Every finding on record at Parke View Rehabilitation & Care Center

Based on record review, Idaho Medicaid Plan Benefit 16.03.26.475.03, observation, and staff interview, it was determined the facility failed to update a residents' Level I PASRR (Preadmission Screening and Resident Review) with new diagnosis which required further screening, a Level II PASRR to be completed. This was true for 3 of 4 residents (#7, #8, and #13) whose PASRR records were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments. Findings include:The Idaho Medicaid Plan Benefit 16.03.26.475.03 dated 7/1/25, documented under change in status, resident reviews for residents with MI or DD must occur and a new determination made after any significant change in their physical or mental condition NFs must notify the Department of any changes within two (2) working days of occurrence when any significant change requires new or increased specialized services.a. Resident #7 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stroke and chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe). Resident #7's physician order dated 6/14/25, for Lithium Carbonate oral capsule, give 300 mg by mouth two times a day for mood stabilization which is an antipsychotic medication that requires an updated Level I PASRR to be completed and promptly submitted to the state mental health authority within 2 days. On 8/19/25 at 2:10 PM, the facility social services staff #1 stated the facility had not yet filed the updated Level I PASRR document for Resident #7. b. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including acute hepatitis C (the initial phase of hepatitis C virus (HCV) infection, typically lasting for the first six months after exposure) and alcoholic cirrhosis of the liver without ascites (a condition where the liver is scarred due to excessive alcohol consumption, but without the accumulation of fluid in the abdomen). Resident #8’s Level I and Level II PASRR’s dated 6/20/25, documented his MMI as depressive disorders, anxiety, and agitation. On 6/24/25, Resident #8’s depressive disorder diagnosis was changed to bipolar disorder requiring an updated Level I PASRR be completed and resubmitted and it was not. On 8/19/25 at 2:30 PM, the facility social services staff #1 stated the facility had just filed the updated Level I PASRR document for Resident #8 on 8/18/25 and she was not aware there was a time frame for when the facility had to file the Level I PASRR update. c. Resident #13 was admitted on [DATE], with multiple diagnoses including depressive disorder and schizophrenia. Resident #13’s Level 1 PASRR dated 4/3/17, documented he had a diagnosis of depressive disorder and mental retardation. There was no documentation Resident #13 had a diagnosis of schizophrenia. Resident #13’s Level II PASRR dated 4/6/17, documented Resident #13 carries a diagnosis of depressive disorder which meets PASRR criteria. He is stable regarding his mental health issues and no further evaluation was needed. There was no documentation Resident #13 had a diagnosis of schizophrenia. On 8/6/25, an updated Level I PASRR was sent to BLTC to include Resident #13’s diagnosis of schizophrenia. On 8/20/25, the DON was asked why the update took 8 years to get the Level I PASRR updated to include his diagnosis of schizophrenia. She stated it was an error the facility did not catch until recently. The DON stated they were still waiting to receive an updated Level II PASRR back from BLTC.

Based on record review and staff interview, the facility failed to ensure residents Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 8 residents (Resident #8) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including acute hepatitis C (the initial phase of hepatitis C virus (HCV) infection, typically lasting for the first six months after exposure) and alcoholic cirrhosis of the liver without ascites (a condition where the liver is scarred due to excessive alcohol consumption, but without the accumulation of fluid in the abdomen).Resident #8's had a new diagnosis of bipolar disorder added on 6/26/25. A significant change in status assessment had not been submitted to update Resident #8's MDS.On 8/19/25 at 2:35 PM, the facility social services staff #1 stated Resident #8's MDS had not been updated when he received the bipolar disorder diagnosis and should have been.

Based on the facility routine standing orders, record review and staff interview, it was determined the facility failed to follow the facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 2 of 8 residents (#7 and #10) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The facility routine standing orders for nursing home dated 8/28/24, documented for resident constipation the following medications may be used:- Miralax 17gm mix with 8oz fluid QD PRN constipation - Senna 8.6mg 1-2 tabs QD PRN for constipation. - Dulcolax 5mg 1 tab QD PRN - Magnesium Citrate 1 bottle QD PRN constipationa. Resident #7 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stroke and chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe).Resident #7's medical record documented in the CNA Task Bowel Activity, he had a bowel movement on 7/27/25 documented at 13:55, and not again until 7/31/25 documented at 13:59, 96 hours later.Resident #7's MAR for July 2025, documented bowel management protocol had not been initiated between 7/27/25 and 7/31/25.b. Resident #10 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood (hypoxia) over an extended period, often due to underlying respiratory diseases).Resident #10's medical record documented in the CNA Task Bowel Activity, he had a bowel movement on 7/25/25 documented at 21:05, and not again until 7/29/25 documented at 9:50, 84 hours later.Resident #10's MAR for July 2025, documented bowel management protocol had not been initiated between 7/25/25 and 7/29/25.Resident #10's medical record documented in the CNA Task Bowel Activity, he had a bowel movement on 8/9/25 documented at 15:31, and not again until 8/14/25 documented at 10:31, 117 hours later. Resident #10's MAR for August 2025, documented bowel management protocol had not been initiated between 8/9/25 and 8/14/25.On 8/19/25 at 2:00 PM, the DON stated staff should start the bowel management protocol when a resident had no BM for 72 hours or more and had not.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 8/18/25 at 3:49 PM, during East Hall medication cart audit, observed the narcotic accountability record, dated 8/1/25 to 8/18/25, with 3 licensed nurse signatures not documented. On 8/18/25 at 3:52 PM, LPN #2 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 8/20/25 at 1:50 PM, during North Hall medication cart audit, observed the narcotic accountability record, dated 8/1/25 to 8/20/25, with 1 licensed nurse signature not documented. On 8/20/25 at 1:55 PM, RN #2 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.On 8/20/25 at 2:54 PM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observation and interviews, it was determined the facility failed to ensure medication carts were locked when unattended. This was observed in 1 of 3 medication carts. This failure created the potential for residents to obtain prescribed medications used for other residents and presented the risk for cross-contamination of medications stored in the cart. Findings include:On 8/18/25 at 9:03 AM, observed an unlocked and unattended medication cart on the TCU hall outside of the dining room. RN #1 came out of the dining room after about 3 minutes and said she was just inside the dining room but stated the medication cart should have been locked. On 8/18/25 at 12:33 PM, observed an unlocked and unattended medication cart on the 200 Hall for over 3 minutes. While standing next to the medication cart, no facility staff were visible to the surveyor at that time. RN #1 was in the chart room on the 200 Hall and stated she did forget to lock the medication cart.On 8/18/25 at 4:08 PM, the DON stated medication carts are to always be locked when unattended and had not been.

Based on observation and staff interview, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not perform hand hygiene prior to providing care from resident-to-resident. This failure had the potential to impact 3 of 3 residents (#5, #17 and #71) observed during resident care, placing them at risk for cross-contamination and infection. Findings include: On 8/20/25 at 8:40 AM, surveyor observed CNA #2 enter Resident #5's room and obtain vital signs; blood pressure, oxygen saturation, and temperature, however CNA #2 did not perform hand hygiene on entering, during care, or exiting Resident #5's room. CNA #2 proceeded down the hall to Resident #71's room.On 8/20/25 at 8:55 AM, surveyor observed CNA #2 enter Resident #71's room and obtain vital signs; blood pressure, oxygen saturation, and temperature, however CNA #2 did not perform hand hygiene on entering, during care, or exiting Resident #71's room. CNA #2 proceeded down the hallway to Resident #17's room.On 8/20/25 at 9:17 AM, surveyor observed CNA #2 enter Resident #17's room and obtain vital signs; blood pressure, oxygen saturation, and temperature, however CNA #2 did not perform hand hygiene on entering, during care, or exiting Resident #17's room.On 8/20/25 at 10:09 AM, CNA #2 stated she had not performed hand hygiene between resident-to-resident care, and she has a bad habit of not doing it.On 8/20/25 at 10:42 AM, the DON stated the CNA should have been performing hand hygiene when providing resident-to-resident care.

Based on observation and interview, the facility failed to provide a safe and functional environment. This was true for 2 of 2 residents (#2 and #76) whose sharps containers were observed to be overfilled. This failure had the potential for injury and infections. Findings include:On 8/18/25 at 2:43 PM, observed in resident #2's room with LPN #1 present, the sharps container was filled past the full line.On 8/18/25 at 2:45 PM, LPN #1 stated the sharps container should have been changed when it was full.On 8/18/25 at 2:48 PM, observed in resident #76's room with LPN #1 present, the sharps container was filled past the full line.On 8/18/25 at 2:49 PM, LPN #1 stated the sharps container should have been changed when it was full.On 8/19/25 at 9:38 AM, the DON stated the sharps containers should have been changed when full.

