygen via mask/NC (nasal cannula) at (2-6) LPM (liters per minute) continuous to keep oxygen saturation at or above 90%. Resident #10's care plan, initiated on 6/19/24, with most recent revision on 8/12/25, did not include oxygen therapy. On 8/20/25 at 9:00 AM, the MDS nurse confirmed Resident #10's care plan should have been updated to reflect the order for oxygen therapy.

Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 1 resident (Resident #14) reviewed for bowel and bladder care. This failed practice created the potential for Resident #14 to experience discomfort when her medications were not administered according to the physician's order. Findings include:Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including stroke, diabetes, and constipation.A Quarterly MDS assessment dated [DATE], documented Resident #14's cognition was moderately impaired.A physician's order, documented Resident #14 was to receive the following medications:-Dulcolax 10 mg (milligram) tablet, give one tablet by mouth every 24 hours as needed for no bowel movement after 3 days, ordered 5/14/25. -Milk of Magnesia (MOM, laxative) suspension, give 30 cc (cubic centimeter) by mouth every 24 hours as needed for bowel care if no bowel movement for 3 days, ordered 9/12/24.-Dulcolax suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel care if no results from MOM, ordered 5/14/25.-Fleets enema, insert 1 rectally every 24 hours as needed for bowel care if no result from Dulcolax suppository, ordered 5/14/25.Resident #14's Bowel Movement Records, dated 7/1/25 through 7/30/25, documented she did not have a bowel movement from: 7/23/25 through 7/27/25 (6 days).Resident #14's MAR, dated 7/1/25 through 7/30/25, documented she did not receive any bowel care medications when she did not have a bowel movement for 6 days.On 8/20/25 at 10:53 AM, the DON reviewed Resident #14's record and stated Resident #14 should have been administered prn bowel medications per the physician's' orders, and she was not.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 3 residents (Resident #10) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:Resident #10 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including stroke with right sided weakness, immunodeficiency, and pneumonia.Resident #10's physician order dated 8/8/25, documented:-apply oxygen via mask/NC at (2-6) LPM continuous to keep saturation at or above 90% every shift to keep O2 above 90% related to pneumonia.On 8/19/25 at 9:42 AM, observed Resident #10 resident in bed, oxygen tubing was in the bag attached to oxygen concentrator and concentrator was off. Humidification bottle observed to be empty.On 8/19/25 at 10:00 AM, with CMA #1, observed Resident #10 in her room without oxygen. When asked the CMA if Resident #10 should have her oxygen on, she stated no, because it is ordered for Spo2 less than 90%. CMA #1 could not provide documentation that Resident #10's Oxygen saturation had been monitored this morning. CMA #1 obtained a reading of Resident #10's Spo2 which was 86% on room air. She then confirmed Resident #10 should have oxygen administered.On 8/19/25 at 10:10 AM, observed CMA #10 leave resident #10's room and return with tubing and humidification bottle. She was observed to not perform hand hygiene when she left the room and when she re-entered the room. She obtained a pair of gloves and donned them before administering Resident #10's oxygen and setting the concentrator at 2 LPM. She was not observed to recheck Resident #10's Spo2 after administering the oxygen.On 8/20/25 at 11:00AM, the DON stated staff should record oxygen readings in the EMR and her expectation is that the physicians' orders are followed regarding oxygen therapy. The DON also stated her expectation for all staff is to perform hand hygiene when entering and exiting all residents' rooms.

Based on observation, staff interviews, and record review, the facility failed to ensure that the approved menus were followed and updated to reflect actual food served. This failure created the potential to affect the nutritional adequacy and dietary preferences of 55 out of 56 residents who consume meals prepared by the facility. Findings include:On 8/20/25 at 8:04 AM, during a tray line observation [NAME] #1 was observed preparing breakfast trays with egg omelets, bacon, and cream of wheat. Additional options available were noted to be small, diced sausage, hard-boiled eggs, toast upon request. During the observation she was noted to be attentive to the dietary slips ensuring diet recommendations were followed unless otherwise requested by the resident.On 8/21/25 at 11:18 AM, the Registered Dietitian stated the facility was on week 2 of the rotating menu. She confirmed that on 8/20/25, the menu should have included hot or cold cereal, seasonal fruit, hard-boiled egg, toast, butter, and jelly. The Registered Dietitian acknowledged that egg omelets were served instead of hard-boiled eggs and that bacon, which was not on the menu, was also served. She stated that the menu itself was not revised to reflect these changes.A review of the dietary menu documented 7 out of 14 meals had not been followed.On 8/21/25 at 11:22 AM, [NAME] #1 stated that seasonal fruit listed on the menu is typically served during snack times, not with meals as indicated.On 8/21/25 at 11:45 AM, the Certified Dietary Manager stated she did not know why it was an issue to provide resident with other options. She also stated sometimes they add a soup that is not on the menu.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented and maintained to provide a safe and sanitary environment to prevent the transmission of communicable diseases, including COVID-19 and infections for all 3 residents and staff who tested negative for 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. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. The facility's Infection Control and Prevention Policy for Emerging Infectious Disease: Coronavirus Disease 2019, dated 3/9/20, stated all Healthcare Personnel (HCP) who enter the room of a resident with known or suspected COVID-19 should adhere to standard, contact, and airborne precautions. The policy also stated, under the section for PPE, staff were to put on clean gloves upon entry to the resident's room or care area. The facility's COVID-19 Unit Plan, dated 11/11/20, documented all residents who tested positive for COVID-19 were placed on contact and droplet isolation precautions, and every encounter with the resident or entry into the resident's room required full PPE. These policies were not followed. The facility had three signs posted outside the door of resident rooms who had tested positive for COVID-19. One sign stated Contact Precautions were in place and directed staff to put on gloves and a gown prior to entering the room. The second sign stated Droplet precautions were also in place and instructed to staff to ensure their eyes, nose, and mouth were fully covered prior to entering the room. The third sign included instructions from the CDC on the use of PPE when caring for patients with confirmed or suspected COVID-19. a. On 11/23/20 at 10:08 AM, CNA #1 was observed prior to entering the room of Resident #9, Resident #10, Resident #11, and Resident #12. CNA #1 was wearing a gown, an N95 mask, and a face shield. She was not wearing gloves when she entered the room. At 10:16 AM, CNA #1 exited the room and had two black trash bags in her hands. She was not wearing gloves when she exited the room. CNA #1 said she put on gloves after she was in the room. When she was shown the signs outside the door, CNA #1 said she should have put on gloves before entering the room. b. On 11/23/20 at 11:42 AM, CNA #2 was observed in Resident #2's room. She was wearing a gown, an N95 mask, and a face shield. CNA #2 was not wearing gloves inside the room. CNA #2 placed a yellow cloth gown on Resident #2 and adjusted the blanket on his lap. CNA #3 then came into the room and wheeled Resident #2 out of the room in his wheelchair. CNA #3 was wearing a gown, an N95 respirator, and a face shield, but was not wearing gloves as he pushed Resident #2 in his wheelchair out of his room. CNA #2 said Resident #2 was going out to smoke, and she said she washed her hands and removed her gloves prior to assisting Resident #2. CNA #2 said she thought she only had to wear gloves when providing direct resident care. CNA #2 said she should have worn gloves when she assisted Resident #2 with putting on the gown and adjusting his blanket. c. On 11/23/20 at 11:58 AM, the CDM was observed in Resident #1 and Resident #3's room. She was wearing a gown, an N95 mask, and a face shield, and was not wearing gloves in the room. The CDM carried five plastic cups, which contained the remaining amounts of various drinks, and she placed them on the bottom shelf of a cart outside the door to the room. Another female staff was at the cart outside the door, and she poured liquid into several plastic cups and handed them to the CDM, who was just inside the doorway. The CDM delivered the drinks to Resident #1 and Resident #3, who were in their beds. The CDM was not wearing gloves when she delivered the drinks to Resident #1 and Resident #3. The CDM said the room was under precautions because the residents were COVID-19 positive, and she said when staff entered the room they were to wear a gown and a face mask. The CDM said she was not providing resident care and was just wiping down tables. The CDM said she was not wearing gloves in the room. When shown the sign outside the room that directed staff to put on gloves before entering the room, the CDM said, I missed that. d. On 11/23/20 at 12:00 PM, CNA #3 wheeled Resident #2 down the hall and into his room. CNA #3 was wearing a gown, an N95 mask, and a face shield, and was not wearing gloves as he pushed Resident #2 in his wheelchair. When asked about the signs outside Resident #2's door, CNA #3 said he did not know why the signs were there. CNA #3 said he took Resident #2 out to smoke, and he said staff were to wear a gown, gloves, a face shield, and a face mask in the room. CNA #3 said gloves were only needed when providing resident care. CNA #3 said he thought he had gloves on when he took Resident #2 out to smoke, but he did not have gloves on when he returned to the room with Resident #2. On 11/23/20 at 1:30 PM, the DNS said staff should put on gloves before entering a resident room that was on precautions. She said staff were to put on all PPE prior to entering the room as indicated by the signs outside the door. The facility failed to ensure staff wore gloves when in resident rooms and when providing care to residents who were COVID-19 positive. 2. The CDC website, accessed on 11/24/20, stated when putting on isolation gowns to tie all of the ties on the gown. The facility had signs posted outside the rooms from the CDC on the use of PPE which included instructions on how to put on and take off PPE. The instructions for isolation gowns stated to tie all of the ties on the gown. The instructions on the sign were not followed by staff. Examples include: - On 11/23/20 at 9:31 AM, CNA #4 was in outside the door of Resident #5's room and had on an N95 mask. She disinfected her face shield, and then took a clean gown out of the PPE bin in the hallway outside of Resident #5's door. She tied the gown at the neck and placed the gown over her head, dragging the inside of the gown over the front part of her face shield. She then tied the waist tie, performed hand hygiene, put on gloves, and went into Resident #5's room. - On 11/23/20 at 9:37 AM, outside of Resident #23's room CNA #2 took a clean gown out of the PPE bin in the hallway. She tied the neck tie and placed the gown over her head. The gown hung loosely around her neck and exposed her scrub top. CNA #2 did not tie the waist tie, and her back and sides were exposed. She then put on her face shield, performed hand hygiene, put on gloves, and went into Resident #23's room. At 9:48 AM, CNA #2 came out of Resident #23's room and had already taken off her gloves and gown. At 9:50 AM, CNA #2 disinfected her face shield and put on a new N95 mask. She then took a clean gown out of the PPE bin in the hallway. She tied the neck tie and placed the gown over her head. The gown hung loosely around her neck and exposed her scrub top. CNA #2 did not tie the waist tie, and her back and sides were exposed. She then put on her face shield, performed hand hygiene, put on gloves, and went into Resident #24's room. - On 11/23/20 at 11:30 AM, CNA #5 stopped in the hallway in the COVID-19 unit by the nurse's station, removed a clean gown from the PPE cart, and put on the gown. CNA #5 did not tie any ties on the gown. She walked down the hall to Resident #6's room and entered the room. When CNA #5 exited the room, the neck ties of the gown were tied. She then went into Resident #7 and Resident #8's rooms wearing the gown tied at the neck. The waist remained untied and her abdomen and back were not covered. On 11/23/20 at 10:06 AM, CNA #2 said she pre-tied the gowns to make it easier to put on. She said she should have tied the waist tie and said she did not. On 11/23/20 at 10:12 AM, CNA #4 said she should not have pre-tied the gown, and she should have tied the gown at the waist. On 11/23/20 at 11:38 AM, CNA #5 said she did not tie her gown because sometimes the gowns did not have ties. When asked if her gown had ties, she said it only had a tie at the neck. She said she should have used a gown with a waist tie. CNA #2 then handed a new gown to CNA #5. CNA #5 doffed the old gown and put on the new gown in the storage room. On 11/23/20 at 1:25 PM, the Infection Preventionist said staff were not to pre-tie gowns and put them on over their head. She said staff were to tie all ties on the gowns.

