Every finding on record at Paradise Creek Health and Rehab of Cascadia

Based on observations, interviews, and policy review, the facility failed to maintain sanitary conditions in the walk-in freezer and in the ice scoop holder on the side of the ice machine. These failures had the potential to cause contamination which could affect 46 residents who consumed food from the kitchen. Findings include:During the initial tour of the kitchen on 05/04/26 at 9:20AM, an observation in the walk-in freezer identified that ice had built up on the freezer lines. The ice extended far enough to encroach on the upper stacked box of burritos. An interview during the tour at 9:45 AM with the Dietary Manager (DM) identified that the ice buildup had happened before. At the end of the initial tour at 9:50 AM, inspection of the ice machine identified an ice scoop holder mounted on the side of the machine. Two ice scoops were stored in the holder. Approximately 20 milliliters of standing water was present in the bottom of the holder, and the scoops were in contact with the standing water. There was no visible way to allow the water to drain. An interview on 05/04/26 at 09:55AM with the DM identified that, No one has ever mentioned that before in regard to the standing water in the scoop holder. Review of the facility's policy titled, Food Safety & Storage, dated 11/28/17, revealed, The facility stores and handles all food, non-food items, and food preparation supplies in a manner that ensures safety, sanitation, and compliance with federal, state and local regulations. Review of the facility's policy titled, Ice Machines Preventative Maintenance program dated 10/6/25, revealed Wipe down the exterior surfaces, including the catch basin, using a clean cloth and food safe sanitizer.

Based on record review and interviews, the facility failed to ensure recommendations to address gradual weight loss were implemented for one of four residents (Resident (R) 2) reviewed for nutrition out of a total sample of 18 residents. This failure had the potential to contribute to continued weight loss, skin breakdown, or malnutrition for R2. Findings include:Review of R2's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, malnutrition, anemia, and osteoporosis. Review of R2's Care Plan, dated 01/05/26 and located under the Care Plan tab of the EMR revealed, [R2] is at risk for nutritional decline r/t [related to] dementia, B vitamin deficiency, hx [history of] ETOH [alcohol] abuse, PVD [peripheral vascular disease], HTN [hypertension], CKD3 [chronic kidney disease stage 3], anemia. The approaches included: Obtain weights weekly and record . Complete Mini Nutritional Assessment and alert dietician that resident triggers as . at risk for malnutrition, [and] . Provide meals per physician diet order and record intakes. Dietician to review as indicated. Review of R2's Care Plan, dated 01/06/26 and located under the Care Plan tab of the EMR revealed, [R2] has dehydration or potential fluid deficit r/t dementia, electrolyte disturbances, [and] diuretic use. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/26 and located under the MDS tab of the EMR, revealed she scored a three out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. She was at risk for pressure ulcers and received a therapeutic diet. She required set-up or clean-up assistance with eating. Review of R2's Nutritional Review note, dated 04/15/26 and located under the Progress Notes tab of the EMR, revealed, Intakes are poor, avg [average] ~ [about] 31%. Fluids with meals, avg ~612ml. No routine supplements are in place, although do feel she would benefit from additional support. Will request. She has been followed for weight loss from admit, more stable over the month . Potential for further weight loss r/t intakes . Initiate 2 oz. [ounces] Med Pass [nutritional supplement] BID [twice a day] between meals for additional support. Nursing to document the amount consumed. Review of R2's EMR under the Orders tab revealed there was no order for Med Pass supplement. Review of R2's EMR under the Vitals tab revealed a ten-pound weight loss since admission. On 01/03/26, R2 weighed 141 pounds (lbs) and on 05/02/26, R2 weighed 131.4 lbs. This represented a 6.8% weight loss in four months. R2's lowest weight was 128.4 lbs on 03/28/26. During a telephone interview on 05/06/26 at 12:00 PM, the Registered Dietician (RD) stated she and another consultant were filling the position temporarily while a new facility RD was being hired. She stated the typical process for communicating recommendations for supplements would be to send an email to the nursing staff at the facility, who would enter the order into the system, notify the physician, and implement the order. The RD stated her expectation was that new recommendations were implemented within 48 hours if there was weight loss involved. She stated she would then follow up with the nursing staff the following week to ensure the recommendations were followed through. The RD stated she did not know why the Med Pass recommendation was not implemented for R2. During an interview on 05/06/26 at 12:07 PM, the Resident Care Manager (RCM) confirmed R2 was not receiving Med Pass as recommended by the RD and stated he did not know why this was not implemented. RCM explained that he was not aware of the recommendation, as the recommendations were typically sent via email by the RD and communicated in the Nutrition At Risk (NAR) committee meetings; however, without a steady facility RD in place, the meetings had not been held consistently since December. The RCM was unable to find any email communication related to R2's RD recommendations. The RCM stated there was no system in place so that he could be aware of new recommendations from the RDs if they were not emailed to the NAR committee. During an interview on 05/06/26 at 1:29 PM, the Clinical Resource Consultant (CRC) stated the RD's recommendation for Med Pass twice daily for R2 was not communicated to the facility staff and therefore had not been implemented. A policy addressing RD recommendations and/or supplement orders was requested on 05/06/26 but was not provided prior to facility exit. A policy on weight loss was requested on 05/07/26 but was not provided prior to facility exit.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's order, in accordance with professional standards of practice, prior to administering oxygen to one of two residents reviewed for respiratory care (Resident (R) 8) out of a sample of 18 residents. This failure had the potential to result in unsafe or inappropriate oxygen administration and inadequate monitoring of the resident's respiratory treatment. Findings include:Review of R8's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R8 was admitted to the facility on [DATE] with diagnoses of pulmonary hypertension, malignant neoplasm of cardia, malignant neoplasm of lower third of esophagus, abnormal findings in the lung fields, and chronic systolic (congestive) heart failure. Review of R8's Care Plan located under the Care Plan tab of the EMR revealed R8 had the potential for altered respiratory status with nursing pulmonary services for pulmonary hygiene related to shortness of breath while lying flat and need for oxygen. O2 [oxygen] therapy as ordered through nasal canula, date initiated 04/02/26. Review of R8's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/08/26 revealed that R8 received oxygen while a resident. Review of R8's Order Recap Report located under the Orders tab of the EMR, dated 04/01/26 through 05/05/26, revealed no physician order for oxygen. Review of R8's Medication Administration Record (MAR) located under the Orders tab of the EMR, dated 04/02/26 through 05/05/26, did not indicate the resident received oxygen. Review of R8's Progress Notes located under the Progress Notes tab of the EMR, dated 04/02/26 through 05/05/26, did not reveal a physician's order for oxygen. During an observation on 05/04/26 at 10:01 AM, R8 was in his room receiving oxygen through a nasal cannula at 1.5 liters per minute (LPM) with no humidification present. During an observation on 05/05/26 at 12:28 PM, R8 was in his room receiving oxygen through a nasal cannula at 1.5 LPM with no humidification present. During an observation on 05/06/26 at 11:33 PM, R8 was in his room receiving oxygen through a nasal cannula at 1.5 LPM with humidification present. During an interview on 05/06/26 at 1:31 PM, Licensed Practical Nurse (LPN) 1, at R8's bedside, confirmed the resident was receiving oxygen at 1.5 LPM through a nasal cannula. LPN1 confirmed R8 did not have a physician's order for oxygen and that there should be an order. LPN1 confirmed there was no documentation in R8's MAR indicating the resident was being monitored while receiving oxygen. LPN1 also revealed R8 had been receiving oxygen since he was admitted to the facility on [DATE]. During an interview on 05/06/26 at 1:40 PM, the Director of Nursing (DON), at R8's bedside, confirmed the resident was receiving oxygen at 1.5 LPM through a nasal cannula. The DON confirmed that R8 did not have a physician's order for oxygen and that R8 should have had an order before the oxygen was administered. The DON revealed there was no documentation in R8's MAR that he was receiving oxygen because there was no physician's order. Review of the facility's policy titled, Oxygen Administration, Safety, Storage & Maintenance, with a revision date of 10/10/25, indicated, the facility will administer, store, and maintain supplemental oxygen safely in accordance with current standards of practice and licensed practitioner orders . Procedure- General Guidelines . 6. Verify provider order prior to initiating/ changes oxygen therapy .

Based on interview, observation, record review, and policy review, the facility failed to ensure two out of 20 sampled residents (Residents (R)30 and R43) were provided with adequate and or timely nursing care and services after: 1. R30 experienced a fall in which she sustained a significant laceration to her forehead and 2. R43's hospice orders were not implemented in a timely manner. The failure to send R30 to the emergency department (ED) timely resulted in harm when R30's laceration could not be sutured and then required debridement and continued treatment three weeks after the fall. Findings include: Review of the facility's Neurological Evaluation policy dated [DATE] revealed, Neurologic vital signs supplement the routine measurement of temperature, pulse rate, and respirations when a resident is suspected to have hit their head (e.g., a fall), has hit their head or has a traumatic brain and/or spinal cord injury . 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R30 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and muscle weakness. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] in the EMR under the Profile tab revealed R30 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of this MDS revealed R30 was impaired in range of motion (ROM) to both sides of her upper and lower extremities, dependent on staff for toilet and tub transfers, and required substantial assistance for chair/bed to chair transfers. R30 experienced one fall with injury since the prior MDS assessment. R30 received hospice services. Review of the Care plan dated [DATE] in the EMR under the Care Plan tab revealed R30, had an actual fall with injury r/t [related to] impulsivity, confusion. Intervention in pertinent part included, Neuro-checks per policy and procedure. Review of a late entry Health Status Note, dated [DATE] at 10:40 PM, revealed Resident had a witnessed injury fall in the common area at 1900 [7:00 PM] hrs [hours]. Resident was observed to have leaned forward from her wheelchair and face planted onto the floor in a prone position. Resident had an abrasion to her forehead measuring 3 cm [centimeters] x [by] 1cm. Resident was asked how she ended to the floor and stated she was attempting to get up. Resident's granddaughter and emergency contact #1 [name] was notified, and so was the hospice nurse [name] and nurse manager on duty [name]. Hospice nurse [name] stated that resident should not be sent out to the hospital and that her nurse will be in tomorrow to f.u [follow up] with her. Resident's neuros are wnl [within normal limits] with no latent injuries noted. Resident assessed and was alert to her baseline, name, and place. First aid rendered to the abrasion site, resident transferred to her w.c. [wheelchair]. Resident continues to be on neuros. Resident c.o [complains of] pain and to her forehead and bilat [bilateral] knees and was administered prn [as needed] Tylenol 650 mg [milligrams] with therapeutic effect. Review of the Neurological Record from [DATE] through [DATE], provided by the facility, revealed neuro checks were due on [DATE] at 10:00 PM, 11:00 PM, and on [DATE] at 12:00 AM and 4:00 AM. Sleeping was documented on the form for each of these times; neuros were not completed after 9:00 PM on [DATE] until 8:00 AM on [DATE]. The neuro checks completed at 8:00 AM on [DATE] were within normal limits. Review of the Hospice Notes, revealed no note written on [DATE] of a hospice nurse visit to R30. Review of the ED [Emergency Department] Provider Note dated [DATE] at 6:11 PM revealed, Pt [patient] feet caught in WC [wheelchair] last evening and fell forward on hard linoleum. Was not sent for eval from [name of facility] where witnessed event took place. Pressure dressing applied last evening . Pt reports mild forehead pain . Family notified last night after hospice and hospice nurse stated pt did not need to be sent. Granddaughter brought pt in and is POA [power of attorney] at bedside .Patient has a significant wound on her forehead as well as abrasions to her knees . Large skin tear and maceration on the forehead . The wound is too old to do any type of suture closure but we will irrigate the wound and dress as best as we can . Given the fact that the wound was not adequately treated for about 24 hours, we can discharge on Keflex [antibiotic] as a prophylactic . Review of the EMR Medication Administration Record (MAR), dated [DATE] revealed the Keflex antibiotic was not documented as administered. Review of the Order Summary, dated [DATE] through [DATE] and under the Orders tab in the EMR, revealed wound care to the forehead laceration one time a day every 3 days for cleanse wound, apply bacitracin [antibiotic ointment] and border foam dressing. Review of the Order Summary dated [DATE] in the EMR under the Orders tab revealed R30 received the following treatment to her forehead, initiated on [DATE], Bactine Max External Liquid ,d+[DATE].13 % (pain reliever), apply to affected area topically as needed for forehead wound cleansing prior to dressing changes, wound care to include wound washed/cleansed with Bactine Max. Place Adaptec [non-adherent dressing] in wound bed, calcium alginate [dressing used to manage moderate to heavy exudate fluid leaking out of blood vessels into nearby wounds, providing a moist healing environment, and supporting debridement (removal of dead, damaged or infected tissue to improve wound healing)] and then bordered foam to cover site, one time a day every 7 day(s) for wound to forehead. During an observation on [DATE] at 3:08 PM, R30 was observed in a recliner chair in her room sleeping. R30 had a large bandage covering most of her forehead. During an interview on [DATE] at 9:10 AM, Family Member (FM)3 stated R30 experienced a fall on [DATE] and the nurse had R30 up in a wheelchair ready to go to the hospital when she arrived in the facility that evening ([DATE] after the fall). FM3 stated the on-call hospice nurse made the decision not to transport R30 to the hospital. FM3 stated R30 had a pretty good gash on the head. FM3 stated she wanted R30 to go to the hospital and offered to take her, but was told a hospice nurse would come the next morning to assess the wound. FM3 stated the next morning she called the nurse on duty and was told the dressing was wet and the hospice would be coming to look at the wound. FM3 stated she arrived at the facility after 2:00 PM and the hospice nurse had not been into the facility. FM3 stated at 4:00 PM, the nurse on the evening shift took R30's dressing off and she saw the wound. FM3 stated it was a bad wound (laceration with some of the tissue separated and missing) and asked the nurse what she was going to do. The facility nurse then called hospice, reported no hospice nurse had been in to assess the wound, and hospice gave the order to send R30 to the ED. During an interview on [DATE] at 10:42 AM, the Director of Nursing (DON) stated the facility called to have R30 sent to the hospital on [DATE], but hospice declined to send her. The DON stated the nurse on duty at the time of the fall thought the wound was bad enough that it warranted R30 going to the ED. The DON stated if the hospice nurse did not come in on [DATE], the facility nurse on duty should have followed up. The DON stated neuro checks should be completed when residents were known to hit their head and they were important to detect a head injury. The DON stated sleeping was an inappropriate reason not to complete the neuro checks on [DATE] and education had been provided to the nursing staff after this incident. The DON stated by not completing the neuro checks, the facility had missed the opportunity to evaluate R30's status to detect a significant change in mental status. During an interview on [DATE] at 11:18 AM, R30's Hospice Nurse stated she was off duty on [DATE] when R30's fall occurred so the call went to the on-call hospice nurse. The Hospice Nurse stated a resident could go to the hospital with an acute injury. The Hospice Nurse stated she did not know if a hospice nurse assessed R30's wound on [DATE]. During an interview on [DATE] at 12:34 PM, the Resident Care Manager (RCM), Licensed Practical Nurse (LPN) stated he did not see R30's wound until [DATE]. The RCM stated there was a large, deep split with abraded skin on either side. The RCM stated when he saw the wound on [DATE] it was a laceration and not an abrasion. The RCM stated he consulted with R30's medical provider and stated R30 should have gone to the ED on [DATE]. 33865 2. Review of the facility's policy titled, Hospice Services, release date [DATE], revealed The hospice, nursing home, and resident/representative collaborates in the development of a coordinated care plan which includes, but is not limited to, the following .Interventions that address, as appropriate, the identification of timely, pertinent non-pharmacological and pharmacological interventions to manage pain and other symptoms of discomfort. Review of R43's Admission Record located in the EMR under the Profile tab revealed R43 was admitted on [DATE]. R43 expired on [DATE]. Diagnoses included malignant neoplasm of the brain, altered mental status, pain, anxiety, and other recurrent depressive disorders. Review of R43's admission MDS with an ARD of [DATE] and located in the EMR under the MDS tab, revealed a BIMS assessment was not conducted due to the resident being rarely/ never understood. The resident was identified as having cognitive skills as modified independence. Pain was marked as having occasional pain frequency. Review of R43's Care Plan located in the EMR under the Care Plan tab, initiated on [DATE], revealed R43 had a terminal prognosis. Interventions included administer medications per order .Integrate care with Hospice agency per resident/ resident advocate request. During an interview on [DATE] at 8:35 AM, the Family Member (FM) 1 stated she met with hospice and signed the hospice papers on [DATE]. FM1 stated orders were faxed by hospice to the facility on [DATE]. She stated she was told by a facility nurse that the orders were found on the nursing manager's desk on [DATE] and the order was not documented into the medical record until [DATE]. Review of the Order Summary Report located in the EMR under the Orders tab revealed the following orders prior to hospice services starting: Order date: [DATE] with end date: [DATE]: Lorazepam [anti-anxiety] oral concentrate 2 mg/ml [milligram/ milliliter] Give 1 mg by mouth every 4 hours as needed for severe anxiety for 14 days. Order date: [DATE]: Morphine [pain medication] Sulfate Solution 20mg/ml. Give 0.25ml by mouth every 2 hours as needed for moderate generalized pain/ dyspnea. Morphine Sulfate Solution. Give 0.5ml by mouth every 2 hours as needed for generalized pain/ dyspnea. Review of the hospice Visit Note located in the EMR under the Documents tab, dated [DATE], revealed Start of Care. The narrative revealed entering his first benefit period for terminal diagnosis of glioblastoma [brain tumor]. Review of the hospice Visit Note located in the EMR under the Documents tab, dated [DATE], revealed Is current pain management effective? Yes. The narrative revealed appears pt [patient] has declined since yesterday admit .whispered yes to being in pain. Requested facility administer PRN [as needed] morphine .New order to discontinue acetaminophen, Dulcolax, and Flomax capsules, and schedule 0.25mls of morphine Q4 [every 4] hours per hospice MD [physician]. Review of the Order Summary Report located in the EMR under the Orders tab, dated [DATE], revealed the following: Order date: [DATE]: Morphine Sulfate Solution 20mg/ml. Give 0.25ml by mouth every 4 hours for pain. Morphine Sulfate Solution. Give 0.5ml by mouth every 1 hour as needed for moderate to severe pain or dyspnea. This order was not added until two days after the hospice visit on [DATE]. Review of the hospice fax, provided by the facility and dated [DATE], revealed Discontinue current orders for lorazepam. Start lorazepam 2mg/dl oral concentrate, give 1mg (0.5ml) .every 1 hour as needed for anxiety or restlessness Further review of the EMR Order Summary Report revealed the following: Order date: [DATE]: Lorazepam oral concentrate 1 mg/0.5ml. Give 0.5ml by mouth every 1 hour as needed for Anxiety and Restlessness. These changes in medications were not started until [DATE]. The fax was documented as received [DATE]. During an interview on [DATE] at 10:30 AM, Licensed Practical Nurse (LPN) 2 stated she came in that Friday/Saturday, talked with FM1, and hospice had come in that day. LPN2 stated she found the hospice orders on the manager's desk and confirmed the fax was dated [DATE]. During an interview on [DATE] at 1:06 PM, the Resident Care Manager (RCM) stated the resident was started on hospice care on [DATE]. He stated the changes in medication orders should have been put into place immediately. During an interview on [DATE] at 1:46 PM, the Director of Nursing (DON) stated the resident received hospice visits starting on [DATE] but that the medication changes were not added until [DATE]. She confirmed that although the resident was receiving pain management the hospice orders should have been put in immediately.

Based on observation, record review, interview, and policy review, the facility failed to ensure food was not expired, freezer temperatures were of proper parameters and thermometers were properly sanitized. This had the potential to affect food safety for the 41 residents served food from the kitchen. Findings include: Review of the facility's policy titled, Refrigerator & Freezer Temperature Monitoring, release date [DATE], revealed Freezers: Recommended temperature range is 0 F [degree Fahrenheit] +/-10 .Post a temperature log for each refrigerator and freezer at the beginning of the month. Review of the facility's policy titled, Food and Supply Storage, release date [DATE], revealed All food, non-food item, and supplies used in food preparation shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption .Expiration date: the last date that food should be eaten .Reject any unacceptable product and make note of return on the invoice. Review of the facility's policy titled, Food Preparation, release date [DATE], revealed When verifying food temperatures, staff should use a thermometer which is both clean, sanitized . During an observation and interview on [DATE] at 9:34 AM, the walk-in refrigerator had two five-pound containers of sour cream (one partial full and one full) with a best if used by date of [DATE]. The Culinary Manager (CM) confirmed the food was expired and stated he would dispose of the items. During an observation and interview on [DATE] at 9:37 AM, the walk-in refrigerator had one partially full 48-ounce container of potato salad with a use by date of [DATE]. The CM confirmed it was expired and stated it would be disposed of. During an observation and interview on [DATE] at 9:40 AM, the freezer had food that was not fully frozen. The CM stated the temperature was 28 degrees F. He stated they had been watching the freezer temperatures and that it was 1.2 degrees F the night before at 5:30 PM. During an interview on [DATE] at 8:38 AM, the CM stated all the walk-in freezer temperature logs included [DATE] ([DATE]-[DATE]); and [DATE] ([DATE]- [DATE]). He stated these were the only logs he had from [DATE] through [DATE]. The CM further stated that the food affected by the warm freezer temperatures was thrown away. During an observation and interview on [DATE] at 8:59 AM, the dry storage area contained two 32-ounce containers of honey thickened dairy liquids with a use by date of [DATE]. There were six 46-ounce containers of honey thickened liquids with best if used by date [DATE]. There was one 50-ounce can of chicken noodle soup with a received date of ,d+[DATE] and was dated [DATE]. The CM confirmed all the expired items. During an observation and interview on [DATE] at 9:48 AM, Cook1 was observed to have taken the temperature of one pan of lasagna. He proceeded to place the thermometer into a bucket of sanitizer water and wiped it with a rag from the sanitizer water. He placed the thermometer directly into the second pan of lasagna without letting the thermometer dry, resulting in the potential for chemical contamination. After he finished taking the temperature of the second pan of lasagna, he placed the thermometer in the sanitizer water and again wiped with a rag from the sanitizer water. At 10:23 AM, Cook1 stated he was in a rush and so he used the sanitizer bucket water instead of the thermometer wipes. The CM confirmed he should have used the thermometer wipes. The pan of lasagna that was temped with the improperly sanitized thermometer was disposed of. During an interview on [DATE] at 10:00 AM, the Registered Dietitian (RD) and the CM stated the freezer was currently working. They confirmed the expired foods observed during the kitchen tours.

Based on record review, interviews, and policy review, the facility failed to ensure annual performance reviews were completed for every nurse aide at least one review every 12 months for five of five (Certified Nursing Assistants (CNA) 1, CNA2, CNA3, CNA4, and CNA5) and failed to include no less than 12 hours of training per year for three of five (CNA) 1, CNA3, and CNA4) reviewed for education and reviews for 43 census residents. The failure had the ability to affect the current skillset and knowledge level in order to care for the residents. Findings include: Review of the facility's policy titled, Nurse Aide Staffing, release date 11/28/17, revealed Each nurse aide receives a performance review at least once every 12 months. Review of the undated document titled, Employee Seniority provided by the facility, revealed the following: -CNA1 had a hire date of 05/01/23. -CNA2 had a hire date of 05/01/23. -CNA3 had a hire date of 05/01/23. -CNA4 had a hire date of 06/06/23. -CNA5 had a hire date of 08/21/23. Review of undated Official Transcript provided by the facility, revealed CNA1 received 2.35 hours over the past year, CNA3 received seven hours of training over the past year, and CNA4 received 8.6 hours of training over the past year. Further review revealed that the training received did include abuse and dementia training, During an interview on 08/29/24 at 12:57 PM, Director of Nursing (DON) stated they only had five CNAs that had worked at the facility for over 12 months. She stated they had not conducted any performance reviews.