Based on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 5 out of 6 resident rooms observed during afternoon CNA rounds. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth. Findings include:Resident #4 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and heart failure.On 8/18/25 at 2:02 PM, observed CNA #1 walk into Resident #4's room without knocking and then he continued down the hall entering rooms 124, 125, 126, 127, and 130 without knocking.On 8/18/25 at 2:13 PM, CNA #1 stated he was late getting off shift and will remember to knock before entering next time. On 8/18/25 at 2:22 PM, the DON stated CNAs should always knock before entering a resident's room and had not.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents who self-administer medications had been assessed and evaluated for cognitive and physical ability to self-administer medications and reviewed by the Interdisciplinary Team (IDT) prior to residents self-administering medications for two of two residents (Resident (R) 38 and R11) observed self-administering medications. As a result of this deficient practice, medications may or may not actually be correctly administered. Findings below: 1. Review of R38's Admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admitted [DATE] and readmission on 12/20/21 with medical diagnosis including cerebral infarction. Review of R38's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R38 was cognitively intact. Observation on 08/19/24 at 12:10 PM, R38 was sitting on the side of the bed and two pills were in a clear medication cup, a big white one and small red one. The resident said, these are the pills I take with lunch. During an interview on 08/19/24 at 12:34 PM, Licensed Practical Nurse (LPN) 1 explained the resident does not like to be rushed when taking medications and when LPN 1 entered the resident room to administer the medication, the resident was being assisted in the bathroom and requested that LPN 1 left the pills on the bedside table. LPN1 confirmed the medications were iron and sodium chloride supplements. Review of R38 EMR under the Assessments tab lacked documentation of an assessment for self-administration of medications. Review of R38's physician orders in the EMR under the Orders tab documented an order for: Ferrous Sulfate Tablet 325 milligrams (mg) Give 1 tablet by mouth one time a day every Mon, Wed, Fri for supplement and Sodium Chloride Tablet 1 gram Give 1 tablet by mouth three times a day for electrolyte supplement WITH MEALS and lacked an order for self-administration of medications. Review of R38's Care Plan under the Care Plan tab in the EMR lacked documentation for self-administration of medications. 2. Review of R11's Admission Record located in the EMR under the Profile tab, revealed and admitted [DATE] and readmission on 12/01/21 with medical diagnosis including dementia with other behavioral disturbances. Review of R11's quarterly MDS located in the EMR under the MDS tab with an ARD of 06/20/24, revealed a BIMS score of three out of 15, indicating R11 was severely cognitively impaired. Observation in the main dining rooms on 08/21/24 at 08:32 AM, R11 was sitting at the table waiting for the meal tray. On the napkin there were five pills covered by an upside-down clear medication cup. During an interview on 08/21/24 at 8:41 AM, LPN 2 confirmed the mediations under the medication cup were Metformin two tablets, Finasteride one tablet, Lisinopril one tablet, and Eliquis one tablet. LPN2 explained R11 wanted to take his pills with food so LPN2 gave him his pills in the medication cup and R11 placed them in his pocket on his way to the dining room so R11 could take the medications with breakfast. Review of R11's EMR under the Assessments tab lacked documentation of an assessment for self-administration of medications. Review of R11's physician orders under the Orders tab documented Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for atrial fibrillation, Finasteride Tablet 5 MG Give 1 tablet by mouth one time a day for BPH, Lisinopril Oral Tablet 2.5 MG (Lisinopril) Give 2.5 mg by mouth one time a day for HTN [hypertension], and metformin HCl ER Tablet Extended Release 24 Hour 500 MG Give 2 tablet by mouth in the morning for DM II [diabetes mellitus] and lacked an order for self-administration of medications. Review of R11's Care Plan under the Care Plan tab in the EMR lacked documentation for self-administration of medications. During an interview on 08/20/24 at 12:50 PM the Director of Nursing (DON) and the Clinical Resource Nurse confirmed the process for a resident to self-administer medications included completing a self-administration assessment located in the Assessments tab in the EMR and an assessment done by the IDT team. During an interview on 08/21/24 at 12:10 PM, the DON confirmed the nurse administering the resident mediation was to observe the medication being administered prior to documenting the medication being administered. The DON confirmed R11 and R38 had not been assessed for self-administration of medications, the IDT process had not been involved and the medications should not have been left with the residents to be self-administered Review of the facility's policy titled Self-Administration of Medications revised 5/22, revealed The residents cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility (this would be dangerous to resident or others), the interdisciplinary team may withdrawal this right. Appropriate notation of these determinations will be placed in the residents care plan.

Based on record review, staff interview and policy review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I assessment was completed after the resident remained in the facility past the initial 30 day exception for one residents (Resident (R)31 out of one residents out of a total sample of 22 residents reviewed for PASARR level I screenings which had the potential to prevent or delay additional services to a resident that may qualify for a level II. Findings include: 1. Review of R31's undated Face sheet, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of R31's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/01/24, revealed a Brief Interview for Mental Status (BIMS), score of 15 out of 15 which indicated R31's cognition was intact. Further review the MDS indicated an active diagnosis of schizophrenia, post-traumatic stress disorder (PTSD), anxiety disorder and major depressive disorder. Review of R31's Abbreviated Level II Preadmission Screening for Nursing Home Placement (PASARR) located under the Resident Documents tab in the EMR and dated and submitted on 06/29/24 indicated admission meets criteria for Hospital Exception and meets all the following and has a known or suspected Mental Illness (MI) diagnosis. The attending physician has certified prior to nursing facility (NF) admission the resident will require less than 30 calendar days of NF services. Further review revealed individuals meeting criteria are exempt from Level II screens. But the facility must complete a PASARR at such time that it appears the individuals stay will exceed 30 days and no later than the 40th calendar day. During an interview on 08/21/24 at 10:04 AM, Medical Records (MR) stated the hospital completed the initial PASARR and she would check to see if they had a 30-day exemption, and she kept a log of those that helped her know when a new PASARR needed to be completed if they remained in the facility past 30 days. MR stated that she missed completing R31's PASARR level 1 and confirmed R31 had been in the facility almost two months. During an interview on 08/22/24 at 9:20 AM, the Director of Nursing (DON) said she was unaware that a new Level I was not completed for R31 and sent in after the resident was in the facility past 30 days. Review of the facility's undated policy titled Preadmission Screening for MI/MR [Mental Retardation] revealed, It is the policy if the facility to ensure that each resident is properly screened using the PASARR specified by the state.

Based on observation, interview, record review, and Fundamentals of Nursing textbook guidance, the facility failed to ensure a physician's order was in place prior to flushing a Foley catheter for one of three residents (Resident (R) 49) reviewed for indwelling urinary catheter care. As a result of this deficient practice there is a potential for introducing bacteria into the closed indwelling urinary catheter system. Findings include: Review of R49's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] and readmission on 01/26/24 with medical diagnosis including obstructive and reflux uropathy [ureteral obstruction-urine flows from bladder backwards to ureter]. Review of R49's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/08/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R49 was cognitively intact. Observation on 08/19/24 at 12:18 PM, R49 was in the wheelchair, sitting in the 500-hall dining room awaiting lunch. The indwelling urinary catheter tubing was visible and the urine was slightly blood tinged. Review of R49's Prog Notes in the EMR revealed a note created by LPN1 on 08/20/24 at 06:13 AM, documented Resident came back from his U/S [ultrasound] and had slight pink tinged urine. Pt [patient] was assessed. The catheter was assessed and flushed. Pt didn't have any c/o [complaint of] pain or discomfort. no burning or redness. nurse will monitor for continued change to urine color. Review of R49's physician orders in the EMR under the orders tab lacked documentation of an order to flush the indwelling urinary catheter. Review of the standing orders for R49 lacked documentation of an order to flush the indwelling urinary catheter. During an interview on 08/20/24 at 12:50 PM, the Director of Nursing (DON) and the Clinical Resource Nurse verbalized the flushing of a Foley catheter required a physician's order and that LPN1 should not have flushed the indwelling urinary catheter without an order. During an interview on 08/21/24 at 12:36 PM, LPN1 stated that she thought there was a standing order for flushing an indwelling urinary catheter, however, she was in error, there was no standing order and should not have flushed the catheter. During an interview on 08/21/24 at 11:20 AM, the Assistant Director of Nursing (ADON) confirmed the nursing procedure reference for the facility was the Fundamentals of Nursing textbook by [NAME] and [NAME], sixth edition. Review of the Fundamentals of Nursing textbook by [NAME] and [NAME], sixth edition, page 438 documented for flushing a closed and open catheter irrigation, indicated, to verify physician's order before performing the procedure.

Based on record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to installation of side rails, for two of three residents reviewed for side rails (Resident (R) 84 and (R) 26) of 22 sampled residents. The lack of alternative measures and proper assessment could lead to potential restraint or side rail entrapment. Findings include: Review of R84's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses included difficulty in walking and aftercare for joint replacement. Review of R84's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24 revealed a Brief Interview for Mental Status (BIMS) score of three out of 14 which indicated the resident was severely cognitively impaired. Review of R84's Care Plan, initiated 07/23/24, located under the Care Plan tab of the EMR revealed at risk for falls with an intervention of side rails as ordered. Review of R84's Side Rail Assessment located under the Observations tab of the EMR, dated 08/16/24, revealed no documentation of alternative measures. Further review revealed only risk and benefits, and consent was obtained. 2. Review of R26's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses included lack of coordination, difficulty in waking, and unsteadiness on feet. Review of R26's admission MDS with an ARD of 07/11/24 revealed a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R26's Care Plan, initiated 07/09/24, located under the Care Plan tab of the EMR revealed at risk for falls with an intervention of side rails as ordered. Review of R26's Side Rail Assessment located under the Observations tab of the EMR, dated 08/16/24, revealed no documentation of alternative measures. Further review revealed only risk and benefits, and consent was obtained. During an interview on 08/21/24 at 7:57 AM, Licensed Practical Nurse (LPN)4 stated she completed the admission side rail assessment for both residents. She spoke with both residents about siderail use, went over the risks and answered the questions on the assessment. She stated that nursing identified if a resident needed side rails. She stated they don't look at alternative measures prior to implementing bedrails for a resident. She said she did not know they were supposed to. During an interview on 08/21/24 at 9:06 AM, Therapy Resource (TR) said therapy only signed off on the bedrail assessment after it was completed by nursing and was unsure if therapy completed their own. During an interview on 08/22/24 at 9:09 AM the Director of Nursing (DON) said during admission, nursing completed the bedrail assessment based on the resident's needs and how they were doing. They would determine if bed rails would assist the resident with getting in and out of bed or to reposition. They would review with the resident if they wanted or needed a bedrail and get consent from them or their responsible party. But she was unaware there needed to be documentation that prior alternatives were explored before implementing bed rails for a resident and that this was not completed. Review of the facility's policy titled Bed Rails revised 12/2023, revealed It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail.