Based on observation, policy review, nationally recognized standards of practice, and staff interview, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination, including COVID-19. 1. The CDC guidance on Preparing for COVID-19 in Nursing Homes, the document the facility used as their policy for COVID-19 Infection Control, dated 5/19/20, documented to screen all staff at the beginning of their shift for fever and symptoms of COVID-19, have staff leave work if they are ill, and staff with a positive screening at entry were to leave the facility. The facility's staff screening and monitoring assessment tool, dated 4/30/20, directed staff to send employees home if they experienced a cough or shortness of breath or at least two of the following symptoms: * Fever (greater than 100 degrees Fahrenheit) * New loss of taste/smell * Repeated shaking with chills * Muscle pain * Headache * Sore throat * Chills The facility's Employee COVID-19 screening logs from 6/11/20 to 6/17/20, included columns with yes/no questions to be answered by individual staff as follows: * Temperature * SOB * Repeated shaking/chills * Gastrointestinal symptoms (Nausea/vomiting/diarrhea) * Muscle pain * Headache * Sore Throat * New loss of taste/smell * Contact outside of the facility with suspected or lab-confirmed COVID-19 * Traveled outside the state The last column on the screening log documented, Review screening answers. Recommend advanced screening by DON/ICP/Designees if yes to SOB, cough or temp (greater than) 100 or any two of the remaining symptoms. LN to sign. By signing you are indicating they are cleared to work. The facility's hourly employee timesheets from 6/11/20 to 6/17/20 were reviewed and compared with the employee COVID-19 screening logs from the same dates. The following inconsistencies were identified. a. Staff were identified who worked without being screened prior to the beginning their shift. * The screening logs and timesheets, dated 6/11/20, documented 2 CNAs, 1 NA and 1 LN were not screened prior to working their shifts. * The screening logs and timesheets, dated 6/13/20, documented 1 NA, 1 administrative staff, and 1 activities staff were not screened prior to working their shifts. * The screening logs and timesheets, dated 6/14/20, documented 7 CNAs, 3 NAs, 2 LNs, 4 activities staff, 2 housekeepers, 1 dietary staff, and 1 administrative staff were not screened prior to working their shifts * The screening logs and timesheets, dated 6/15/20, documented, 2 therapy staff, 3 CNAs, 2 NAs, 2 activities staff, and 1 administrative staff were not screened prior to working their shifts. * The screening logs, and timesheets, dated 6/16/20, documented 1 therapy staff and 1 activities staff were not screened prior to working their shifts. * The screening logs and timesheets, dated 6/17/20, documented 3 CNAs, 2 LNs, and 1 therapy staff were not screened prior to working their shifts. b. Staff who answered yes to 2 or more questions on the screening log did not have documentation they received further screening prior to beginning their shift. * On 6/11/20, CNA #1 answered yes to having a headache and sore throat. The column where the LN was to screen the staff member and sign was blank. Timesheet hours for 6/11/20, documented CNA #1 worked from 5:52 AM to 1:59 PM. * On 6/11/20, CNA #2 answered yes to having a headache and a sore throat. The column where the LN was to screen the staff member and sign was signed by CNA #2. Timesheet hours for 6/11/20 documented CNA #2 worked from 2:00 PM to 10:11 PM. * On 6/15/20, CNA #3 answered yes to having a cough and headache. The column where the LN was to screen the staff member and sign was signed by CNA #3. Timesheet hours for 6/15/20, documented CNA #3 worked from 9:47 PM to 6:07 AM. c. Columns on the staff screening logs were left blank, had a checkmark instead of answering the questions yes or no, or the screening log did not include the LN's signature. * On 6/12/20, CNA #2 left the column for temperature blank and the column where the LN was to screen the staff member and sign was signed by CNA #2. Timesheet hours for 6/12/20, documented CNA #2 worked from 2:03 PM to 10:34 PM. * On 6/12/20, 6 staff members' logs had checkmarks for responses to the screening questions instead of yes or no responses for the questions. * On 6/13/20, CNA #2 left the temperature column blank and the column where the LN was to screen the staff member and sign was signed by CNA #2. Timesheet hours for 6/13/20, documented CNA #2 worked from 2:02 PM to 10:15 PM. On 6/18/20 at 8:45 AM, in the entryway of the building was a sign on the wall which documented, Report any (signs and symptoms) to charge nurse before reporting to work station. RN #1 said staff screened themselves by documenting yes or no to the questions and taking their own temperature and recording it. She said if staff had a temperature or reported signs or symptoms on the log sheet they were to have a nurse screen them further. On 6/18/20 at 8:52 AM and 9:15 AM, the DON said staff screened themselves because she did not have enough staff to complete the screenings. She said facility staff knew to report any signs or symptoms to the charge nurse. The DON said she reviewed the screening logs several times a day to make sure they were accurate. On 6/18/20 at 10:10 AM, CNA #4 said he checked himself in at the front entryway, answered the questions on the screening log, and took his own temperature before each shift. On 6/18/20 at 10:18 AM, CNA #5 said she checked herself in at the front entryway, answered the questions on the screening log, and took her own temperature before each shift. On 6/18/20 at 10:32 AM, Housekeeper #3 said she checked herself in at the front entryway, answered the questions on the screening log, and took her own temperature before each shift. On 6/18/20 at 10:45 AM, Activity Assistant #1 said she came into the facility in the back of the building through the door next to the kitchen, used hand sanitizer, put on a facemask, and went through the dining room and hallway into the front entryway to check in before her shift. She said she checked herself in at the front entryway, answered the questions on the screening log, and took her own temperature before each shift. On 6/18/20 at 11:05 AM, the back door of the facility was unlocked. Just inside between the back door and the door leading into the dining room was a tray table with a box of surgical facemasks and a bottle of hand sanitizer. On the door leading into the dining room was a sign that documented, STOP Mask required to enter, 20 second hand sanitization required to enter. If staff came in through this door, they entered directly into the dining room and could either walk straight through the dining room into the main hallway and then into the front entryway or could come into the dining room and make an immediate right turn into a short hallway that connected to the main hallway. On 6/18/20 at 11:10 AM, Dietary Aide #1 said she came into the building in the back of the building through the door next to the kitchen, used hand sanitizer, put on a facemask, and went through the dining room and hallway into the front entryway to check in before her shift. She said staff walked to the front entryway, answered the questions on the screening log and took her own temperature before each shift. On 6/18/20 at 11:15 AM, the Van Driver sat in a chair by the front entryway. She said she was also a CNA and was asked to screen staff that morning. She said sometimes there was a staff member to check others in. The Van Driver said if there was not a staff member to check in staff, they checked themselves in at the front entryway, answered questions on the screening log, and took their own temperature before each shift. On 6/18/20 at 11:20 AM, the Business Office Manager said staff checked themselves in at the front entryway, answered the questions on the screening log, and took their own temperature before each shift. On 6/18/20 at 1:20 PM, the CDM said depending on where she parked in the morning, she entered the building either through the front or the back entrances. She said if she used the back entrance she sanitized her hands and put on a mask. She said she checked herself in at the front entryway, and answered the questions on the screening log and took her own temperature before each shift. On 6/18/20 at 2:15 PM, the DON said she expected staff to screen themselves, take their temperature, document the answers completely, and report any symptoms to the nurse on duty or to her. She said on 6/11/20, CNA #1 was re-screened by the nurse on duty when CNA #1 reported she had a sore throat and headache and it was due to a pet allergy. She said there was no documentation regarding the re-screen and the nurse did not sign the column and it was blank. The DON said staff were probably confused about the signature area and how they documented their answers because the screening log was changed to a different format on 6/10/20. She said staff were familiar with the old form where the answer 'no' was a check mark instead of an 'N' and might have been confused with the new form. The DON said if staff presented to work with symptoms of COVID-19 they were sent home if it was not allergy related. She said the back door was unlocked because the laundry room was across the back alley way and laundry staff needed to come and go from there. The DON said very few staff entered the back door to begin their shift. She said staff who entered the back door were expected to use the hand sanitizer and masks before they walked through the building to screen themselves in the front entryway. On 6/19/20 at 1:35 PM, the Administrator said there were some questions on the screening logs missing a response and some staff had not documented they screened themselves. She said she expected staff to screen themselves before reporting to duty. She said everyone was responsible to make sure the screening logs were completed. 2. The facility's Infection Control Policy for Laundry Services, dated 11/2007, directed staff to perform hand hygiene after handling soiled linens and to keep linens clean. The facility's hand hygiene policy, dated 8/2014, directed staff to perform hand hygiene after coming in contact with contaminated objects. These policies were not followed. On 6/18/20 at 10:15 AM, CNA #5 was in the rehabilitation hallway and had a plastic bag of soiled linen in her right hand, which was bare. She opened the door handle of the soiled utility room with her left hand and then opened the lid of the soiled linen barrel with her left hand and threw the bag into the barrel. She then left the soiled utility room and did not perform hand hygiene. CNA #5 then used the key pad lock to open up the clean linen room door, grabbed the handle with her right hand and retrieved a clean washcloth. She handled the washcloth with both hands and then delivered the washcloth to Resident #2 who was in her room. On 6/18/20 at 10:18 AM, CNA #5 said she did not perform hand hygiene after disposing of the bag with the dirty linen. On 6/18/20 at 2:15 PM, the DON said staff were to perform hand hygiene after handling soiled linens and before handling clean linen. 3. The facility's Long Term Care Facility Assessment Tool for Infection Control, undated, documented the facility would place a sign for residents on transmission based precautions including required PPE that was clear and visible on their door or next to their door. This was not followed. On 6/18/20 at 9:06 AM, Resident #1's room was observed to have a PPE cart outside his room. There was no signage outside of Resident #1's room regarding when and what PPE to wear. A urine analysis report, dated 6/7/20, documented Resident #1 had Escheria coli, ESBL confirmed and next to it was a handwritten note isolation. On 6/18/20 at 1:10 PM, LPN #1 said Resident #1 had a urinary tract infection and was on contact precautions due to Extended Spectrum Beta-Lactamase (ESBL) in his urine. ESBL was an enzyme produced by certain bacteria causing a urinary tract infection that could spread by direct contact with an infected person's body fluids. The CDC website, accessed on 6/22/20, documented ESBL enzymes broke down and destroyed some commonly used antibiotics, and made these drugs ineffective which meant there were fewer antibiotics available to treat ESBL producing bacteria infection. LPN #1 said a facemask, gloves and a gown should be worn by staff when they provided direct care to Resident #1. LPN #1 said a PPE cart and Stop please see the nurse sign were placed at residents' doors when they were placed in isolation. The surveyor and LPN #1 then looked at Resident #1's door. LPN #1 said there was not a sign outside Resident #1's room. On 6/18/20 at 9:38 AM, Housekeeper #1 was inside Resident #1's room mopping the floor. Housekeeper #1 was not wearing a gown. On 6/18/20 at 10:15 AM Housekeeper #1 said she knew what was inside the PPE cart, when Beautician #1 then joined the surveyor and Housekeeper #1. Beautician #1 said Housekeeper #1 spoke mainly Spanish and she would interpret for the surveyor. Housekeeper #1 said via Beautician #1, she wore a gown when the infection was big. When asked what she meant by that, Housekeeper #1 said there would be