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure residents received meals that were palatable for five of 20 sampled residents (Resident (R) 19, R36, R22, R13, and R35) reviewed for palatability. This failure had the potential to affect resident meal intake. Findings include: Review of the facility's policy titled, Food Preparation, release date 11/28/17, revealed Food is prepared by methods that conserve nutritive value, flavor, and appearance .Food is stored, prepared, and held by methods that preserve the nutritive value of the food to the extent possible. 1. Review of R19's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/24 revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated the resident had moderately impaired cognition. During an interview on 08/26/24 at 10:41 AM, R19 stated the food had no flavor and no salt. 2. Review of R36's admission MDS with an ARD of 07/25/24 revealed a BIMS score of 15 out of 15 which indicated the resident had intact cognition. During an interview on 08/26/24 at 11:00 AM, R36 stated the food was ok for an institution but it was awful. She stated the menu sounded good but how could it taste so bad? During an interview on 08/28/24 at 12:17 PM, R36 stated the lasagna was warm to taste. She stated the salad was warm and Limpy. 3. Review of R22's annual MDS with an ARD of 06/14/24 revealed a BIMS score of 14 out of 15 which indicated the resident had intact cognition. During an interview on 08/26/24 at 11:26 AM, R22 stated she could eat the food, but it was not tolerable. 4. Review of R13's quarterly MDS with an ARD of 06/14/24 revealed a BIMS score of 14 out of 15 which indicated the resident had intact cognition. During an interview on 08/26/24 at 12:43 PM, R13 stated the meal with chicken and rice was a bit dry. 5. Review of R35's admission MDS with an ARD of 07/18/24 revealed a BIMS score of 15 out of 15 which indicated the resident had intact cognition. During an interview on 08/27/24 at 8:29 AM, R35 stated the food was cold and had no seasoning. He stated the water was not hot for cocoa, and they had no condiments. 6. During an observation on 08/28/24 at 11:15 AM, the temperatures of the food on the steam table were taken by Cook1. The lasagna was 192 degrees Fahrenheit (F), the salad was 39.6 degrees F, and the custard was 37.6 degrees F. During an observation and interview on 08/28/24 at 11:33 AM, a test tray was prepared from the steam table at 11:36 AM and placed on a cart. The cart left the kitchen at 11:48 AM. Staff started to pass trays from the cart at 11:55 AM. The last tray passed at 12:01 PM. An evaluation of a test tray was conducted at 12:01 PM, alongside the Registered Dietitian (RD). The lasagna was 118 degrees F, the salad containing ranch dressing was 89 degrees F. The salad was on the same plate as the lasagna. The custard was 54 degrees F. The RD confirmed the food temperatures and stated the hot food should have been in the 130 degrees F range and the cold food should have been around 50 degrees F by the time it was received by the resident. She stated the standard was to place the salad in a bowl with a packet of salad dressing on the side per resident choice. The test tray revealed the salad tasted watered down and soggy. The lasagna was slightly warm. During an interview on 08/29/24 at 10:00 AM, the RD and the Culinary Manager (CM) stated resident council touched on food. The RD stated they had not had a regular food committee group in a while. They stated they always put the salad in a separate bowl with dressing of choice on the side. The RD stated the lasagna may have been at the proper temperature if the salad had not been on the same plate.

Based on observation, interview, record review, and policy review, the facility failed to ensure a verbal grievance was documented, investigated, and the results were reported back for one out of 20 sampled residents (Resident (R) 8). This failure resulted in R8's grievance not being resolved timely. Findings include: Review of the facility's Complaints and Grievances policy dated 10/15/22 and provided by the facility revealed, The facility should make prompt efforts to resolve grievances the resident may have . Complaints/grievances may be written or verbal . Complaints/grievance are acknowledged, investigated, and the complainant apprised of progress toward a resolution and takes appropriate corrective action if the alleged violation is confirmed by the facility . Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R8 was admitted to the facility on [DATE] with a primary diagnosis of atherosclerotic heart disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/24 in the EMR under the MDS tab revealed R8 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS documented that R8 was frequently incontinent of urine. Review of the Resident Council Meeting Minutes dated 06/26/24 and provided by the facility revealed, Ask Activity Manager [name] or Social Services [name] for Grievance or Concern forms. Staff may assist in filling the forms out if needed. The form will be given to the appropriate department for review. Have forms filled out as soon as possible so a resolution can be reached in a timely manner. Paradise Creek has been keeping track of this process and has shown that this system is working to take care of concerns quickly/thoroughly. Review of Resident Council Meeting Minutes dated 07/31/24 and written by the Activity Manager (AM) revealed R8 raised a concern, [R8] says Dr [name] ordered large heavy briefs for him, but he hasn't got them. He is upset that his bed and clothes [are] always full of urine and he has a rash from it. He wants one of us to order those briefs for him . During an interview on 08/27/24 at 4:10 PM, R8 stated he voided a large amount of urine frequently and wanted different incontinent briefs. R8 stated he frequently soiled his clothing and bedding due to the type of incontinent products not holding enough urine. R8 stated when he came to the facility, he had two boxes of incontinence pull up briefs and they had worked well. R8 stated that the Director of Nursing (DON) wanted him to continue to wear wrap around briefs and not the pull up briefs that worked for him previously. R8 stated he told the DON he would like to go back to the heavy duty large pull up briefs. During an interview on 08/28/24 at 11:16 AM, the AM stated she attended Resident Council Meetings and took the minutes. The AM stated she initiated grievances coming out of resident council and they went to the Social Services Manager (SSM). The AM stated she thought she initiated a grievance for R8's concern raised in the July 2024 resident council meeting; however, verified there was no grievance. The AM stated she thought R8's concern about his incontinence briefs had been resolved due to a different product being ordered. During an interview on 08/28/24 at 11:54 AM, Certified Nursing Assistant (CNA) 6 stated R8 required assistance with dressing and hygiene. CNA6 stated R8 struggled with fastening the tabs on the incontinence briefs; however, he could remove them. CNA6 stated R8 had some pull up briefs previously, but they were not currently being used. CNA6 stated R8 was incontinent of urine. CNA6 stated R8 preferred pull up briefs over the tab type of briefs that were currently in use. During an interview on 08/28/24 at 1:40 PM, the SSM stated no grievance had been initiated to address R8's concern about the type of incontinence brief he used and soiling his clothing/bedding. The SSM stated different incontinence products had been ordered for R8 and she thought the issue had been resolved. On 08/28/24 at 1:57 PM the SSM and surveyor went to R8's room. The SSM checked the supply of incontinence briefs in R8's room and there were the tab briefs in his closet. There were no pull up briefs in the room During an interview on 08/28/24 at 3:05 PM, the Central Supply Specialist (CSS) stated she ordered incontinence products and R8's concern regarding briefs was brought to her attention in July 2024. The CSS stated she ordered him a case of pull ups in two sizes (72 briefs in each case) to trial. The CSS stated she had not checked back with the resident after the second case was ordered and staff were to notify her if he ran out, which they had not done. During a follow up interview on 08/29/24 at 9:39 AM, R8 stated he was informed the staff ordered the pull up briefs yesterday. R8 stated he had not been provided with pull up briefs after bringing his concern to staff in July 2024. R8 stated the staff told him the wrap around briefs held more urine than the pull up briefs and that he should use the wrap around briefs. During an interview on 08/29/24 at 5:44 PM, the DON stated the tabs briefs (referred to as wrap around briefs by R8) held more urine than the pull up briefs. The DON stated the facility had provided a pull up brief to R8 after he expressed his concern but was unable to show documentation that the briefs were ordered and provided to R8.

Based on observations, record review, staff interview, and review of the facility policy, the facility failed to ensure interventions were put in place and followed to prevent additional falls for three of six residents reviewed for falls (Resident (R) 9, R33, and R42) out of a total sample of 20 residents. This failure increased the potential for additional falls and potential injury for residents with a history of falls. Findings include: Review of the facility's policy titled, Accidents and Supervision to Prevent Accidents, revision date [DATE], documented, The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents .Avoidable Accident-an accident that occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or .Evaluate/analyze the hazards and risks and eliminate them, if possible: and/or .Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible and if not, reduce the risk of an accident, and/or Monitor the effectiveness of the interventions and modify the care plan as necessary in accordance with current professional standards of practice. 1. Review of R9's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with diagnosis of pelvic fracture, osteoporosis, dementia, macular degeneration, and cognitive communication deficit. Review R9's Annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating R9 was moderately cognitively impaired. Review of the MDS revealed R9 was assessed for the use of a walker for mobility and was independent with chair/bed to chair transfers and independent for toileting. Review of R9's Care Plan, dated [DATE], located in the EMR under the Care Plan tab, revealed R9 was at risk for falls and was updated with additional interventions after the resident experienced several falls within the last year. During an interview with the DON on [DATE] at 1:58 PM, she stated the physician ordered a bed and chair alarm due to R9's cognitive history and desire to be independent increasing her risk for falls. Review of the EMR Orders tab revealed a Treatment Administration Record (TAR), for [DATE], that indicated the chair and bed alarm were ordered on [DATE]. An observation on [DATE] at 5:20 PM revealed R9 was sitting on the side of her bed. Licensed Practical Nurse (LPN)3 entered the resident's room to respond to the silent alarm from the sensor pad on her bed and assisted the resident to her wheelchair. LPN3 was asked if there was an alarm in her wheelchair and she confirmed there was not an alarm in her wheelchair. LPN3 stated R9 had a bed alarm since most of her falls happen at night. During an interview with Certified Nursing Assistant (CNA) 6 on [DATE] at 11:00 AM, she stated the resident used a bed alarm but was not sure if she had a chair alarm. Observed the resident's wheelchair and CNA 6 verified there was not a chair alarm in use. During the interview with the DON on [DATE] at 01:58 PM, she stated the resident should have an alarm in her wheelchair and confirmed, there was not one in use. 2. Review of R 33's Face Sheet, located in the EMR under the Profile tab, revealed an admitted [DATE] with diagnoses including muscle weakness and dementia. Review of R33's quarterly MDS, located in the EMR under the MDS tab with an ARD of 06//,d+[DATE], revealed the resident had a BIMS score of four out of 15 indicating the resident was severely cognitive impaired. Further review of this MDS revealed R33 was also assessed as having impairment on upper and lower extremities and was dependent on staff for transfers from bed to chair. Review of the Care Plan located in the EMR under the Care Plan tab, dated [DATE], identified the resident as being at risk for falls due to weakness and confusion. An intervention to add a Dycem (anti-slip) pad and a comfort cushion to the seat of his wheelchair was added to the care plan on [DATE] to prevent falls. Review of the facility's Incident Packet Checklist, dated [DATE], provided by the DON, revealed R33 was in his wheelchair in dayroom and was observed by staff sliding out of the chair onto the floor. Staff could not reach him in time. Review of the Post Fall IDT Review revealed the resident had been restless in the wheelchair and had been self-propelling throughout the facility. He was previously adjusted by staff for comfort in the chair and was witnessed seated forward. As staff walked toward the resident to assist, R33 slid out of the wheelchair onto the floor on his buttocks. He was assessed for injury, pain, and assisted back in the wheelchair. Review of the 5 Why's Tool, included in the summary of the event indicated the Dycem pad was not under the resident in the wheelchair. Review of two additional Incident Packet Checklist, dated [DATE] and [DATE], revealed R33 slid out of his wheelchair onto the floor while in the dayroom. Staff witnessed the fall on [DATE] and [DATE] but could not reach the resident in time. The falls did not result in an injury. The Post Fall IDT Review for the fall on [DATE] revealed the root cause as weakness and follow up to place a cushion to assist for better position. Review of the Post Fall IDT Review for the [DATE] fall was to place comfort curve cushion in wheelchair for comfort and aid in position in the chair. During an interview with the DON on [DATE] at 3:15 PM, an observation was made of R33's wheelchair. She stated the cushion that was currently in use was the comfort cushion that had to be ordered after the falls on [DATE] and [DATE] even though the cushion was an intervention placed on the care plan on [DATE]. The DON confirmed that the Dycem mat was not placed in the chair when the resident fell on [DATE]. 33865 3. Review of R42's Admission Record located in the EMR under the Profile tab revealed R42 was admitted on [DATE]. R42 expired on [DATE]. Diagnoses included malignant neoplasm of upper lobe, left bronchitis or lung and muscle weakness. Review of R42's admission MDS with an ARD of [DATE] and located in the EMR under the MDS tab, revealed a BIMS score of 13 out of 15 which indicated the resident had intact cognition. Further review of this MDS revealed R42 required partial/ moderate assistance for putting on/ taking off footwear, and for rolling left and right. R42 was marked as having a fall within the past two-six months and a fracture related to a fall in the six months prior to admission. No falls were documented since admission. Review of R42's Care Plan located in the EMR under the Care Plan tab, initiated on [DATE], revealed the resident had impaired mobility with risk for falls .Interventions included Monitor for gait changes .Provide standard style of call light. Validate that it is in reach prior to leaving the room . Monitor resident position in bed . All initiated on [DATE]. Review of R42's Care Plan located in the EMR under the Care Plan tab, initiated on [DATE], revealed the resident had a terminal prognosis related to lung cancer with metastasis to the liver Interventions included administer medications per order .work with nursing staff to provide maximum comfort for the resident. a. Review of the fall investigation, provided by the facility and dated [DATE] at 1515 (3:15 PM) revealed the fall was unwitnessed. Immediate interventions included removed clutter and placed pillow under head, resident covered in urine from BSC [bedside commode] spilling. There was 4cm [centimeters] x 0.1cm, abrasion to the left knee, discoloration to right knee and back. The resident was found on the back lying next to the commode. The resident was self-transferring to the BSC, and the commode was unsteady related to a folding chair under the commode. The resident was marked as barefoot. Recommendations included check and offer toilet every two - three hours, staff educated to not leave resident unattended while on the commode. Neurochecks were not documented on [DATE] at 1530 (3:30 PM), 1545 (3:45 PM), 1600 (4:00 PM), 1715 (5:15 PM), 1815 (6:15 PM), 1915 (7:15 PM), and/or 2015 (8:15 PM). During an interview on [DATE] at 1:00 PM, the Director of Nursing (DON) stated for this fall, there was a commode stored on a chair and the resident tried to use the commode that was stored on top of the chair. She stated the commode should have been in a safe place and he should have been toileted with assistance. She stated the fall interventions included leaving the door open, and he was encouraged to use the call light. She stated the next fall happened the next day. b. Review of the fall investigation, provided by the facility and dated [DATE] at 2000 (8:00 PM) revealed the fall was unwitnessed. There was no injury. He was marked as barefoot. He was found on the floor, and resident stated, unsure of what happened. Interventions implemented included staff continuing to remind the resident to use a call light for assistance with transfers, proper footwear in place, use standby assistance for transfers and ambulation. He was found lying on the side next to the bed. Recommendations included staff to leave door open for observation for more frequent observation, encourage resident to use call light for assistance. During an interview on [DATE] at 1:00 PM, the DON stated for this second fall, the resident was barefoot She stated the resident fell out of bed and there were no items in proximity. She stated the right footwear would have been shoes or non-skid socks. She stated Leaving the door open was not added to the care plan until [DATE]. c. Review of the fall investigation, provided by the facility and dated [DATE] at 2300 (11:00 PM) revealed the fall was unwitnessed. There was bruising-discoloration caused by impact. Bilateral bruising and left rib area redness. The resident was barefoot. The resident was found prone (face down) on the floor by the side of bed. Interventions included bed placed against wall and ensure in lowest position and mattress side propped to assist in resident not rolling off bed again. Increased weakness due to disease process. No defining bed edges. Recommendation included bed placed against wall, needs scoop mattress. During an interview on [DATE] at 1:00 PM, the DON stated for this third fall, he was found on the floor to the left side of the bed. She stated they recommended a scoop mattress to define the edges of the bed. She stated they recommended a bed against the wall and special mattress, but there was no indication if the door was open or closed. She stated the bolsters were added on [DATE] per care plan. d. Review of the fall investigation, provided by the facility and dated [DATE] at 0542 (5:42 AM) revealed the fall was unwitnessed. There were no injuries. The resident was barefoot. Interventions included neuros and elevation of mattress edge. The resident was found on the floor in a prone position beside bed. Recommendations included bolsters to be placed on mattress on AM shift. During an interview on [DATE] at 1:00 PM, the DON stated for this fourth fall, bolsters were on the care plan but were probably not on by that morning. She stated the bolsters were placed after this fall. Review of R42's Care Plan located in the EMR under the Care Plan tab, initiated on [DATE], revealed the resident had an actual fall with minor injury r/t [related to] disease process/ condition. Interventions included bolsters to be placed on mattress to reduce the risk for falls (initiated [DATE]) .Place bed against the wall to reduce risk for rolling out of bed on weaker left side (initiated [DATE]) .Staff to leave door open to room to observe more frequently to prevent falls (initiated [DATE]).

Based on interview, record review, and policy review, the facility failed to ensure the pharmacist made a written recommendation to the physician for a gradual dose reduction (GDR) for one of five residents reviewed for unnecessary medications (Resident (R) 16) out of a total sample of 20 residents. This failure increased the potential for R16 to be overmedicated. Findings include: Review of the facility's Drug Regimen Review policy dated 11/28/17 and provided by the facility revealed, The facility contracts with a pharmacy to complete monthly drug regimen review to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications . Any irregularities noted by the pharmacist during this review are to be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing . The attending physician documents in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R16 was admitted to the facility on [DATE] with a diagnoses of dementia with mood disturbance and depression. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/24 in the EMR under the MDS tab revealed R16 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of four out of 15. Further review of this MDS revealed R16 was identified as having verbal, physical, and other behavioral symptoms one to three days out of the assessment period (of seven days) and was administered an antipsychotic medication without a gradual dose reduction having been attempted. Review of the Order Summary Report from 05/25/23 through 08/28/24 in the EMR under the Orders tab revealed R16 was prescribed Seroquel (antipsychotic medication) Oral Tablet 25 milligrams (mg), give 12.5 mg by mouth at bedtime related to unspecified dementia with mood disturbance on 01/16/24. R16 continued on this dose during the survey; the Order Summary Report revealed no gradual dose reduction had been attempted. A request was made for all the pharmacist's medication recommendations of irregularities for R16. No pharmacy recommendations were provided. During an interview on 08/28/24 at 10:16 AM, the Director of Nursing (DON) stated R16 was started on Seroquel due to aggressive behaviors in January 2024. The DON stated on 04/15/24 the facility conducted a monthly summary review of R16s medications with the pharmacist and a psychiatric doctor. The DON stated a gradual dose reduction was discussed prior to when the gradual dose reduction (GDR) was due (six months after initiation); a formal written pharmacist recommendation had not been completed. A request was made for the psychiatric physician's rationale that a dose reduction not be implemented. The DON verified there was no documentation from the pharmacist or the psychiatric physician regarding a gradual dose reduction. A call to the pharmacist was made on 08/29/24 at 10:02 AM and a message was left but not returned. During an interview on 08/29/24 at 5:21 PM, the Director of Nursing (DON) verified there were no medication recommendations made by the pharmacist for R16 over the past 12 months.

Based on policy review, record review, review of the State Agency's Long-Term Care Reporting Portal, review of I&A reports, and staff interview, it was determined the facility failed to ensure residents were free from abuse. This was true for 2 of 4 residents (#23 and #39) reviewed for abuse. This failure resulted Resident #39 and Resident #23 not being free from verbal abuse. Findings include: The facility's Abuse policy, revised 7/23/19, documented the facility prohibited abuse and implemented policies and procedures to prevent all types of abuse, including and not limited to verbal, sexual, physical, and mental abuse. The prohibitions on abuse applied to facility staff, other residents, consultants, volunteers, agency staff, family members, legal guardians, friends, and visitors. The facility's Detecting Abuse policy, revised 7/23/19, documented when identifying events and occurrences that may constitute or contribute to abuse, the facility's procedure was to evaluate the resident for signs and symptoms of the negative psychosocial impact of the event, including but not limited to: - Fear of a person or place, being left alone, being in the dark, disturbed sleep, nightmares. - Extreme changes in behavior (aggressive or disruptive behavior toward a specific person). - Running away, withdrawal, isolating self, feeling of guilt and shame, depression, crying, talking of suicide or attempts. The policy further stated the procedures to protect residents during and after an investigation included increased supervision of the alleged victim and other residents as indicated. These policies were not followed. 1. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including extrapyramidal and movement disorder (a group of neurological conditions that cause either increased movements or reduced or slow movements). Resident #39's admission MDS, dated [DATE], documented Resident #39 was cognitively intact, required one staff supervision for transfer, locomotion, and toileting, and she was occasionally incontinent of bladder and bowel. An I&A report, dated 12/16/21, documented Resident #39 was subjected to verbal abuse from a facility staff member resulting in psychosocial harm, as follows: An I&A report, dated 12/16/21 during the evening shift, documented Resident #39 reported the night nurse [LPN #6] told her she had to stay in bed. The report documented Resident #39 had difficulty sleeping and got up frequently during the night to use the restroom. The report documented Resident #39 reported there is one nurse on night shift that is ultra-mean to me and she tells me that I have to stay in bed because I get up too much. I know they think I am disgusting but I can't help it. The report further documented Resident #39 was in tears when she told the charge nurse she could no longer get out of her chair or walk in her room. She reported it made her feel bad when LPN #6 gets after her and the nurse changes her tone of voice and loses her temper with her. Resident #39 stated she had gone [urinated or stooled] in her brief instead of asking for help to go to the restroom, so she did not have to bother LPN #6. The facility's investigation report, dated 12/21/21, documented the LMSW interviewed CNA #2 and CNA #3 on 12/20/21 about the exchange between LPN #6 and Resident #39 that occurred on 12/15/21. CNA #3 stated she did not witness anything directly, but she overheard LPN #6 relaying what had occurred to CNA #2. CNA #3 stated she did not hear what transpired completely but remembered LPN #6 saying she told Resident #39 she was the boss and Resident #39 needed to wait 30 minutes. CNA #2 stated she did not observe the altercation, but LPN #6 reported it to her. CNA #2 stated LPN #6 told her she informed Resident #39 she needed to wait because she had been to the bathroom [ROOM NUMBER] minutes prior. LPN #6 told CNA #2 she then helped Resident #39 to the restroom and while Resident #39 was on the toilet, she leaned into Resident #39's face and said, I am the nurse and I am the boss and you will do what I say. The investigation documented CNA #2 said [LPN #6] thought it was funny when she was relaying this information to her. The facility's investigation report did not include documentation LPN #6's verbal interaction with Resident #39 was determined as abuse or that LPN #6 received education on abuse and neglect. The investigation did not include documentation CNA #2 and CNA #3 were trained on reporting alleged abuse. Additionally, Resident #39's record did not include documentation she was evaluated for signs and symptoms of potential negative psychosocial impact of the verbal abuse by LPN #6, per facility policy. On 7/12/23 at 11:00 AM, the CEO reviewed Resident #39's I&A and State Agency's Long-Term Care Reporting Portal report and stated the allegation of abuse should have been substantiated. 2. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture) and repeated falls. Resident #23's admission MDS, dated [DATE], documented Resident #23 was cognitively intact. An I&A report, dated 4/4/22, documented Resident #23 was subjected to verbal abuse from a facility staff resulting in psychosocial harm, as follows: An I&A report, dated 4/4/22, documented a staff member, a COTA, reported a concern about the verbal exchange between the PTA and Resident #23 on 4/4/22 at 10:30 AM. The staff member stated the PTA spoke to Resident #23 in a demeaning-like way and treated him like a child. The I&A documented that on 4/5/23, Resident #23 continued to ruminate about the verbal exchange with the PTA and talked to the LMSW about it. The report documented Resident #23 stated he did not want to work with the PTA any longer and could not work with someone who did not respect him. Resident #23 stated he felt like he was talked to like a child. The LMSW interviewed the COTA who witnessed the interaction. The COTA stated he felt the interaction between the PTA and Resident #23 may constitute verbal abuse. The COTA gave a statement of events, as follows: He was in the gym working with another resident when the PTA and Resident #23 entered. He stated the PTA turned down the speed on Resident #23's power wheelchair and Resident #23 appeared visibly upset. Resident #23 attempted to verbalize and began swinging his arms around angrily. The COTA stated the PTA told Resident #23 if you want to be treated like an adult, stop acting like a baby and throwing a fit. Resident #23 had saliva running down his mouth from being upset. The COTA reported the PTA tossed a washcloth at Resident #23 and stated, wipe your mouth off. The facility's investigation report did not determine that the PTA actions constituted abuse. The report stated, the PTA may have acted unkindly but not abusively and that this is likely due to a communication barrier. To prevent this from happening again [PTA's name] was asked to no longer provide therapy for [Resident #23]. The investigation did not include documentation interviews were conducted with other staff and residents to determine if the PTA had any incidents of verbal abuse with other residents had occurred during treatment. Additionally, Resident #23's record did not include documentation he was evaluated for signs and symptoms of potential negative psychosocial impact of the verbal abuse by PTA, per facility policy. On 7/12/23 at 11:00 AM, the CEO reviewed Resident #23's I&A and State Agency's Long-Term Care Reporting Portal report and stated the allegation of abuse should have been substantiated. The facility failed to ensure Resident #23 and #9 were free from abuse.