Based on observation, interview, manufacturer's instruction review, and policy review, the facility failed to ensure expired mediations were discarded in one of two medication rooms (main medication room on TCU unit) reviewed for outdated medications. As a result of this deficient practice residents may receive medication with decreased potency and effectiveness. Findings include: During an observation on [DATE] at 10:31 AM, in the medication room for the TCU unit, two boxes of Bisacodyl suppositories were stored in the refrigerator with an outdate of ,d+[DATE]. The box that held the vial of Tuberculin Purified Protein Derivative (TB) (Tubersol) was dated on the box as opened on [DATE]. During an interview on [DATE] at 10:32 AM, Registered Nurse (RN)1 confirmed the suppositories were out of date and should not be used for residents. The TB box with the date of [DATE], was unable to explain when the opened vial expired. During an interview on [DATE] at 11:54 AM the Director of Nursing (DON) confirmed outdated medications are not to be administered and when outdated medications are found, they are to be discarded. Review of the manufacturer's instructions for Tuberculin Purified Protein Derivative (Tubersol revealed, a vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Review of the facility policy titled Specific Medication Administration Procedures-Administration Procedures for all Medications, with an effective date of ,d+[DATE] revealed, Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container.

Based on record review and staff interview, it was determined the facility failed to ensure residents received information and assistance to exercise their right to formulate an Advance Directive. This was true for 5 of 16 residents (#10, #31, #34, #56, and #65) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated. Findings include: Resident #10, Resident #31, Resident #34, Resident #56, and Resident #65 did not have a copy of an Advance Directive in their records. The five residents' medical records did not include documentation an Advanced Directive was discussed with them. Additionally, the residents' medical records did not include documentation they were provided assistance to formulate an Advance Directive, or of their decision not to formulate an Advance Directive. On 6/6/19 at 3:30 PM, the LSW stated she talked to the residents about creating Advance Directives, however, she did not always document her conversations. On 6/6/19 at 4:00 PM, the Administrator stated he was sure the LSW talked to the residents about Living Wills and DPOAs (Durable Power of Attorney for Healthcare) and if a copy was provided it was kept in the residents' hardcopy charts. On 6/7/19 at 9:00 AM, the LSW confirmed she had no further documentation regarding Advance Directives for the five residents.

Based on staff interview, review of admission agreement paperwork, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to residents upon transfer. This was true for 1 of 2 residents (Resident #21) reviewed for transfers. This deficient practice had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's Resident Admission Agreement documented if a more immediate transfer or discharge was required due to urgent medical need, a written notice of transfer was given to the resident or their representative as soon as practicable before the transfer or discharge. Resident #21 was admitted to the facility on [DATE], with unspecified dementia with behavioral disturbance. A discharge MDS assessment, dated 2/22/19, documented Resident #21 was discharged to a hospital. She was readmitted from the hospital on [DATE]. Resident #21's medical record did not include documentation she or her responsible party were provided a transfer notice. On 6/6/19 at 10:49 AM, the Director of Medical Records stated the transfer and the reason for the transfer was communicated by telephone to the resident and her responsible party.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representative upon transfer to the hospital. This was true for 1 of 2 residents (Resident #21) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold/Reservation of Room policy, dated 9/2017, documented the resident, or the resident's representative, would be informed, in writing, of their right to exercise the bed-hold provision. The notice was to include the following: * The duration of the state bed-hold policy (if any) and/or the facility policy that the resident's bed will be held for the duration of 3 days, during which time the resident was permitted to return and resume residence in the facility. * The amount required to be paid by the resident or the resident's payor source to hold the bed for the duration of the bed-hold period. * This information would be provided to the resident and/or their representative in a language they could understand at the time of admission and transfer to the general acute hospital. Resident #21 was admitted to the facility on [DATE], with dementia. A discharge MDS assessment, dated 2/22/19, documented Resident #21 was discharged to a hospital. She was readmitted from the hospital on [DATE]. She was readmitted from the hospital on [DATE]. A Notification of Bed-Hold Policy and Readmission form, dated 2/22/19, documented Resident #21 was discharged to an acute care hospital. The form documented the resident's bed would be held without charge for 3 days and to notify the Business Office Manager for a room rate if the bed-hold exceeded 3 days. The form documented Resident #21 and her responsible party were notified of the policy and terms via telephone on 2/22/19 at 11:57 PM. The resident and the responsible party signature lines were blank. On 6/6/19 at 10:49 AM, the Director of Medical Records stated she did not have a bed-hold notice signed by the resident or her representative.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to; a) ensure staff stored the nebulizer mouthpiece appropriately after each use and let it dry and b) ensure professional standards of practice were followed for [MEDICAL CONDITION] (Continuous Positive Airway Pressure) administration This was true for 1 of 1 resident (Resident #64) reviewed for respiratory care. This failure placed residents at risk of respiratory infections due to the growth of pathogens (organisms that cause illness) in the respiratory equipment and increased respiratory problems if they did not receive the necessary treatment. Findings include: Resident #64 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. a. The facility's Use and Care of Nebulizer Equipment policy, revised on 7/17, directed staff to: * Remove the mouthpiece from the T-piece, the T-piece from the nebulizer cap, unscrew the nebulizer cap from the nebulizer jar and remove the nebulizer jet (if it is removable), and disconnect the nebulizer jar from the air tubing. * Rinse all of the disassembled nebulizer parts with water and allow to air dry on a clean towel before using the pieces again. On 6/3/19 at 11:36 AM, 6/4/19 at 4:28 PM and 6/5/19 at 4:13 PM, Resident #64's nebulizer mouthpiece was observed resting on top of her nebulizer machine which was on top of her bedside table. On 6/5/19 at 4:17 PM, LPN #2 was shown Resident #64's mouthpiece resting on top of the nebulizer machine. LPN #2 removed the mouthpiece and the nebulizer cap and washed it. LPN #2 said the nebulizer mouth piece and nebulizer cap should be washed after each use, air dried and placed in a plastic bag. b. Resident #64's admission MDS assessment, dated 5/14/19, documented she used a [MEDICAL CONDITION] machine. A care plan, initiated on 5/6/19, directed staff to administer Resident #64's [MEDICAL CONDITION] machine at night and when necessary. a. Resident #64's 5/6/19 through 6/4/19 TAR, documented [MEDICAL CONDITION] at home setting at night and PRN. The TAR documented Resident #64 refused to use her [MEDICAL CONDITION] machine on 18 out of 30 opportunities. A Nursing Note, dated 5/10/19 at 11:36 PM, documented Resident #64 refused to use her [MEDICAL CONDITION] machine multiple times. The note documented Resident #64 stated it made her cough and did not like the way it made her feel. A Nursing Note, dated 5/15/19 at 1:40 AM, documented Resident #64 refused to use her [MEDICAL CONDITION] machine due to her cough. The note stated the nurse asked Resident #64 if she would like to inform the physician and discontinue her [MEDICAL CONDITION] machine. Resident #64 said she would like to use it once she felt better. On 6/5/19 at 5:48 PM, the ADON reviewed Resident #64's TAR and said Resident #64's physician should have been notified of her continued refusals to use her [MEDICAL CONDITION] machine. The ADON said she did not find documentation Resident #64's physician was notified. b. On 6/3/19 at 11:36 AM, a [MEDICAL CONDITION] machine was observed on top of Resident #64's left bedside table. Resident #64 said the staff was not able to make her [MEDICAL CONDITION] machine work the night before and she was not able to use it. On 6/4/19 at 4:28 PM, Resident #64 said she did not use her [MEDICAL CONDITION] machine the night before because it was not working, but she found out that morning it was not plugged into the wall outlet. Resident #64 pointed to the cord and said it was behind the table the night before. On 6/5/19 at 4:17 PM, Resident #64 told LPN #2 she found the cord for her [MEDICAL CONDITION] machine and she hoped she could use it that night. On 6/5/19 at 4:22 PM, LPN #2 said the nurse set-up residents' [MEDICAL CONDITION] machines, and she did not know why Resident #64 was unable to use hers the previous two nights.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure pharmacy labels were on resident medications prior to use. This was true for 1 of 4 residents (Resident #275) reviewed for medication storage and labeling. This failed practice created the potential for residents to receive unidentified or expired medications. Findings include: The facility's policy and procedure for Services of a Licensed Pharmacist, dated 8/2017, documented the pharmacist was responsible for pharmaceutical services that were consistent with current standards of practice and met state and federal requirements. Resident #275 was admitted from home to the facility on [DATE], for a five-day respite under hospice care. On 6/7/19 at 10:34 AM, an inspection of the 500 Hall medication cart was completed with LPN #1 present. The medication cart contained 25 medication cards for Resident #275. The medication cards did not have a pharmacy label. Each medication card had a white sticker on the front with the resident's name, date of birth, the name of the medication, and direction for use. This information was handwritten. The back of the medication card included an area for the pharmacy to fill in the following information: * Filled by/checked by * Medication * Strength * Lot Number * Expiration Date * Manufacturer The above information was not filled in on the medication cards. The hospice agency provided Resident #275's medications for his respite stay. The medications included [MEDICATION NAME], a sedative useful for anxiety; [MEDICATION NAME]-[MEDICATION NAME], a narcotic for pain management; [MEDICATION NAME], a blood thinner; and [MEDICATION NAME], a diuretic. There were also cardiac medications and 2 insulin pens for diabetes mellitus. The medication cards did not provide warnings about side effects, possible drug interaction, precautions during use, a description of the medication, or the expiration date. At 10:50 AM, the DON viewed the medication cards for Resident #275. She confirmed she could not ensure the medications inside the cards matched the labels or when they expired.