a sign at the door to see the nurse and she asked the nurse if she needed to put a gown on before entering a room with a PPE cart outside of it. Beautician #1, Housekeeper #1 and the surveyor went to Resident #1's room. Housekeeper #1 said there was no sign to see the nurse at the door of Resident #1. On 6/18/20 at 1:45 PM, the ICP said a sign was placed outside the door for the residents in the COVID-19 quarantine unit. The ICP said for other residents in isolation, staff placed a PPE cart outside the room and an alert message would be sent to the staff through their electronic health system to inform them of the required PPE. The ICP said staff passed isolation information on between shifts and by their telephone system. The ICP said Standard Precaution signs were posted by the nurse's station. The ICP said it was not in the facility's policy to put a STOP please see the nurse sign outside the residents' door because it was a Health Insurance Portability and Accountability Act (HIPAA) violation unless the resident was in a quarantine unit. 4. The facility's Laundry Services policy and procedure, revised 11/2007, documented all clean linens should be stored and transported in carts used exclusively for this purpose. On 6/18/20 at 9:38 AM, the housekeeping cart was outside of Resident #1's room. The housekeeping cart had a clear plastic container on top of it containing folded clean washcloths. On 6/18/20 at 10:47 AM, the housekeeping cart was outside of room [ROOM NUMBER]. The plastic container on top of the housekeeping cart contained several clean washcloths and a black colored round material was observed at the bottom of the plastic container. When Housekeeper #1 stepped out of room [ROOM NUMBER], Housekeeper #1 was asked to open the plastic container and show what was inside the plastic container. Housekeeper #1 opened the plastic container, took all the washcloths out of the plastic container and there was one white pillow case in the container. Housekeeper #2 then joined the surveyor and Housekeeper #1 and said she would interpret for Housekeeper #1. Housekeeper #1 said via Housekeeper #2, the washcloths and pillow case were clean. Housekeeper #1 said she replaced the residents' washcloths by their sinks and changed the residents' pillow cases if she was asked to by the residents. At the bottom of the container were five 1.5 volt batteries, several pens and markers, clothes pins, one apple sauce container, a pad of paper and a butterfly pin. On 6/18/20 at 1:10 PM, the Housekeeping Supervisor said clean linen should be transported in a clean container and there should be nothing in the container except clean linen.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure a) Residents were provided accurate information regarding Advance Directives upon admission, and if necessary they were assisted to formulate Advance Directives, b) Residents' records included a copy of the Advance Directives, or documentation of their decision not to formulate an Advance Directive, c) Residents' Advance Directives were recognized and honored, and d) The physician's orders [REDACTED]. This was true for 4 of 4 residents (#7 #13, #40 and #148) reviewed for Advance Directives. These failures created the potential for harm should residents not have their decisions documented, honored, and respected when they were unable to make or communicate their health care preferences. Findings include: The State Operations Manual, Appendix PP, defines an Advanced Directive as .a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The State Operations Manual also states a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an Advance Directive. The facility's policy for Advance Directive Documentation, revised (MONTH) 2007, documented the following: * At the time of admission, the facility provided written information to residents regarding Their right under State Law to accept or refuse medical treatment and the right to formulate Advance Directives such as the Natural Death Act, Durable Power of Attorney for Health Care Decision, or living will, in accordance with the Resident Self Determination Act. * The facility included documentation in the resident's record that written information was provided upon admission regarding Advance Directives and whether the resident had completed an Advance Directive. * The facility provided education to staff and residents related to Advance Directives. * The Admission Coordinator, Social Service Director or designee inquired whether the resident completed an Advance Directive and provided the Concerning Life Prolonging Procedures form if an Advance Directive did not exist. * When an Advance Directive was completed, it was reviewed to ensure it was signed and dated by the resident and it reflected their wishes. If the resident was no longer capable of making decisions independently, the Advance Directive was accepted. * Copies of the Advance Directive and conservatorship/guardianship were obtained and placed in the resident's record. * A written order was obtained from the physician to carry out the Advance Directive. * If the resident was capable of making decisions independently, assistance was provided to complete the desired documents if they wanted to complete an Advance Directive. * If the resident was not capable of making decisions independently, their decision maker was asked to document their wishes regarding initiating an Advance Directive for the resident. * All Advance Directive orders were reconfirmed monthly in the physician's orders [REDACTED]. On [DATE] at 11:02 AM, the DNS said the facility was trying to get rid of the POST (Physician order [REDACTED]. The top portion of the form included space for the resident's or the resident's legal guardian's name and date. It stated the resident or legal guardian requests the following care in the event that the attending physician determines that (the resident's) condition (be it injury, disease or illness) is terminal, incurable and irreversible, and that death is imminent): The form stated You must indicate Yes or No for each listed procedure. Yes means to do the procedure, No means DO NOT do procedure. The procedures listed for which the resident or resident representative was to indicate yes or no to, included: *Cardiopulmonary resuscitation (CPR) *Use of respirators or ventilators *Blood transfusion *Administration of medications other than those necessary to prevent infection, provide comfort, or alleviate pain *Transfer to an acute care hospital *Other, with two lines to document specific information The form documented I fully understand the impact and potential consequences of this document and wish to emphasize my desire to have the procedures performed or withheld (as indicated above) if death is imminent. The bottom portion of the form included spaces for the dated signature of the resident or guardian, physician, and a witness, and space for the attending physician's comments. The form addressed residents' wishes when death was imminent. It did not address residents' healthcare wishes if they were to become incapacitated and death was not imminent. The form did not address the right to establish a Living Will and/or Durable Power of Attorney for Healthcare. Idaho Code, Title 39, Chapter 45, The Medical Consent and Natural Death Act, specifies the required contents of a Living Will and/or Durable Power of Attorney in Idaho. It states the following: Any competent person may execute a document known as a Living Will and Durable Power of Attorney for Health Care. Such document shall be in substantially the following form, or in another form that contains the elements set forth in this chapter. The facility's Request Concerning Life-Prolonging Procedures form did not address residents' wishes regarding the administration of artificial or non-artificial hydration and nutrition, an element required for a living will under Idaho Code, Title 39, Chapter 45, The Medical Consent and Natural Death Act. 1. Resident #40 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #40's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented his code status was DNR and he did not want respirators, ventilators, blood [MEDICAL CONDITION], or sent to an acute care hospital. Resident 40's record included a Living Will and Durable Power of Attorney for Health Care, dated [DATE]. Resident #40's Living Will documented his code status was DNR. On [DATE] at 4:02 PM, the SSD said the facility copied residents' living wills and power of attorney documents and they were kept in the residents' records. She said the facility's Request Concerning Life-Prolonging Procedures form superseded residents' Living Wills and DPOA documents. The SSD said residents and their families had been educated that the Request Concerning Life-Prolonging Procedures form was the Advanced Directive. Resident #40's Living Will and Durable Power of Attorney for Health Care, were not recognized by the facility as his Advance Directives. 2. Resident #148 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #148's physician orders [REDACTED]. Resident #148's care plan documented he wished his code status to be Full Code, initiated on [DATE]. Resident #148's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented he wished to receive CPR, blood transfusion, medications other than those necessary to prevent infection, provide comfort, or alleviate pain, and transfer to the hospital. He did not wish to receive respirators or ventilators. The form was signed by Resident #148 on [DATE]. Resident #148's Social Services Assessment/Evaluation, dated [DATE] at 1:30 PM, documented his Advance Directive wishes included Full Code. Resident #148's record did not contain documentation an Advance Directive was offered, explained, or discussed with him. An Advance Directive was not present in Resident #148's medical record. On [DATE] at 4:15 PM, the SSD said the Request Concerning Life-Prolonging Procedures form was the documentation of Advance Directive information for Resident #148, and his code status was documented on the Social Services Assessment. 3. Resident #7 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #7's annual MDS assessment, dated [DATE], documented she had severe cognitive impairment. Resident #7's POST documented her code status was Full Code (resuscitate), and it was signed by her legal guardian on [DATE]. On [DATE] at 11:55 AM, Resident #7's physician orders [REDACTED]. Resident #7's record did not contain documentation an Advance Directive was offered, explained, or discussed with her legal guardian. A Progress Note, dated [DATE] at 3:23 PM, documented a care plan conference was held via phone call to Resident #7's guardian. Her code status was reviewed and it was Full Code at that time. A Request Concerning Life-Prolonging Procedures form was sent to her guardian by e-mail to replace her POST. Resident #7's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented no CPR and was signed by her guardian on [DATE]. Resident #7's record did not contain documentation an Advance Directive was offered, explained, or discussed with her legal guardian. On [DATE] at 4:09 PM, the Social Services Designee (SSD) said after the Request Concerning Life-Prolonging Procedures form was completed, she thought the nurse may have overlooked the need to update the physician's orders [REDACTED].#7's code status to Do Not Resuscitate (DNR). On [DATE] at 11:02 AM, the DNS said Resident #7's form came back to the facility after being completed by her guardian, and the physician's orders [REDACTED]. Resident #7's legal guardian was not provided information regarding Advance Directives and Resident #7's physician's orders [REDACTED]. 4. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented her code status was Full Code. Resident #13's POST, dated [DATE], documented her code status was DNR. Resident #13's physician orders, dated [DATE], and her care plan, documented her code status was DNR. On [DATE] at 3:24 PM, Resident #13 said when she came to the facility she wanted to be resuscitated but had since changed her mind and wanted to her code status to be DNR. Resident #13's record did not include an Advanced Directive. On [DATE] at 2:45 PM, RN #1 said she would find residents' Advanced Directives in the electronic medical record under the documents tab. RN #1 demonstrated how she looked for residents' Advanced Directives and navigated to where the Request Concerning Life-Prolonging Procedures form was located. On [DATE] at 4:02 PM, the SSD said Resident #13's record should have contained a new Request Concerning Life-Prolonging Procedures form when she changed her code status from Full Code to DNR. The SSD said the POST was not an Advanced Directive and staff should have filled out a new Request Concerning Life-Prolonging Procedures form for Resident #13. The facility failed to ensure residents' and residents' representatives were educated that their living wills and powers of attorney were Advance Directives and failed to educate them on what an Advance Directive was. The facility failed to honor residents' Advance Directives when they were directed to complete the Request Concerning Life-Prolonging Procedures form as the facility's recognized Advanced Directive.