Based on policy review, record review, I&A review, and staff and resident representative interview, it was determined the facility failed to ensure adequate supervision and interventions for residents to prevent falls. This was true for 2 of 7 residents (#24 and #31) reviewed for falls. This resulted in harm to Resident #31 and created risk of injury to Resident #24. Findings include: The facility's Fall Response and Management policy, revised 5/17/21, documented for a fall without injury staff were to implement immediate interventions to prevent a repeat fall, and for a fall with injury, to revise the care plan with interventions and communicate the event and intervention changes to staff. The policy was not followed. 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure, weakness, and repeated falls. Resident #31's care plan, initiated 6/13/23, documented she was at risk for falls. The care plan directed staff to keep her adjustable bed in position for safe transfers, lock the bed brakes, and keep her bed at an appropriate height when she was in bed. Resident #31's I&A reports, documented she fell three times from her bed since admission, resulting in harm after the third fall as follows: - On 6/25/23 at 11:00 PM, Resident #31 had an unwitnessed fall and was found sitting on the floor in her room between the bed and the wall in front of her wheelchair. Resident #31 said she was in bed right before she fell . No injury was reported, and immediate interventions included Resident #31 was assessed, lifted, and seated in her wheelchair. There were no interventions documented in her care plan. - On 6/27/23 at 12:00 AM, Resident #31 had an unwitnessed fall and was found on the floor face down in her room between her bed and the wall. Resident #31 said she was lying in bed right before she fell and was trying to pick something up off the floor. No injury was reported, and immediate interventions included Resident #31 was assisted to bed and transferred to the living area for closer observation. There were no interventions documented in her care plan. - On 7/4/23 at 4:45 AM, Resident #31 had an unwitnessed fall and was found on the floor in her room by the bed. Resident #31 said she was lying in bed before she fell and she was trying to get out of bed. She had a large hematoma on her forehead, and she was to sent to the hospital. The Post Fall Review recommendation was to lock her bed control for up/down function at an appropriate height for Resident #31. The investigation of the fall documented her bed was in the highest position at time of the fall. A nurses note, dated 7/4/23 at 6:56 AM, documented Resident #31 had a large goose egg hematoma, purple in color and was the size of a baseball above her right eye. During an interview, on 7/11/23 at 11:00 AM, Resident #31's representative stated Resident #31 had a third fall with injury when a CNA left the bed in its highest position. During an interview, on 7/11/23 at 2:50 PM, LPN #1 stated Resident #31's bed was in the highest position when she fell on [DATE] with her bed control lying on the floor. She stated Resident #31 was on floor on right side of her bed. During an interview, on 7/13/23 at 9:34 AM, CNA #1 stated the CNAs reviewed the Kardex index on the computer where they charted to obtain information regarding resident cares, such as bed height. She stated residents' bed height should be about knee level unless instructed by the Kardex index for special heights, such as keeping the bed at a low level. CNA #1 stated Resident #31's bed height should be at knee level. CNA #1 stated she was not aware of any bed locked situations. 48402 2. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness. An MDS admission assessment dated , 5/25/23, documented Resident #24 required a 2-person physical assist for transfers. Resident #24's care plan, dated 5/20/23, directed staff to place her personal items and assistive devices within her reach. A nurse's progress note, dated 6/25/23, stated Resident #24 was found on the floor, between her bed and the wall. On 7/10/23 at 3:15 PM, Resident #24 stated she fell because the care staff moved her assistive devices away from her bed and she was not able to reach them. On 7/12/23 at 12:10 PM, The RCM stated Resident #24 fell while trying to get out of bed on the left side. She also stated the care staff had just been in the room [ROOM NUMBER] minutes prior to providing care and forgot to place the assistive devices within her reach.

Based on observation, record review, policy review, review of manufacturer disinfection instructions, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. This was true when staff failed to perform hand hygiene, blood glucose (BG) machines were not sanitized, and unused tables were visibly dirty. These failures had the potential to impact all 35 residents in the facility by placing them at risk for cross contamination and infection. Findings include: 1. The facility's Hand Hygiene policy, dated 9/10/20, stated staff should use hand hygiene before preparing or handling food and before touching another resident's utensils when helping multiple residents with meals. This policy was not followed. On 7/12/23 at 7:43 AM, Dishwasher #1 was observed in the dining room serving breakfast to residents. He was observed not using gloves or performing hand hygiene after he touched the following surfaces/items while bringing residents their food and drinks: - The frame and wall above the kitchen service window - His clothing - His cell phone - Chairs - Drawers - A stool - The counter - The doors to the kitchen and dishwashing room Dishwasher #1 was also observed completing the following tasks without performing hand hygiene or using gloves: - Served residents' food by placing his thumb on the top of each plate, occasionally touching the food. - Served a resident's uncovered drinks while holding the cups by the rim. - Carried clean silverware from the kitchen with his bare hands, adding it to the clean silverware tray in the dining room. - Brought clean silverware to residents while holding the top, not the handle. - Held a resident's bowl of food by the rim. - Opened residents' containers/packets of brown sugar, milk, and butter with bare hands. - Threw empty packets and used plastic wrap in the garbage can During an interview on 7/12/23 at 8:14 AM, Dishwasher #1 stated they were supposed to wash hands frequently, especially if touching surfaces or personal belongings. He stated he was never told he should his wash hands between serving each resident but stated he would from now on. He stated he should have washed his hands after touching high touch areas, like the doors, his clothing, and food. He stated he should not have held the cups from the rim while serving them resident residents. 48402 2. The facility's Medication Administration Subcutaneous Insulin policy, dated 09/10/20, stated their policy was to administer subcutaneous (below the skin) insulin as ordered and in a safe, accurate and effective manner. The policy included staff were to cleanse the injection site with an antimicrobial agent and allow to it dry. This policy was not followed. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including diabetes. A quarterly MDS assessment, dated 4/20/23, documented Resident #6 received insulin injections. On 7/10/23 at 5:16 PM, LPN #1 was observed administering insulin to Resident #6 without cleaning the injection site prior to administering the insulin. LPN #1 stated she did not use alcohol wipes to cleanse the injection site because it broke down the skin on diabetics. She said she was not sure if that was the correct thing to do. On 7/10/23 at 5:30 PM, LPN #1 stated she should have sanitized Resident #6's injection site before administering the insulin. 44210 3. The facility's Blood Glucose monitoring policy, revised 5/7/21, documented the blood glucose (BG) procedures included the following: Prior to BG check: - Wash hands and put on gloves. - Prior to the initial BG check, clean the exterior of the glucometer with a germicidal or bleach wipe, wrap and monitor in a damp wipe, wait 2 minutes (or per device for contact time), and dry with damp non-sterile cloth (gauze). - Place the cleaned machine on a barrier. - Wash hands, put on gloves. - Assemble BG testing strip, alcohol wipe, lancet, and gauze pad. After BG check: - Dispose of the test strip. - Clean the exterior of the glucometer with a germicidal or bleach wipe, wrap and monitor in a damp wipe, wait 2 minutes (or per device for contact time), and dry with a damp non-sterile cloth (gauze). Place the cleaned machine on a barrier and/or store it for next use. - Remove gloves and wash hands. This policy were not followed. On 7/12/23 at 7:40 AM, LPN #3 was observed preparing and performing a blood glucose check for Resident #24 in front of the medication and treatment cart. LPN #3 wore a pair of gloves, held the glucometer in his right hand and opened the treatment cart's top drawer with his left hand, pulled out a BG test strip and inserted it into the glucometer and performed the BG check wearing the same pair of gloves. LPN #3 did not clean the glucometer before assembling the glucometer and strips. LPN #3 did not perform hand hygiene and change his gloves after opening the treatment cart drawer prior to inserting the BG test strip into the glucometer. After the BG check, LPN #3 wiped all sides of the glucometer in less than 10 seconds with one PDI Sani Hands wipe (a hand hygiene wipe). LPN #3 then put the glucometer on the medication cart without a barrier. On 7/12/23 at 8:00 AM, LPN #3 stated he should have washed his hands and put on gloves prior to assembling the test strips and preparing the glucometer for Resident #24's BG check. He stated he forgot to perform hand hygiene and to change his gloves after he touched the treatment cart drawer and before BG check. He stated he also forgot to place a barrier prior to putting the glucometer on the medication cart. LPN # 3 further stated he used the wrong wipes for sanitizing the glucometer, and he should have used the Sani-Cloth wipe instead of the PDI Sani-hands wipe to clean the glucometer.

Based on observation, staff interview, and policy review, it was determined the facility failed to monitor, discard outdated food items and maintain the kitchen in a sanitary manner. This had the potential to affect the 33 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food and Supply Storage policy, dated 11/28/17, documented food products that were opened and not completely used or prepared at the facility and stored, should be labeled with its contents and use-by dates. 1. On 7/10/23 at 2:45 PM, the following food items were observed in the walk-in refrigerator as follows: - 1 mildly thick AJ (apple juice) - used by 3/28/23 - 4 moderately thick/Honey thick AJ - used by 3/28/23 - 1 grape juice - used by 6/2/23 - 3 mildly thick AJ - used by 6/12/23 - 1 moderately thick orange juice (OJ) - used by 6/14/23 - 2 mildly thick lemon water - used by 6/27/23 - 1 moderately thick berry water - used by 6/29/23 - 2 pudding thick Cranberry Juice and one Prune Juice - undated - 1 regular milk and one supplement - unlabeled The Dietary Manager (DM), stated none of the residents were using the thickened drinks and should have been discarded. The DM stated they never had the chance to sort it out. When asked about the unlabeled and undated food items, the DM stated the regular milk and one supplement was for a resident who passed away about a week ago and the pudding thick cranberry juice and prune juice was for a resident who passed away about a few days ago. The DM stated they should have disposed of them. 2. On 7/12/23 at 8:49 AM, the following was observed in the kitchen: - There was build-up of whitish material on top of the dishwasher machine and the sides were observed to have whitish and brownish (rusty looking) material. - There was build up of whitish material on the metal cart located under the sink near the dishwasher machine. - There was build up of whitish material on the floor under the dishwasher machine and metal cart. - A hammer, crowbar tool and Caution Extremely Hot signage with rusty wires for hanging were observed on the table located under the sink where pots and pans were being washed. On 7/12/23 at 8:56 AM, Dishwasher #1 pulled the metal cart under the sink located near the dishwasher machine, picked up a broken handle from a cup and threw it in the trash can. Dishwasher #1 stated the metal cart was old and not being used in the kitchen. When asked about the hammer and crowbar on the other metal cart table, Dishwasher #1 stated they had a drain problem about two months ago and the Maintenance staff went on vacation and the tools were never picked up. 3. On 7/12/23 at 9:15 AM, the following food items were observed: - A container of undated spices and seasonings were observed on the metal rack. An unlabeled and undated container of grayish powder was also observed on the metal rack. - A carton of Quaker Cream of Wheat was not marked with date opened. - Four plastic containers of gravy powder were unlabeled and not marked with date opened or use by date. The DM stated the spices, seasonings and gravy powder should have been labeled with the date opened or use by date. 3. On 7/12/23 at 10:55 AM, an open area on the floor about 2 by 2 feet in size was observed on the floor of the kitchen near the stove. Another open area was observed on the floor near the door of the pantry were two men were observed roto rootering. The Facility Service Manager was observed standing at the door of the pantry and looking at the two men working in the open area. Water was observed at the entrance of the pantry. The DM stated the steamer broke down and they were trying to get the Roto Rooter men to come in and this was the day they were able to come in to clear the drainage. There was no barrier between the food preparation area and the area where the Roto Rooter work was being done. On 7/12/23 at 11:25 AM, the CEO was asked to come in and observe the Roto Rooter men working in the kitchen. On the way to the kitchen, one of the Roto Rooter men was observed to walk by the preparation table out of the kitchen to go to the restroom and walked back to the kitchen using the same route. In the kitchen, the CEO stated the open area where the Rotor Rooter men were working on was the drainage for the steamer and it was connected to the open area where the other drainage was located. The CEO stated the Roto Rooter men were using city water and not grey water to clear the blockage in the drain pipes. When asked how sure they were the food prepared in the kitchen was free from splashes of water being used by the Roto Rooter men, the CEO looked at the surveyors and then asked the DM to discard the food that was prepared while the Roto Rooter was in the kitchen and prepare another meal for the residents. On 7/12/23 at 11:33 AM, the DM stated they should have put a barrier between food area and the area where the Roto Rooter men were working or asked them to come during the off hours and not during the meal preparation time.

Based on policy review, review of Resident Council meeting minutes, and resident and staff interview, it was determined the facility failed to ensure Resident Council meetings were held regularly. This deficient practice placed residents at risk of ongoing frustration and decreased sense of self-worth and unmet needs, when residents were unable to voice their concerns. Findings include: The facility's Resident Council policy, revised 5/24/19, documented Resident Council meetings would be held at least monthly. This policy was not followed. On 7/11/23 8:38 AM, the CEO provided the following Resident Council meeting minutes to the surveyor: January 2022, April 2022, November 2022, December 2022 and February 2023. The CEO stated it looked like the Resident Council meeting minutes were spotty, when asked what he meant by spotty the CEO stated it looked like the Resident Council meeting was not being held regularly. On 7/11/23 10:13 AM, seven residents attended the Resident Council meeting with the surveyors. When asked if they were meeting regularly as a group, one of seven residents stated Yes. Resident #26 stated he did not remember attending or being invited to a meeting but he would be interested and happy to join in discussions with the other residents. The remaining residents who attended the meeting did not provide an answer to the question. On 7/11/23 at 2:30 PM, Resident #13 stated she did not remember the last time she attended the Resident Council meeting. Resident #13 stated it would be good to have the Resident Council meeting at least monthly. On 7/11/23 at 3:50 PM, Resident #12 stated we haven't had a meeting for a while and it would be nice to have a meeting. On 7/14/23 at 4:02 PM, Resident #10 stated she did not remember the last time she attended a Resident Council meeting. When asked if she would be interested in attending a meeting if there was one, Resident #10 stated I think so. On 7/14/23 4:22 PM, the CEO stated he started in the facility on 5/1/23 when it was acquired by new ownership. The CEO stated the Social Service Manager was trying to catch up with the social work, and the Resident Council meeting was on their list of things to do.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure resident care was provided in accordance with professional standards of nursing practice. This was true for 6 of 12 residents (Resident #5, #6, #9, #17, #23, and #24) reviewed for quality of care. Specifically: - Resident #5 and Resident #9 were not administered their medications as ordered by the physician. - Resident #6 had no monitoring for her anti-coagulant and had bruising. - Resident #17 was not provided skin treatment. - Resident #23 did not have neurological checks completed after a fall. - Resident #24 was not provided skin treatment and had empty oxygen tanks. These failures created the potential for harm if care was delayed due to lack of assessment, lack of treatment, or medication not being given as ordered. Findings include: 1. Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnosis including dementia and pain. Resident #9's physician orders included the following: - Carafate (an anti-ulcer/antacid medication) oral tablet 1gm, ordered 5/11/23 - Pantoprazole (used to decrease the amount of stomach acid produced) Sodium tablet delayed release 40 mg, ordered 5/23/22 A pharmacist review, dated 5/31/23 and 6/30/23, documented Resident #9's Carafate should be taken one hour before meals or two hours after. The pharmacist stated Carafate interfered with the absorption of most medications and must be given two to four hours after all other medications. Resident #9's MAR for July 2023, documented Carafate was scheduled to be given at 7:00 AM, 11:00 AM, 5:00 PM, and 9:00 PM. Resident #9's other medications were scheduled to be given during AM or PM medication passes (no specific times indicated on the MAR). During an interview on 7/13/23 at 2:41 PM, the CNO reviewed Resident #9's MAR and stated she could not say whether the Carafate was administered two to four hours separated from other medications. She stated the morning AM medication pass was from 6:30 AM to 12:00 PM and evening PM was from 7:00 PM to 11:30 PM. The CNO stated based on the medication pass schedule there was a potential for overlap during the morning and night doses. She stated the medication pass schedule could be better defined. During an interview on 7/13/23 at 3:31 PM, LPN #2 stated Resident #9 received all her medications at the same time, including her Carafate. She stated Resident #9 requested all her medications together. LPN #2 stated there was no specification on the orders or MAR that Carafate should be given separately from other medications. 48402 2. The facility's Prevention and Treatment of Pressure Ulcer and Other Skin Alterations policy, revised 7/13/18, stated a weekly skin assessment was performed to validate there were no unidentified skin concerns. The policy also stated the review addressed potential new areas of concern. Additionally, the review addressed potential new areas of concern; for example, fit of footwear, health of feet, need for protective sleeves, etc. Following the identification of skin concerns, the facility implemented treatment for new or existing pressure or non-pressure related wounds following the principles of wound healing. This policy was not followed. a. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus. Resident #17's care plan, dated 6/5/23, documented she would remain free of skin breakdown. An MDS admission assessment, dated 6/10/23, documented Resident # 17 had no skin concerns. Resident # 17's skin assessments dated 6/12/23, 7/3/23, and 7/10/23 documented she had an open area to her buttocks. A nurse's note, dated 7/8/23, documented a dressing was applied to Resident #17's bottom and a call was made to the physician's office for further instructions, 26 days after the skin assessment on 6/12/23 when the open area to her buttocks was identified. On 7/10/23 at 3:59 PM, Resident #17 stated she had a 9 out of 10 pain [pain scale indicating level of pain - 0 being no pain and 10 being the most pain] on her bottom because the staff had not put a dressing on her open area. LPN #3 was observed applying a dressing on the open area. He stated it was open, but it was self-inflicted because Resident #17 scratched herself. b. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus. An MDS admission assessment, dated, 5/25/23, documented Resident #24 required application of dressings to her feet. Resident #24's care plan, dated 5/20/23, directed staff to apply lotion to her feet and legs and observe for breaks in skin, swelling, inflammation, and ill-fitting shoes. The care plan also directed staff to make a referral to podiatry/foot care nurse as indicated. Resident #24's record did not include documentation her skin was checked for open areas, swelling or inflammation. On 7/10/23 at 3:11 PM Resident #24 stated she had an open area on her left foot. She stated the nurse was applying a dressing on it. On 7/12/23 at 5:03 PM, Resident #24 was observed to have a callus the size of a quarter on the bottom of her left foot. She stated the staff always but a dressing on it, so it does not bother her. Resident #24's record did not include documentation the physician was notified of the callus on her left foot. On 7/13/23 at 10:15 AM, LPN #2 stated she was not informed Resident #24 needed foot care. She reviewed Resident #24's physician orders and stated she did not see orders for treatment, but she did see a standing podiatry order. LPN #2 stated Resident #24's feet should be checked for breaks in the skin since she was diabetic. 48172 3. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including stroke. Resident #6's physician orders included the following: - Eliquis (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke) 5 mg, give 0.5 tablet by mouth two times daily, ordered 5/9/22 Resident #6's MAR, dated 7/1/23- 7/31/23, documented she received Eliquis 2.5 mg two times daily. There was no side effect monitoring documented on her MAR. Resident #6's care plan directed staff to: - notify nurse immediately of any new areas of bruises noted during bath or daily care, initiated 9/8/16 and - perform weekly skin assessment by licensed nurse and report alterations as indicated, initiated on 6/10/23. Resident #6's care plan did not include interventions to protect her skin from injuries. Resident #6's weekly skin assessments documented as follows; - On 6/17/23, there was a new bruise and soreness to her left wrist. There was no intervention documented for the bruise. - On 6/25/23, Resident #6 had a bruise on her right arm which was described as the length and shape of the arm of the wheel chair. The color was described as deep red to purple. There was no intervention documented for the bruise. - On 7/02/23, no skin issues were documented. -On 7/9/23, no skin issues were documented. On 7/10/23 at 3:52 PM, Resident #6 was observed with multiple bruises of various colors on the back of her hands. On 7/13/23 at 10:51 AM, Resident #6 was observed to have a dark blue discolored area to her left wrist and between the thumb and first finger of her right hand. Resident #6 stated she bumped her hands while pushing the wheels of her wheel chair. During an interview on 7/14/23 at 10:06 AM, the CNO stated the nurse who noted the bruise should make a notation in the nurses notes why or how a skin issue may have occurred. The CNO stated Resident #6's nurses note and care plan were not updated and no interventions were added regarding her bruises. 44210 4. The facility's Medication Management policy, revised 10/15/22, documented if medications ordered were unavailable from the pharmacy or the facility, the facility staff would contact the physician for information and further orders and document the physician directives as an order for signature. The facility's Refusal of Treatment policy, revised 11/28/17, documented residents had the right to refuse treatment and care. The facility staff would notify the physician, consult for any alternative treatment, and document in the resident's medical record. These policies were not followed. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements) and depression. A physician order, included an order to give Resident #5 mirtazapine (antidepressant) 7.5 mg, 1 tablet by mouth one time a day at bedtime for depression, started 7/26/21. Resident #5's MAR for June to July 2023, documented Resident #5 did not receive mirtazapine as follows: - Medication refused on 6/2/23, 6/3/23, 6/20/23 - Medication not available on 6/1/23, 6/4/23, 7/4/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23 Resident #5's record did not include documentation the pharmacy was contacted, or the physician was notified. On 7/12/23 at 4:31 PM, the RCM reviewed Resident #5's MAR and confirmed the dates Resident #5 did not receive mirtazapine. She stated if a medication was not available, she would contact the pharmacy first to find out why, then notified the physician and documented it in the progress note. The RCM reviewed the progress note and stated, there was no documentation the physician or pharmacy was notified. She stated the physician should be notified as soon as one medication dose was not given. 5. The facility's Fall Response & Management policy, revised 5/17/21, documented the procedures to determine the resident's post-fall injuries, including monitoring neurological assessments. This policy was not followed. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture) and repeated falls. An I&A report, dated 6/21/23, documented Resident #23 had an unwitnessed fall at 9:00 AM, he was found on the floor after attempting to self-transfer. Resident #23's record did not include documentation the neurological assessment was initiated and completed. On 7/13/23 at 2:45 PM, the CEO stated Resident #23's I&A report did not have a neurological assessment, and for unwitnessed fall, it should be completed.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 1 of 12 resident (Resident #1) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Resident's Environment policy, revised 11/28/19, documented call lights were adapted to accommodate the individual needs of the resident. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a disease that results in nerve damage that disrupts the communication between the brain and body). Resident #1's care plan, initiated 2/14/22, documented she had alteration in musculoskeletal status and staff were directed to provide her with an alternative call light - flat disc call light (soft touch call light that enables residents with limited movement to summon help). Resident #1 was observed in her bed on the following dates with her soft touch call light not within her reach as follows: - On 7/10/23 at 5:42 PM, Resident #1's soft touch call light was observed hanging over the suction machine on her bedside table. - On 7/11/23 at 9:30 AM, Resident #1's soft touch call light was behind her head under her pillow. - On 7/12/23, Resident #1's soft touch call light was on the floor. LPN #5 then entered the room and administered Resident #1's medications and exited the room without picking up Resident #1's soft touch call light from the floor. When asked, LPN #5 stated she was not aware Resident #1's soft touch call light was on the floor. The facility failed to ensure Resident #1's call light was availabe to accommodate her needs.