Based on observation, staff interview and policy review, it was determined the facility failed to ensure a glucometer used to check blood glucose levels was cleaned after each use. This was true for 2 of 3 residents (#44 and #64) observed for blood glucose testing. This deficient practice created the potential for the spread of infectious organisms from cross contamination which could harm all residents in the facility. The facility's Care of the Blood Glucose Meter Policy, dated 10/14/10, directed staff to clean the outside of the meter per the manufacturer's guidelines, before initial use, and after every patient. On 6/4/19 at 4:35 PM, LPN #3 was observed performing a capillary blood glucose test to Resident #64 using a glucometer. After the completion of the capillary blood glucose test, LPN #3 placed the glucometer inside a plastic cup, removed her gloves and washed her hands. LPN #3 picked up the plastic cup, returned to the medication cart, placed the plastic cup on top of the medication cart, and wrote the result of Resident #64's blood glucose on a sticky note pad. LPN #3 was not observed to sanitize the glucometer. On 6/4/19 at 4:42 PM, LPN #3 was observed performing a capillary blood glucose test to Resident #44 using the same glucometer she used for Resident #64. After the completion of the capillary blood glucose test, LPN #3 placed the glucometer on a paper towel on top of Resident #44's overbed table. She removed her gloves and washed her hands. LPN #3 picked up the glucometer, placed it in a plastic cup and returned to the medication cart. She placed the plastic cup on top of the medication cart and started charting. LPN #3 did not sanitize the glucometer before using it for Resident #44. On 6/4/19 at 4:54 PM, LPN #3 said she used a multi-use glucometer and she did not sanitize it between uses. LPN #3 said she thought she did not need to sanitize the glucometer if she placed it on top of a barrier when she was inside the resident's room.

Based on record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for medication and [MEDICAL CONDITION] (Continuous Positive Airway Pressure) administration. This was true for 1 of 3 residents (Resident #40) reviewed for bowel care . This failed practice created the potential for residents to experience complications related to constipation (Resident #40) if they did not receive the necessary treatment. Findings include: Resident #40 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 4/29/19, documented Resident #40 had severe cognitive impairment, required extensive two person assistance for toileting, and was continent of bowel. Resident #40's physician orders, dated 3/4/19, included the following: * Biscolax suppository 10 mg, insert one rectally as needed for bowel care. * [MEDICATION NAME] Powder, give 17 gms by mouth as needed for bowel care. * Milk of Magnesia, give 30 mls by mouth as needed for bowel care. Resident #40's physician's orders [REDACTED]. Resident #40's MARs from 5/9/19 to 5/14/19, did not include documentation bowel care medications were provided as ordered by the MD as follows: * From 5/9/19 through 5/14/19, Resident #40 did not have a bowel movement (6 days). Resident #40's MAR indicated [REDACTED]. On 6/7/19 at 12:44 PM, the DON stated the facility did not have a policy for bowel care or a protocol for bowel care. She stated the facility had standing physician orders [REDACTED].