Based on record review, policy review, and resident, resident representative, and staff interview, it was determined the facility failed to ensure transfer notices were provided in writing to the residents and residents' representatives. This was true for 2 of 2 residents (#13 and #29) reviewed for transfers. This created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's transfer and discharge policy, revised 11/2016, documented residents' records were to include the reason for transfers. The policy did not document that residents or residents' representatives were to receive a written notification of the reason for transfers. a. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's Nurse's Progress Notes documented she was transferred to the hospital for evaluation on 3/9/19 and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #13's record did not include a written notice of transfer to her or her representative. On 6/3/19 at 2:16 PM, Resident #13 said she did not remember receiving a transfer notice when she was transferred to the hospital. b. Resident #29 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #29's Nurse's Progress Notes documented she was transferred to the hospital for evaluation on 5/26/19 and was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #29's record did not include a written notice of transfer to her or her representative. On 6/5/19 at 10:13 AM, Resident #29's representative said the facility notified him via phone of the hospitalization . On 6/6/19 at 9:18 AM, RN #1 said when residents were transferred to the hospital their representatives were notified via phone, and they were not provided a written notice of transfer. On 6/6/19 at 9:37 AM, the Administrator said when residents were transferred to the hospital, the facility had not been providing written transfer notices to residents or their representatives.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a resident was appropriately assessed by a nurse after it was reported they had a [MEDICAL CONDITION]. This was true for 1 of 12 residents (Resident #4) reviewed for quality of care. This failure created the potential for harm should residents experience undetected changes in neurological status related to their disease process. Findings include: The Lippincot Manual of Nursing Practice, tenth edition, documented after a [MEDICAL CONDITION] a patient should be assessed for the degree of memory of recent events and coordination, paralysis, or weakness. The Lippincot Manual also stated the nurse needs to assess the length of time of the postictal state (the time after a [MEDICAL CONDITION] until the condition returns to normal) and pupil reaction. Resident #4 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #4's quarterly MDS assessment, dated 2/27/19, documented the following he had moderate cognitive impairment, required extensive assistance of 2 persons with bed mobility and transfers, and had two or more falls since admission or the prior assessment, with one fall resulting in injury. Resident #4's care plan documented the following: * He had a [MEDICAL CONDITION] disorder related to [MEDICAL CONDITION]. Interventions, initiated on 7/22/17, included assessing asap (as soon as possible) if [MEDICAL CONDITION] activity occured, and after [MEDICAL CONDITION] check vital signs and neurological assessments. Resident #4's physician orders [REDACTED]. * [MEDICATION NAME] (medication to control [MEDICAL CONDITION]) 750 mg daily and 1000 mg at bedtime, ordered on [DATE]. * [MEDICATION NAME] (medication to control [MEDICAL CONDITION]) 150 mg twice a day, ordered on [DATE]. An I&A Report, dated 6/1/19 at 5:34 AM, documented Resident #4 had [MEDICAL CONDITION] activity which caused him to land on his hands and knees on the ground next to his bed. A Nursing Progress Note, dated 6/1/19 at 5:35 AM, documented Resident #4 complained of dizziness and nausea. The nurse told him she would return with medication to help the dizziness and nausea. When the nurse returned to the room, Resident #4 was on his hands and knees on the floor, and he stated he had a really bad [MEDICAL CONDITION]. A Nursing Progress Note, dated 6/1/19 at 9:51 AM, more than 4 hours after the reported [MEDICAL CONDITION] activity, documented Resident #4 did not have further [MEDICAL CONDITION] activity. There was no documentation his condition was monitored or assessed after the reported [MEDICAL CONDITION] until that time. There was no documentation in Resident #4's record a neurological assessment or physical assessment was completed after he was found on his hands and knees and reported to the nurse he had a [MEDICAL CONDITION] on 6/1/19. On 6/5/19 at 10:16 AM, RN #1 said neurological assessments were done only if a resident hit their head when they fell . On 6/5/19 at 11:18 AM, the DNS said if a resident was not able to say whether they hit their head, then neurological assessments should be done, but if the resident said they did not hit their head then she probably would not do neurological assessments. The DNS said Resident #4 was able to tell staff whether he hit his head, and if he said he did not hit his head she would not do neurological assessments. On 6/5/19 at 2:06 PM, the DNS presented the policy for Neurological Assessment, dated 8/22/97, and said that was the way the nurses were trained. The DNS said neurological assessments should be done if there was evidence of head trauma or if the resident said they hit their head, and otherwise neurological assessments were not needed.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure fall prevention interventions were consistently implemented following resident falls. This was true for 2 of 2 residents (#4 and #45) reviewed for falls. This failure created the potential for harm should residents experience injuries from falling. Findings include: The facility's policy for Fall Protocol, revised (MONTH) 2007, documented if any significant, pertinent measures to reduce risk for falls have not been taken, and in a timely manner, then deficient practice may exist. 1. Resident #4 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. to move and maintain balance), repeated falls, and dizziness. Resident #4's quarterly MDS assessment, dated 2/27/19, documented the following: * He had moderate cognitive impairment. * He required extensive assistance of 2 persons with bed mobility and transfers. * He had two or more falls since admission or the prior assessment, with one fall resulting in injury. Resident #4's physician orders [REDACTED]. * [MEDICATION NAME] (medication to control [MEDICAL CONDITION]) 750 mg daily and 1000 mg at bedtime, ordered on [DATE]. * [MEDICATION NAME] (medication to control [MEDICAL CONDITION]) 150 mg twice a day, ordered on [DATE]. Resident #4's care plan documented he was at risk for falls related to a history of falling, generalized weakness, unsteady gait and balance, impulsive behaviors, and poor safety judgment. Interventions included the following: * One person assistance with transfers, initiated on 2/5/19 and revised on 5/6/19. * 4-P hourly rounds (hourly checks for pain, position, potty, and possessions), and ask if any assistance was needed, initiated on 10/31/17. * He wished for simple signs to remind him to call nursing for assistance, initiated on 5/16/18. * Non-skid strips in front of the toilet in the bathroom, initiated on 7/30/17 and revised on 9/19/17. * Safety notes that he could read to be posted in his room, initiated on 2/20/18. Resident #4's Fall Risk Evaluations documented he was at high risk for falls on 2/2/19 at 6:04 AM, 2/4/19 at 4:27 PM, 5/21/19 at 12:25 PM, and 6/2/19 at 2:23 PM. Resident #4's I&A Reports documented the following falls: * On 2/1/19 at 9:15 PM, he was found on the floor in his room. He attempted to self-transfer to get to the bathroom. * On 2/3/19 at 9:40 PM, he slipped and fell when attempting to self-transfer. Resident #4's care plan was updated to include one person assistance with transfers on 2/5/19. * On 2/21/19 at 1:00 AM, he was found on the floor in his room. He lost his balance when he self-transferred to the bathroom, and sustained abrasions to his forehead and right wrist. Additional interventions were not added to Resident #4's care plan following the fall. * On 6/1/19 at 5:34 AM, he was found on the floor on his hands and knees after the nurse told him she would return with medication for nausea. It was determined he had [MEDICAL CONDITION] activity which caused him to land on his hands and knees on the ground. Resident #4's care plan was not updated to include new fall prevention interventions. Resident #4 was observed in his room self-transferring from his wheelchair to his recliner or bed on 6/3/19 at 2:02 PM, 2:25 PM, and 2:30 PM. On 6/5/19 at 9:34 AM, Resident #4 was in his room leaning far forward in his wheelchair as he grabbed his recliner chair and moved it. Resident #4 leaned toward the floor, looked around the floor and room, and attempted to get behind the recliner while in his wheelchair. A male staff member entered the room and asked Resident #4 if he needed help. Resident #4 said he was trying to find the remote control for his television. The 4-P hourly rounds were documented once per shift on Resident #4's ADL (Activities of Daily Living) flowsheet section with a staff member's initial and time. The flowsheet did not contain documentation of the time each round was completed. Resident #4's Fall Prevention Devices flowsheet documented visual checks were completed by staff on two occasions from 5/8/19 through 6/6/19, on 5/26/19 at 10:05 AM and 6/2/19 at 3:29 PM. The non-skid strips were not present in Resident #4's bathroom, and safety notes were not posted in his room, as directed in his care plan, on 6/5/19 at 10:47 AM. On 6/5/19 at 10:52 AM, CNA #2 said she checked on Resident #4 a lot, and she was always looking to see where he was and reminding him to call if he needed anything. CNA #2 said Resident #4 usually tried to self-transfer into his recliner. CNA #2 said she checked on residents who were at risk for falls every hour, and Resident #4 was to be checked every 30 minutes or hourly. On 6/5/19 at 10:57 AM, RN #1 said Resident #4 was on every 15 minute checks in the past, but at the present time there was no direction regarding how often he should be checked. RN #1 said staff constantly walked by Resident #4's room to see what he was doing, and he knew how to use his call light but sometimes he would not use it. RN #1 said there were no posted signs or notes in Resident #4's room. On 6/5/19 at 11:18 AM, the DNS said the facility did just about everything they could think of to prevent Resident #4 from falling, including signs in his room to call the nurse for assistance. The DNS said staff were to do hourly 4-P checks, place his bed in low position, and keep slick blankets off his bed. The DNS said Resident #4 required one person assistance with transfers and he was not safe to self-transfer. The DNS said if staff saw Resident #4 go to his room they would try to catch him, but he may try to do what he wanted to do and he moved fast. The DNS said Resident #4 may not have signs in his room anymore because sometimes he took the signs down, and the facility was told signs could not be placed if resident information was displayed. The DNS said she did not know what to say about the non-skid strips not being in Resident #4's bathroom, there may have been a room change and the non-skid strips did not get moved. On 6/5/19 at 11:34 AM, the DNS said it was documented once a shift that Resident #4's hourly 4-P checks were done. On 6/5/19 at 12:07 PM, RN #1 said she was just reminded Resident #4 was on hourly 4-P checks, and the CNAs documented it. On 6/5/19 at 12:12 PM, CNA #2 said she was just informed by RN #1 that staff were to check on Resident #4 hourly, and they were to document it. CNA #2 said the hourly checks should not be documented just at the end of the shift, and they were previously documented on a sheet of paper but now it was entered in the computer. CNA #2 said there was no documentation of the times the hourly checks were completed for Resident #4. On 6/6/19 at 3:16 PM, the DNS said it was not possible to document hourly checks in the electronic medical record, so it was set up to document it each shift.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure staff performed appropriate hand hygiene during medication administration. This was true for 1 of 12 residents (Resident #32) reviewed for infection control. This failure placed residents at risk of infection from cross-contamination. Findings include: The facility's policy for Hand Washing, revised (MONTH) 2007, documented hand washing was the most important procedure to prevent facility-acquired infections. The Center for Disease Control and Prevention website, accessed 6/10/19, documented hand hygiene should be performed after touching a patient or their immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after removing gloves. On 6/6/19 at 11:41 AM, LPN #1 administered eye drops to Resident #32, removed her gloves, and did not perform hand hygiene. LPN #1 then picked up a blood glucose meter (a machine used to check the resident's blood sugar level) from Resident #32's bedside tray and returned to the medication cart. LPN #1 obtained an alcohol wipe from the medication cart and returned to Resident #32's room with the blood glucose meter. LPN #1 placed the blood glucose meter on the bedside table on a paper towel, cleansed the blood glucose meter with a disinfectant wipe, removed her gloves, and did not perform hand hygiene. LPN #1 applied new gloves and performed a blood glucose test on Resident #32's right third finger. The blood glucose meter read error. LPN #1 removed her gloves, did not perform hand hygiene, applied new gloves, obtained a new blood glucose test strip, and performed a blood glucose test on Resident #32's left index finger. At the end of the observation, LPN #1 said she did not perform hand hygiene after removing her gloves in Resident #32's room. On 6/6/19 at 2:40 PM, the DNS said she expected staff to perform hand hygiene with any contact with a resident when they might contact bodily fluids, before applying gloves, and after removing gloves.