Based on record review and staff interview, it was determined the facility failed to ensure residents received information and assistance to exercise their rights to formulate an Advance Directive. This was true for 2 of 12 residents (#24 and #32) whose records were reviewed. This failed practice created the potential for harm or adverse outcome if the resident's wishes were not followed or documented regarding their advanced care planning. Findings include. The State Operation Manual, Appendix PP, defined as Advance directive is 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. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. a. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including asthma. An MDS admission assessment, dated 5/25/23, documented Resident #24 was cognitively intact. Resident #24's record did not include an advanced directive or documentation an advanced directive was provided or discussed. b. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including severe protein-calorie malnutrition. An MDS admission assessment, dated 6/18/23, documented Resident #32 was severely cognitively impaired. Resident #32's record did not include an advanced directive or documentation information an advanced directive was provided or discussed. On 7/12/23 at 2:05 PM, the CEO stated the advance directive documents were requested and social services was working on obtaining them. He also stated if the conversation about advance directives was not documented in a resident's record, the facility did not discuss with the resident or their representatives the importance of obtaining an advance directive.

Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, review of I&A reports, and staff interview, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated for 3 of 4 residents (Residents #20, #23, and #39) reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protection measures not being implemented by the facility. Findings include: The facility's Abuse policy, revised 7/23/19, documented the facility prohibited abuse and implemented policies and procedures to prevent all types of abuse, including but not limited to verbal, sexual, physical, and mental abuse. The facility implemented 7 components: - Screening, - Training - Prevention - Identification - Investigation - Protection - Reporting/responding to allegations of abuse The facility's Detecting Abuse policy, revised 7/23/19, documented when identifying events and occurrences that may constitute or contribute to abuse, the facility's procedure was to evaluate the resident for signs and symptoms of the negative psychosocial impact of the event, including but not limited to: - Fear of a person or place, being left alone, being in the dark, disturbed sleep, nightmares. - Extreme changes in behavior (aggressive or disruptive behavior toward a specific person). - Running away, withdrawal, isolating self, feeling of guilt and shame, depression, crying, talking of suicide or attempts. The policy further stated the procedures to protect residents during and after an investigation included increased supervision of the alleged victim and other residents as indicated. These policies were not followed. I&A investigation reports did not include thorough investigations of allegations to ensure the safety of all facility residents, as follows: 1. An I&A report, dated 4/4/22, documented alleged staff abuse to Resident #23. The report documented a staff member reported concern about the verbal exchange between the PTA and Resident #23 on 4/4/22 at 10:30 AM. The staff member stated the PTA spoke to Resident #23 in a demeaning-like way and treated him childlike. The I&A further documented Resident #23 continued to ruminate on the event on 4/5/23 and went to talk to the LMSW about it. Resident #23 stated he did not want to work with the PTA any longer and could not work with someone who did not respect him. Resident #23 stated he felt like he was talked to like a child. The LMSW interviewed the COTA who witnessed the interaction. The COTA reported to the LMSW he felt the interaction between the PTA and Resident #23 may constitute verbal abuse. The COTA gave a statement he was in the gym working with another resident when the PTA and Resident #23 entered. He stated the PTA turned down the speed on Resident #23's power wheelchair and Resident #23 appeared visibly upset. Resident #23 attempted to verbalize and began swinging his arms around angrily. The COTA stated the PTA told Resident #23 if you want to be treated like an adult, stop acting like a baby and throwing a fit. Resident #23 had saliva running down his mouth from being upset. The COTA reported the PTA tossed a washcloth at Resident #23 and stated, wipe your mouth off. The facility's investigation report did not determine that the PTA actions constituted abuse. The report stated, the PTA may have acted unkindly but not abusively and that this is likely due to a communication barrier. To prevent this from happening again [PTA's name] was asked to no longer provide therapy for [Resident #23]. The investigation did not include documentation interviews were conducted with other staff and residents to determine if the PTA had incidents of verbal abuse with other residents during treatment. 2. An I&A report, dated 12/17/21, documented staff abuse to Resident #39. The report documented on the evening shift of 12/16/21, Resident #39 was in tears making statements to the charge nurse that she could no longer get out of her chair or walk in her room. Resident #39 reported there is one nurse on night shift that is ultra-mean to me, and she tells me that I have to stay in bed because I get up too much. I know they think I am disgusting but I can't help it. The I&A report further documented Resident #39 reported the night nurse told her she had to stay in bed. Resident #39 stated she had difficulty sleeping and had to get up and use the restroom frequently. She stated the nurse came in and gets after her. Resident #39 stated she had gone [urinated or stooled] in her brief instead of asking for help to go to the restroom, so she did not have to bother the nurse. The facility's investigation report, dated 12/21/21, documented the LMSW spoke with CNA #2 and CNA #3 on 12/20/21 about the exchange between LPN #6 and Resident #39 that occurred on 12/15/21. CNA #3 stated she did not witness anything directly, but she overheard LPN #6 relaying what had occurred to CNA #2. CNA #3 stated she did not hear what transpired completely but remembered LPN #6 saying she told Resident #39 she was the boss and Resident #39 needed to wait 30 minutes. CNA #2 stated she did not observe the altercation, but LPN #6 reported it to her. CNA #2 stated LPN #6 told her she had informed Resident #39 she needed to wait, and she had been to the bathroom [ROOM NUMBER] minutes prior. LPN #6 told CNA #2 she then helped Resident #39 to the restroom and while Resident #39 was on the toilet, she leaned into Resident #39 by her face and said, I am the nurse and I am the boss and you will do what I say. The investigation documented CNA #2 and CNA #3 said they thought it was funny when LPN #6 was relaying this information. Investigation interviews with staff were related to LPN #6's interaction with Resident #39. The investigation did not include documentation interviews were conducted with other staff and residents to determine if LPN #6 had incidents of verbal abuse with other residents. Resident #39's record did not include monitoring for signs and symptoms of negative psychosocial impact after the allegation of verbal abuse. On 7/13/23 at 8:45 AM, the Administrator stated the process for abuse investigations included: Screening/interviewing other residents in the same hall where a resident making an allegation was residing to ensure there were no further allegations. The Administrator stated they interviewed staff, and investigated to determine the perpetrator and then monitored a resident for negative signs and symptoms and psychosocial outcomes after the event. The CEO stated there was no documentation these steps were completed in the facility's investigation. 3. Two I&A investigations alleged Resident #20 was sexually abused, as follows: a. An I&A report, dated 3/30/23, documented on 3/30/23 at 8:50 PM, Resident #20 reported to CNA #7 someone raped her last night. CNA #7 stated she responded to Resident #20's call light with CNA #8, she asked Resident #20 what she needed, and Resident #20 said she was hoping someone was going to come in and confess. CNA #7 asked Resident #20 Confess to what? Resident #20 said confess to raping me last night, Resident #20 said she was laying on her back and someone came in and raped her. CNA #7 asked her if it happened in the middle of the night, and Resident #20 said no. CNA #8 said he reminded Resident #20 he was with her last night, but Resident #20 said no you were not there. CNA #7 asked if it happened after she was put to bed, Resident #20 said yes, and then asked what they were going to do about it. CNA #7 told Resident #20 she would report it. The I&A further documented CNA #7 reported to the charge nurse and the charge nurse went to Resident #20's room and asked what happened. Resident #20 stated a young-looking man came to her room sat down with her, pull her pajama [sic], raped her and left. The report documented two nurses went to Resident #20's room to get her statement. Resident #20 pointed toward the second nurse and said she was there with the man. Resident #20 said that man put his penis into her on her back and it was very painful, he then turned off the television and lights and left. The charge nurse asked if this second nurse had seen everything. Resident #20 said no, nobody saw anything. The facility's investigative report, including the prior CEO's incident progress note, dated 3/31/23 at 3:44 PM, documented based on the investigation, the allegation of rape was unsubstantiated. The most likely explanation was Resident #20 misinterpreted personal care as a sexual act. The facility was also requesting a urinary analysis to be completed to rule out potential infection that would lead to discomfort in her peri-area that could be misinterpreted as sexual trauma. The investigation did not include documentation interviews were conducted with facility staff and residents regarding a male who was abusing residents to ensure resident safety. b. An I&A report, dated 4/18/23 at 9:00 PM, documented Resident #20 reported to a CNA that someone came into her room and accosted her. Resident #20 stated someone came into her room, did not turn on her lights, and climbed into bed with her. She stated the person penetrated her anally as opposed to vaginally as normal. Resident #20 stated she did not know the person. Resident #20 was questioned if she needed to have a bowel movement and she denied needing to have one. The facility's investigative report, including the LMSW's note dated 4/25/23, documented based on the facility's investigation, this allegation was unsubstantiated. The report documented the most likely explanation was Resident #20 felt the need to have a bowel movement and interpreted it as sexual trauma. The report documented both allegations of abuse on 3/30/23 and 4/18/23 occurred during nighttime hours when Resident #20 was in bed. The report also documented it was also a possibility Resident #20 was dreaming and was unable to decipher dreams from reality. The investigation did not include documentation interviews were conducted with all facility staff and residents regarding a male who was abusing residents to ensure resident safety. Resident #20's record did not include monitoring for signs and symptoms of negative psychosocial impact after the allegation of sexual abuse. On 7/12/23 at 11:00 AM, the CEO reviewed the facility's investigation documents for Resident #20's two sexual assault allegations and stated the investigations should include interviews and screening of staff working during that period of time and all working male staff. The facility failed to ensure allegations of abuse were thoroughly investigated.

Based on observation, and resident and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 12 residents (Resident #32) reviewed for respect and dignity. This deficient practice placed Resident #32 at risk of embarrassment and diminished sense of self-worth. Findings include: Resident #32 was admitted on [DATE], with multiple diagnosis including severe protein-calorie malnutrition. On 7/11/23 at 2:28 PM, Resident #32 was observed sitting in the common area watching TV with a bright yellow wrist band on his right wrist. In bold writing was his therapeutic diet soft bite size thin liquid. On 7/12/23 at 2:57 PM, Resident #32 stated he hated wearing the bright yellow wrist band and would like it removed. He stated it was placed on him when he was admitted at the hospital on 6/5/23. On 7/13/23 at 3:32 PM, LPN #4 stated the bright yellow wrist band was a dignity issue especially if Resident #32 did not want to wear it.

Based on observation, staff and resident interview, Policy and Procedure review and record review, it was determined the facility failed to: * Prevent pressure ulcers from developing; * Prevent healed pressure ulcers from recurring; * Ensure a resident's skin care plan interventions were effective; * Ensure interventions were updated after residents developed pressure ulcers; * Ensure skin and pressure ulcer assessments were completed and accurate; * Ensure treatment orders were received and implemented; and, * Ensure the physician was notified of changes in condition related to pressure ulcer size. This affected 3 of 5 residents (#s 1, 3 and 12) reviewed for pressure ulcers. The deficient practice caused harm to Resident #1 when the resident developed 2 Stage II pressure ulcers to the left and right buttock while in the facility, caused harm to Resident #3 when a healed Stage II pressure ulcer reopened as a Stage II pressure ulcer on the left buttock, and created the potential for more than minimal harm when Resident #12's pressure ulcer was not assessed correctly. Findings included: The facility's Pressure Ulcer Practice Guidelines, revised on 6/14, documented: * Develop and implement individualized prevention strategies and include on the Care Plan; * Report changes to the resident's primary care provider and document notification; * Perform weekly skin checks; * Perform at a minimum weekly documentation of pressure ulcer/wound characteristics; and, * Reevaluate the treatment plan and interventions. 1. Resident #1 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent admission MDS assessment for Resident #1, dated 8/6/14, documented: * Impaired cognition with a BIMS of 4; * Required extensive assistance for bed mobility, transfers, dressing, personal hygiene, bathing and toilet use; * Range of motion impairment for the upper and lower extremities on one side; * Frequently incontinent of bowel; and, * Had a Stage 1 pressure ulcer or greater with new skin growing in the superficial ulcer. Resident #1's Care Plan, with a date of 8/25/14, documented a focus, "The resident has potential for pressure ulcer development R/T (related to) immobility and incontinence," and interventions which included, "Educate resident/family as to causes of skin breakdown including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; Encourage, assist, supervise with use of assist bar for resident to assist with turning; Provide pressure relieving mattress on bed and cushion in chair." A Nursing Admit Re-admit Data Collection Progress Note for Resident #1, dated 7/30/14, documented the resident was admitted with a, "small stage one pressure ulcer 5*2cm (5 x 2)" on the left buttock. A Wound RN Assessment, dated 8/8/14, documented the Stage 1 pressure ulcer healed. The Braden Scale, dated 7/30/14, documented a score of 16 which placed Resident #1 at mild risk of developing pressure ulcers. The following documentation was gathered from Resident #1's Wound Data Collection (WDC), Wound RN Assessment (WRA) and Progress Notes (PN): * 8/14/14 (WDC) - Wound name: "pressure wound on upper left buttock at level of coccyx wound bed pale pink;" Type: Left buttock; Initial data collection on wound which was not present on admission/readmission; Measurements: 1.2 x 0.8 cm; Presence of possible complications: "whole of area is dark pink but blanchable. Has shearing going on;" 100% [MEDICATION NAME]; Surrounding Skin: intact, pink skin without any open areas or drainage; Dressing and/or Treatment: "will ask MD for [MEDICATION NAME] as area is hard to keep clean;" * 8/14/14 (WRA) - Type: Left buttock; Wound name: "pressure area left upper buttock at level of coccyx has pale pink wound bed;" Type of wound: Pressure ulcer; Staging; Stage 2; Healing process: "new wound;" Modifications to Interventions: Repositioning/turning, support surfaces, moisture/incontinence protection and wound treatment; Physician Notification and Documentation: Physician was notified regarding wound status; * 8/14/14 (WRA) - Left buttock; "most distal stage 2 pressure area on left buttock;" Pressure ulcer; Stage 2; "new;" Repositioning/turning, support surfaces and wound treatment; Physician was notified regarding wound status; * 8/14/14 (WDC) - "pressure area on right buttock;" Initial data collection on wound which was not present on admission/readmission; 0.5 x 0.5 cm; "tissues on bottom are a blanchable deep pink;" 100% [MEDICATION NAME]; "will ask MD for [MEDICATION NAME];" * 8/14/14 (WRA) - Right buttock; "stage 2 pressure area right buttock with pink center;" Stage 2; "new;" Repositioning/turning, support surfaces and wound treatment; Physician was notified regarding wound status;" * 8/14/14 (PN Nutritional Status) "...Has 3 stage 2 wounds on her bottom. Will add air overlay and roho cushion to care plan...;" and, * 8/14/14 (PN Communication/Visit with Physician) "(Resident's name) has 3 new stage 2 pressure areas on bottom the largest of which is 1.2 x 0.8 (cm). May we try [MEDICATION NAME] cream to wounds to see if they will heal?" The August 2014 TAR for Resident #1 contained open boxes on the assigned days for LNs to document the skin assessment. On 8/13/14 the boxes were left blank. Resident #1's September and October 2014 MRR (recapitulated physician's orders [REDACTED]." The September 2014 MRR documented a discontinued order for the assessment to be completed on Wednesdays. On 10/6/14 at 9:30 a.m., Resident #1 was interviewed while she rested in bed on an air mattress. The resident said the mattress was for wound prevention but currently she did not have any wounds. On 10/7/14 at 3:55 p.m., the DON was interviewed regarding Resident #1's skin. The DON said the identified risk factors for pressure ulcer development were immobility, potential for altered nutrition and bladder incontinence. The DON identified interventions put into place on admit as skin care right away for the existing Stage 1 pressure ulcer, a pressure relieving mattress which all beds in the facility had, and a cushion in the wheelchair. When asked what interventions were put into place after the development of multiple pressure ulcers, the DON said the Physician was called and faxed for [MEDICATION NAME] cream. The DON added there would be an order for [REDACTED].#1, the DON stated she did not find the order but would continue to look. Documentation of the physician's orders [REDACTED]. Resident #1 was admitted to the facility with a Stage 1 pressure ulcer which healed. The skin check on 8/13/14 was not completed as ordered, and the resident acquired 3 new Stage II pressure ulcers, 2 on the left buttock and 1 on the right buttock on 8/14/14. The Care Plan did not reflect skin breakdown had occurred, did not direct staff to reposition the resident, nor did it direct staff how often repositioning should occur. Modifications to the skin care plan were not made after the development of multiple pressure ulcers and treatment orders were not received by the physician. In addition, the only assessments and skin documentation provided for the 3 Stage II pressure ulcers were on 8/14/14. 2. Resident #3 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment for Resident #3, dated 9/4/14, documented: * Severely impaired cognition - resident unable to complete interview; * Required extensive assistance for bed mobility, dressing personal hygiene and toilet use; * Required total assistance for transfers and bathing; * Range of motion impairment on bilateral lower extremities; * Always incontinent of bowel and frequently incontinent of bladder; and, * One unhealed Stage II pressure ulcer not present on prior assessment. A Nursing Admit Re-admit Data Collection Progress Note for Resident #3, dated 2/27/14, documented the resident was admitted with, "has 2 areas- 1) Left side of coccyx= 2cm x 1.5 cm and superficial, 2) right side of coccys (sic) = 3cm x 1.5 cm and superficial." A Wound RN Assessment, dated 3/19/14, documented, "initially admitted with two pressure ulcers to coccyx 2*1.5 (cm) and 3*1.5 (cm). now one pressure ulcer measuring 1.5*1.5 (cm)." The assessment identified the wound as a Stage II pressure ulcer. An additional Wound RN Assessment, dated 5/12/14, documented the remaining pressure ulcer had healed and to discontinue the weekly RN assessments. Resident #3's Care Plan, with an initiation date of 6/10/14, documented the focus, "The resident has stage 2 pressure ulcer to coccyx R/T immobility," and interventions included, "Provide low-air loss mattress on bed and cushion in chair; TRANSFER resident to bed to rest after meals." The following documentation was gathered from Resident #3's Wound Data Collection (WDC), Wound RN Assessment (WRA), Progress Notes (PN) and Care Plan (CP): * 7/3/14 (PN MD/Nursing Communications) - "Resident has a small stage two pressure ulcer developing on her coccyx. At this time the wound is 1 X 0.5 cm. May we resume her orders for [MEDICATION NAME] ointment and cover with [MEDICATION NAME] QD (every day) to treat?" The MD responded with, "yes;" * 7/10/14 (WRA) - Type: Coccyx; Type of wound: Pressure ulcer; Staging: Not documented; Healing Process: "Regranulation tissue surrounding the wound. Wound itself is pale pink, no swelling, no foul drainage, no skin redness;" Modifications to Interventions: Repositioning/turning and wound treatment; Physician Notification and Documentation: Continue with current plan of treatment; * 7/11/14 (WDC) - Type: Coccyx; Not initial data collection on wound; (Note: First WDC after admit pressure ulcer healed and area reopened) Measurements: 0.3 x 0.3 cm; Dressing present, intact, no drainage or leaking; Wound Characteristics: 75% [MEDICATION NAME] and 25% granulation; Dressing and/or Treatment: "[MEDICATION NAME] covering with copa;" * 7/12/14 (WDC) - Coccyx; 1.5 x 1 cm, "Moist whitish wound bed with surrounding tissue pink;" 10% [MEDICATION NAME] and 90% granulation, minimum amount of serous drainage; "[MEDICATION NAME] and absorbent dressing;" * 7/13/14 (WDC) - Coccyx; 1.5 x 1.5 cm; "Wound is moist-wound bed whitish with surrounding tissue pink and blanchable. No s/s (signs and symptoms) of infection;" (Similar Wound Data Collection documentation without measurements or wound characteristics 7/14/14 - 7/18/14, 7/23/14, 7/25/14, 8/5/14 - 8/9/14, 8/12/14 - 8/15/14, 8/17/14 - 8/19/14, 8/21/14 - 8/22/14, 8/24/14 - 9/13/14, 9/17/14 - 9/22/14) * 7/19/14 (WDC) - Coccyx; 1 x 1 cm, "wound is whitish and moist with surrounding tissue pink and blanching with < (less) than 2 sec. (second) capillary refill;" 80% granulation and 10% slough, minimum serous drainage; "[MEDICATION NAME] dressing with [MEDICATION NAME] applied;" * 7/24/14 (WRA) - Coccyx; Stage 2, "new skin growth, no s/s of infection at this time;" No modifications to interventions; Continue with current plan of treatment; * 7/26/14 (WDC) - Coccyx; 2 x 3 cm 10% [MEDICATION NAME] and 80% granulation; * 7/31/14 (WRA) - Coccyx; Healing Stage 2, "new growth;" No modifications to interventions; * 8/4/14 (WDC) - Coccyx; 0.5 x 0.5 cm; * 8/7/14 (WRA) - Coccyx; Healing Stage 2, "new growth around area;" No modifications to interventions; (Similar Wound RN Assessment documentation on 8/21, 9/4 and 9/11/14) * 8/11/14 (WDC) - Coccyx; 1 x 1 cm with dressing intact; * 8/16/14 (WDC) - Coccyx; 2 x 1.5 cm; * 8/20/14 (WDC) - Coccyx; 1 x 1 cm with dressing present and intact with drainage; * 8/23/14 (WDC) - Coccyx; 2.5 x 1 cm; * 8/28/14 (WRA) - Coccyx; Repositioning/turning and pain management; * 9/16/14 (WDC) - Coccyx; 2.5 x 3 cm, "wound is larger at this time, appears to have more superficial damage to surrounding area;" * 9/23/14 (WRA) - Coccyx; Stage 2; "Wound has incresed (sic) in size;" Repositioning/turning, support surfaces, nutritional, moisture/incontinence protection, friction/shear management and wound treatment; Physician was notified regarding wound status; "Wound has not been healing and in the last week has increased in size. MD notified of wound change and requested to see resident in clinic;" * 9/26/14 (CP) - Interventions added: "Assist resident to turn/reposition at least every 2 hours. Reposition with 1 person assist; Avoid positioning resident on back; Provide low-air loss mattress on bed and cushion in chair;" and, * 9/30/14 (WRA) - Coccyx; Stage 2; "Wound increased in size;" (Note: No correlating measurements on WRA or WDC) Repositioning/turning, support surfaces, nutritional, moisture/incontinence protection, wound treatment and pain management; Physician was notified regarding wound status; "Resident was seen by MD on 9/29/14 who reported that we currently have all the interventions in place that he can think of and referred her to (MD's name). Referral sent to (local wound clinic)." August through October 2014 MRRs (recapitulated physician's orders [REDACTED]./5/14 and, "[MEDICATION NAME] Gel (Wound Dressings) Apply to pressure ulcer topically every evening shift related to PRESSURE ULCER, STAGE II...Apply and cover [MEDICATION NAME] (sic) once daily," ordered on [DATE]. The July through October 2014 TAR for Resident #3 documented the aforementioned physician's orders [REDACTED]. On 10/6/14 at 9:43 a.m. until 11:10 a.m., Resident #3 was observed sitting in her wheelchair in the lounge area near the nurse's station. At 11:37 a.m., the resident was observed sitting in her wheelchair in the dining room, and at 1:10 p.m., the resident was observed sitting in her wheelchair in the lounge area. On 10/8/14 at 10:20 a.m., the DON was interviewed. She said Resident #3 had a Stage III or Stage II, "That is just not healing," and said the resident was taken to see the physician for input, and the physician referred the resident to a wound clinic in a nearby city. The DON said the resident had been on comfort care and the facility had looked into the nutritional component, but the family did not want any nutritional support. The DON was asked how staff knew to reposition the resident every 2 hours and where it would be documented. She stated, "That's a standard of care, wouldn't necessarily put that on the care plan," and, "I don't know they'd document that." When asked how measurements were obtained when the dressing was in place, the DON stated, "Good question, possibly pulling last measurements forward." On 10/8/14 at 11:05 a.m., LN #6 was interviewed regarding Resident #3. The LN said the pressure ulcer was a Stage II on admit, healed and reopened as a Stage II. The initial interventions for pressure ulcer prevention included a pressure relieving mattress, repositioning every 2 hours at least, extra protein with meals and a pressure relieving cushion in the wheelchair. LN #6 said the interventions changed after pressure ulcer development to a low air loss mattress and a roho cushion to the wheelchair. The LN added the physician could not think of anything else to try and referred the resident to a wound clinic. When asked why the wound had not yet healed, LN #6 said the dressing was soiled a lot related to incontinence and the wound edges were frequently macerated. The LN was asked how measurements were obtained when the dressing was in place, and she said it might mean the dressing was present, then removed. LN #6 said the Wound RN Assessments were done weekly which included wound measurements, and the Wound Date Collections were done daily. The LN said if the dressing was to be changed every 3 days, the nurses would document on the surrounding skin and dressing in between dressing changes. On 10/8/14 at 1:40 p.m., Resident #3's pressure ulcer on the coccyx was observed with LN #6 present. The LN measured the pressure ulcer at 3 x 2 cm with a depth of 0.2 cm. The pressure ulcer was bright pink around the edges and pale in the wound bed. LN #6 said the wound edges were macerated with maybe 20% of slough in the wound bed. The LN was asked how long the resident should be up in the wheelchair, and she stated, "We try to make her last up and first down for meals," but sometimes the resident refused. Resident #3 was admitted to the facility with 2 Stage II pressure ulcers on the coccyx which healed. On 7/3/14, a Stage II pressure ulcer had reopened on the coccyx and orders were received to treat, however, the pressure ulcer was not assessed or treated for [REDACTED]. Modifications to the skin care plan were not made until 9/26/14, over 2 months after the Stage II reopened. Wound measurements and characteristics were documented when the dressing was present and intact on 7/11/14 and 8/11/14. The pressure ulcer increased in size significantly on 7/12/14, 7/26/14 and 9/16/14, and the physician was not notified until 9/23/14. Daily Wound Data Collections were not completed from 7/20 - 7/23, 7/27, 8/2, 8/25 - 8/26, 8/28 - 8/29, 9/3 - 9/4 and 9/11/14. Weekly Wound RN Assessments were not completed the weeks of 7/17, 8/14 and 9/18/14. On 10/8/14 at 4:30 p.m., the Administrator and DON were informed of the pressure ulcer issues. No further information or documentation was provided. 3. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 8/20/14, documented Resident #12 was cognitively impaired with a BIMS of 3, required extensive assistance of 2 people for bed mobility, personal hygiene and toilet use, frequently incontinent of bladder and bowel, and no pressure ulcers or skin breakdown. The skin Care Plan documented Resident #12 had the potential for pressure ulcer development related to incontinent associated [MEDICAL CONDITION] with interventions which included, "Resident prefers to be positioned in the recliner during day and will lay down in bed at night. Has a ROHO cushion in recliner," initiated on 12/3/13 and revised on 5/29/14. Resident #12's September 2014 TAR documented the order, "[MEDICATION NAME] Gel (Wound Dressings) Apply to Open area topically one time a day related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION," dated 8/29/14. A Wound Data Collection, dated 8/28/14, documented Resident #12 had a, "pressure area on left buttock" which was not present on admission, and measured 2.0 x 0.2 cm. A description of the wound documented, "whole of buttocks are discolored deep purple but per report this is normal for resident." The wound had 100% granulation tissue, surrounding skin was pink without any open areas, and treatment included, "calmosetptine (sic) vs (versus) dressing." Wound RN Assessments (WRA) and Progress Notes (PN) for Resident #12 documented: * 8/28/14 (WRA) - Pressure ulcer staged at Stage III with modified interventions which included repositioning/turning, support surfaces and wound treatment; * 8/28/14 (PN, MD/Nursing Communications) - "during skin assessment, area on buttock has opened up to a stage II ulcer; will apply dressing and monitor daily; do you want any other treatments done at this time?" The MD said, "Ok, Rx (Treat)..obs(erve)." * 8/29/14 (PN, MD/Nursing Communications) - "(Resident's name) has an open area on her bottom that is 2.0 cm x 0.2 cm x 0.1 cm. May we try [MEDICATION NAME] ointment to it q (every) day to see if we can heal it up? Please advise." The MD said, "Ok(,) obs(erve);" * 9/11/14 (WRA) - Non-pressure wound with tissue loss which decreased in size with no signs and symptoms of infection; and, * 9/17/14 (WRA) - Wound healed, weekly RN assessments were discontinued and, "area is blanchable, red, minimal excoriation noted." On 10/8/14 at 2:40 p.m., LN #6 was interviewed with LN #5 present. LN #6 said Resident #12 ambulated but sat in her recliner most of the time, but agreed to use a bed at night. In addition, the resident was frequently incontinent and was care planned to be toileted every 2 hours while awake, which the CNAss charted on. The resident had occasional excoriation which was treated with Tena cream. LN #6 said she noticed documentation which called the excoriation pressure, so herself and the DON examined the area and felt it was not pressure because it did not have the same consistency as a pressure ulcer. LN #6 stated, "Looks like 9/11 we did a wound assessment." The LN was referred to the Wound RN Assessment which documented the wound as a Stage III pressure ulcer and she stated, "I would say that is an error," and the resident did have discoloration on her buttocks. When asked why the area was only measured once, the LN stated, "I don't have a good answer for that." LN #6 said the excoriation had healed. Initial wound assessments on 8/28/14 documented Resident #12 had a Stage III pressure ulcer and provided measurements.The LN said the assessment was inaccurate, however, an asessment to clarify the type of skin breakdown was not done until 9/11/14, 14 days later. The 9/11/14 assessment did not include a rationale as to why the skin breakdown was not pressure related. In addition, the skin breakdown area was only measured once, on 8/28/14, and not measured on 9/11/14. On 10/8/14 at 4:30 p.m., the Administrator and DON were informed of the inaccurate wound assessment and concerns. No further information or documentation was provided.