Based on closed record review and staff interviews, it was determined the facility failed to ensure the necessary care and services were provided for a resident admitted with medication administration stop or discontinue dates. This was true for 1 of 6 sample residents (#5) whose medications were reviewed. Resident #5 was harmed when he suffered a grand mal [MEDICAL CONDITION], required emergent transport to a local ED, IV medication and fluids, and was admitted to a local medical center. Findings included: Resident #5 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #5's 9/17/14 admission MDS coded: - moderately impaired cognition, - CAD, HTN, [MEDICAL CONDITIONS], TIA, or stroke, [MEDICAL CONDITION] disorder or [MEDICAL CONDITION], depression, [MEDICAL CONDITION], and - received injections, antidepressant, anticoagulant, and antibiotic medications. Resident #5's Order Listing Report (computer generated copy of physician orders [REDACTED]. - [MEDICATION NAME] 750 mg every other day for infection until 9/13/14 - [MEDICATION NAME] 40 mg one time a day for clot prevention until 9/18/14 - [MEDICATION NAME] 20 mg every day for cholesterol until 9/23/14 - [MEDICATION NAME] 10 mg daily for depression until 9/24/14 - [MEDICATION NAME] Bisulfate 75 mg daily for CAD until 9/24/14 - [MEDICATION NAME] 15 mg daily for CAD until 9/24/14 - Aspirin 81 mg daily for CAD until 9/24/14 - [MEDICATION NAME] 250 mg two times a day for [MEDICAL CONDITION] until 9/24/14 - [MEDICATION NAME] 5 ml twice daily for bowels until 9/25/14 - [MEDICATION NAME] 25 mg twice daily [MEDICAL CONDITION] 9/25/14 - [MEDICATION NAME] 5 mg daily [MEDICAL CONDITION] 9/26/14 - [MEDICATION NAME] Respimat 20-100 mcg one puff as needed for [MEDICAL CONDITION] until 9/24/14 - [MEDICATION NAME]-[MEDICATION NAME] 3 ml as needed for SOB or wheezing until 9/24/14 - Tylenol 325 mg as needed for pain until 9/24/14 Resident #5's 9/2014 MAR documented nursing staff discontinued the administration of the above identified medications on the above "until" indicated dates. a. When he was admitted to the facility, RN #1 entered the medication orders into the facility's electronic MAR program and faxed a copy of Resident #5's medications to the PCP. During an interview on 2/11/15 at 9:41 a.m., RN #1 said, when she faxed Resident #5's medication information to the PCP, she did notice the medication stop or discontinue dates specifically for [MEDICATION NAME]. She also said she did not include any documentation to the PCP to draw the doctor's attention to the different stop or discontinue dates nor did she ask the PCP for any clarification. She stated, "I thought the doctor would look at the medication stop or discontinue dates on the MAR and determine if the dates were appropriate." b. Resident #5's medical record documented he was seen by two different doctors during the month of September 2014. The resident was seen by MD #1 on 9/15/14 and MD #2 on 9/23/14. Neither of the doctor's progress notes documented or addressed the stop or discontinue dates of the above identified medications on the resident's 9/14 MAR. Please refer to F386. c. Resident #5's medical record included a pharmacy Medication Chart Review form, dated 9/18/14. The form did not identify any medication irregularities, concerns, recommendations, or comments from the consultant pharmacist. Please refer to F428. Resident #5's 10/3/14 at 2:37 a.m. Progress Note documented, "Called to room at 0200 (2:00 a.m.) resident in room having a [MEDICAL CONDITION] (MD's name) who is on call for (MD's name) and was given an order to transfer to the emergency room . Resident was unresponsive to stimuli for 20 min (minutes) after [MEDICAL CONDITION] and then started to respond when ambulance crew came to facility. Resident transferred at 0225 (2:25 a.m.)." Resident #5's 10/3/14 ED report documented "...history of prior [MEDICAL CONDITION] and [MEDICAL CONDITION] ED...via EMS after...a prolonged [MEDICAL CONDITION] at...nursing facility...history of being on [MEDICATION NAME], but for some reason was taking (taken) off the medication about 2 weeks ago. The nursing staff reported that they found him having a grand mal [MEDICAL CONDITION] on [MEDICATION NAME] 1000 mg IV x1 (one time)...continue on IV [MEDICATION NAME] and IV fluids...admitted ...in stable condition." A grand mal [MEDICAL CONDITION], also known as a generalized tonic-clonic [MEDICAL CONDITION], features a loss of consciousness and violent muscle contractions. The nursing staff, two different doctors, and the consultant pharmacist failed to determine the appropriateness of discontinuing or stopping the resident's medications. Resident #5 suffered a grand mal [MEDICAL CONDITION], required emergent transport to a local ED and IV medication and fluids, and was admitted to a local medical center. On 2/11/15 at 11:15 a.m., the Administrator was informed of the finding. No further information was provided.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents who entered the facility without pressure sores did not develop pressure sores. This was true for 3 of 3 (#'s 1, 9 & 4) sampled residents reviewed for pressure sores. Resident #9 developed a stage II pressure ulcer to her coccyx which developed into an unstageable ulcer with undermining and became infected, which harmed the resident. The facility also failed to prevent unstageable pressure ulcers to Resident #1's left hip and Resident #4's coccyx. Findings included: 1. Resident #9 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #9's most recent annual MDS assessment, dated 3/26/14, documented: * Moderately impaired cognition with a BIMS of 8; * Extensive assistance required with 2 or more people for bed mobility, transfers, dressing and toilet use; * Extensive assistance required with 1 person for personal hygiene: * Always incontinent of bladder and bowel; * At risk of developing a pressure ulcer with no unhealed pressure ulcers; * Pressure reducing device for bed and chair; and, * No turning/repositioning program and no nutrition or hydration intervention to manage skin problems. Resident #9's Care Plan, dated 10/24/13, documented the focus area of, "Has actual and potential for skin breakdown & pressure ulcer development with poor wound healing potential r/t (related to) decreased mobility, total bowel incontinence, poor caloric & protein intake to support wound healing, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]) with [MEDICAL CONDITION] & diuretic therapy and chronic reoccurrence of blood blisters to bilateral lower extremities, anticoagulation therapy, advanced age, deteriorating vascular disease. (MD statement that skin breakdown is expected and unavoidable) Pt. (patient) choice for no artificial nutrition or hydration." Revised on 5/7/14. Initial interventions included: "Encourage fluid intake and assist to keep skin hydrated;" "Float heels off of bed as resident will allow;" "Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested;" "Shift weight in chair Q (every) 2 hours and PRN;" and, "Weekly head to toe skin at risk assessment;" The Care Plan had an additional focus area of, "Has bowel incontinence r/t Physical limitations, Impaired Mobility, Activity Intolerance," initiated on 10/2/14. The interventions included: "BRIEF USE: uses disposable briefs. Change Q 2 hrs and prn;" and, "INCONTINENT: Check as required for incontinence. Wash, rinse and dry perianal area. Change clothing PRN after incontinence episodes." A Braden Scale for Predicting Pressure Sore Risk for Resident #9, dated 3/18/14, documented a score of 14, which placed the resident in the moderate risk category. An ADL flowsheet documented Resident #9 was turned and repositioned on 3/26/14 at 5:50 a.m., 1:37 p.m., 4:12 p.m. and 11:14 p.m. Note: From 5:50 a.m. to 1:37 p.m., over 7 hours passed before it was documented the resident was turned/repositioned. Over 2.5 hours went by between 1:37 p.m. and 4:12 p.m. before it was documented the resident was turned/repositioned. Another 7 hours passed between 4:12 p.m. and 11:14 p.m. before turning/repositioning the resident was documented. The ADL flowsheet documented Resident #9 was turned and repositioned on 3/27/14 at 8:36 p.m. Turning/repositioning was not documented again until the following day, 3/28/14 at 4:32 a.m. Note: From 3/26/14 at 11:14 p.m. until 8:36 p.m. on 3/27/14, over 21 hours passed before it was documented the resident was turned or repositioned. From 3/27/14 at 8:36 p.m. until 4:32 a.m. on 3/28/14, 8 hours went by before it was documented the resident was turned or repositioned. Note: Documentation of toileting or check and changes was requested on 5/8/14. No documentation was provided. An Incident Report for Resident #9, dated 3/28/14 at 7:00 a.m., documented: * Description - "During AM cares noted 1cm x (centimeter by) 1cm superficial open area just (left) of coccyx non-blanchable. Surrounding tissue red- blanches well." * Corrective Action - "Cleansed (with) NS (normal saline), skin protectant applied Covered (with) [MEDICATION NAME] dsg (dressing) Will place air mattress - pt. already has RoHo in w/c (wheelchair)." * Medication/DX (diagnostic) labs that may contribute to incident - "[AGE] year old pt. (patient with) extremely fragile skin. [MEDICAL CONDITION]. Poor appetite, Constantly Consumes (less than) 25 % at meals. Accepts supplement shakes TID. Receives Anticoagulant daily." * Staff/Visitors/other residents interviewed - Blank * Resident Statement - Unaware of skin issue - denies pain at site;" * Comments of investigation/prevention measures in place - "Resident is a [AGE] year old female (with) dx of Dementia, [MEDICAL CONDITIONS]. Res(ident) is on anticoagulant of Elequis BID (two times per day) r/t reoccurring blood blisters to bilat(eral lower) legs as well as recent [MEDICAL CONDITION] ([MEDICAL CONDITION] to (left) leg. Res has extremely fragile skin (with) chronic ecchymotic areas to bilat extremities. Res is one of the last residents up (and) last down for meals. (Note: there was no documetation on the CP related to the resident being last resident up and last resident down for meals. In addition, the intervention of, "last up last down" should be last up, first down to decrease the amount of time spent up in the wheelchair.) res transfers (with) 1 assist during the day x2 during evenings is check and (change) during noc (night) (every) 2 (hours) and PRN r/t Hx (history) of vagal episodes on toilet during noc when gotten up Res has had (increased) weakness and down time in bed since [MEDICAL CONDITION] to (left) leg. Res is on a RoHo cushion to her w/c, Airbed was placed upon finding of skin concern. Moisture barrier is applied (with) peri(neal) care Res is incontinent of urine. Will leave OTA (open to air) (at) noc (with) frequent changing of airpad. Will monitor via tx (treatment) sheet (un)til resolved." A Fax Request for Physician Response, dated 3/28/14, documented, "Noted superficial open area just (left) of coccyx - non-blanchable. Placed [MEDICATION NAME] dsg per protocol - will (change every) 3 days (and) PRN. May we have an order for [REDACTED]." The following documentation was gathered from Resident #9's LN-Skin Pressure Ulcer Weekly assessment (SPUW), Interdisciplinary Team Skin Review - Weekly Update (ITSR) reports, Physician order [REDACTED]. 