Based on observations, record review and staff interviews, it was determined the facility failed to ensure hand hygiene practices were performed in a manner consistent with current CDC guidelines. This was true for 2 of 20 sample residents (#7 and #20) and for one kitchen staff member. This failed practice created the potential for residents to develop infections from cross-contamination. Findings include: 1. The facility's Handwashing Policy/Procedure, dated 5/2007, documented the following: * Hand washing is generally considered the most important single procedure for preventing nosocomial (facility acquired) infections. * Staff were directed to wet hands and apply soap to hands, rub hands in a circular motion for not less than 15 seconds, rinse hands with warm water, dry hands with a paper towel, and turn off the faucet using a paper towel. * Waterless hand cleansing products may be used in areas where a sink is not readily available; however, hand washing with soap and water should be completed as soon as possible. The Center for Disease Control and Prevention (3/7/16) documented the following recommendations for appropriate hand hygiene: * Hands should be washed before, during, and after food preparation, before eating, and before and after using the toilet. * Wet hands with clean, running water and apply soap. * Scrub hands for at least 20 seconds. * Rinse hands well under clean, running water. * Dry hands using a clean towel. * When using hand sanitizer, apply the sanitizer to the palm of one hand, rub hands together and rub sanitizer over all surfaces of hands and fingers until dry. Resident #7 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. On 3/5/18 at 11:45 AM, CNA #2 assisted Resident # 7 to the toilet in the resident's room. When Resident #7 was done toileting, CNA #2 assisted the resident to stand and cleansed the resident's peri area. CNA #2 assisted Resident #7 off the toilet and into her wheelchair, and then CNA #2 removed her gloves . CNA #2 did not perform hand hygiene and wheeled the resident out of her room and down the hall towards the dining room. CNA #2 said she should have washed her hands after assisting Resident #7 to the toilet and she did not. CNA #2 said hand hygiene should be performed after providing care to a resident. CNA #2 said hands should be washed for 30 seconds, or use use hand sanitizer until it's rubbed in. On 3/05/18 at 3:33 PM, CNA #1 was assisting Resident #20 to the restroom and after she assisted Resident #20 with her needs CNA #1 was observed washing her hands. CNA #1 turned the water on, put soap in her hand and rubbed her hands together for 3 seconds, and then rinsed her hands under running water. CNA #1 dried her hands with paper towels and turned the water off. CNA #1 assisted Resident #20 out of the restroom and repeating the process. On 3/09/18 at 9:16 AM, the Cook #1 was observed washing her hands. The Cook turned the water on, put soap in her hand and rubbed her hands together for 3 seconds, and then rinsed her hands under running water. Cook #1 dried her hands with paper towels and turned the water off. On 3/9/18 at 10:13 AM, the Infection Control Specialist LPN stated stated the observations described above were inappropriate forms of hand hygiene. The RN stated during cares staff should perform hand hygiene, prior to assisting residents, before transitioning from dirty to clean, and after cares were completed. The LPN stated gloves should be changed when transitioning from dirty to clean and hand hygiene as well performed. The LPN stated staff should wash their hands for a minimum of 20 seconds with soap and water and if hand sanitizer was used then until their hands were dry. The LPN stated she did not teach hand hygiene in the kitchen.

Based on observation, interview, and record review, it was determined the facility failed to provide written notice before a resident room was changed and to notify another resident of a new resident moving into the room. This was true for 2 of 2 sample residents (# 8 and #12) reviewed for a room change, and created the potential for harm should the resident experience a diminished sense of self-worth due to lack of control over their environment. Findings include: 1. The facility's Room to Room Transfer Policy/Procedure, dated 11/2016, documented the following: * The resident would be provided with advance notice of a room transfer, and the notice would include the reason for the recommended move. * Prior to the room transfer, the resident, his/her roommate, and the resident's representative would be provided with information regarding the decision for the room transfer. * A roommate would be informed of any new transfer into their room, including the reason for the transfer and any additional information that would be helpful to the roommate transition. Resident #8 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #8's quarterly MDS assessment, dated 2/2/18, documented moderate cognitive impairment. A Notification of Room or Roommate Change, dated 3/7/18, documented Resident #8 was moved to a different room and the resident was informed in person on 3/7/18. On 3/5/18 at 2:21 PM Resident #8 resided in room [ROOM NUMBER]. On 3/8/18 at 3:00 PM, Resident #8 was residing in room [ROOM NUMBER]. Resident #8 said she did not remember any details about moving into a different room. Resident #12 occupied the other bed in room [ROOM NUMBER]. On 03/8/18 at 3:04 PM, the DNS said she left a message for Resident #8's son the night before and left a message for her daughter earlier on the morning of 3/8/18 regarding moving the resident to a different room. The DNS said Social Services was not involved in the room change. The DNS said she filled out a room change form, which was an internal document used by the facility, and they did not provide a copy of the form or written notification to the resident or her family. On 03/8/18 at 3:10 PM, the Administrator said usually she and/or the DNS discuss room and roommate changes with the resident, and if the resident is agreeable to the move they will contact the resident's family. On 3/9/18 at 9:38 AM, Resident #8's family member said she received a message in the afternoon a day or two ago from the DNS regarding the resident moving into a new room. Resident #8's family member said she called back the next morning and was told they moved Resident #8 into another room because the facility was doing renovations. Resident #8's family member said she did not receive any written notification of the room change. 2. Resident #12 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #12's annual MDS assessment, dated 2/14/18, documented short term and long term memory problems. On 3/6/18 at 3:00 PM, Resident #12 was the sole occupant of her room (#23). On 3/8/18 at 3:00 PM, Resident #8 was residing in the same room as Resident #12. On 3/8/18 at 3:04 PM, the DNS said she talked to Resident #12 about getting a new roommate but did not talk to the resident's family. On 3/9/18 at 9:43 AM, Resident #12's family member said he received a call from the facility's Administrator the previous day around 1:00 PM that Resident #12 had a new roommate. Resident 12's family member said he talked to the resident last night she did not mention a roommate. Resident #12's family member stated they did not receive any written notification regarding a change in roommate status.

Based on observation, staff interview, and review of policies and procedures (P&P), it was determined the facility failed to ensure professional standards of quality were maintained for 1 of 1 residents (#190) sampled for tube feeding. Specifically, when Resident #190 was administered water via gastrostomy tube without proper positioning. This failed practice created the potential for harm if the resident aspirated and other complications arose related to the use of Resident #190's [DEVICE]. Findings include: 1. Resident #190 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 3/05/18 at 3:54 PM, Registered Nurse (RN) #1 was observed administering 60 cc of water via Resident #190's [DEVICE]. After the administration of the water RN #1 was ready to begin Resident #190's tube feeding administration. RN #1 was asked about the positioning of Resident #190 and she stated the resident's head of the bed was elevated. Resident #190's head of the bed was approximately at a 30-degree angle. Resident #190 had slid down in bed to where he was lying flat on his back, his feet were extended past the end of the bed, approximately 10 inches. On 3/5/18 at 3:54 PM RN #2 present during the observation assisted RN #1 with repositioning Resident #190 up in bed further. On 3/6/18 at 10:17 AM the Regional RN Consultant stated when administering any kind of medications, fluids, or tube feedings residents should be minimally elevated to 30 - 45 degrees.

Based on record review and staff interview, it was determined the facility failed to ensure residents receiving psychoactive medication monitored the efficacy of the medication. This was true for 1 of 5 (#32) sampled residents who received psychoactive medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need. Findings include: Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 2/16/18 documented Resident #32 had a moderate cognitive impairment and no signs or symptoms of depression. The [MEDICAL CONDITION] Medication Use Care Plan, dated 8/29/17, documented Resident #32 required the medication related to her [MEDICAL CONDITION]. The care plan documented Resident #32 was tearful, self-isolated, had delusional thoughts, and increased anger or agitation. The (MONTH) 9, (YEAR) Medication Regimen Review (MMR) documented Resident #32's depression medication was due for consideration of a gradual dose reduction (GDR). On (MONTH) 23, (YEAR) the physician responded to the pharmacist's recommendation to GDR the [MEDICATION NAME] by responding, pt (patient) has depression, hx (history) of [MEDICAL CONDITION], has severe delusions/hallucinations. Doing well, GDR contraindicated. The (MONTH) (YEAR) Physician orders [REDACTED]. Resident #32's Medication Administration Record [REDACTED]. Resident #32's Behavior tracking was on the [DATE]/1/18 through 3/7/18 which documented staff monitored Resident #32 for tearfulness, self-isolation, delusional thinking, and increased anger or agitation. The behavior tracking did not include hallucinations. On 3/9/18 at 11:49 AM, the DNS and the LPN #1 stated when Resident #32 first came to the facility she saw hallucinations. and had delusions. The DNS stated Resident #32 would focus on seeing her son and anger would control her life. The DNS stated the facility was not currently monitoring for hallucinations. The DNS stated she would correct the issue.

Based on observation and staff interview, it was determined the facility failed to ensure: *Bed canes were assessed as safe for resident use, and *Harmful chemicals were secured safely. This was true for 2 of 9 residents (#2 & #4) sampled for side rail use, and 1 of 3 storage closets in the facility's hallways. This failure created the potential for harm should a resident become entrapped in a device attached to their bed, and for any independently mobile, cognitively impaired resident who could access the unsecured chemicals. Findings included: 1. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and muscle weakness. Resident #4's clinical record did not identify the need for side rails and did not contain a side rail safety assessment. On 9/6/16 at 10:55 am and throughout the survey process, bed cane side rails on both sides of the resident's bed were observed in the upright position. On 9/8/16 at 9:20 am, the DON said Resident #4 did not have a side rail safety assessment because the facility did not consider bed cane side rails a safety hazard as they were there only to hold bed controls. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including insulin dependent Type II diabetes, COPD, CHF, and dementia. Resident #2's clinical record did not identify the need for side rails nor include a side rail safety assessment. During observations on 9/6/16 at 10:00 am and throughout the survey process, Resident #2's bed cane side rails were both observed in the upright position. When a side rail safety assessment was requested on 9/8/16 at 11:20 am, the DON stated Resident #2 did not have an assessment, as the cane side rails were not considered a restraint, but rather an assistive device. She stated the side rails would be removed that day. 3. On 9/6/16 at 9:07 am, the storage closet across from resident Room 23 was found to be unlocked. Inside on the shelf was a half full bottle of isopropyl rubbing alcohol that included on its label the following warning: Flammable . If swallowed contact Poison Control immediately . Do not apply to eyes. On 9/6/16 at 9:10 am, LN #3 said the isopropyl rubbing alcohol should not have been in an unlocked storage closet. LN #2 then took the bottle from LN #3, drained the alcohol down a sink in the nurses station, and disposed of the bottle.