Based on observation, record review, staff interview, review of the facility's bowel care interventions, and review of the facility's Procedure for Hypoglycemic Incidents, it was determined the facility failed to: a) Provide bowel care interventions for 1 of 8 residents (#4) sampled for bowel care. Resident #4 was harmed when the facility failed to intervene in a timely manner when Resident #4 experienced bowel impaction that resulted in discomfort and required a manual invasive intervention. Additionally the facility failed to: b) Follow their 1/09 hypoglycemic procedure which had the potential to negatively impact Resident #2's blood glucose levels. c) Ensure Resident #s 3 & 6 received effective relief when as needed medications were not effective. This failed practice had the potential to negatively impact the residents' level of functioning. d) Perform physician ordered [MEDICAL CONDITION] checks for Resident #4. This failed practice had the potential to affect the resident's fluid status. These failed practices affected 4 of 8 sample residents (#s 2, 3, 4, & 6). Findings included: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident #4's 12/12/11 or 12/13/11 (date illegible) Interdisciplinary Progress Notes (IPNs) documented a manual removal of, "Hard hard BM (bowel movement) this AM." On 5/10/12 at 8:30 a.m. the surveyor requested information from the ADON regarding the above IPN. On 5/11/12 at 9:00 a.m., prior to the exit meeting, the ADON and the Administrator provided the No BM Alert Reports (BMAR) that documented Resident #4 had not had a BM from 12/6/11 through 12/12/11. The BMAR included handwritten statements as follows: 12/7/11 through 12/9/11 - "MOM (Milk of Magnesia) not ordered received/refused (writing was illegible) Prune juice." 12/9/11 through 12/11/11 -Supp (suppository) and the resident's last name, all the other names on the BMAR had a line through them. 12/10/11 through 12/12/11 -Supp and the resident's first name with a question mark by it. 12/11/11 through 12/13/11 -Supp and the resident's first name with a check mark by it. Resident #4's MAR documented she had received MOM (Physician order [REDACTED]. Resident #4's 5/12 Physician order [REDACTED]. The MARs did not document Resident #4 received MOM until 12/15/11 even though the BMAR documents there were no BMs since 12/6/11 (9 days). The BMAR for 12/13/11 documented the resident received a suppository, however, the 12/11 MAR did not document the administration of the suppository. The morning of 5/14/12 the ADON was contacted by phone to clarify why other residents had a line through their name on the BMAR and Resident #4 did not. The ADON stated Resident #4 had not received the MOM. When asked about the question mark by the resident's name, the ADON stated it was unclear if the resident had received the suppository on the 12/10/11 BMAR. Resident #4 was harmed when the facility failed to implement interventions for constipation. The lack of interventions resulted in the resident being uncomfortable, required the invasive intervention of manual removal of the impaction and had the potential for possible injury. b. Resident #4's 5/1/12 physician's orders [REDACTED]. Resident #4's Treatment Record (TR) included an area to document the weekly [MEDICAL CONDITION] check. Weekly [MEDICAL CONDITION] checks were not documented for the month of 9/11 or the first week of 5/12. On 5/10/12 at 8:26 a.m. the ADON stated that the weekly [MEDICAL CONDITION] checks should have been documented on the TR. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 4/18/12 Admission MDS assessment coded: * Cognitively intact * Extensive assistance by 2 or more staff for bed mobility and toileting * Insulin injections 5 of 7 prior days The 4/26/12 CCP documented: * Provide treatment and medications as ordered The resident's 5/1/12 physician's orders [REDACTED]. * Accucheck blood glucose (BG) before meals and at bedtime. If less than 60 give 50 milliliters D50W. Recheck in 1 hour. The facility's Procedure for Hypoglycemic Incidents documented: "For (BG) levels 70 and below... give a rapidly absorbed carbohydrate... repeat (BG) test after 15 minutes... repeat administration of carbohydrate if necessary... follow with longer acting carbohydrate protein... notify physician. Monitor (BG) levels every 15 minutes until (BG) level is above 70." Medication Administration Records, Treatment Records, and Daily Skilled Notes for 4/11/12-5/8/12 documented BG levels below 70 without interventions in accordance with the Procedure for Hypoglycemic Incidents and physician orders [REDACTED]. The ADON and Administrator were informed of the findings on 5/9/12 at 1:30 PM. Neither the ADON nor Administrator had been aware of the failure to intervene for hypoglycemic incidents. No further information was received from the facility related to these concerns. 3. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 7/21/11 Admission and 4/2/12 Quarterly MDS assessments coded: * Severe cognitive impairment * Behaviors including rejection of care and wandering * Anxiolytic medication use The resident's 4/10/12 Comprehensive Care Plan (CCP) documented: * "Alteration in thought process... staff will anticipate resident's needs and ensure they are being met... When restless give her something to organize or help with... may be searching for meaningful activity - offer magazine or a fresh cup of coffee... offer to walk with (resident) up and down hallways." * "Potential for adjustment reaction... reassure and redirect when anxious... listen carefully and reassure that she is being heard and staff is here to help her... walk with (resident) to ensure she is safe, attempt to calm and reassure... attempt to redirect to diversional activity." The resident's 5/1/12 physician's orders [REDACTED]. Medication Records and Interdisciplinary Progress Notes dated 1/1/12-5/7/12 documented ineffective relief of anxiety after [MEDICATION NAME] was administered, without additional interventions to ensure the resident's anxiety or agitation was relieved: * 1/30/12 at 2:15 PM - "Still agitated" at 4:00 PM * 2/6/12 at 6:45 PM - "Still anxious" at 8:30 PM * 3/5/12 at 4:30 PM - "Still anxious" at 6:30 PM * 3/6/12 at 4:30 PM - "Eating/wandering" at 5:30 PM * 3/16/12 at 4:45 PM - "Eating/wandering" at 5:45 PM * 3/17/12 at 5:35 PM - "Still agitated" at 7:00 PM * 5/3/12 at 4:40 PM - "Still (increased) agitation" at 5:30 PM * 5/4/12 at 3:00 PM - "Still agitated" at 4:00 PM The ADON and Administrator were informed of the findings on 5/10/12 at 5:30 PM. The Administrator stated she was aware of problems with documentation of medication effectiveness and had been attempting to resolve them. No further information was received from the facility related to these concerns. 4. Resident #3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 4/11/12 Pain Data Collection Tool form documented the resident expressed the number 8 as extreme pain on a rating from 0 to 10. Ten being Worst pain ever. The resident's 4/18/12 admission MDS assessment coded: -occasionally experienced pain that limited daily activities, -pain intensity on a scale of 1 to 10 was 10, and -fell with fracture prior to admission. The resident's 4/18/12 MDS Section V, Care Area Assessment (CAA) Summary and the Resident Care Area Assessment documented the resident triggered and was care planned for pain due to, "has pain which rates at times as high as 10/10, but which can be somewhat relieved by [MEDICATION NAME] and tylenol." The resident's 4/27/12 CCP identified the problem of alteration in comfort related to left hip arthropasty manifested by complaints of pain, guarding, wincing, calling out. The problem goals was, will have discomfort relieved within one hour through 7/27/12. The problem approaches included in part, "...offer to reposition to comfort...administer medications as ordered...observe for signs and symptoms of pain and report to charge nurse." The 5/1/12 physician's orders [REDACTED]. - 4/11/12 order for aspirin 325 mg po bid (millilgrams by mouth two times a day) antiembolic [MEDICATION NAME] - 4/11/12 order for Tylenol 650 mg po every 4 hours as needed for LHF - 4/12/12 order for [MEDICATION NAME] 50 mg po BID as needed for LHF On 5/8/12 at 9:05 a.m., the survyor spoke with the resident about the quality of care provided. The resident stated she did have pain and felt nursing staff provided care for her concerns. Review of the resident's April 11, 2012 through May 8, 2012 MARs revealed: * 61 as needed pain medication administrations * Prior to the administrations, the resident said that her pain ranged from of 4 out of 10 to 10 out of 10 * 24 administrations were not monitored for effectiveness, please refer to F329 * 26 times the pain medications did not completely relieve the resident's pain * 10 times the medications were effective * One time the [MEDICATION NAME] was not effective On 5/5/12 at 2:00 p.m., the DSNs documented that a telephone call was made to the resident's physician requesting a stronger pain medication. The resident's phsycian said "not at this time." According to the 5/1/12 MAR under Documentation Notes, the resident was administered [MEDICATION NAME] on 5/6/12 at 6:30 p.m. for back pain but had "no relief" at 8:00 p.m. On 5/10/12 at 8:20 a.m., the surveyor informed LN #5 that Resident #3's [MEDICATION NAME] did not provide relief on 5/6/12. The LN stated, "There should be something in the IPNs." Review of the resident's April and May 2012 Daily Skilled Notes and IPNs did not provide evidence that any additional actions or interventions were taken to relieve the resident's back pain when the [MEDICATION NAME] did not provide the relief on 5/6/12. Nursing staff did not notify the resident's physician, on 5/6/12, when the [MEDICATION NAME] did not relieve the resident's pain. The pain relief ratings indicated the resident rarely experienced complete pain relief from the as needed pain medications. Ten effective administrations divided by 61 total administrations equals 16.39% effectiveness. On 5/11/12 at 10:00 a.m., the Administrator and the ADON were informed of the concern that the resident's pain relief was not effective on 5/6/12 and the clinical record did not provide evidence of any additional interventions. The facility did not provide any further information.