3/28/14 - MD order, "Document status of ulcer to coccyx on daily ulcer observation record Q (every) day;" 4/2/14 - SPUW, "Date of Onset: 3/28/14; Site: coccyx; Stage: Stage 2; Size: 1cm x 0.5cm; depth: superficial; Comments: New pressure ulcer identified to coccyx 3/28/14. Wound at stage 2 ulcer, superficially open, red and granular in color. No drainage, no odor and no s/s of infection present. Wound is improved since identified. No periwound redness, skin is pink periwound and is blanchable. Wound size is smaller since identification. Wound cleansed with NS, no sting skin barrier applied to periwound skin and [MEDICATION NAME] dressing was placed over wound per aseptic technique. Pt. tolerated dressing change without c/o (complaints of) pain or discomfort. Pt. was turned and repositioned off right side onto left side when wound assessment and dressing change was completed. Pt. is using airbed for additional pressure reduction and roho cushion when in wheelchair, pt. is checked and changed/toileted q2hrs (every 2 hours) and PRN and has been totally incontinent of bowel and bladder. Pt. is assisted to turn and reposition q2hrs and PRN." 4/9/14- SPUW, "Site: Coccyx; Stage 2; Size: 0.5cm x 0.3cm; Comments: Pressure ulcer to coccyx is healing, measures smaller in size over past week and remains superficially open with presentation as stage 2 ulcer. Periwound skin is pink and blanchable (sic) without maceration. No s/s of infection are evident. Scant serosanginous drainage present from wound. Pt. denies pain to coccyx wound with assessment and with dressing change. Wound was cleansed with NS, no sting skin barrier applied to periwound skin and [MEDICATION NAME] dressing was applied over wound per aseptic technique. Pt. was turned onto left side from right side following wound care. Pt. education was provided to pt. regarding importance of adequate fluid and food intake to help heal wound as well as importance of tuning at least q2hrs off coccyx to help with wound healing. Pt. verbalizes understanding of instruction." 4/9/14 - ITSR, "Skin Progress/Status and Compliance with treatment plan: [REDACTED]. Wound is smaller in size and is superficially open with no s/s (signs and symptoms) of infection evident. Pt. is turned q2hrs and PRN off coccyx, is checked, changed, toileted q2hrs and PRN. Current wt. is 104# with no change in wt. in 1 month. Meal intakes are poor with majority of meals taken less than 25% consumed. Pt. accepts mighty shakes TID at meals and will take toast at each meal as well. Pt. is served fortified mechanical soft diet with small portions at pt. request. Accepts about 1/3 of TID snacks. Pt. continues taking MVI with mineral po qd (by mouth every day). Pt. is using airbed, roho cushion in w/c to help off load pressure from coccyx; IDT Recommendations/Comments: Dietician consult was completed 4/2/14, requests MD be contacted to ask for 2cal 2oz to hot chocolate TID at meals. With improvement in wound recommended contacting MD for possible change in topical treatment to Marathon q3d (every 3 days) and PRN along with possibly adding 2 scoops protein powder TID with meals to boost protein intake and aid wound healing as MD sees fit. Request pt. be added to weekly wt.'s from monthly. (MD's name) and (Responsible Party) were notified of current status of coccyx pressure ulcer healing and of current wound healing interventions in place. Pt. remains at high risk for skin breakdown, poor or delayed wound healing due to poor caloric and protein intake at meals, wt. loss, [MEDICAL CONDITIONS] with [MEDICAL CONDITION] & diuretic therapy, total bowel and bladder incontinence and diminished independent mobility skills.; This resident is at High Risk for Skin Integrity Breakdown which may not be Preventable and may have Delayed healing Due To the Identified Conditions/Risk Factors: Yes; Care Plan Updated and Revised: Yes." 4/9/14 - CP revisions, "Administer pain relieving medication prior to treatments as needed and as per MD orders; Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD; Document status of pressure ulcers qd (every day) on Daily Ulcer Observation Record; Educate resident, family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during mobility, good nutrition and frequent repositioning; Encourage pt. to keep HOB (head of bed) as flat as possible to reduce sheer; If refuses treatment, meet with resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods; Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx ( signs and symptoms) of infection, wound size and stage; Requires supplemental MVI (multivitamin) with mineral po (by mouth) qd to promote wound healing." 4/13/14 - A Braden Scale documented a score of 9 which placed the resident in the very high risk category for pressure ulcer development. 4/16/14 -SPUW, "Site: Coccyx; Stage 2; Size 1cm x 0.5cm; Comments: Pressure ulcer to coccyx is larger in size over past week since change of treatment from [MEDICATION NAME] dressing to marathon skin protectant. Wound presents as stage 2 pressure ulcer, superficially open with red wound bed. Periwound skin is bright red, but blanchable extending out 3cm from wound edges. No wound drainage, no odor and no s/s of infection. Pt. continues to use airbed, roho w/c cushion, is up for limited time in w/c and is turned side to side predominantly to off load pressure from coccyx. Pt. is totally incontinent of bowel and bladder and requires total assistance with check and change q2hrs and PRN. Wound cleansed with NS, Marathon skin protectant applied to wound bed. [MEDICATION NAME] skin barrier applied to periwound skin. (MD's name) notified of large wound size with change of treatment over past week." 4/16/14 - ITSR, "Skin Progress/Status and Compliance with treatment plan: [REDACTED]. Wound measures larger in size this week since change of treatment from [MEDICATION NAME] dressing to marathon skin protectant... is accepting 2oz 2Cal TID with med passes and accepts TID snacks about half of the time. Pt. is provided with supervision and cues during meal, but will not allow staff to assist her with meals... Current wt. is 104# with no change in 1 week; IDT Recommendations/Comments: New orders were received over past week for 2oz 2Cal TID, to change treatment from [MEDICATION NAME] dressing to Marathon skin protectant. (MD's name) notified of current status of wound with increased wound size since last treatment orders change and request possible change of treatment as MD sees fit. Request also make to (MD's name) for possible [MEDICATION NAME] lab draw. Pt. and (Responsible Party) were notified of wound status and current healing interventions in place. Patient remains at very high risk for poor or delayed wound healing due to advanced age, poor nutrition with inadequate caloric and protein intake to heal wound...dependence with ADL cares, anticoagulant therapy; Care Plan Updated and Revised: Yes." Note: No CP update was documented. 4/21/14 - MD order, "Monitor coccyx Q shift for placement of dressing every shift;" 4/23/14 - SPUW, "Site: Coccyx; Stage 2; Size 3cm x 2.5cm; Comments: Pressure ulcer to coccyx is larger in size and shows increased amount of drainage. Wound is open superficially 2cm x 1.5cm with dark red wound color, moderate serosanginous drainage is present without foul odor. No s/s of infection is evident. Open portion of wound is surrounded by 1cm of nonblanchable dark purple/red coloration that is with intact skin, but is boggy to touch. Total wound size 3cm x 2.5cm including open and nonblanchable portions. Skin surrounding nonblanchable area is pink and intact. (MD's name) has been contacted to clarify treatment orders. Orders for PT to diagnose and recommend treatment orders. Pt. has been OOB (out of bed) for extended periods of time over weekend for celebration parties with family for 102nd birthday. Wound care provided as per MD orders per aseptic technique. Pt. tolerated well without c/o pain." 4/23/14 - ITSR, "Skin Progress/Status and Compliance with treatment plan: [REDACTED]. Pt. is using Genesis III airbed... Skin turgor is very poor and tenting. Skin is extremely fragile and thin due to age. Braden Scale recalculated with score of 9 putting pt. at very high risk for skin breakdown... IDT Recommendations/Comments: New orders received 4/18/14 for [MEDICATION NAME] (results pending) along with PT to diagnose and recommend treatment for [REDACTED]. Request from MD clarification of treatment orders...PT to complete consult for wound [DIAGNOSES REDACTED]. Request from MD 2 scoops protein powder TID mixed in mighty shakes. Request airbed with rotation function. Request from MD unavoidable wt loss & skin breakdown. Pt. has chosen no artificial hydration or nutrition directives per her living will. Pt. is at very high risk for skin breakdown...thinning of subcutaneous tissue, very poor skin turgor, very poor nutritional intake w/ (with) inadequate caloric and protein intake to support wound healing... Care Plan Updated and Revised: Yes." 4/24/14 - MD order (telephone), "Full Airbed with 4 1/2 siderails and siderail pad for skin integrity." Written above the order in pen was, "Air Dyne Air Bed;" "[MEDICATION NAME] dsg (dressing) to coccyx wound. Change Q 3 days and PRN every day shift every 3 day(s) for pressure ulcer;" Note: On 4/16/14 the Physician was notified of the increased wound size after a change in the dressing order, and a new dressing order was requested. On 4/24/14, 8 days after the request had been made, the dressing order was changed back to the [MEDICATION NAME] dressing. It is unclear why it took over a week to receive an order for [REDACTED]. 4/25/14 - CP revision, "Requires pressure relieving/reducing device on bed: Static LAL (low air loss) airbed with four 1/2 side rails with padding chair: roho cushion in w/c (wheelchair) seat;" "Use foley catheter 16 French with 5ml (milliliters) balloon change q month and PRN to help prevent contamination of pressure ulcers;" 4/30/14 - SPUW, "Site: Coccyx; Stage: Unstageable(Slough/Eschar); Size: 4cm x 3cm; Comments: Pressure ulcer to coccyx measures larger size length and width and presents as an unstageable ulcer due to presence of gray slough 90% of wound and black eschar 10% of wound. Portions of slough/eschar are loose, but unable to remove with cleansing. Large amount of purulent drainage present from wound with dressing removed 100% saturated and leaking onto underpad. Wound has foul odor even after cleansing. Periwound skin is bright red and blanchable extending out from wound edge 0.5cm. Slight maceration is present at wound edges. Wound was cleansed with NS, no sting skin barrier was applied to periwound skin and [MEDICATION NAME] dressing was placed over wound. Pt. is using Static LAL airbed was turned and positioned onto left side at time of dressing change. Pt. tolerated dressing change without c/o pain or discomfort." 5/1/14 - ITSR, "Skin Progress/Status and Compliance with treatment plan: [REDACTED]. Wound is malodorous even after cleaning. Presents as an unstageable pressure ulcer...Current wt. is 105# up 1# in 1 week. Pt. has consumed all but one meal over past week less than 25% consumed or refused and has accepted TID snacks only 1/3 of the time. Pt. drinks mighty shakes at meal times and 2 scoops protein powder is added TID and 2 cal 2oz with meals. Pt. is using Static LAL airbed with 1/2 side rails x4... up for short periods of times for meals... foley catheter in place to help prevent contamination of wound bed from urine... IDT Recommendations/Comments: Contact (MD's name) to request wound culture or treatment for [REDACTED]. New orders received from (MD's name) that pt. skin breakdown & wt. loss is expected & unavoidable due to pt.'s advanced age, deterioration of vascular disease & wishes for no aggressive treatment measures including no artificial nutrition or hydration. New orders received from (MD's name) for protein powder 2 scoops TID with meals & airbed, foley catheter to help prevent wound contamination, [MEDICATION NAME] dressing to coccyx change q3days & PRN...Pt. is at risk for worsening, delayed & poor wound healing d/t deterioration of vascular disease... Care Plan Updated and Revised: Yes." 5/1/14 - CP revision, "Wt. (weight) loss and skin breakdown is expected and unavoidable d/t (due to) advanced age, deterioration of vascular disease and family requests for no aggressive treatment as per MD orders;" 5/2/14 - MD order, "Foam dressing to coccyx one time a day every 2 day(s) for Coccyx wound;" 5/6/14 - MD order, "Minnisota Solution wet to dry dressing to coccyx TID (three times per day). pack loosely in wound three times a day for Skin breakdown." 