Based on staff interview, medical record review and incident review, it was determined the facility failed to ensure that 1 of 10 (#5) sampled residents received care according to their care plan. As a result Resident #5 was harmed when staff failed to follow the resident's care plan to transfer the resident with a mechanical lift. This resulted in a fractured femur and eventual above the knee amputation. Findings include: Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 7/2/14 significant change MDS assessment documented the resident: - had short and long term memory problems, - was total assist with ADL cares, - required mechanical lift for transfers. On 6/6/14 the resident was found to have an injury to her left leg. On 6/6/14 at 8:10 p.m. the director of nursing documented a progress note of, "Resident was discharged to hospital this afternoon after it was reported that her L(eft) leg did not 'look right', (Physician name) notified and x'rays obtained which showed a L(eft) femur fracture." The facility's investigation report documented that on 6/6/14 at 9:15 a.m., "Charge Nurse (name) was coming down the hallway, meet (sic) her in hallway she stated that (resident name) leg does not appear normal something wrong with it. I went right to (resident name) room to assess her left leg. Left leg is swollen and disformed, (charge nurse name) gave her extra pain meds and I called Dr (name) getting orders for x-rays." The incident report documented the resident had a shower on 6/6/14 at 6:30 a.m. and the resident had a fall assessment of 16 (Note: date of assessment not documented.), which indicated she was at high risk for falls. The conclusion of the investigation determined that two CNAs transferred the resident to a shower chair using a two person stand and pivot transfer, rather that a mechanical lift as care planned. The pivot transfer resulted in a spiral [MEDICAL CONDITION]'s left femur. Resident #5's care plan, dated 4/23/14, (Note: This was the care plan in place when the incident occurred, not the current care plan.) documented a "Focus" of "ADL Self Care Performance Deficit, cognitive loss and severely impaired mobility Alzheimer's." One of the interventions was, "Transfers: Requires Hoyer lift transfers with staff assist of 2." On 11/4/14 at 3:30 p.m. the DON stated the incident was investigated as an injury of unknown origin. The bath aide and another CNA stated they performed an improper transfer of the resident. Both employees were terminated because they failed to follow the resident's care plan. The resident returned to the facility on [DATE]. The resident's medical record documented the resident had a knee immobilizer in place to support the fractured area. The residents legs were small and the facility had difficulty keeping the fractured area immobilized. Some of the nursing documentation was: On 6/10/14 at 5:37 p.m., an LN documented, "... readmitted from (Hospital name) at noon...Tylenol given for fever upon arrival. Resident alert and rocking in her normal type of movement. Appears that she may have pain related to leg fracture...Fracture to left femur near knee. No surgery (due to) (name) is not a candidate. Knee immobilizer in place. Superficial blister to back of left thigh with red irritation from brace noted. Sheepskin to top to keep from rubbing skin, staff to monitor (each) shift. Staff instructed to change position every 2 hours and support left leg carefully with each movement. Can be up in chair with proper support of leg..." On 6/11/14 at 10:02 p.m., an LN documented, "...Awake a lot of the day. Bed in low position fall mat on floor. A little restless but this is her norm. Routine pain meds have kept her calm and no non-verbal indicators such as furrowed brow, excessive restlessness. Was up in wheelchair at supper time. Hoyer lift used for transfers. After, tilted back and at nurses station so could be observed... Resident kept putting her leg over edge of the wheelchair. Replaced at least 7 times in a short period of time. Was put to bed and positioned on her side. Knee immobilizer in place with sheepskin lining...Position change and leg elevated when in bed but does not stay when she is restless. Did not have leg over edge of bed today..." On 6/13/14 at 3:21 a.m., an LN documented, "...Knee immobilizer in place to L leg...Noted bruise to L(eft) Labia. The top of the brace has rubbed when up in wheelchair causing her skin to bruise. Adjusted immobilizer to keep away from the labia when her body is in a bent position..." On 6/17/14 the physical therapist documented a late entry of, "Provided CNA training with pt (patient) on safety with Hoyer lift transfer and management of RLE (right lower extremity) during transfer. Provided instruction on bed mobility with management of RLE, positioning within Geri Chair with use of tilt component and LE positioning to maintain R knee in knee immobilizer with knee extension and good support. Pt continues to have lab (sic) buddy for positioning purposes as well..." (Note: the resident's LLE (left lower extremity) had the fracture and immobilizer not the RLE.) On 6/20/14 at 5:03 p.m., and LN documented, "...L leg immobilizer in place. Brace released and skin checked for pressure areas. Superficial peeling skin on the outer aspect of the L knee and lotion applied. Cleansed right groin superficial split in the skin. Area cleaned and barrier cream applied. Cont(inues) to have internal rotation of her L foot. Positioned with pillows carefully. Continue to monitor labia for bruising." On 6/21/14 at 3:06 p.m., an LN documented, "...During weekly SAR (skin at risk) last evening the following skin issue was noted to left lateral knee? (sic) Lateral L. knee has raised area which appears to be fluid filled with palpation. Warm to touch. Near bottom is a 0.5 whitish area with dark center? This afternoon it appears that a ? skin plug ? came out of lateral side of knee and created a 0.5 cm opening. A copious amount of serosanguinous fluid came at first, then only a small amount occasionally as she moved her knee. As we were cleaning the area and apply an ABD pad, (name) was moving her leg and knee. When she bent her knee the outline of a bone under the skin was visible that is approximately 1 cm above the opening..." On 6/22/14 at 4:21 a.m., an LN documented, "... Dressing changed to left knee. Copious amount of serosanguineous drainage noted to old dressing. 0.5 cm open area noted to lateral side of left knee with bone visible. No odor or warmth noted. Knee immobilizer carefully re-applied. Routine pain medication given and is helpful. No moaning or facial grimacing noted..." On 6/22/14 at 9:04 a.m., the LN documented, "(Physician Name) notified regarding bone protruding out of Left lateral knee. Gave new order to send to (Hospital name). The resident was admitted to the hospital and an above the left knee amputation was performed. The resident was readmitted to the facility on [DATE] for post-operative and long term care. The resident was harmed when two CNA staff failed to follow the resident care plan and performed a pivot transfer of the resident when she was care planned to be a mechanical lift. This inappropriate transfer resulted in a fractured left femur which eventually resulted in a left above the knee amputation.

Based on observation, staff interview, and record review, the facility failed to ensure: - a resident's sore on the coccyx that was healed did not reoccur, - a resident with a recurrent pressure sore was repositioned every 2 hours as care planned. - a catheter strap was not positioned and tight to cause a pressure blister on the leg. These issues were found on 1 of 9 (#3) sampled residents. Findings include: Resident #3 was admitted to the facility 12/11/09 with [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], documented the resident: - had moderate cognitive impairment with a BIMS of 9, - required total assistance with transfers, toileting, and bathing, - required extensive assistance with bed mobility, dressing, personal hygiene. - had a catheter, - did not have any identified skin problems. The resident had a care plan dated 2/20/13 that documented a problem of "Skin Tear (recurring) to coccyx." The interventions were: (Note: none of the interventions were dated.) "-Turn with turn sheet only - Requires 2 person for safety. Turn slow and gentle - do not pull on skin. - Nurse to monitor repositioning and peri-care each time doing et offer education to DCS (direct care staff) during cares. Vitamin C and Zinc per orders et added protein in diet." The resident's current care plan had multiple areas where skin issues were documented. Examples were: Problem: Diabetes Mellitus (initiated 10/4/13) Interventions: (Note: none of the interventions had a date associated with it.) - Check all of body for breaks in skin and treat promptly as ordered by doctor. - Check skin when assisting with ADLs. - Dietary consult for nutritional regimen and ongoing monitoring. - Ensure socks/hosiery are clean absorbent every day. Make sure that they are not too tight to hinder circulation. - Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Problem: Has potential impairment to skin integrity r/t decreased mobility and DM. (initiated 10/4/13) Interventions: (Note: none of the interventions had a date associated with it.) - Air Mattress overlay on bed. - Assist resident to turn and reposition q 2 hrs. (every two hours) - Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. - Educate resident/family/caregivers of causative factors and measures to prevent skin injury. - Encourage good nutrition and hydration in order to promote healthier skin. - Follow facility protocols for treatment of [REDACTED]. - Identify/document potential causative factors and eliminate/resolve where possible. - Keep skin clean and dry. Use lotion on dry skin. - Monitor/document location, size, and treatment of [REDACTED]. to MD. - Need assistance to apply protective garments: geri sleeves. - Needs pressure relieving pad in w/c and on bed to protect the skin. - Needs pressure relieving/reducing mattress and pillows to protect the skin while in bed. - Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. - Pad bed rails, wheelchair arms or any other source of potential injury if possible. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Problem: Has [MEDICAL CONDITION]. (initiated 12/11/13) Interventions: - Reposition or encourage resident to change positions every 2 hours. Problem: Has actual impairment to skin integrity r/t fragile skin on both upper thighs. (initiated 2/20/14) Interventions: (Note: none of the interventions had a date assosciated with it.) - Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. - Encourage good nutrition and hydration in order to promote healthier skin. - Follow facility protocols for treatment of [REDACTED]. - Identify/document potential causative factors and eliminate/resolve where possible. - Keep skin clean and dry. Use lotion on dry skin. Apply Duoderm per order. - Monitor/document location, size and treatment of [REDACTED]. to MD. - Pad sling to prevent rubbing and monitor for any other source of potential injury. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp object or hard surface. The February 2014 physician recapitulation orders documented: - Geri - Gloves to bilateral arms daily for protection on in AM off at HS. order date: 7/2/10 start date: 6/24/13 - Nurse to observe all pericare, turning,and repositioning each shift. Nurse to educate aide on providing tender care to protect skin. order date: 2/27/13 start date 6/24/13 On 2/22/14 a Braden Scale for Predicting Pressure Risk was completed and the resident scored a 16.0. This score was equal to Low Risk for pressure sores. The resident was admitted to the facility on [DATE] and the admission note by the LN documented: "....3.5 cm crack noted to coccyx..." The physician's "New Patient history and physical examination [REDACTED]. The patient does have some skin issues of denuded skin. The [MEDICATION NAME] is being applied and otherwise this should improve with hygiene and skin care." The facility was able to heal the area. On 10/15/2012 the physician documented during a "Nursing Home Visit" the resident had a "linear split at her coccyx region and it is a little bit sore and they want me to see the area...." The physician's "Physical Examination:" documented, "Extremities:...On the patient's upper gluteal cleft is approximately a 2.5 cm linear fissure like split at the upper gluteal cleft..." The "Assessment:" documented "1. Linear ulceration at the upper gluteal cleft." The facility was able to heal the ulceration with treatment. A review of the interdisciplinary progress notes (IDTPN) and LN-Skin assessment (LNSA) revealed the "slit" returned and also a catheter strap was too tight and caused a sore on her leg. Not all of the documentation will be included, only information specific to status of the slit and pertinent resident activities related to her skin issues. The documentation was: On 8/3/13 at 1:01 a.m. the IDTPN documented, "Barrier cream applied to split to buttocks...Aids (sic) educated to use draw sheet when turning resident and not to pull on skin..." On 8/7/13 