Based on record review, resident and staff interview, it was determined the facility failed to ensure a resident at risk for pressure ulcers did not develop recurrent Stage II pressure ulcers when interventions were not implemented. This resulted in harm for 1 of 5 residents sampled for pressure ulcer prevention and treatment (Resident #4) and had the potential for harm for 3 of 5 residents (#s 1, 2 and 3). Findings include: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Pressure Ulcer Risk Assessments for Resident #4 completed on 12/6/11, 12/12/11 and 3/7/12 documented the resident was at mild risk to develop pressure ulcers. Resident #4's current 8/30/11 Comprehensive Care Plan (CCP) identified the problem of alteration in skin integrity related to immobility and incontinence. The Approach section included to reposition the resident every 2 hours, apply lotion after baths, weekly skin checks, pressure relieving mattress and resident education regarding sitting too long. Treatment Records (TR) for Resident #4 had a section to place a check mark if the resident's skin was intact. If the skin was not intact a Wound Flow Sheet (WFS) was to be completed. NOTE: CMS guidance at F314 includes that the facility should have a procedure to assure: assessments are timely and appropriate; interventions are implemented, monitored, & revised as appropriate; and changes in condition are recognized, evaluated, reported to the practitioner, & addressed. Further guidance requires with each dressing change or at least weekly (more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. Inteterdisciplinary Progress Notes (IPN), TRs and WFSs were reviewed for 8/11 through 5/1/11. The TR for 8/11 documented the Resident's skin was intact for 8/1/12 through 8/31/12, however an IPN dated 8/29/12 documented information was faxed to the physician regarding an "Update on healing pressure ulcer to ischeum." The medical record contained no further information regarding a pressure ulcer to the ischeum. The TR for 9/11 documented on 9/22/11 the skin was not intact, however a WFS (as required) was not in the medical record. The TR documented a bandage was in place from 9/22/12 through 9/26/12 and the wound was resolved on 9/29/12. The 9/23/12 IDT notes documented, "Rec'd (received) order for Stage II. Small split in coccyx. No drainage..." IDT notes for 9/30/12 documented a small slit on the coccyx that was not open. The medical record contained no further information regarding the split on the coccyx. The TR for 10/11 documented the skin was intact. The attached documentation notes documented a cream was put on a red area to the coccyx. The medical record contained no further information regarding the split on the coccyx. The TR for 11/11 documented the skin was intact. A 11/28/11 IPN documented an order for [REDACTED].#4's skin. The TR for 12/11 documented the skin was intact, however there was no documentation the skin was assessed on 12/28/11. There was no further information regarding the assessment of Resident #4's skin. The TR for 1/12 documented the skin was intact, however a 1/30/12 WFS documented a Stage II pressure ulcer that was 1 cm by 1 cm without drainage or odor. The IPN documented the physician was notified of an open area on the coccyx in the shape of a "V." The TR for 2/12 documented a Stage II pressure sore (location not identified) that resolved on 2/6/12. The 2/1/12 WFS documented a Stage II on 2/1/12 with minimum drainage that was 1 cm by 1 cm. The 2/8/12 WFS documented there was no pressure ulcer and resolved was written on the 2/10/12 WFS. A WFS for 2/21/12 documented a Stage II pressure ulcer to the coccyx that was 0.5 cm by 1.3 cm without drainage or odor. The IPNs documented on 2/22/12 the physician was faxed information regarding an open area on Resident #4's coccyx that was previously healed but is now forming, "A small white spot in the middle of the coccyx." The physician sent an order for [REDACTED]. The TR for 3/12 documented the skin was intact. The WFS dated 3/2/12 documented the pressure ulcer to the coccyx was healed. On 5/10/12 at 8:26 a.m. the ADON was asked about the 8/29/11 Stage II pressure ulcer on the ischeum. The ADON stated she had no information regarding that pressure ulcer. When asked for weekly documentation for each pressure ulcer identified that included the size, depth, the surrounding skin appearance, etc. the ADON stated there should have been WFSs for each pressure ulcer but there was not. When asked if the Roho cushion was a new intervention for the reoccurring Stage II wound, the ADON stated the cushion had always been in place and the order on 11/28/11 was after an assessment by physical therapy. When asked if there were interventions prior to the physician order [REDACTED]. The ADON was asked for documentation the resident had been out of her chair as ordered by the physician. Later that day the ADON stated there was no documentation. Resident #4 was harmed when the facility failed to implement interventions for the reoccurring Stage II pressure area to her coccyx. Additionally the facility failed to document weekly assessments of the status of the coccyx ulcer and did not have any information regarding the 8/29/12 ischeum Stage II pressure ulcer. 2. A complaint from the public was received at the Bureau of Facility Standards on 2/22/12. The complainant stated that in July (2011) the facility sent a letter indicating that Resident #1's "level of care" had increased and so her bill would increase based on her MDS assessment. Upon inquiry, the complainant was told the resident had developed pressure ulcers, "possibly on her feet." The facility reimbursed extra charges for October and indicated the pressure ulcers had healed. The complainant wanted surveyors to investigate "care concerns" related to the pressure ulcers. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. NOTE: The A.D.A.M. (brand name) Medical Encyclopedia 2011 describes [DIAGNOSES REDACTED] as "a skin disorder characterized by large blisters... symptoms come and go... the blisters are usually located on the arms, legs, or middle of the body... the blisters may break open and form ulcers or open sores. Other symptoms may include itching (and) rashes... anti-[MEDICAL CONDITION] medicines called corticosteroids may be prescribed... creams may be used." The resident's MDS assessments coded: * 4/11/11 - No pressure ulcers * 7/5/11 - 3 unstageable pressure ulcers not present at admission; the largest wound was 2 centimeters (cm) long x 1 cm wide x 0 depth; slough was present on the worst wound. * 10/6/11 - No pressure ulcers * 12/20/11 - No pressure ulcers * 3/13/12 - No pressure ulcers The resident's 4/20/11 and 7/14/11 Comprehensive Care Plan documented the problem of potential alteration in skin integrity related to immobility, incontinence, decreased circulation, bullae pemphigoid as manifested by reddened skin, open areas, and psoriasis. Interventions included turn and reposition every 2 hours, and treatments per orders. A 7/1/11 Fax Communication To Physician documented, "(Resident) has a quarter size blister lateral side (left) foot. Has three areas next to blister that may have been blisters. Please advise." The physician responded on 7/5/11, "Please treat with dressings - clean (twice daily with) [MEDICATION NAME] or similar antibiotic ointment to the site (avoid [MEDICATION NAME]). Pressure protection to the site." NOTE: The physician did not document in the medical record that the wounds were pressure related or disease related. The resident's July 2011 Treatment Administration Record documented the physician-ordered treatments were administered from 7/6-7/14 when the wound was documented as, "healed". The resident's 7/7/11 Wound Flow Sheet documented a 1.5 cm long x 0.5 cm wide x 0 depth wound on the left lateral foot, with minimal serosanguinous drainage. The wound was documented as "Pressure Ulcer, Stage 2." The ADON and Administrator were interviewed about the resident's wound documentation and MDS assessments on 5/9/12 at 3:00 PM. The Administrator stated that she had discussed the resident's foot wounds at great length with the interdisciplinary team and the resident's family member. The facility was unable to state with absolute certainty that the wounds were related to the resident's disease process. Because the LN had documented the wounds as pressure related and the physician had ordered pressure prevention to the site, it had been determined that the best course of action would be to code the MDS assessment as pressure ulcers to be most honest and accurate in documentation. On 5/10/12 at 1:50 PM, the ADON stated that she had seen the resident's wounds in July 2011, and she described the blisters as, "clear, gelatinous... one of the resident's feet is everted, it's possible that it could be pressure related." The ADON and Surveyor observed the resident's feet moments later, and it was observed that the resident's right foot was everted. The ADON stated, "Well then it wouldn't be pressure related." At that point, the LN who documented on the 7/7/11 Wound Flow Sheet was asked how she determined that the foot wounds were pressure related and not related to the resident's [DIAGNOSES REDACTED]. I was taught in school that any blister is an unstageable pressure ulcer." NOTE: Federal Guidelines document, "At the time of the assessment, clinicians (physicians, advance practice nurses, physician assistants, and certified wound care specialists, etc.) should document the clinical basis (for example, type of skin injury/ulcer, location, shape, ulcer edges and wound bed, condition of surrounding tissues) for any determination that an ulcer is not pressure related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one." There was no evidence that the facility considered the resident's [DIAGNOSES REDACTED]. The wounds were not over a bony prominence or in typical pressure sore area, and were treated and healed in 2 weeks with an antibiotic ointment. Based on surveyor observations, staff interviews, and review of all evidence in the resident's medical record, the surveyor was unable to definitively determine that the resident's left lateral foot wounds were pressure related. The ADON and Administrator were informed of the findings on 5/9/12 at 1:30 PM. The Administrator stated that education about wound assessment and documentation would be provided to the LN providing wound care at the facility. On 5/10/12 at 2:30 PM, the ADON stated that the facility would, "check on the charges and consider an MDS revision." No further information was received from the facility related to Resident #1's wounds. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with multiple open wounds. The resident's 4/18/12 Admission MDS assessment coded: * Cognitively intact * Extensive assistance by 2 or more staff for bed mobility * Continent of bowel; indwelling catheter in use * At risk for development of pressure ulcers * Unhealed pressure ulcers present at admission, Stage II, the worst measured 18 centimeters (cm) x 12 cm and had slough or eschar present. The 4/26/12 CCP documented the problem of alteration in skin integrity related to impaired mobility, diabetes mellitus, and [MEDICAL CONDITION] manifested by multiple decubiti including but not limited to coccyx, bilateral heels, scrotum, and 1 great toe. Interventions included: provide treatments and medications as ordered. The resident's weekly Braden Scale For Predicting Pressure Sore Risk form documented scores of 16 on 4/12/12, and 15 on 4/19/12, 4/25/12, and 4/26/12. A score of 15-18 indicated Mild Risk, and the Intervention Guide recommended frequent turning, maximal remobilization, pressure-reduction support surfaces if bed- or chair-bound, protect heels, and to manage moisture, nutrition, friction, and shear. Wound Flow Sheets documented healing progress on each of the resident's wounds which were present at admission. However, 2 new pressure ulcers were documented on 4/29/12, on the resident's bilateral great toes. The initial assessment documented the right toe wound as 0.3 cm x 0.3 cm x unmeasurable depth, with "100% eschar." The left toe wound was documented as 0.3 cm x 1.1 cm with no documented depth and "100% eschar." A Daily Skilled Note dated 4/29/12 documented, "New pressure ulcer (sic) to both (right and left) great toe (sic). Both are 100% eschar. Measurements on wound sheet. Both covered with [MEDICATION NAME] (and physician) faxed... (resident) slides down in bed (and) toes touch air pump for bed." The resident's bilateral toes were observed with the ADON on 5/10/12 at 8:15 AM. The areas of concern were pinpoint darkened areas of intact skin at the ends of the great toes. The ADON stated, "A discoloration of skin is what I saw (on 4/29/12 when the wounds were discovered and documented by the LN). She's a new nurse. There were never any eschar or open areas." NOTE: Federal Guidelines define a Stage I pressure ulcer as, "An observable, pressure-related alteration of intact skin." A Stage II pressure ulcer is defined as, "Partial thickness loss of dermis." Based on surveyor and ADON observation, it was determined the LN documented 2 Stage II pressure ulcers in error when in fact they were 2 Stage I pressure ulcers. Appropriate interventions were implemented, and the wounds were almost entirely healed during survey. The ADON and Administrator were informed of the findings on 5/9/12 at 1:30 PM. The Administrator stated that education about wound assessment and documentation would be provided to the LN providing wound care at the facility. No further information was received from the facility related to Resident #2's wounds. 4. Resident #3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 4/18/12 admission MDS assessment coded: -moderately impaired cognition -fell with fracture prior to admission, -one or more unhealed pressure ulcer(s) at Stage 1 or higher -one stage 2 pressure ulcer, onset date 417 (4/17/2012) The resident's physician's orders [REDACTED]. The 4/27/12 CCP documented the problem area of alteration in skin integrity related to impaired mobility, poor circulation, incontinence manifested by small Stage II coccyx, reddened skin or open area. One of the problem approaches was to assist the resident to reposition in bed and chair every 2 hours. The resident's Wound Flow Sheet documented a slid (slit) to the coccyx: *4/17/12, "coccyx center, length 0.5," there were no other measurements on the form for this date. *5/2/12, width "<0 (less than 0), depth 0" There were no other measurements on the form for this date. Note: The open area on the coccyx developed 6 days after the resident was admitted . The resident's 5/3/12 Daily Skilled Notes did not document that the resident's coccyx skin was healed. The Nutrition at Risk IPNs on 5/3/12 at 10:54 a.m. documented, "...coccyx healed..." On 5/10/12 at 9:15 a.m., the surveyor informed LN #5 that the clinical record did not provide evidence that the resident was repositioned every 2 hours to prevent skin breakdown. At 10:30 a.m., LN #1 provided information taken from the facility's automated computer system however the information did not provide evidence that the resident was turned, repositioned, or refused turning and repositioning every two hours. On 5/10/12 at 11:15 a.m., the surveyor was not able to engage the resident in a conversation related to repositioning and turning every two hours. On 5/11/12 at 10:00 a.m., the Administrator and the ADON were informed of the finding.

Based on observation, staff interview and record review, it was determined the facility failed to provide assistive devices to keep residents safe from accidents and injury. This was true for 3 of 8 residents sampled for falls and accidents (Residents #3, #4, and # 9), and resulted in harm to resident (#4) when she sustained a fracture when transferred without an assistive device. Additionally the facility failed to ensure care plans to prevent falls were revised and/or implemented to include recommended interventions for 3 of 8 sampled residents (#'s 10, 11 and #13). This failure had the potential to place residents at risk for falls and injury. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Comprehensive Care Plan (CCP) dated 8/30/11 included a problem area of impaired mobility with a potential for injury related to the removal of the resident's right hip. The approach section included the resident was only be transferred with the use of a mechanical lift. An Incident Detail (ID) report dated 11/20/11 documented Resident #4 was being transferred from her wheelchair to bed. Attached to the ID report was a narrative written by the social worker that documented Resident #4 refused to use the lift to transfer from her wheelchair to the bed. Resident #4 convinced the CNA to use a stand pivot to transfer her to the bed. After being transferred the resident complained of knee pain. The resident was taken by ambulance to the hospital and returned with orders to be seen by a physician to evaluate the resident's left knee. Resident #4 continued to complain of pain and returned to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED]. The hospital admit report documented the intractable pain could be from her fibular fracture or from gout. Interdisciplinary Progress Notes(IPN) documented on 11/21/11 Resident #4 refused to get up because of too much pain to her left knee and requested her pain medication. The 11/25/11 IPN documented, "With a lot of encouragement" the resident went to the dining room for her meals. On 5/10/12 at approximately 8:30 a.m. the acting DON (ADON) stated Resident #4 had insisted to the CNA she could be transferred without the use of a lift. When asked if the CNA handled the situation correctly the ADON stated the CNA should not have used a stand pivot transfer but contacted the nurse. Resident #4 sustained a fracture to her left fibula causing intractable left knee pain when the facility failed to follow her CCP to use a mechanical lift for transfers. 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's fall risk assessment dated [DATE] documented a score of 21. The rating on the assessment documented a score of 12 or more assessed the resident to be at high risk for falls. Resident #11's medical record included 4 Incident Detail (ID) reports for falls between 2/28/12 and 3/6/12. The ID reports included the following interventions were to be implemented. 3/1/12 - Documented the resident fell when her "knees went" out and she slid to the floor. Interventions included she was to move to room 202 which was closer to the nurses station. There were no apparent injuries, however, it was documented the resident was "Crying to get up." 3/2/12 - The resident attempted to self transfer from the bed to a bedside commode. The interventions included a floor mat was to be placed and a pressure sensor was to be placed (location not specified). There were no apparent injuries. 3/3/12 - The resident was found on the floor and complained of pain to the sacral area. The resident used the commode after the fall. The intervention was to complete laboratory tests for a urinary tract infection. There were no apparent injuries. 3/6/12 - The resident was found sitting on the floor and stated she was looking for her husband. The interventions were the continued use of alarms and the floor mat. There were no apparent injuries. The above interventions were not included on the plan. Resident #11's CCP, dated 3/13/12, included a goal for, "Will sustain no major injury as result of fall." The approaches included to use a lift for transfers, a geri chair for mobility and up to two staff for bed mobility. 3. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13 was discharged from the facility on 1/13/12. Resident #13's medical record included 5 ID reports for falls between 11/29/11 and 1/3/12. The ID reports included the following interventions were to be implemented. 11/29/11 - Documented the resident fell when attempting to go to the bathroom. The corrective actions documented safety devices were in place. The LN had written "Sensor" under the above documentation. 11/30/12 - Found on floor. Corrective actions included to install a pressure sensor, pads put on the side of the bed and to amend the CCP. There no apparent injuries. 12/1/11 - The resident was found on his knees beside the bed. Corrective actions included to get the resident up if anxious. There were no apparent injuries. 12/3/11 - The resident was found sitting by the side of the bed on his knees and stated he had slipped out of bed and could not get back into the bed. There were no injuries documented. The corrective action documented a low bed was put in the room on 12/5/11. 12/10/11 - The resident rolled out of bed to his knees. The corrective actions were to increase supervision. The ID documented injuries to the knee and left and right toe. NOTE: The corrective action of increased supervision did not specify how the intervention would be implemented (15 minute checks, resident within arms length etc.). Resident #13's CCP, dated 12/8/11, documented in the problem section the resident was unable to independently ambulate and was a high risk for falls. The approach section included a pressure sensor to bed and chair, floor pads and the sit to stand for transfers. The CCP did not include to get the resident up if the resident was anxious, a low bed or increased supervision. On 5/11/12 at 9:00 a.m. the Administrator was informed of the lack of CCP revisions for falls for Residents #s 11 and 13. The Administrator stated the facility was aware that care plan revisions were not always completed and was in the process of addressing the problem. 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 6/20/11 PPS assessment coded intact cognition and required one person physical assistance for transfers, walking in room, ambulation, and bathing. Note: The resident's 6/10/11 admission MDS assessment did not document the resident's cognition status, therefore, the PPS was used. The resident's Incident Details (fall reports) from 11/4/11 through 2/20/12 provided the following evidence: *11/4/11, reported at 11:45 a.m., Found on floor, no injury or pain noted. Corrective actions: Install/modify safety device "TABS." Immediate interventions: "tab alarms placed, and rn (pressure) sensor." *11/28/11 at 9:15 p.m., Found on floor, no signs or symptoms of pain. Corrective actions: "Safety/assistive device in place" *2/20/12 at 8:00 a.m., Found on floor, denied pain. Corrective actions: "Highsided mattress" The resident's 9/29/11 Comprehensive Care Plan (CCP) contained the following fall problems and approaches: *Problem- Risk for falls related to activity intolerance manifested by decreased strength and impaired balance. The problem approaches were: 1) Keep pathways free of clutter and 2) Assist resident with transfers as needed. *Problem- Alteration in mobility related to activity intolerance manifested by inability to independently walk in halls, propel self in wheelchair outside of room. The problem approaches were: 1) Transfers: Independent. 2) Ambulation: Independent in room. CGA (contact guard assist) of 1 with front wheeled walker in halls. 3) Mobility: Independent in room, propel to destination out of room in wheelchair. The resident's 11/10/11 CCP identified the problem of alteration in mobility related to activity intolerance. In the approaches column, there was a handwritten entry "rn sensor in bed" that was lined through without a date or initials to indicate when the approach was initiated or when the approach was discontinued. Note: The 9/29/11 and 11/10/11 care plans did not provide evidence of care plan revision for the use of the rn sensor, tab alarms, and highsided mattress. On 5/11/12 at 9:25 a.m., the surveyor informed the Administrator, ADON, and LN #5 that the resident's care plan contained a handwritten entry for the rn sensor that was lined out with no date or initials. The resident's 3/8/12 significant change MDS assessment coded: -Moderately impaired cognitive skills -Required physical assistance of one person for transfers, bed mobility dressing, hygiene and bathing -Unsteady balance during transitions -Wheelchair primary mode of transportation -fell prior to admission and within last 2-6 months prior to admission -No fracture in last 6 months The resident's 3/8/12 MDS Section V, Care Area Assessment (CAA) Summary and Resident Care Area Assessment documented the resident triggered and was care planned for falls due to, "at risk for further falls r/t (related to) refusals of cares, weakness." The resident's Incident Details (fall) from 2/21/12 through 3/11/12. * 3/11/12 at 4:25 p.m., Sitting on floor by bed. Corrective actions: TABS alarm. The resident's 2/2/12 CCP again identified the problem of alteration in mobility. The CCP did not provide evidence that the care plan was revised for the use of tab alarms, rn sensor, or highsided mattress. On 5/10/12 at 4:33 p.m., the resident's room and wheelchair were reviewed for the use of a rn sensor and use of tab alarms. The resident was in her wheelchair in her room. LN #3 and CNA #4 were in the room with the resident. The CNA was leaving the room as the surveyor entered the room. An alarm was observed on the resident's bed. The LN stated, "It is a rn sensor. When activated, the sensor sounds if the resident moves out of bed." Note: There were no tab alarms observed on the resident's wheelchair or bed. - At 4:36 p.m., CNA #4 entered the room with a tab alarm in hand. The LN stated, "She (the resident) did not have a tab alarm on and she needs it." On 5/10/12 at 5:20 p.m., the Administrator and the ADON were informed of the observation. The survey team informed the facility that the interventions or corrective actions taken after the resident sustained [REDACTED]. And on observation, there were no tab alarms to the resident's bed or wheelchair. On 5/11/12 at 10:00 p.m., the Administrator and the ADON were informed of the finding. The facility did not provide any additional information. 5. Resident #3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 4/18/12 admission MDS assessment coded: -moderately impaired cognitive skills with a BIMS score of 12, -required extensive physical assistance for transfers, -did not walk in room or corridor, -totally dependent on staff for locomotion, and -fell with fracture prior to admission. The resident's 4/27/12 CCP identified the problem of alteration in mobility manifested by a need for assistance in all ADLs and mobility. One of the problem approaches was slide board transfers with cga (contact guard assist) of one. On 5/9/12 at 7:40 a.m., CNA #6 was observed transferring the resident from a chair in the activity-television area to a wheelchair. The use of a gait belt was not observed. The CNA then wheeled the resident to the dining room. -At 9:24 a.m., The surveyor asked CNA #6 about the use of a gait belt. The CNA stated, "I should have used a gait belt. I thought about that afterwards." On 5/10/12 at 8:28 a.m., the surveyor informed LN #1 of the observation of CNA #6 transferring the resident from a chair to a wheelchair. The LN stated, "CGA (contact guard assist) of one on the care plan means, one person transfer and the CNA should use a gait belt." On 5/11/12 at 10:00 a.m., the Administrator and the ADON were informed of the finding. The facility did not provide any additional information. 6. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 3/28/12 MDS assessment coded: * Severely impaired cognition with short- and long-term memory impairment * Extensive assistance by 2 or more staff for bed mobility * Dependent upon assistance by 2 or more staff for transfers * Unsteady, only able to transfer from surface to surface with assistance of staff * Frequent incontinence of bowel and bladder * No falls since prior assessment The resident's 4/5/12 Comprehensive Care Plan (CCP) included the problem of potential for injury related to medication use and dementia. The goal was, "Will not sustain injury thru 7/5/12." The interventions, none of which had changed since the 10/19/11 CCP, included: Keep pathways free of clutter. Transfer and ambulate with 2 contact guard assist. Do not leave unsupervised on the toilet. High sided mattress on bed. Mat on floor next to bed, her right side. The resident's 7/26/11 CCP included the intervention, "Place RNSensor in bed vertically (down spine) to prevent rolling (out of bed)." This intervention was removed prior to the 10/19/11 CCP. The resident's Falls Data Collection Tool documented high fall risk on 8/13/11 and 9/12/11. The scores were 23 and 25 respectively, and a total score of 12 or more "equals high risk." NOTE: The Falls Data Collection Tool had not been updated since 9/12/11. Incident Reports documented the resident fell out of bed: * 11/8/11 at 7:30 PM - Found on floor, lying on right side by the bed. Personal alarm sounded. Fall mat and low bed in use. resident sustained [REDACTED]." Immediate interventions were: "Remind (staff) to get to tabs alarms quickly. Check on (resident) often." Corrective Actions were: employee education/training or re-instruction. * 11/22/11 at 3:00 PM - Found with body from waist up bending over the side of the bed onto the floor mat, with head resting on mat. Fall mat and low bed in use. Personal alarm was not marked. Immediate interventions were: "Looking into foam block or inflatable cube to prevent this." Corrective Actions were: "Looking into additional padding for floor that is same height as bed." * 5/7/12 at 7:00 AM - Found on floor, lying prone on mat on right side of bed. Fall mat and low bed in use. Personal alarm was not marked. Immediate interventions and Corrective Actions were: "Frequent checks while in bed x 72 hours." On 5/10/12 at 4:15 PM, the Administrator was interviewed about Resident #10's falls out of bed, what interventions had been implemented, and whether or not the CCP was accurate. The Administrator stated that the foam block, inflatable cube, or other additional padding had not been implemented, because "She's not safe if we do that. I think we are interventioned (sic) out... I don't know what else to do." The Administrator was not able to say why the RNSensor had been removed from the CCP prior to 10/19/11. When asked if increased supervision had been attempted as an intervention for this resident, the Administrator replied that the falls were, "happening at night." NOTE: The resident fell out of bed at 7:00 AM, 3:00 PM, and 7:30 PM. On 5/10/12 at 4:30 PM, the Administrator and Surveyor observed the resident's bed. A tab alarm was in place; there was no RNSensor; a lipped mattress was in place, and a standard 1 inch floor mat was in the top of the closet. The resident was not in the room, and the Administrator stated that the floor mat was removed from the bedside when the resident was not in bed, to reduce trip hazards. The Administrator pointed out that the resident's dresser had been moved to the far corner of the room, away from the bed, "to reduce risk of injury." On 5/10/12 at 4:45 PM, the resident was observed in her wheelchair in the lobby of the SCU. A tab alarm was in use. CNA #2 stated that the resident used the tab alarm "in bed and in the wheelchair." NOTE: The tab alarm had never been added to the CCP. On 5/11/12 at 9:15 AM, the ADON and Administrator were informed of the findings. The Administrator stated that the RNSensor had been discontinued because, "At the time we looked at it there were no falls for a period of time." After the 5/7/12 fall, "We increased the number of times we checked on her." The Administrator clarified that the 11/8/11 Incident Report indicated that a "tabs" alarm sounded when the resident fell . Resident #10 fell from bed 3 times in 6 months, but her CCP had no increased or modified interventions for falling out of bed during that period of time. No further information was received from the facility related to the resident's fall interventions.