5/7/14 - SPUW, "Site: Coccyx; Stage: Unstageable; Size: 4cm x 4.5 cm; Undermining: 11-2 o'clock; Exudate Type: Purulent; Exudate Amount: Large; Odor: Foul; Wound Bed: Black/Brown (Eschar); Surrounding Skin Color: Bright Red Is resident experiencing pain related to wound: Yes; Non-verbals Demonstrated: Grimacing, Moaning/Crying; Pain Location: coccyx wound; Nature of Pain: "that's tender", only with palpation/touch of wound with assessment; Comments: Coccyx pressure ulcer measures larger in size over past week. Wound was debrided by PT 5/6/14. Wound is unstageable d/t presence of slough and eschar. Wound bed covered 90% with gray loose slough and 10% black eschar. Wound measures at least 1.3cm deep, but unable to measure full depth d/t slough/eschar. Wound edge undermining present 11-2 o'clock measuring 0.5 cm with likely further undermining present with further debridement of wound, intact skin at wound edges 11-2 o'clock is boggy to touch and bright red/purple, extending out 2cm-blanchable. Periwound skin 2cm red blanchable extending out 2cm more dark pink, blanchable. Wound drainage remains purulent, large amount, dressing removed 100% saturated, with foul odor evident. Pt. using oral and topical antibiotic treatment to resolve infection. Dressing changed per aseptic technique per MD orders, periwound skin protected with No Sting. 5/7/14 - CP revision, "Minnesota solution wet to dry dressing to coccyx TID (three times per day), open gauze fully and loosely pack into wound;" "Monitor nutritional status. Serve diet as ordered (trial full liquid, fortified, Mighty shakes TID and offer toast with each meal, 2oz (ounces) 2Cal TID, snacks TID, 2 scoops protein powder TID mixed in pudding or fruit, monitor intake and record;" and, "PT (Physical Therapy) to evaluate and treat for sharp debridement of coccyx wound." Note: The pressure ulcer started as a stage 2 and deteriorated to an unstageable pressure ulcer with an infection. On 5/8/14 at 8:40 a.m., the DON and LN #4 were interviewed regarding Resident #9's pressure ulcer. When asked how the pressure ulcer developed in the first place, LN #4 said it was because of age, skin fragility and vascular disease issues which were mostly in the resident's legs. The LN added the Physician stated that the pressure ulcer was unavoidable. The LN was asked about the resident's nutritional status prior to the development of the pressure ulcer. She stated the resident had poor nutritional status related to eating less than 25% of meals, would push staff away and the resident did not want supplemental nutrition. The LN said the CNA staff did not chart repositioning or toileting. When asked how the LN knows staff are turning and toileting the resident, she said the charge nurses oversee cares everyday with general oversight to ensure cares are being provided. LN #4 was asked what interventions were put into place after the pressure ulcer developed. She said the facility changed support surfaces to an airbed, continued with the roho cushion, dietary changes and continued with repositioning and check and change. The LN added they inserted a foley catheter to prevent infection. When asked what extended periods of time in the wheelchair meant, which was written in the SPUW notes, the LN stated, "Greater than 2 hours at a time." The LN continued that the weekend of 4/20/14 the resident celebrated her 102nd birthday and had multiple parties throughout the weekend with family and friends. LN #4 was asked if during that weekend the nursing staff attempted to provide pressure relief for the resident such as off-loading, laying in bed or toileting. She was also asked if the nursing staff provided any education to the family regarding the importance of pressure relief related to the pressure ulcer. The LN said the nurses were concerned and offered and tried to lay the resident down during down times and educated the family. Documented evidence was requested. When asked why the pressure ulcer deteriorated to an unstageable pressure ulcer and acquired an infection, the LN said it was general condition decline and incontinence of bowel. Note: No documentation from the birthday weekend was provided. On 5/8/14 at 11:00 a.m., LN #4 provided a physician's orders [REDACTED].#9 which included an order for [REDACTED]. After the LN reviewed the clinical record, no further documentation was provided regarding the night the pressure ulcer developed. Resident #9 acquired a stage 2 pressure ulcer to the coccyx; documentation shows the resident was not turned the night prior to the pressure ulcer's development, and no documentation the resident was toileted or checked and changed. The wound declined to an unstageable pressure ulcer after the resident spent extended periods of time in the wheelchair over the course of a weekend; the clinical record did not contain documentation the facility attempted measures to reduce the time spent in the wheelchair, or to offload pressure from her coccyx. In addition, the unstageable pressure ulcer developed an infection; there was no documentation the resident was toileted or checked and changed to prevent fecal contamination of the wound. 2. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses. The most current [DIAGNOSES REDACTED]. Resident #1 annual MDS assessment, dated 3/4/14, coded: *BIMS of 13, indicating the resident was cognitively intact; *No behavioral symptoms; and *Extensive assistance of one for bed mobility; extensive assistance of two for transfers, dressing, personal hygiene, and toileting. On 3/12/14 Resident #1's Care Area Assessment (CAA) for pressure ulcers form documented. "Pressure relief mattress and wheel chair (w/c) cushion in use. (Note: It was unclear what specific mattress or cushion were in place or what the pressure relieving characteristics were). Staff assist resident with toileting and perianal cares to keep skin clean and dry. Daily skin screening during cares and baths. Weekly head to toe skin checks by license nurse (LN). She is at risk for skin breakdown related to dx/meds, decreased mobility, exposure to moisture, and poor cognitive status." Facility documentation regarding the wound included. Skin assessment weekly (SAW), Skin Ulcer Non-Pressure Weekly (SUNPW), Skin Pressure Ulcer (SPU), Weekly Interdisciplinary Team Skin Review Weekly Update (WITSRWU), Pressure Ulcer Prevention Policy, Care Plans (CP), Physician's Telephone Orders (PTOs), facility physician's notification from, Resident Incident form (I/As) Progress Notes (MD PN's), Nurses's Progress Notes (PN's), physician's orders [REDACTED]. The time line of the wound was documented as: On 4/2/14, a Skin Assessment Weekly (SAW) for the resident documented her skin was warm, dry, and fragile with lower extremities discolored. [MEDICAL CONDITION] was noted on her lower extremities. On 4/7/14 at 5:00 PM, an Incident Report (I/A) documented, "Certified Nursing Assistant (CNA) called the LPN in to assess...skin issue to left hip. Area is 6 centimeter (cm) by (x) 5 cm round with 1.5 x 1 cm black/discolored open area to center. No drainage or odor noted, Res denies pain to area. Res lays on left side at night. Issue is located on a bony prominence." The I/A documented the plan for the resident was to have foam [MEDICATION NAME] placed and changed every 3 days and as needed, repositioned every two hours while in bed and in wheel chair (WC), use bath blanket folded to relieve pressure when in WC (Note: "A folded blanket does not provide pressure relief"), covered her toilet screws, nuts, and bolts with sheep skin, and check the resident's left hip more than every two hours. The form further documented, "CNA's said no skin issue was reported to them and they found area while toileting (resident) around dinner time." On 4/8/14, Resident #1's care plan was documented: *Focus-"Has actual skin impairment related to pressure ulcer to left posterior hip. (Patient) is at high risk for poor or delayed wound healing due to poor intake of calories and protein, [MEDICAL CONDITIONS] disease, incontinence, use of diuretic and anticoagulation therapy and increased ADL dependence." *Goal-"To be free of slough and signs/symptoms of infection by next review. *Interventions-"Hydration, wound care, education, daily ulcer observation and documentation, keep wound dry, patient off left hip, monitor labs, encourage good nutrition, toileting or change briefs every 2 hours and as needed, off loading pressure from left hip, use airbed, and roho cushion." (Note: Other facility documentation did not identify wound as a pressure ulcer was not initiated until 4/18/14.) On 4/8/14, a Nurse Progress Notes (PN) documented, "Assessed area to left hip. Area continues with non-blanchable redness to outer area with middle hard black tissue. No c/o pain. No drainage noted. Foam dressing changed. resident repositioned. Fax sent to (physician) for airbed and roho cushion." On 4/8/14, a MD order documented, "Change foam dressing to left hip every three hours and and as needed until resolved. Every 72 hours." On 4/9/14, a MD order documented, "May have air bed and roho cushion for WC..." On 4/10/14, a PVCR documented, "Suspected deep tissue injury to left hip-Foam (dressing) in place for protection (no drainage), denies pain with palpation. Need order for wound nurse/specialist consultation." On 4/10/14 at 5:05 PM, a PN documented, "Patient returned from wound care clinic with verbal report from (employee) physical therapist (PT)...stating to keep pt (patient) off left ischeal when laying, very limited time up sitting each day for meals, keep area dry, no debridement at this time, cover with foam dressing as ordered. Roho wheelchair cushion has been placed to wheelchair seat for additional pressure reduction." On 4/10/14, a MD order documented, "Keep patient off left hip 100% of the time. Every shift for wound to left hip." On 4/11/14, MD order documented, "May X-ray left hip." On 4/11/14 a Skin Ulcer Non-Pressure Weekly (SUNPW) form documented, "Requesting consult with Wound Ostomy Certified Nurse (WOCN) and x-ray of left hip ordered to r/o (rule out) previous hip repair hardware issues. Wound may be reclassified following further follow up with MD, WOCN and x-ray." On 4/11/14, a SUNPW documented, "Wound on left hip with black dry eschar, leathery to touch, portioned skin blanchable, bright red oval shape, and purple discoloration with no drainage. Wound measured at 1.5 cm x 1.5 cm, depth was unable to determine, tunneling unable to determine, and undermining was unable to determine." *The SUNPW narrative documented on 4/11/14, stated, "New wound to left posterior hip presented 4/8/14 with rapid onset. Cause at this time is being fully determined. Wound is 100% covered with black dry eschar, leathery to touch." On 4/11/14 at 12:20 PM, an Interdisciplinary Team Skin Review Weekly Update (ITSRW) documented, "The resident's wound to the left posterior hip. Resident was provided a Panacea AirAdvance airbed and a roho cushion for additional pressure reduction, assisted with turning and reposition every 2 hours and as needed. Resident also assisted with toileting every 3 hours and as needed. Foam dressing to left hip change every 3 days and as needed. X-ray ordered on [DATE] to rule out hardware malfunctions. "As part of the ITSR, the dietician completed a consultation and recommended protein powder twice daily, contact physician and request consult with the WOCN, Multivitamin (MVI) with minerals, and [MEDICATION NAME] lab. ITSR documented, "Patient (Pt) is at risk for poor or delayed wo