at 1:10 a.m. the IDTPN documented, "No change in split inner buttocks crease below coccyx. Whitish in color but remains open however it is improving....Report stated she did not lay down hardly at all today. Air Mattress, position changes, heels floated,..." On 8/8/13 at 11:14 p.m. the IDTPN documented, "Inner buttocks split cleansed and skin paste applied...Leg strap for catheter. Has not wanted to lay down right after meals spending a lot of time in the wheelchair..." On 8/13/13 at 11:11 p.m. the IDTPN documented, "split to inner buttocks crease near total resolution again. Whitish in color but no open areas noted tonight with treatment....Resident sat up quite a bit this afternoon through supper and complained of legs bothering her. She does have complaints of pain when she does set up too long at any given time..." On 8/30/13 at 4:21 a.m. the LNSA documented the "Coccyx healing split measured .5 cm x .2 cm x .05 cm." The note failed to stage the area. The narrative documentation was, "Split in buttocks slightly opened .5 cm...Air bed in place and working. Repos(itioned) (every) 1 1/2 hours and (as needed). On 9/1/13 at 7:04 p.m. the IDTPN documented, "Split inner buttocks crease is open slightly....Encouraged to lay down between meals but frequently wants to stay up...." 9/12/13 at 3:15 a.m. the LNSA documented, "Coccyx area remains closed but fragile..." (Note: there was no documentation describing when the area on the coccyx closed.) On 10/10/13 at 3:15 a.m. the LNSA documented, "...Has .4 cm raised area anterior left thigh and also one above it. Placed catheter strap on opposite right leg to prevent friction....Coccyx intact..." On 10/15/13 at 3:22 a.m. the LNSA documented, "5 cm split to coccyx..." On 10/18/13 at 3:04 a.m. the LNSA documented, "Split on coccyx smaller than a few days ago at 2.5 cm..." On 10/25/13 at 3:04 a.m. the LNSA documented, "...Split on coccyx 2.0 cm (improved from last week and very superficial)....Left groin and left anterior thigh is pink. Leg strap was changed to right side..." On 10/28/13 at 9:33 a.m. the IDTPN documented, "It was reported to me that resident has a line of fluid filled blisters on the front of her right thigh where the catheter strap was sitting. it appears the strap was too tight...." On 11/8/13 at 3:04 a.m. the LNSA documented, "....Split on coccyx 3.0 cm....Left and right groin has 3 cm split noticed after shower...Healing blister 1 cm left right thigh..." On 11/15/13 at 3:04 a.m. the LNSA documented, "...Coccyx is now healed..." On 12/6/13 at 2:27 a.m. the LNSA documented, "Sacrum: fold split superficial, 6 cm..."(Note: no other information about this open area) On 12/13/13 at 2:27 a.m. the LNSA documented, "Sacrum: Superficial split 2 cm, Sacrum: Superficial split 1 cm." (Note: no other information about these open areas was documented.) On 12/14/13 at 2:29 a.m. the IDTPN documented, "...Buttock crease has two small open areas but the rest whitish and fragile. Will continue treatments as ordered until resolved." On 1/3/14 at 4:34 a.m. the LNSA documented, "Residents skin much improved...split in buttocks crease have resolved...." On 2/14/14 at 2:30 A.M. the LNSA documented, "Coccyx, skin tear, 4 cm x 0.5 cm, x 0.1 cm., Superficial open area noted to coccyx that was fragile in previous weeks...." On 2/21/14 at 4:16 a.m. the LNSA documented, "Superficial split in coccyx area is closed at this time but fragile..." At the time of the survey the resident's area on the coccyx was closed according to the nursing staff. Observation of the area was not done. The facility policies for "Skin Monitoring and Management - Pressure Ulcers" and Skin Monitoring and Management/ Non-Pressure Ulcers," dated 7/2010 were reviewed. Both policies had a section about assessment of wounds and open areas. These policies documented that the assessments should include: "a. Measurements... b. Staging... c. Describing the nature... d. Describing the location... e. Describing the characteristics... f. Describing the progress with healing, and any barriers to healing which may exist. g. Identifying any possible complications or signs/symptoms consistent with the possibility of infection." The documentation of the slit area on the coccyx failed to follow the policies, there was lacking documentation about section "f." information. The resident initially was observed during the survey on 2/24/14 at 8:05 a.m. in bed waiting for staff to get her up. The Aides got the resident up but the LN was administering medications and did not go and watch them transfer the resident to the wheelchair. The resident was observed to be returned to bed at 10:15 a.m. The resident had an air mattress overlay on her bed and a 1 1/2 inch cushion in her wheelchair. At 11:35 a.m. the resident was observed in the living area engaged in a balloon activity. The sling for the lift was noted to be in the wheelchair at that time. Resident #3 went to lunch in the dining room and after lunch at 12:45 p.m. was brought to the hallway and interacting with staff that walk by. The afternoon activity was B; ingo starting at 1:30 p.m. and the resident was involved in the activity. The resident was observed playing Bingo at 1:55 p.m. She had been out of bed since 11:35 a.m., a period of 2 hours, 20 minutes. On 2/25/14 at 9:45 a.m. Resident #3 was in the dining room with another resident. The resident attended resident group meeting held by the surveyors from 10:00 a.m. until 10:45 a.m. then went to the dining area where snacks were served. The resident remained up until after lunch; she was observed in the dining room at 12:24 p.m. She had been up in the wheelchair for at least 2 hours, 39 minutes. The resident was observed in bed on her back awake at 2:45 p.m. At 4:40 p.m. the resident was up in the living area watching a television program with other residents. On 2/27/14 at 2:20 p.m. the DON was interviewed about the recurrent sore on the resident's coccyx. The DON indicated the resident had the open area to the coccyx when she was admitted to the facility in 2009. The area was fragile and breaks down frequently, the resident was diabetic, had [MEDICAL CONDITION], had decreased mobility requiring a mechanical lift and was obese. The facility had put in place an air mattress, a pad in the resident's wheelchair, and a special sling for the mechanical lift. The lack of documentation was discussed and the DON indicated there should have been documentation for the areas lacking. The facility submitted additional information on 2/28/14 and that information was added to the information contained in the deficiency. The facility failed to: - position the resident off the coccyx every 2 hours as care planned. - document wound information identified in policy, - keep the coccyx clean and dry. The Administrator and DON were informed of the issue on 2/27/14 at 4:00 p.m. Additional information was submitted and used in this report.

Based on record review, staff interview, and review of Occurrence Reports, it was determined the facility failed to provide staff supervision and increase the frequency of that supervision for residents at high risk for falls, develop and follow appropriate care plans, complete a root cause analysis and monitor the safety of equipment. This was true for 2 of 9 sampled residents (#1 and #2). This failed practice resulted in harm when Resident #2 fell and fractured a hip. Findings included: 1. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had [DIAGNOSES REDACTED]. The 2/11/14 quarterly MDS documented the resident: - had severe cognitive impairment (BIMS = 6), - needed extensive assistance of two for bed mobility, transfers, walking in her room, personal hygiene and bathing, - was frequently incontinent of bowel and bladder, - had two falls since previous assessment. The February 2014 physician recapitulation orders documented an original order dated 9/29/10 of, "Use bed alarm and motion monitor on at all times to help prevent falls R/T unassisted transferring from bed...." The resident's care plan, dated 9/20/11, documented, "Potential for falls and injury." The care plan was reviewed every three months with the last review dated 9/30/13. The care plan was then changed to an electronic care plan. The approaches for the electronic care plan were: "- Monitor safety issue at all times-keep walkways free of obstacles that could cause tripping, - Provide adequate lighting, including a night light if needed, - Keep call bell within reach and answer as promptly as possible, - Monitor for medication side effects that could contribute to falls, - Assist resident to toilet as per schedule, see inc(ontinent) care plan, - Assess and medicate for pain as ordered by MD to keep comfortable, - Encourage resident to wear glasses if needed, - Encourage that resident uses walkers, cane, or other needed devices, - Siderail order: 1/2 SR (side rail) (up) x 1 to assist (with) bed mobility, -Ambulation status: Ambulate ad lib (with) close supervision in common areas. -Devices needed for ambulation: Tab alarm in recliner et (and) while in bed, Floor alarm DC'd (discontinued) d/t tripping risk, Amb(ulate) (with) walker - Tends to walk too fast and needs cues to slow down." The resident's electronic medical record had a fall care plan, with a date initiated of 9/23/13, that documented: "Has had an actual fall with Left hip fracture." (Note: the resident fell on [DATE] but fractured the left hip on 11/5/13 after a fall.) The interventions were: (Note: none of the interventions were dated so it was not possible to identify when they were initiated.) "- bed in lowest position. - check range of motion. - For no apparent acute injury, determine and address causative factors of the fall. - Monitor/document/report to MD for s/sx: pain, bruises, Change in Mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation. - Neuro-checks as ordered. - Provide activities that promote exercise and strength building where possible. Before lunch group activity (resident name) enjoys.(sic) - Vital signs as ordered." The electronic medical record had another fall care plan, with a date initiated of 10/4/13, that documented: "At risk for falls r/t decreased agility and safety judgement." The interventions were: (Note: none of the interventions are dated so it is not possible to identify when they were initiated.) "- Re-evaluate as needed for continued appropriateness and to ensure least restrictive device or restraint. - Anticipate and meet needs. - Avoid rearranging furniture. - Be sure the call light is within reach and encourage to use it to call for assistance as needed. - Bed in lowest position. - Educate resident/family/ and care givers about safety reminders and what to do if a fall occurs. - Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility. - Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c. - Keep needed items, water, etc, in reach. - Maintain a clear pathway, free of obstacles. - Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, personal items within reach. - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. - Tab alarm on when in bed." On 09/09/13 the physician saw the resident during a "Nursing Home Visit" and documented, "She is at risk for falls at time due to poor safety awareness...." The physician under "Assessment:" documented: "... 2. Recurrent falls with poor safety awareness and impulsivity...." On 10/21/13 the physician saw the resident during a "Nursing Home Visit." The resident had a fall on 9/23/13, however the physician failed to address the fall. The Physician's "Assessment:" documented: "... 2. Recurrent falls with poor safety awareness and impulsivity...." On 12/2/13 the physician saw the resident during a "Nursing home Visit" and documented a "Nursing Home Readmission history and physical examination [REDACTED] "...She is an elderly female who initially had a fall on 11/05/2013, at which time she was noted to have left hip pain and a left hip fracture was suspected so she was sent....where a left hip fracture was confirmed....She does have advanced dementia and is quite forgetful. She just recently has her hip surgery and has not really recovered very much from that...." The "Social History:" documented: "...She is a high fall risk and has had several falls. She remains impulsive with poor safety awareness..." The "Assessment: documented: "...5. Fall with hip fracture and open reduction, internal fixation on 11/06/2013. 