Based on record review and staff interview, it was determined the facility failed to immediately inform the resident's physician of a need to alter treatment significantly when the resident allegedly informed a LN of her desire to change her code status the day before she was found unresponsive and no CPR was initiated. The facility ultimately did not follow the Idaho Physician order [REDACTED]. This was true for 1 of 13 (#13) sampled residents. The resident was harmed when the physician was not notified, resulting in the physician not having the opportunity to consult with the resident about a change in status. No resuscitation efforts were initiated and the resident expired. Findings included: Resident #13 was admitted to the facility on [DATE] and expired in the facility on [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Resident #13 had an Idaho Physician order [REDACTED]." Also noted was the resident's choice of aggressive interventions, which included endotracheal intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated. The resident had also documented her desire for intravenous fluids for artificial fluids and nutrition, as well as antibiotics and blood products if needed. The Physician's (recapitulation) Orders, dated [DATE], documented, "CPR: Resuscitate." In Interdisciplinary Progress Notes for Resident #13, dated [DATE], Social Services documented, "Greeted Resident and her daughter-in-law...Inquired of code status, Resident states she is full code and has POST stating the same. Resident's son states that discharge goal is to transfer to asst. (assisted) living as soon as Resident is able." Resident #13's Daily Skilled Note, dated [DATE] at 1:30 pm, documented the following: "Res (resident) fell on way to lunch. (LN) responded to resident...When nurse responded found Res unresponsive. Res not breathing, no pulse could be found. Res pupils dilated to 6. Res remained like this for close to 10 min. Res then yelled out and whole body jerked. Slowly res woke up and pupils constricted down to 2. Res was able to move both LE (lower extremities). Verbalized she was in (city). Hand grips strong and equal. Res lifted up with TL (transfer lift) and taken to bed in w/c (wheelchair). Neuro checks initiated which have been WNL (within normal limits). Res denies pain and states she does not remember incident. (Family member) was notified and came to see Res. Res remains A & O (alert and oriented) x 3 at this time. Currently Res resting in bed." At 2:00 pm, two hours after the incident, nursing staff documented they had placed a call to the physician to inform him of the incident. It was noted the physician would call back. In the same Daily Skilled Note, at 11:00 pm, 11 hours after the incident, was documented: "Res A & O x 3. Neuro checks done per policy protocol. No adverse signs noted. Res denies pain. Does not remember the episode....Talked to on call MD (physician) to inform of incident." NOTE: It could not be determined when the on call physician returned the call or what information was relayed to the physician. The facility Incident Report, dated [DATE], documented the following for follow-up: (NOTE: The form documented the follow-up to be completed within 24 hours of incident. The DNS, Administrator, and Social Worker signed the form on [DATE].) * Vital Sign Changes NO * On-Site First Aid Given NO * Outside Medical Treatment Needed NO * hospitalization Required NO The following information was recorded on the facility Neuro-check flow sheet for Resident #13: [DATE] at 11:55 am * Temperature 96.0 * Pulse ? * Respirations ? * Blood Pressure ? * Orientation Unresponsive * Level of Consciousness Unresponsive * Pupil Size Right 6 Left 6 * Pupils Reactive Negative * Hand Grasps & Movement N/A (not applicable) * Spontaneous Movement None * Speech None [DATE] at 12:00 pm * Temperature 96.0 * Pulse ? * Respirations ? * Blood Pressure ? * Orientation Unresponsive * Level of Consciousness Unresponsive * Pupil Size Right 6 Left 6 * Pupils Reactive Negative * Hand Grasps & Movement N/A * Spontaneous Movement None * Speech None [DATE] at 12:05 pm * Temperature 96.0 * Pulse 86 * Respirations Shallow * Blood Pressure ? * Orientation Oriented to place and person * Level of Consciousness Responsive * Pupil Size Right 2 Left 2 * Pupils Reactive Positive * Hand Grasps & Movement Equal * Spontaneous Movement Moves all extremities * Speech Clear [DATE] at 12:20 pm * Temperature 96.0 * Pulse 50 * Respirations 22 * Blood Pressure ,[DATE] * Orientation Alert & oriented x 3 * Level of Consciousness Responsive * Pupil Size Right 2 Left 2 * Pupils Reactive Positive [DATE] at 12:40 pm * Temperature 96.0 * Pulse 54 * Respirations 20 * Blood Pressure ,[DATE] * Orientation Alert * Level of Consciousness Alert and Responsive * Pupil Size Right 2 Left 2 * Pupils Reactive Positive [DATE] at 1:30 pm * Temperature 96.6 * Pulse 51 * Respirations 20 * Blood Pressure ,[DATE] * Orientation Alert and oriented x 3 * Level of Consciousness Alert and Responsive * Pupil Size Right 3 Left 3 * Pupils Reactive Positive [DATE] at 2:30 pm * Temperature 97.4 * Pulse 44 * Respirations 20 * Blood Pressure ,[DATE] * Orientation Alert and oriented x 3 * Level of Consciousness Alert [DATE] at 6:30 pm * Temperature 97.0 * Pulse 43 * Respirations 20 * Blood Pressure ,[DATE] * Orientation Alert and oriented x 3 * Level of Consciousness Alert [DATE] at 10:30 pm * Temperature 97.5 * Pulse 51 * Respirations 22 * Blood Pressure ,[DATE] * Orientation Alert and oriented x 3 * Level of Consciousness Alert [DATE] at 2:30 am * Temperature 96.6 * Pulse 44 * Respirations 16 * Blood Pressure ,[DATE] * Orientation Oriented x 3 * Level of Consciousness Alert The facility did not document any interventions performed while the resident was documented as having no pulse and not breathing. In an interview with the DON on [DATE] at 10:20 am, she stated the facility's policy for a resident who was documented as a full code, with no pulse or respirations, was that the facility would initiate CPR (cardiopulmonary resuscitation) and send the resident to the Emergency Department of the closest hospital. The resident was documented as having no pulse and no respirations and CPR was not initiated at that time. In addition, Resident #13 exhibited [MEDICAL CONDITION] (slow heart rate) and no notation was found to document nursing staff addressed this abnormal vital sign. NOTE: It is unclear from the nursing documentation whether the on call physician, who was contacted at 11:00 pm that night (11 hours after the incident), was informed of the [MEDICAL CONDITION], the 10 minute period of unresponsiveness, or of the resident's code status for full resuscitation or any desire to change code status. In a Daily Skilled Note, dated [DATE] at 7:55 am, LN #3 documented the following: "This RN went in to Res room to give pills. Found res unresponsive, pale, no HR (heart rate) could be found." At 8:00 am, "(LN #4) called son to inform of Res. Son coming in. Wishes for no interventions to be done." The resident was pronounced dead. A facility Incident Report, dated [DATE] by the DNS, Administrator, and Social Worker, documented, "Res was full code. No CPR started upon finding Res without HR or resp (respiration). Res told this RN (LN #3) previous day that she didn't want CPR with son present." Results of investigation documented, "RN will call physician when res states that they wish for no CPR if chart states Full Code to get order from MD. RN will also chart conversations had with res in future." This incident was called in by telephone to the Idaho Bureau of Facility Standards on [DATE] and a report was faxed to the same on [DATE]. To ensure an incident such as this would not reoccur, the facility provided an in-service for all nurses was given on the American Heart Association Ethical Guidelines for CPR and the facility policy and procedure on Advance Directives. The American Heart Association Ethical Guidelines for CPR which were used to in-service the facility staff, included the following: * "Scientific evaluation shows that few criteria can accurately predict the futility of CPR. In light of this uncertainty, all patients in [MEDICAL CONDITION] should receive resuscitation unless -The patient has a valid Do Not Attempt Resuscitation (DNAR) order -The patient has signs of irreversible death (eg. rigor mortis, decapitation, decomposition, or dependent lividity)" * "Unlike other medical interventions, CPR is initiated without a physician's orders [REDACTED]. A physician's orders [REDACTED]." * "The attending physician should write the DNAR order in the patient's chart with a note explaining the rationale for the DNAR order and any other specific limitations of care." * "Oral DNAR orders are not acceptable. If the attending physician is not physically present, nursing staff may accept a DNAR order by telephone with the understanding that the physician will sign the order promptly." NOTE: The physician was not notified of Resident #13's alleged request to change her code status to DNR. * "Studies about DNAR orders suggest that healthcare providers who respond to those in cardiac or respiratory arrest who do not exhibit signs of irreversible death (listed below) should promptly provide resuscitative measures to the best of their ability unless or until they receive legally valid instructions (interpretable advance directives, DNAR orders, or valid surrogate directives) not to intervene." (Please see F225 as it relates to their failure to promptly investigate this incident as alleged neglect and F281 as it relates to nursing standards of practice.) The Administrator was informed of these issues on [DATE] at 6:40 pm. No further information was received from the facility.

Based on observation, record review, family and resident interview, and staff interview, it was determined that the facility failed to provide residents with appropriate and timely social services related to their need for psychiatric evaluation and/or treatment. Resident #5 was harmed by this deficient practice as evidenced by the resident's declining participation in activities, weight loss, and diminished ability to perform activities of daily living (ADLs). The facility also failed to provide social service interaction with Resident #2 who was assessed and care planned for one-to-one visits with social services staff. This was true for 2 of 8 residents (#2 & 5) sampled for social services. Findings include: 1. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 8/12/10, documented the following: * Moderately impaired cognitive skills for daily decision making with short-term memory impairment * Anger with self * Indicators of sadness * Indicators of depression * No physical assistance required for personal hygiene cares * Limited assistance of one staff member required for toileting * Continent of bowel * Continent of bladder * Height of four-foot, nine inches - Weight of 110-pounds NOTE: Resident #5 sustained a fractured femoral neck and greater trochanter secondary to a fall at the facility on 1/29/11. The resident was readmitted to the facility following surgical repair to the fracture on 2/3/11. Please refer to F323. Resident #5's 14-day re-entry admission MDS assessment, dated 2/18/11, documented the following: * Cognitively intact * Feelings of being "down, depressed, or hopeless" * "Trouble falling or staying asleep, or sleeping too much" * Extensive assistance of one staff member required for personal hygiene cares * Extensive assistance of one staff member required for toileting * Occasionally incontinent of bowel * Frequently incontinent of bladder * Height of four-foot nine inches - Weight of 96-pounds The resident's ADL Function/Rehabilitation Potential RAP (Resident Assessment Protocol), dated 7/20/10, documented, "Resident (was admitted with) primary problem of atypical chest pain and hx (history) of weight loss and lack of appetite. When she first came to (the) facility (she) needed limited assist(ance) for toileting, transfeers (sic), and bed mobility, and extensive assist with bathing. Currently is independent in all ADLs except bathing. She is receiving OT and PT (Occupational Therapy and Physical Therapy) to increase safe mobility and self care." Resident #5's Urinary Incontinence RAP, dated 7/20/10, documented, "Resident ... has been fully continent of bowel and bladder. She takes self to bathroom." The resident's Mood State RAP, dated 7/20/10, documented, "Persistent anger, sad facial expression, anx(ious) mood. Resident has memory deficit and Dx (diagnosis) of dementia. Her primary concern is getting to WA (Washington) State as she was working towards moving in with her sister so both would be geographically close to her sister's family, yet able to live independently. She has fears that she will be left in SNF (Skilled Nursing Facility) and not able to meet stated goal. Family is working to move both resident and her sister. Staff reassure that plan is to d/c (discharge) to WA and remind her when forgetful." An Activity Interest Data Collection Tool, dated 7/27/10, documented the resident's "current" leisure interests included playing cards, conversing, reminiscing, puzzles, crocheting, art, watching baseball, walking, fishing, listening to music, reading books and magazines, religious worship services, visiting with clergy, reading the Bible, traveling, pets, using the phone, associating with children and youth, and helping others. The resident stated that she enjoyed staying up late at night. Under the heading, "Additional Data," the Activity Interest assessment documented, "1:1 (One-to-one) visits (she loves to talk) very sweet (and) personable." An Interdisciplinary Rehab Rounds form, dated 8/3/10, documented that Resident #5 "needs encouragement dsg (dressing) self (independently). Family in process of moving (resident's) sister to Seattle area, plan to move resident there within next few months." An Interdisciplinary Rehab Rounds form, dated 8/10/10, documented that Resident #5 "has demo'd (demonstrated) ability to complete all personal ADLs when chooses." A FAX Communication to Physician form, dated 9/1/10, documented, "(Resident #5) not eating well. 13/15 on geriatric depression scale. Could she be started on antidepressant Remeron or since on prozac obviously not working well - another one or add megace, whatever." The FAX documented that the physician, in response to the communication, ordered Wellbutrin, an antidepressant, and continuation of the previously ordered Prozac. NOTE: Resident #5's recapitulated physician's orders [REDACTED]. * "Prozac 40 mg (milligrams) PO QD (by mouth daily)." Start date: 2/3/11. * "Lorazepam 1 mg PO BID (twice daily)." Start date: 2/3/11. * "Wellbutrin 100 mg PO BID." Start date: 2/3/11. A Physician's Telephone Order, dated 12/1/10, documented, "OK to have mental health eval(uation) and treat(ment." A Behavioral Health Progress Note from an outside provider, dated 12/13/10, documented, "Chief complaint by staff is that she is in bed all of the time, which is okay. The patient denies any thoughts of suicide or self harm. She does not have much interaction during the day, and I talked to the staff about increasing her interactions and getting her up whether she want to or not. She will return to (mental health) clinic in four weeks." A Discharge Summary written when Resident #5 was transferred to a nearby hospital for surgical repair to a femoral neck and greater trochanter fracture, dated 1/31/11, documented, "(The resident) worked with therapy on admit. Not currently working with RA (Restorative Aides) r/t (related to) refusal. Res(ident) recently has spent a lot of time in bed - has hx (history) of 'taking to her bed' when stressed or sad." A Discharge Summary from the hospital where the resident's fractured femoral neck and greater trochanter was surgically repaired, dated 2/3/11, documented, "The patient is well known to me over many years. I have been her primary care physician. She has chronic anxiety and depression. (She) is again being returned to (the facility) for physical rehabilitation and the usual parameters for recovery from postoperative status." An Occupational Therapy Evaluation and Plan of Treatment, dated 2/4/11, documented, "This formerly (independent) lady has good potential to regain PLOF (previous level of function) if we can adjust her recent routine of being in bed all day." A Patient Health Questionnaire, dated 2/16/11, documented the resident felt "down, depressed or hopeless when in pain only. Able to tell when in pain (and) get relief then no longer feels down." The resident also stated she had "trouble falling or staying asleep or sleeping too much." The resident's score of "2-3" indicated "minimal depression." The resident's Comprehensive Care Plan, dated 2/17/11, documented the following: * "Problems/Needs/Concerns: Pot(ential) for ineffective individual coping and alt(erations) in thought process r/t (related to) Dx of dementia, Dx of anxiety/depression, m/b (manifested by) suicidal ideation, withdrawal from socialization and fear that she won't be able to reunite with her sister in WA state." * "Long/Short Term Goals: Will not make suicidal statements (and) will be oriented to facility (and) will express needs and can explain if needs being met by 5/17/11." * "Plans and Approaches: Medicate per order. 1:1 visits to express feelings. Immediately report to nursing any suicidal ideation or statements of feeling hopeless. Validate resident's feelings. Allow time for resident to voice opinions and concerns. If statements of hopelessness reassure resident that she is safe and cared for. Facilitate outpatient mental health. Explain, remind, cue while adjusting to SNF (Skilled Nursing Facility). Has life long history of 'taking to the bed' for long periods of time." Resident #5's Nutrition Care Plan, dated 2/17/11, documented that the resident was at risk for "nutritional decline r/t (related to) poor meal intake," required weekly weights, received supplements, and required only "set up (and) verbal encouragement with meals." NOTE: The resident's dietary documentation revealed a number of assessments were performed and interventions put into place to address "significant" and "severe" declines in the resident's weight and that the facility's Registered Dietician (RD) communicated regularly with the resident's physician regarding those weight losses. On 3/31/11, at 8:15 a.m., the RD was interviewed. The RD confirmed that the resident's diminished meal intake was "probably" due to the amount of time the resident spent sleeping and stated, "There's nothing else I can do for her at this time nutritionally; we've added supplements, we've fortified her meals, she gets a med pass (supplement), we've tried in-between meals snacks. Her BMI (body mass index) is normal (and) her weight is (now) right in the ideal (range). We've tried all the interventions and we've re-intervened when we had to." A Physical Therapy Daily/Weekly Documentation form, dated 2/21/11, documented, "Pt making gains despite limited participation. Pt (with) limited participation. Remains in bed most of the time." A Physical Therapy Daily/Weekly Documentation form, dated 2/23/11, documented, "Pt (with) limited participation. Spends most of the time in bed. Multiple refusals for PT." Resident #5's Activity Participation Record was reviewed from 7/16/10 through 3/29/11. Resident participation in activities was documented as either, active, independent, unable to attend, slept, or invited but refused. Times were not included on the documentation of the daily activities offered to Resident #5. The Activity Participation Record (APR) documented "No Activities Found" for that day, or that the resident was either "unable to attend," "slept," "observed," or was "invited but refused." Those APRs documented the following: * 7/16/10 - 7/31/10 - "No Activities Found" on 7/17, 7/19-21, and 7/31. - Total number of Activity Participation Opportunities (APO) = 40. - "Active" or "Independent" participation = 34. - "Unable to Attend" = 6. * August 2010 - "No Activities Found" on 8/1, 8/4-8, 8/14-15, 8/17, 8/21-22, and 8/27-29. - APO = 25. - "Active" or "Independent" participation = 12. - "Unable to Attend" = 12. - "Slept" = 1. * September 2010 - "No Activities Found" on 9/4, 9/12, 9/19, 9/23, and 9/26. - APO = 59. - "Active" or "Independent" participation = 43. - "Unable to Attend" = 1. - "Slept" = 13. - "Observed" = 1. - "Invited but Refused" = 1. * October 2010 - "No Activities Found" on 10/2-3, 10/12, 10/17, 10/20, and 10/30. - APO = 92. - "Active" or "Independent" participation = 74. - "Unable to Attend" = 9. - "Slept" = 7. - "Invited but Refused" = 2. * November 2010 - "No Activities Found" on 11/17. - APO = 158. - "Active" or "Independent" participation = 134. - "Unable to Attend" = 19. - "Slept" = 1. - "Invited but Refused" = 4. * December 2010 - "No Activities Found" on 12/5. - APO = 137. - "Active" or "Independent" participation = 118. - "Unable to Attend" = 14. - "Slept" = 1. - "Invited but Refused" = 4. * 1/1/11 - 1/30/11 (Transferred to hospital 1/31/11 - 2/3/11) - "No Activities Found" on 1/15, and 1/30. - APO = 190. - "Active" or "Independent" participation = 104. - "Unable to Attend" = 74. - "Invited but Refused" = 12. NOTE: Resident #5 was "unable to attend" any activities, according to the Activity Participation Record, on 1/7, 1/8, 1/9, 1/10, 1/11, and 1/14. Please refer to documented observations and Interdisciplinary Progress Notes (IPN) documentation below. * 2/3/11 - 2/28/11 - "No Activities Found" on 2/13. - APO = 102. - "Active" or "Independent" participation = 67. - "Unable to Attend" = 24. - "Slept" = 6. - "Invited but Refused" = 5. NOTE: The Activity Participation Record for February 2011 documented that Resident #5 either "slept" or was "unable to attend" any activities on 2/12 and 2/23. The APR also documented that Resident #5 was "unable to attend" any activities on 2/10, except for "TV viewing" and "independent persuits," (sic), for which she was documented as an "active" participant, and "reading," for which the resident was documented as "independent." * 3/1/11 - 3/30/11 - "No Activities Found" on 3/12-13, and 3/30. - APO = 153. - "Active" or "Independent" participation = 91. - "Unable to Attend" = 40. - "Slept" = 20. - "Invited but Refused" = 2. NOTE: The March 2011 APR documented that Resident #5 "slept" for all activities on 3/19 and 3/24, except for "TV viewing," for which she was an "independent" participant; "slept" or was otherwise "unable to attend" all activities on 3/25, 3/26, and 3/29; either slept or was otherwise "unable to attend" any activity except one on 3/22 and 3/27; and on 3/28, Resident #5 was documented as "unable to attend" any activity except two - the resident was documented as an "active" participant for an "activity round," and an "active" participant for "TV viewing." As noted below, however, Resident #5 was not observed awake from 3/28/11 until 3/31/11. During this time the resident's television was on, however the resident was sleeping. A review of Resident #5's IPN for January 2011 through 3/31/11 revealed the following: * 1/10/11 - "Late entry for 1/9/11. Resident refused to wake up for meals for past two days (and) would not take meds. Than (sic) refused shower (and) bed bath to CNA. Placed a call to resident's (family member) to talk to her, not helpful at all." * 1/20/11 - "LSW (Social Worker) did 1:1 (one-to-one visit) (with) resident who was in bed but awake. She informed feeling really tired today, but was alert and recognized LSW. She thought she might be 'willing to get up a few hours from now.'" * 1/21/11 - "Res(ident) has also been noted to be tired (and) having trouble getting up for meals." * 2/8/11 - "Resident was interviewed by (Social Worker) (and) (right) hip pain caused her verbal out depressed statement, 'Why don't you just give me a gun (and) I will shoot myself in the head." * 2/9/11 - "Resident has been very sleepy all AM. Refused BF for wanting to sleep. Up at 11:00 (a.m.) (with) PT (and) out to DR (dining room) for lunch. Refused shower this AM." * 2/10/11 - "Late entry for 2/8/11. LSW did 1:1 (with) res(ident) for interview for MDS. Resident stated, 'Why don't you give me a gun so I can shoot myself.' LSW offered encouragement and reassurance. Res(ident) stated that she has no plan to hurt herself. Nurse (name) was present in room. LSW informed assist(ant) DON, and wrote memo for each shift to document whether further suicidal ideation for 7 days." * 2/12/11 - "Resident has been very sleepy all day. Took meds (and) ate BF (breakfast), but refused lunch." * 2/13/11 - "Resident very sleepy all AM (morning) again. Took BF (and) refused lunch. Had to hold her milk to assisst (sic) her in order to drink." * 2/14/11 - (3:00 p.m.) - Resident refused BF for wanting to sleep. Did get up for lunch (and ambulated with forward-wheeled walker with Physical Therapy)." * 2/14/11 - (10:00 p.m.) - Res(ident) sleepy this shift, but awake for dinner. Res(ident) stated she couldn't believe she slept through the day when she awoke in the eve(ning)." * 2/17/11 - "Resident very sleepy all AM. Did awake enough to eat both meals." * 2/18/11 - "Resident remain (sic) very sleepy all AM. Able to wake up enough to eat both meals (and) meds." * 2/19/11 - "Rsdt (Resident) refused to get OOB (out of bed) this AM and refused AM meds until 11:45 (a.m.). She sat up in bed (at) this time, took AM meds (and) ate some lunch." * 2/20/11 - "Rsdt alert (and) oriented X3 (person, place, time), but has been very tired and has refused to get OOB or to take AM meds (at) this time." * 2/21/11 (2:30 p.m.) - "Resident has been very sleepy all AM. Has (sic) to wake her up for meds (and) meals." * 2/21/11 (8:30 p.m.) - "Rsdt has been in bed t/o (throughout) shift. She is alert (and) oriented, but sleepy. Compliant (with) meds. Did not eat any dinner." * 2/22/11 (2:30 p.m.) - "Resident is alert (and) responsive. Stayed in bed all day (and) took meds (and) meals." * 2/22/11 (10:00 p.m.) - "Rsdt alert and oriented X3. Rsdt stayed in bed t/o shift, but did eat some (and) took medications (without) problem. Rsdt states she wants to go leve (sic) (with) her sister. Explained that she needs to be doing more than staying in bed all the time if she wants to go. She expressed that she stays in bed because she was told she couldn't go anywhere alone. Told her that she did need someone with her to ambulate and that staff could walk with her." * 2/23/11 (3:00 p.m.) - "Resident is alert (and) responsive. Very sleepy all day again. Took all meds (and) meals, but refused shower today for too sleepy." * 2/23/11 (10:00 p.m.) - "Res(ident) remained in bed during eve(ning) per preference. Refused dinner, but had a snack." * 2/26/11 (3:00 p.m.) - "Resident in bed sleeping all AM. Awake enough to take BF (and) meds. Refused to get up." * 2/27/11 (3:00 p.m.) - "Resident alert (and) awake. Ate her meals (and) meds, but refused to get out of bed." * 3/1/11 (3:00 p.m.) - "Resident refused to go (to) otho (orthopedic) appoint(ment) for too early in AM. In bed sleepy (and) ate meals (and) took meds." * 3/7/11 - "Aides report res(ident) crying at times this weekend r/t (related to) neg(ative) comments from roommate r/t lights (and) TV at night. Informed resident's (family member) (and) resident of need for room change today." * 3/28/11 (10:30 p.m.) - "Res(ident) couldn't stay awake for more than a couple min(utes), she felt weak and couldn't sit up. At end of shift she was having entire conversations, had color in face, and was sitting up drinking water." * 3/29/11 - "Refused all medications (and) meals this PM. Has remained in bed t/o shift." * 3/30/11 (3:00 a.m.) - In bed resting at this time. Res(ident) with poor oral intake over last 48 (hours) only 25% of one meal consumed (and) 420 cc (cubic centimeters) over 2 days with meals. Res(ident) has had (no) voids in past 24 (hours). Denies feeling pain or pressure." * 3/30/11 (3:30 p.m.) - "Spoke (with resident's family member). Will be in AM to talk. Stated we are providing excellent care - that we offer everything - that (resident's family member) has tried to talk to her to get her to get (out of bed) (and) eat, walk, etc - but (Resident #5) won't do it - (psychiatric nurse practitioner - PNP) will be in 8A (family member) to be here (at) 10A - LSW contacted Ombudsman - stated records private unable to share, but will have (name) Ombudsman here weekly to call LSW. (Resident #5) cont(inues) to refuse all meals even those she asks for that meal (sic). Doesn't get OOB unless she wants." * 3/30/11 (4:45 p.m.) - "Call to (physician) to do visit." Resident #5 was observed in her bed asleep with a nasal cannula delivering oxygen at 2L/m (2 liters per minute) on 3/29/11 at 9:00 a.m., 10:17 a.m., 11:20 a.m., and 2:16 p.m.; on 3/30/11 at 7:18 a.m., 8:20 a.m., and 10:12 a.m.; and on 3/31/11 at 9:35 a.m. The resident was not observed out of bed throughout the five days surveyors were in the facility for the annual re-certification and licensure survey. On 3/30/11, at 1:15 p.m., the DON was interviewed and asked whether the facility had determined the cause for Resident #5's sleepiness and prolonged periods in bed. The DON stated she had known the resident for "[AGE] years" and that the the resident had a "lifelong pattern of taking to the bed." On 3/30/11, at 2:15 p.m., the LSW was interviewed and asked whether the facility had attempted to assess the cause of Resident #5's withdrawal from community and individual activities as well as her decline in several ADL areas. The LSW stated that Resident #5 had been admitted to the facility for short-term rehabilitation with plans to reunite with her family in a neighboring state. The LSW said Resident #5 "took a downturn" when several factors with the family and the resident prevented that short-term plan from taking place. The LSW noted that the facility had attempted to provide a "mental health assessment," however the resident refused to participate. The LSW stated, "I think this is her response to disappointment, it's part of her coping pattern. I think she's sleeping to avoid being where she doesn't want to be ... here." On 3/31/11, at 8:50 a.m., the LSW and Psychiatric Nurse Practitioner #5 (PNP #5) were interviewed. PNP #5 stated that she had just visited with the resident for the first time immediately prior to meeting with surveyors for the interview and would need to "rule out" medical causes for the resident's sleepiness and prolonged periods in bed before assessing the resident's mental health. PNP #5 stated that Resident #5 was "probably depressed even though she denies it. We can send her for psychiatric testing, but it's probably not going to change what we do with her." When asked whether the resident had been examined at the mental health clinic in January 2011 as ordered on the 12/13/10 Behavioral Health Progress Note, the LSW stated that the appointment had not been made. When asked to explain why the resident had not been re-examined by mental health staff until the facility's annual re-certification survey on 3/31/11, the LSW stated, "I missed it." On 3/31/11, at 2:15 p.m., the resident's family member was interviewed via telephone. The resident's family member stated that Resident #5 was residing in an assisted living facility, but " ... got confusion (and) no one knew what was going on. She slept for days and they asked her to leave." When asked what the resident was like prior to this time, the family member stated that Resident #5 "used to read and did all her own errands. She enjoyed life. We had to admit her to (the facility) when she started sleeping so much and wouldn't leave her apartment." The family member stated that Resident #5's condition had steadily declined both before and since her admission to the facility. On 3/31/11, at 2:40 p.m., the resident was observed awake in bed. When asked by the surveyor whether she realized that she had been asleep for four days, the resident stated she did not realize she had been asleep for that long. When asked whether she typically slept for days without getting out of bed, Resident #5 stated, "I sleep a lot when I'm not feeling well and I've been sick." The facility monitored, but failed to assess or intervene, when Resident #5's sleeping patterns resulted in a decline in the resident's ADL performance, weight loss, and withdrawal from participation in activities that had previously been of interest to the resident. An appointment for psychiatric services was made to address the resident's behavioral pattern and decline, however that appointment was not fulfilled until more than three months after the facility was asked in December 2010 to schedule a follow-up appointment for January 2011. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 2/7/11, coded: * Cognitively intact, * Required extensive assistance of two staff for bed mobility, transfers, and dressing, * Anxiety and depressive disorder * Shortness of breath or trouble breathing when sitting, and * Received oxygen services. The resident's current physician's orders [REDACTED]. The order date for both antidepressants was 8/17/09. On 3/7/11 the Cymbalta was decreased to 60 mg every day, and a third antidepressant (citalopram 10 mg every day) was added. During observations on 3/29/11 (8 times between 8:35 a.m. and 3:05 p.m.) and on 3/30/11 (6 times between 7:15 a.m. and 9:00 a.m.) Resident#2 was observed to remain in her room. A tray was brought to her room for the breakfast and lunch meals. The room was observed to be dark and the blinds were closed. On 3/30/11 at 10:00 a.m., LN #4 stated the previous counselor for Resident #2 wanted the facility to encourage Resident #2 to come out of her room. LN#4 stated Resident #2 kept her room dark and did not come out to socialize with staff or residents because she was depressed. Resident #2 was eating her meals in her room because she had been ill. Resident #2's "Comprehensive Care Plan" (CP) documented in the "Problems/Needs/Concerns" section "Ineffective individual coping and potential alterations in thought process R/T (related to) Dx (diagnoses) dementia, depression....Reluctance to socialize." The "Long/Short Term Goals" documented, "Will express feelings and voice needs and concerns." The "Plans and Approaches" section documented, "Medicate per order. 1:1 (one to one) visits to express feelings PRN (as needed)." On 3/30/11 at 10:00 a.m. the Licensed Social Worker (LSW) was asked for documentation of the 1:1 visits, and stated she did not have specific documentation but they possibly could be in the Interdisciplinary Progress Notes (IPN). The IPN's were reviewed and documented: *3/25/10 - "S.W. (social worker) did 1:1 with resident inquired of her satisfaction with care provided. She stated she is doing well...." *4/16/10 - "1:1 w/resident (with resident) for outdoor stroll- Resident enjoyed smelling and looking at flowers in (facility) gardens. Resident smiles and appears comfortable." 4/27/10 - "Informed resident of new roommate's expected arrival either today or early am 4/28/10." 5/14/10 - Delivered care conference letter to resident. *5/21/10 - "1:1 w/resident for outdoor stroll. Resident enjoyed looking at/gathering spring flowers for a bouquet.....Resident expressed her gratitude for stroll & visit and desires to do again." 6/10 - No entries 7/28/10 - "...Reminded resident of diet restrictions...." 8/2/10 - Delivered care conference letter to resident in her room. 8/27/10 - Met with resident to discuss allegations of verbal abuse. Resident #2 stated, "I am well treated here and very happy...." 9/21/10 - S.W. did 1:1 to explain Resident #2's roommate was moving. Resident #2 stated "That would be nice" when told she will be getting a larger bed. 10/10 - No entries 11/3/10 - Delivered care conference letter to resident. 11/4/10 - 1:1 w/resident in her room. 11/12/10 - "LSW (licensed social worker) did 1:1 w/resident interviewed for MDS, she states her cares are good...." 12/10 - No entries 1/25/11 - "Asked (Resident #2) to allow staff to provide cares." 1/28/11 - Delivered care conference letter to room. "She had no concerns at this time..." 2/7/11 - Interviewed for MDS. Resident reported she is comfortable in facility and considers it her permanent home. 2/28/11 - Informed that she would be moving to a private room. * 3/1/6 - Resident #2 stated she is happy with her new room. Note: The days marked with an asterisk include documentation of feelings as required in the care plan. There were 0 entries for the months of 6/10, 10/10 and 12/10. There was one entry in 7/10 and 9/10. The IPNs documented on 2/17/11 Resident #2 had, "Wanted aide to kill her." The notes documented the RN had spoke to the resident about the statement. Resident #2 told the RN, "If she had said something like that it had been pain talking." On 2/21/11 (5 days after Resident #2 asked the aide to kill her), the LSW requested a mental health assessment and treatment for [REDACTED]. The IPNs documented social services did not meet with Resident #2 until 2/28/11 to discuss a room change. On 3/31/11 at 4:35 p.m., the surveyor met with the LSW and asked for copies of any mental health notes for Resident #2. The LSW stated the facility did not have a contract for mental health services between 6/10 and 11/10. She reported a mental health evaluation was completed on Resident #2 on 3/7/11, but the report had not been received. The surveyor expressed concern regarding Resident #2 being on antidepressants (3) and the lack of documentation Resident #2 received one to one visits by social services to discuss her feelings. The LSW stated she talked with Resident #2 about her feelings every time she met with her, but did not document the conversations or Resident #2's feelings. No further information was provided by the facility.