Based on observation, record review, and staff interview, it was determined that the facility failed to put effective interventions in place and/or revise care plans to prevent falls. This was true for 1 of 9 (#6) sampled residents and resulted in harm to Resident #6. Resident #6, who was at high risk for falls upon admission, was harmed when she fell forward from her wheelchair and sustained a laceration that required sutures. The facility failed to implement interventions such as increased supervision, increased toileting, or provide meaningful activities. She suffered severe pain related to the laceration. Findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessments dated 9/4/11 and 12/3/11 documented the following: * Severely cognitively impaired * Extensive assistance of two staff for bed mobility, dressing, transfers and personal toileting * Inattention continuously present and disorganized thinking comes and goes The facility's Fall Risk Assessment documented a score of 10 placed a resident at a high risk for falls. Resident #6's assessments documented high risk for falls with a score of 15 on assessments completed on 12/8/11 and 3/8/11. Resident #6 scored 17 on assessments completed on 3/22/11, 6/8/11, 8/20/11 and 16 on 9/14/11. The facility provided 3 Care Plans for falls between 1/2/11 and 12/4/11. The fall Care Plan with approaches dated 3/15/10 had a handwritten statement, "Updated 3/18." The approaches were: Explain to resident to not get up without assistance and the use of a call light Non-skid slippers Toilet routinely and as needed Keep needed items within reach Pressure alarms to bed and wheelchair A star posted by the door to signify resident is a fall risk The bed in lowest position and ambulation path free of clutter Regular exercise, educate resident and family on risk factors and proper use of mobility devices, frequent visual checks by staff. Toilet between 3:30 - 4:30 p.m., scoop mattress, low bed and mats on the floor was dated 3/29/10 Don't leave in room in wheelchair dated 6/11/10 Attempt to keep visual on resident in wheelchair at all times dated 1/2/11. The fall care plan dated 3/15/11 (handwritten statement updated 10/26/11) included the above interventions all with the approach date of 3/15/11. The intervention to toilet between 3:30 - 4:30 p.m. had a line through 3:30 p.m. and discontinued was written with a date of 8/22/11, however, 10:00 a.m. and 2-2:30 p.m. had been added as toileting times. A handwritten note dated 4/7/11 was to toilet the resident at 10:30 - 11:00 p.m., 8/22/11 seatbelt to wheelchair with release during meals, activities and toileting was added. On 9/7/11 the seat belt was discontinued and shoulder straps and wedge cushion were added. The shoulder straps and wedge cushion were discontinued on 9/30/11. Note: There was at least 4 hours between toileting in the care plan on 8/22/11 for toileting at 10:00 a.m. and 2:00 to 2:30 p.m. The fall care plan dated 10/26/11 was the same except the approach date was 10/26/11. The handwritten statement to toilet the resident between 10:30 -11:00 p.m. was not transferred to this care plan (a discontinue date was not on the previous plan). On 10/28/11 the plan was revised to include extended pedals on the resident's wheelchair, on 10/30/11 the care plan was revised for the restorative aide to include standing at the parallel bars (discontinued 12/6/11) and on 11/2/11 a high back reclining wheelchair was added. Resident #6's medical record included Incident Reports documenting the following: 1/2/11 - 10:50 a.m. - A CNA assisted Resident #6 to the dining room and left to assist another resident. The CNA heard an alarm and returned to the day room to find the resident on the dining room floor. The corrective action section documented the resident would be monitored for complications, the physician was called and neurological checks were started. The Comments section of the investigation documented Resident #6 was, "Often in perpetual motion. She has recently been tx'd (treated) for UTI (urinary tract infection).....will continue to provide visual checks and not leave alone in dining room in wheelchair." No injuries were noted. The Care Plan for falls included a revision dated 1/2/11 which documented, "Attempt to keep visual on res (resident) at all times in wheelchair." Note: The revision did not include to not leave the resident alone in the dining room in her wheelchair. 1/30/11 - 11:20 a.m. - The resident was in the recreation center and stood up before staff could reach her. The corrective action section documented to, "Monitor patient closely." The comments section of the investigation documented, "She (Resident #6) goes in cycles of agitation etc. She requires 2 assist to transfer. She was in rec (recreation) room for her RNA (Restorative Nurse Activity).... and stood up before staff could reach her. Will care plan that she is taken in last for program so staff can monitor her more closely." No injuries were noted. Note: The care plan had not been revised to include the resident would be the last person taken in for activities. 4/7/11 - 1:00 a.m. - The LN was sitting at the nurses desk and heard the alarm. The resident was found in her room on the floor with her back to the bed. The corrective action section documented, "Call light in reach bed lowered at all times. Explaining not to attempt to get up without assistance." The comment section documented, "Has a low bed with bolster mattress, alarms to bed and wheelchair - padded mats on floor... participate with RNA exercise program to maintain current level of strength. Will care plan for her to be ambulated or taken to bathroom at beginning of NOC (night shift)." No injuries were noted. Note: The care plan included, "Frequent contact and visual checks by staff." The "Falls Only" section did not document the last time staff had contact with the resident, however, the last time toileted was documented at 8:30 p.m. (4 1/2 hours prior to fall) 6/5/11 - 4:20 p.m. - The resident's pressure alarm was sounding and the resident was found sitting on her wheelchair pedals in the dining room. The corrective action section documented Resident #6 was placed in her wheelchair and moved to the hallway, "In constant sight of staff." The comment section documented the resident had a UTI with increased anxiousness and restlessness and, "Requires frequent supervision... resident will be supervised in day room and Life Enrichment providing meaningful activities at target times of day when she has history of increased restlessness." No injuries were noted. Note: A prior care plan, dated 6/11/10 (previous year) documented the resident was not to be left in her wheelchair unattended, however, the care plan was not revised on 6/5/11 to include the intervention that she was to be supervised in the day room or to provide meaningful activities. Additionally the care plan included, "Frequent contact and visual checks by staff." The Falls Only section documented the last time staff had contact with the resident was almost 1 hour prior to the fall. 8/7/11 - 6:10 a.m. - The resident's alarm sounded. The resident fell from bed and she was on the mat on the floor by her bed. The corrective action section documented neurological checks were initiated and the resident received a pain medication. The comments section documented Resident #6 was, "Known to attempt to self transfer," has a low bed with padded mats on the floor, toileted every 2 hours, and RNA program to maintain strength. "Interventions appropriate and effective." The resident complained her stomach and her head hurt. Note: The care plan was not revised to ensure the resident did not fall from bed. The comments section documented, "Interventions appropriate and effective." The last contact with the resident was when she was toileted at 4:00 a.m. (Over 2 hours before the fall) 8/20/11 - 10:15 a.m. The resident fell forward out of her wheelchair while unsupervised. The description did not state the location of the incident but a CNA interviewed stated she had seen the resident at 10:10 a.m. in her wheelchair in the dining room. All other staff interviewed stated they had not seen the resident since breakfast (approximately 1 1/2 hour earlier). The corrective action stated the resident was assessed for injury and placed in a recliner and the use of a seatbelt would be discussed with the IDT (inner disciplinary team). The comments section documented the resident attempted to stand, there was a pressure alarm on her wheelchair and she was wearing non-skid socks. Also documented in the comments section was, "...she does require 2 person assist to stand and transfer. Have tried different alarms, activity plans toileting plans etc. - but her attempts to stand are random. Occurrence committee and IDT agree with seatbelt recommend (sic)." No injuries were noted. Note: The care plan was revised on 8/22/11 to include the use of a seat belt that was to be released during meals, activities and toileting. The Incident Report documented the resident was unsupervised even though she had fallen on 6/5/11 when unsupervised in the dining room. The Falls section documented the last contact staff had was at breakfast but the last time she was toileted was at 7:45 - 8:00 a.m. (at least 2 1/4 hours earlier) 10/21/11 - 11:30 p.m. - The resident's alarm sounded and she was found on the floor next to her bed. The corrective action section stated to toilet the resident more frequently and, "Reinforced use of call light." The comments section documented the use of a scoop mattress, a low bed and the use of mats by the bed. Also documented the resident was to be toileted between 10:30 - 11:00 p.m. which had not been done. No injuries were noted. The care plan was not followed as the resident had not been toileted between 10:30 - 11:00 p.m. (not toileted since 8:00 p.m. or 3 1/2 hours) The resident was cognitively impaired and had periods of disorganized thinking. 10/22/11 - 11:45 p.m. - The LN was called to the resident's room by the CNA. The resident was laying on her side in front of the wheelchair and there was a laceration to the right side of the forehead which required gauze and pressure to control the bleeding. The corrective action documented the bleeding was controlled, the resident went to the emergency room for sutures and neurological checks would be initiated when the resident returned. The comments section documented the resident had dementia and poor safety awareness and had a tendency to lean forward in her wheelchair. The comments section also documented occupational therapy was to assess for wheelchair and or adaptive equipment to keep the resident upright. The resident was diagnosed with [REDACTED]. The staff interviewed section documented, "I had her parked at the edge of the bed and I was putting the blanket down fixing her bed... when I heard her fall." Another CNA documented she was assisting the resident's roommate and, "Seen (resident #6) jolt forward face first." The Summary of Event section in the report documented, "Resident was taken to the emergency room . A CT was done and it indicated right extr[DIAGNOSES REDACTED]l soft tissue swelling for there frontal region with possible small nondisplaced cortical fracture of the right frontal bone. The laceration was sutured at that time." The Falls section did not document the last time of contact but documented the resident was toileted approximately 1.5 hours earlier. 12/4/11 - 11:15 p.m. -The alarm sounded and the resident was found laying on the floor mats by the bedside. The corrective action documented the resident was assessed and there were no injuries. The comments section documented the resident had a scoop mattress, bilateral floor mats and was toileted prior to going to bed at 8:15 p.m.. the comments section documented, "Anticipate Res (Resident) will get up unassisted...poor safety awareness ....will continue current interventions." The care plan was not revised as the resident was not injured from the fall. Additionally the resident had not been toileted since 8:15 p.m. (3 hours prior to the fall) Resident #6's Care Plan included she was to have, "Frequent contact and visual checks by staff." It was not clear how often the visual checks and contact were to occur, however the resident was not toileted for as long as 4 1/2 hours. The Incident report did not consistently document staff's last contact with the resident. Incident Reports for Resident #6 documented she fell 4 times when she had not been toileted for over 2 hours. Previous falls documented Resident #6 was impulsive and had fallen before staff could reach her (1/30/11) or had been unsupervised (1/2/11 and 8/20/11). Resident #6 suffered harm when she required sutures from the fall on 10/22/11. The Incident Report Investigation documented the resident had a, "Tendency to lean forward in her wheelchair." The investigation report included the resident was reaching for, "That picture," indicating the resident was leaning forward. The CNA did not prevent the resident from falling by placing her hand on the resident to alert her (CNA) when the resident started to move, keep the resident in her line of sight or have a 2nd CNA (who was in the room with roommate) provide supervision. On 12/16/11 at 12:05 p.m. the DON was interviewed and asked to provide the care plan that included the revision to take the resident to activities last (1/30/11). The DON stated the revision was not written in the care plan but was included in the Focus Nursing Progress Note (FNPN) notes. When asked about the revision to attempt target times with activities (6/5/11) the DON stated the revision was not in the Care Plan but in the FNPN. The DON was asked about revisions to the care plan when the resident fell from bed. The DON stated the care plan was effective as the resident had not been injured when she fell from bed and the care plan had not been revised. FNPNs dated 10/22/11 documented Resident #6 required 6 sutures to her forehead when she fell from her wheelchair. Without including planned interventions in the care plan for staff to follow it was unclear how interventions could be assessed for effectiveness. The resident sustained [REDACTED]. Resident #6 had a history of [REDACTED]. On 12/16/11 at 3:00 p.m. the Administrator and DON were informed of the concerns. The Administrator stated the facility reviewed all falls for residents and the resident had been ill when she fell and required sutures.