6. Recurrent falls with poor safety awareness and impulsivity..." Review of the Occurrence Reports, medical record interdisciplinary (IDT) notes and additional information, dated 2/28/14, provided by the DON, documented a history of resident falls and impulsivity and risks the resident exhibited that were not care planned. These documents showed the following dates for falls. May 16, 2013 September 23, 2013 November 5, 2013 - fall with a fractured left hip. December 28, 2013 December 30, 2013 January 26, 2014 The documentation provided the following information: * On 5/9/13 at 5:44 p.m. an LN completed a fall risk assessment. The resident scored an 11 and the LN documented the resident was "High Risk." * On 6/3/13 at 10:33 a.m. an LN documented in progress notes, "...She continues to be a risk for falls, she has a motion monitor at night to alert staff to assist her with toileting at night for safety. Will review with therapy to see if has she may (sic) need to increase her strength to make her safer with is (sic) impulsivity gets up to do things to help prevent falls with her, she does have dementia with history of anxiety and depression which symptoms are controlled at this time..." NOTE: The fall care plans provided did not address impulsivity, for example, a care plan intervention to implement hourly staff rounds to check on the resident's needs. If hourly was determined to be inadequate, more frequent checks could be implemented based on on-going assessment. * On 6/5/13 at 2:50 p.m. an LN documented, "...Resident has been having more balance issues when standing, Resident has had a recent falls (sic), and is weak with all ADL's will review with the IDT team and decide what next step with her." (Note: the most recent documented fall prior to this note was 5/16/13) * On 8/14/13 at 8:53 p.m. an LN completed a fall assessment on the resident. The resident scored a 12 and the document indicated the resident was "High Risk." * The 8/16/13 annual MDS assessment documented a BIMS of 7 which equates to severe cognitive impairment. * On 9/1/13 at 12:23 a.m. an LN documented, "...Toileted every two hours and staff does wash and dry applying skin barrier. They follow her to her room when seeing her head towards it when observed. Has a tendency to attempt self toileting. Uses a walker and walks very fast. Reminders to slow down so she does not fall..." (Note: The "Reminder to slow down" was on the 9/20/11 care plan but not on the most recent care plans provided to surveyors.) * On 9/18/13 at 12:28 a.m. an LN documented, "...Resident has a tendency to try to take herself to the bathroom herself and staff will intervene when seeing her and give assist...." * On 9/23/13 at 3:58 p.m. an LN documented, "Resident was in the BR (bathroom) she stated when she stood up she lost her balance and slid down the wall onto her bottom....No difficulty noted with ambulation. No evidence of injury noted...." * On 9/23/13 at 2:00 p.m. an Occurrence Report documented, "Who was the last person to see resident before accident occurred if accident was not witnessed (attach statement)? Was in the DR (dining room) for lunch." The report continued with, "Describe what happened and any injuries: Resident was in the BR (bathroom) when she stood up she lost her balance and slid down the wall onto her bottom." The report further documented the resident was not a "High Risk" for falls, did have a history of falls and was being treated with antibiotics for a urinary tract infection. (Note: The unwitnessed fall was not fully investigated.) * On 11/5/13 at 9:00 a.m. an Occurrence Report documented, "Describe what happened and any injuries: Resident was ambulating from dining room to living room. Heard resident yell from living room. She was lying on the floor." The report further documented the resident was not a "High Risk" for falls and did not have a history of falls. * On 11/5/13 at 6:10 p.m. an LN documented, "(Name) fell this morning while ambulating from the dining room to the living room. Staff heard her yell and responded quickly to find her on the floor. She c/o hip pain and was noted to have external rotation of L foot...." (Note: The Occurance Reports for 9/23/13 and 11/5/13 documented the resident was not at high risk for falls but fall risk assessments for 5/9/13 and 8/14/13 documented the resident was at high risk.) The resident was admitted to the hospital and required an open reduction internal fixation of the left hip. The resident returned to the facility on [DATE] and IDT notes documented the resident did not feel well. The resident was readmitted to the hospital on [DATE] with choledocholithiasis (gallstones). The resident returned to the facility on [DATE] on antibiotics. * On 11/20/13 at 4:36 a.m. an LN documented, "...Did attempt to get up one time to toilet. Safety alarm sounded and assisted to the bedside commode by staff...." * On 12/14/13 at 6:14 p.m. an LN documented, "... Repositioned every 1 1/2 hour....Transferring with assist of 1 person with walker and gait belt and walking short distance from w/c to bed, or bed to BSC (bedside commode) and pivots..." * On 12/28/13 at 8:15 p.m. an Occurrence Report documented, "Heard someone calling out - went to check - (Name) was on the floor on wheelchair cushion, w/c behind her, Tab alarm disconnected. resident denied hitting head." (Note: no nursing note for the fall.) * On 12/30/13 at 6:00 a.m. an Occurrence Report documented, "Resident was trying to take herself to the BR (bathroom) and slid off of the side of the bed with the blankets on her. Resident had removed the tab alarm on her right side and the alarm on her left side was still intact." * On 12/30/13 at 9:35 a.m. an LN documented, "At 0600 I was called to resident's room and found resident sitting on her buttocks on the floor. stated 'I was fooling around trying to get over there' and pointing to her bedside commode. resident had been incontinent at the time...resident assisted up to commode with gait belt and max assist of 2..." * On 1/4/14 at 2:30 a.m. an LN documented, "...Will be working with therapy d/t recent falls. Motion monitors in place to alert staff of unassisted transfers. Did try to ambulate self to BR (bathroom) tonight. Will continue to anticipate residents needs...Extensive assistance with transfers, toileting, and bed mobility...." * On 1/26/14 at 7:30 a.m. an Occurrence Report documented, "Resident trying to self transfer to BSC and slid off of bed, (No) injury." * On 1/26/14 at 10:59 a.m. an LN documented, "Resident found sitting at the side of her bed on the floor by a CNA student. No apparent injury noted on assessment. Lifted from floor after assessment by 2 CNAs using gait belt and placed into wheelchair. Resident had been toileted 15-20 minutes prior to being found and had been put back to bed per her request with alarm in place. Resident had removed the alarm and was attempting to transfer herself to BSC (bedside commode). Resident has dementia and did not realize she had just been toileted. Neurological checks initiated and resident placed on every 15 minute checks." * On 1/28/14 at 10:59 p.m. an LN documented, "...Forgetful and confusion continues per her norm, significant cognitive deficits and does not remember what has been said or talked about. Poor safety awareness and has set her tab alarm off many times this evening trying to get up from her wheelchair. She did not know what she wanted..." * On 2/11/14 at 4:50 p.m. an LN documented, "Resident making progress to increase her mobility, and able to ambulate with one person assist and walker, with gait belt. She continues to show improvement with transfer and short distance ambulation. Continue current rehab plan, and encourage resident to do as much as she can for herself. Cueing by staff is needed d/t resident dementia. Current rehab plan to help increase resident function level." On 2/26/14 at 9:45 a.m. the DON was interviewed about the resident's falls and specifically the fall on 11/5/13, where the resident fell and required surgery due to a fractured left hip. The DON stated the resident came out of the dining room with her walker and turned right and headed to the day area where she liked to go after breakfast. The resident went by the LN who was at the medication cart. The resident went into the living area and fell on the floor fracturing the left hip. Staff responded within 30 seconds from the time they heard the resident yelling. The resident was evaluated and transferred to her bed until the ambulance arrived. The DON provided further information on 2/28/14, portions of which were included in the documentation. The facility failed to: - Provide supervision for the resident who was at "high risk" for falls, such as hourly rounding to check on the resident's needs. -Increase the frequency of supervision checks when the resident continued to fall. - Develop a care plan for the resident that recognized the resident's severe cognitive impairment as it related to fall supervision. - Complete a root cause analysis for the resident's falls as per resident care plan. The DON and administrator were informed of the issue on 2/27/14 at 4:00 p.m. Additional information was provided and included in the deficiency citation. 2. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 2/18/14 Quarterly MDS Assessment documented the resident: - was severely impaired for daily decision making; - was totally dependent on staff for bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, personal hygiene and bathing; - was always incontinent of bowel and bladder; and, - had no falls since Admission/Entry or Reentry or Prior Assessment. The resident's Fall Risk Evaluation, dated 11/13/13, documented the resident was at high risk for falls. The resident's care plan, dated 6/12/13, with a focus of "Potential for falls r/t impaired mobility and cognitive loss r/t Alzheimers documented: - Lap buddy when in w/c (wheelchair) to help prevent falls d/t (due to) leaning forward. Check q (every) 30 minutes. Release q 2 hours and for cares; - Tab alarm on bed and w/c." An Occurrence Report, dated 11/27/13, documented an unwitnessed fall at 7:45 PM. CNA #6 was assigned to Resident #1's care and was the last person to see the resident before the accident occurred. The description of what happened documented the resident was in her chair in her room. CNA #6 left to find help from another aide and when they entered the room, the resident was on the floor. The report documented the resident was identified as "HIGH RISK" for falls and had a history of [REDACTED]. The report included CNA #6's handwritten statement, dated 11/27/13, in which she documented putting the resident in her nightgown with the lap buddy on and asked for help with putting the resident to bed. CNA #6 documented as soon as another aide was free they went to the resident's room and found the resident "on the floor with the lap buddy under her head." The report included CNA #7's handwritten statement, undated, in which she documented CNA #6 was helping her with a random resident when CNA #6 asked for help with Resident #1. She documented when she walked into the resident's room the resident "was on the floor with lap buddy." The report documented the probable cause of the accident as "wt (weight) of body caused lap buddy to fail - sides were weak." The facility documented the following interventions: Changing the lap buddy and staff education. NOTE: The Occurrence Report did not investigate how long the resident had been left alone in her room, what kind of education was given to the staff, nor was there an attached in-service with CNA signatures. The report did not mention the resident's weight at the time of the fall. Record review documented the resident weighed 102.2 pounds on 11/25/13. A Progress Note by LN #8, dated 11/27/13 at 23:35 PM, documented, "At 7:45 this evening resident slid out of her chair in her room. Not witnessed. Will do neuro checks and report any issues...Small superficial 2 cm scratch like mark noted mid spine level. Not open just discolored pink. No other injury noted at this time." NOTE: There was no mention of a scratch on the Occurrence Report. Progress notes over the next two days documented there was no evidence of further injury related to the fall and neuro checks were within normal limits. On 2/26/14 at 2:15 PM, the DON was interviewed regarding the resident's fall on 11/27/13. The DON stated she was not sure how long the resident had been left alone or how long she might have been on the floor. The DON stated the resident was referred to physical therapy for an evaluation and now has a high backed wheelchair with a lap buddy. A Physical Therapy Evaluation, dated 12/6/13, documented "Reason for Referral: Staff reporting pt's (resident's) positioning in w/c is declining as w/c is too large with pt leaning laterally and scooting fwd (forward) out of chair with 1 fall." On 2/27/14 at 3:40 PM, the DON and administrator were made aware of the issue regarding falls. On 3/3/14 a fax was received from the facility in which the DON documented, "the weight of her (resident's) body on the lap buddy caused it to come loose. The lap buddy was not put in place to restrain (resident's name) in her chair, but rather assist with her positioning in the chair." The DON further documented, "Given her prior history, this fall could not have been predicted or prevented." NOTE: The resident's care plan for the focus of potential for falls, dated 6/12/13, documented an intervention "Lap buddy when in w/c (wheelchair) to help prevent falls d/t (due to) leaning forward." The facility failed to: - Assess and identify the resident's position in the wheelchair was declining and the wheelchair was too large; - Assess the lap buddy, which was considered a restraint, according to the interpretive guidance regarding restraints, in spite of the fact it was care planned to "help prevent falls;" and, - Assess the lap buddy was safe and in good working order for a resident weighing 102 pounds.