Based on observation, record review, and staff interview, it was determined the facility failed to maintain a safe environment or provide adequate supervision to prevent injury accidents. This was true for 1 of 3 residents (#5) sampled for falls. Resident #5 was harmed when she experienced a fractured rib in one fall and a fractured greater trochanter in a second fall at the facility. This was also true for 1 of 3 resident hallways, where a sit-to-stand mechanical lift was observed blocking a handrail throughout the facility's annual re-certification and state licensure survey. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 8/12/10, documented the following: * Moderately impaired cognitive skills for daily decision making with short-term memory impairment * Limited assistance of one staff member required for bed mobility * No range-of-motion limitations * Independent with ambulation Resident #5's 14-day re-entry MDS assessment, dated 2/18/11, documented the following: * Cognitively intact * Extensive assistance of one staff member required for bed mobility * Range of motion impairment for one leg * Supervision of one staff member required for ambulation The resident's Falls RAP (Resident Assessment Protocol), dated 7/20/10, documented, "Resident triggered for this RAP because she has taken ativan and prozac (anti-anxiety and anti-psychotic medications respectively) in the last seven days, she has poor peripheral vision, and initially was assessed as being slightly unstable on her feet. Currently is okayed to walk at will with cane through out (sic) the facility. She has shown no problems r/t (related to) vision deficits in relation to mobility. Per physician H&P (history and physical) she has been treated long term for depression and anxiety. She has no noted recent or remote hx (history) of falls." Falls Data Collection Tools for Resident #5 were reviewed. Those assessments documented the following scores (scores of 12 or greater indicated the resident was a "high risk" for falls): * Undated - 19 * 10/15/10 - 18 * 10/22/10 - 23 * 1/1/11 - 17 * 1/29/11 - 23 Resident #5's Falls Prevention Care Plan, dated 9/1/10, documented the following: * "Problems/Needs/Concerns: Pot(ential) for impaired mobility r/t (related to) OA (osteoarthritis), C/P (chest pain), SOB (shortness of breath), weakness." Start date: 7/29/10. * "Long/Short Term Goals: Will not sustain injury (and) will maintain current level of mobility thru (sic) 10/29/10." * "Plans and Approaches: Uses low bed. Provide P.T. (physical therapy) for safe mobility. Use cane for mobility." A handwritten note on the 9/1/10 Falls Prevention Care Plan, dated 10/19/10, documented, "When shaky assist/supervise smoking, may need to wear smoking apron." The Resident's Falls Prevention Care Plan, (illegible date), documented the following: * "Problems/Needs/Concerns: Pot(ential) for impaired mobility r/t OA, C/P, SOB, weakness, smoking m/b (manifested by) falls." Start date: 1/18/11. * "Long/Short Term Goals: Will not sustain injury (and) will maintain current level of mobility thru (sic) 4/18/11." A handwritten note, not dated, documented, "2-16 (illegible) fall not her re (unknown) side of bed." * "Plans and Approaches: Will ask for help with transfer and ambulation at times. Uses low bed. Use cane for mobility; in room independent w/fww (with front-wheeled walker) through out (sic) facility. Wears pendant call bell." A handwritten note, undated, documented, "RN sensor in bed." Resident #5's Falls Prevention Care Plan, dated 2/17/11, documented the following: * "Problems/Needs/Concerns: Impaired mobility r/t OA, C/P, SOB, weakness, smoking m/b falls fx (fractured) hip." Start date: 2/17/11. * "Long/Short Term Goals: Will not sustain injury (and) will be able to amb(ulate) safely by 5/17/11." * "Plans and Approaches: Uses low bed. Amb to all destinations as tol(erated) (with stand-by assist and) FWW, use O2 (oxygen) (at 2 liters flow per minute). Wears pendant call bell. RN sensor (at) all times. (Fall) Mat on floor on her rt (right) side." Resident/Visitor Incident Reports for Resident #5 were reviewed for the six months immediately preceding the facility's annual re-certification and state licensure survey. Those reports documented the following: * 10/15/10 - 11:15 p.m. - Summary: "Res(ident) fell on the floor when her feet got tangled up in bed linen. Only res(ident) was involved in this incident. Res(ident) had (no) prior falls." - Corrective Actions Taken: "Have few linens on bed not [DIAGNOSES REDACTED] the bed." - Staff Responsible for Corrective Actions: "Staff taking care of res(ident) will ensure that bed linens are not [DIAGNOSES REDACTED] the environment." - Results of Investigation: "Res(ident) had a fall in her room when her feet got tangled up in bed linen (and) she landed on her (right) hip. (No) injuries observed. (No) c/o (complaints of) pain from res(ident). ROM WNL (Range of motion within normal limits). Will monitor res(ident) for next 72 hours." 10/20/10 - 12:50 p.m. (Report written by staff member for whom English is not the native language) - Summary: "Saw resident lying on the top of flower bed when reported by visit(or). Resident was able to lying on her back (after) instruction by self. Move all extremities by self, but unable to get herself up for there (Report written by English as second language staff member). - Corrective Actions Taken: This section of the report was left blank. - Staff Responsible for Corrective Actions: "1X (Isolated) incident." - Results of Investigation: "Resident was not remember how she fell . According to visitor reported that she pulled in parking lot (and) saw resident lying on the top of flower bed calling for help. Visitor said that she came in the nurse's station to report right away without assist resident." 10/20/10 - 9:45 p.m. - Summary: "CNA saw res(ident) by dining room door (where she) tripped (and) fell . Landed on rt (right) side - hit nose on carpet. fell earlier today. Gait was very steady all PM (evening) (with) cane." - Corrective Actions Taken: "Safety/assistive device in place. SBA (Stand-by assist) to all destinations." - Staff Responsible for Corrective Actions: "Nsg (Nursing) - (Check) for acute illness." - Results of Investigation: "Res(ident) lost balance amb(ulating) (with) cane. Needs SBA to all destinations (and) tabs (alarm) unit in bed." * 11/30/10 - 9:45 p.m. - Summary: "Res(ident) was reaching for empty pill cup that was on bedside table, fell on floor." - Corrective Actions Taken: "Asked (resident) not to wear silky pajamas." - Staff Responsible for Corrective Actions: "Try panecea (sic) (pressure reducing mattress)." - Results of Investigation: "(Change) mattress." * 12/25/10 - 1:10 p.m. (Report written by staff member for whom English is not the native language) - Summary: "Saw resident sitting on the floor in front of the (illegible) (and) FWW. Resident said that she just turned around (and) then slid down to the floor. ROM on all extremities WNL. With staff hold on the FWW, resident was able to get up by herself." - Corrective Actions: This section of the report was left blank. - Staff Responsible for Corrective Actions: "Nursing - Have (resident's name) get assist (with) amb(ulation) on sidewalk if sidewalk not clean - use call pendant if outside." - Results of Investigation: "The area resident was sitting has a lot of gravels (little rocks) on the floor. Which resident choice far end of flower pad to smoke instead of closer to the garbage cane (sic) area." NOTE: An Emergency Department Chart record, dated 12/26/10, documented the following for Resident #5: * "Pt (Patient) states she slipped on loose gravel on sidewalk yesterday, had to be assisted up and has acute pain today in right rib area. Taken to X-ray via stretcher. Pt ambulates to restroom with one person assist while in X-ray. Pt returns from X-ray via stretcher. Pt states she is feeling sick. Exam started at 12:00 (p.m.). The onset of the presenting problem started 1 days (sic) ago. Constant chest pain has been present for more than several hours. (X-ray) Results: Single rib is fractured. Has a non-displaced fracture of the 10th rib(s) on the right side. The most likely [DIAGNOSES REDACTED]." * 1/1/11 - 8:20 p.m. - Summary: "Res(ident) was walking down 100 hall (independently with) steady gait - was going out for cigarette. This writer had hold of her arm to escort (and) supervise a cigarette - her underwear fell down (and) res(ident) tripped - lowered to floor." - Corrective Actions: "Not to wear huge ex-large underwear over protective underwear." - Staff Responsible for Corrective Actions: "Nsg." - Results of Investigation: Res(ident's) underwear too big for her (and) was wearing them over her protective underwear. Has been ill (with) URI (upper respiratory infection) (and) medicated starting 12/29/10 ... periods of confusion like not needing regular underwear over protective underwear." * 1/29/11 - 11:45 p.m. - Summary: "Res(ident) was responding to bladder urge (and) was incontinent when she got up (and) went to BR (bathroom) barefoot (and) without walker (and) fell down (and) hit head on side of sink. Only res(ident) was involved in the incident (and) prior falls occurred in the past." - Corrective Actions: "Non-skid socks on." - Staff Responsible for Corrective Actions: "Non-skid socks put on (and) res(ident) was re-instructed to use walker whenever going to BR (and) ask for assistance using call light if res(ident) feels unsteady, will monitor res(ident) (every) 30 (minutes) throughout NOC (night)." - Results of Investigation: "Res(ident) fell in the bathroom (and) hit her head on the side of sink while responding to bladder urge (and) res(ident) had (no) socks or shoes on (and) was not using walker (at) the time. Res(ident) was medicated (with) prn (as needed) pain med for pain in (right) hip (and) leg. ROM otherwise WNL to all extremities. VS (Vital signs) currently WNL. (No) apparent injury. Knees slightly red due to res(ident) being found on knees on the floor. Res(ident) was re-instructed to put shoes or nonskids on when OOB (out of bed) (and) use walker (and) ask for assistance (with) call light if feeling unsteady on feet." * 3/1/11 - 8:05 p.m. - Summary: "Res(ident) attempted to pick up Kleenex box off of floor." - Corrective Actions: "Resident education/training or re-instruction." - Staff Responsible for Corrective Actions: "(Check with) each visit that items (with)in reach." - Results of Investigation: "Res(ident) had (no) injuries. Teaching on use of call light (and) asking for assistance done. Res(ident) fell to knees while trying to pick up a Kleenex box from the floor." * 3/22/11 - 3:00 p.m. - Summary: "Res(ident) responded to bladder urge (without) using call light (and) walker. Alarms went on. When staff reached the room res(ident) was found on BR floor. Res(ident) had previous falls before. Only res(ident) was involved in the incident." - Corrective Actions: "Install/modify safety device - motion sensor." - Staff Responsible for Corrective Actions: "Res(ident) was re-instructed to use call light for assistance (and) will be evaluated for further (changes) in status for next 72 hrs (hours) by nurse on duty. Motion sensor to end of bed." - Results of Investigation: "Res(ident) was transferring self to BR (without) using call light (and) FWW (and) slipped (and) fell on BR floor. (No) apparent injuries. (No) c/o (complaints of) pain. ROM WNL to all extremities. Will evaluate for (changes) for next 72 hrs." Interdisciplinary Progress Notes for Resident #5 documented the following: * 1/29/11 - 11:55 p.m.: "Res(ident) had a fall in BR while responding to bladder urge ... neurochecks started." * 1/30/11 - 9:00 p.m.: "Resident c/o 10/10 (10 out of 10 on a 10-point pain scale) pain rt hip (at) 2:00 p.m. - Med(icated) ... relieved pain level to 5/10. Amb(ulated) (with) FWW to toilet. Rt hip pain conts (continues) to increase. Unable to do ROM (with) rt leg. On call (physician) notified. Orders to send to ER (emergency room ) to eval(uate) rt hip." * 1/31/11 - 1:10 a.m.: "Contacted ER, res(ident) admitted with fx (fractured) hip ..." The facility's Discharge Summary for Resident #5, dated 1/31/11, documented, "Res(ident) A&Ox3 (alert and oriented to time, place, and person), but with varying degrees of orientation at times, normally easily reoriented. Able to make needs known (and) request assist as needed. Some short term memory deficits (and) impaired decision making skills. Res(ident) with multiple falls during stay. Sent to ER after continual pain (and decreased) ambulating ability after most recent fall (and) admitted with fx (fractured) hip." Resident #5's admission History and Physical at the hospital, dated 1/31/11, documented, " ... female who fell on to right hip 24 hours prior to admission. States that she was in her bathroom when she fell . Believes she was attempting to sit down on the toilet when she lost her balance. LE (Lower extremity) swelling. Developed immediate right hip pain. Found to have mildly displaced fracture of right greater trochanter. CT (Computed Axial Tomography) showed nondisplaced fracture of right femoral neck. admitted (to hospital) for orthopedic evaluation, pain/medical management." The resident's hospital Discharge Summary, dated 2/3/11, documented, "... female, resident of (facility), fell in her bathroom hitting a sink and then falling to the floor, with a complication of a nondisplaced right hip fracture. The patient has been on fall precautions at the nursing facility but for some reason the alarm did not go off and she had gotten up to go to the bathroom. Patient was brought to the emergency room and found to have a fracture of the right greater trochanter and a nondisplaced fracture of the femoral neck. She has been a high fall risk ... the patient has a recurrent potential for fall ..." A Patient Transfer Form, dated 2/3/11, documented, "[DIAGNOSES REDACTED]. Patient is pleasant and cooperative with cares. fell at (facility) had ORIF on 1/31/2011 - confused at times - disoriented to place and situation, but re-orients easily. Ambulates with walker. Slow - needs contact guard assist." A Physical Therapy Evaluation and Plan of Treatment, dated 2/4/11, documented, "Pt s/p (status [REDACTED]. Pt reports minimal pain, but shows (decreased) functional wt (weight) bearing and use of RLE (right lower extremity). Pt not (independent) as per prior level of function and would benefit from balance re-education to (decrease) fall risk." A Pain Data Collection Tool, dated 2/14/11, documented that Resident #5 was experiencing "sharp pain" in the right hip that occurred "when I get out of bed or walk." The resident was documented as saying that "moving (her) leg (and) hip" increased the pain and that pain medication and not moving the hip helped relieve the pain. On 3/30/11, at 1:15 p.m., the DON was interviewed. When asked about the 2/3/11 hospital discharge report that documented the resident's alarms failed to activate when Resident #5 fell and fractured the right trochanter and femoral neck, the DON stated that the resident was "capable of removing the alarms and getting out of bed unassisted." No further information was provided by the facility. 2. On 3/29/11 at 10:40 am, a sit to stand mechanical transfer device was observed in the hallway of the Special Care Unit (SCU). It was located against the handrail between the Spa Entrance door and the Janitor room. It was plugged into an electrical outlet in the wall. It was observed again at 3:15 pm that same day and throughout the survey week, stored in the SCU hallway when not in use. Storing the device against the handrail in the hallway blocked access to the handrail and prevented residents and visitors who might need the handrail for ambulation assistance. The Administrator was informed of this issue on 3/31/11 at 6:40 pm. No further information was received from the facility.