Every finding on record at Payette Healthcare of Cascadia

Based on observation, CDC recommendation review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and transmission of infection. Findings include:The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, accessed on 9/16/25, documented hand hygiene should be performed:-Immediately before touching a patient.-Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.-Before moving from work on a soiled body site to a clean body site on the same patient.-After touching a patient or patient's surroundings.-After contact with blood, body fluids, or contaminated surfaces.-Immediately after glove removal.The following was observed for hand hygiene and Personal Protective Equipment (PPE):On 9/12/25 at 9:20 AM, observed RN # 3 enter Resident #63's room to administer an injection. RN #3 placed the injection on the bedside table then sanitized his hands and donned gloves. Resident #63 asked to be repositioned in bed prior to the injection and RN #3 then pressed the call light button, then the bed positioning control to adjust bed height. CNA #2 then entered the room, sanitized her hands then reached into her pocket and retrieved a pair of gloves before donning them. RN #3 and CNA #2 then assisted Resident #63 to his requested position. RN #3 then retrieved the injection from the bedside table, cleansed the injection site in Resident #63's abdomen then administered the medication. After removing the needle from Resident #63's abdomen, RN #3 then placed a gloved finger over the injection site and held it there for several seconds. RN #3 then removed his gloves, sanitized his hands and left the room. CNA #2 was observed emptying Resident #63's bedside urinal in the resident's bathroom and placed it back by his bed. She did not rinse the urinal out and a small amount of urine was noted to be in the bottom of the urinal, and an odor of urine was present.On 9/12/25 at 9:40 AM, RN #3 stated, I should have changed gloves after providing patient care and before giving the injection. When asked about pressing his finger against the injection site, RN #3 stated since COVID there hasn't been a lot of quality control training. On 09/12/25 at 11:15 AM, the DON stated, nurses should always perform hand hygiene and change gloves when alternating between patient care to giving an injection. The DON also stated, when giving an injection the nurse should always place a barrier on the table prior to setting items down, perform hand hygiene, don gloves, clean site, administer the injection, and if bleeding occurs, use gauze or a Band-Aid to stop leakage. When asked about rinsing urinals after emptying them, the DON stated, our facility doesn't have a way to rinse urinals in any resident bathrooms, so we don't do it.

Based on observation and staff interview, it was determined the facility failed to ensure medications carts were secured and house stock medications were labeled when opened. This deficient practice created the potential for harm if the medications were left unsecured and if the medications administered were expired. Findings include: 1. On [DATE] at 3:25 PM, the [NAME] Hall Medication Cart was observed to be unlocked and unobserved by the assigned nurse. On [DATE] at 3:30 PM, RN #2 returned to the medication cart and stated, I was in there (pointing to the therapy office) eating a muffin and should not have left my cart unlocked and unattended. On [DATE] at 3:30 PM, the DON stated the medication carts are to always be locked when the nurse is not there with it. 2.) On [DATE] at 9:00 AM, during observation of RN #3's medication pass. A bottle of liquid Prosource (a protein supplement) was observed to be previously opened and had no open by or use by date written on it. On [DATE] at 9:03 AM, RN #3 stated the bottle should have had a date written on it when it was opened, and it did not. On [DATE] at 2:15 PM, the ADON confirmed all house stock medications should be dated when opened to ensure quality.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were free from unnecessary medications. This was true for 2 of 7 residents (#28 and #53) whose medications were reviewed. Resident #28 had duplicate bowel medication orders and Resident #53 had medications at her bedside with no physician's order. This failure created the potential for harm and adverse reactions if Resident #28 and Resident #53 were to receive their medications inappropriately. Findings include: 1. Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by increasing breathlessness). On 9/8/25 at 9:45 AM, Resident #53 was in her room sitting in her recliner and watching the television. The following medications were observed on top of her overbed table: -oxymetazoline hydrochloride nasal spray a (decongestant) -oxymetazoline hydrochloride (Equate) nasal spray -fluticasone propionate (steroid nasal spray) When asked how often she used the nasal sprays, Resident #53 stated it depends on which medication was going to work. Review of Resident #53's physician's order did not include an order for the oxymetazoline hydrochloride or fluticasone propionate. On 9/10/25 at 10:07 AM, the DON reviewed Resident #53's physician's order and stated there was no order for Resident #53 to use either nasal spray. 2. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including a complete intestinal obstruction and had a colostomy (a surgical opening from the intestine through the abdominal wall to bypass the rectum). Resident #28's physician orders documented the following: -bisacodyl rectal suppository 10 MG, insert 1 suppository rectally as needed for constipation, dated 9/1/23 -Dulcolax suppository 10 MG, insert 1 suppository rectally as needed for bowel care, dated 9/1/23 -magnesium hydroxide oral suspension 400 MG/5 ML, give 30 ML by mouth as needed for constipation, dated 9/1/23 -Milk of Magnesia suspension 1200 MG/15 ML, give 30 ML orally as needed for no BM for 2 days, dated 9/1/23 On 9/12/25 at 10:45 AM, the DON stated, Dulcolax was the brand name for bisacodyl, and Milk of Magnesia was the brand name for magnesium hydroxide, Resident #28 had duplicate orders for the same medications in error.

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents' oxygen tubing were changed per physician's orders. This was true for 2 of 3 residents (#41 and #53) reviewed for oxygen therapy. This failure created the potential for harm from respiratory infections due to growth of pathogens (organisms that cause illnesses) in oxygen tubing. Findings include:1. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the lower half of the body) and cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth). Resident #41's September 2025 MAR directed staff to change her oxygen and nebulizer tubing, humidification bottle, clean the filter every week, date and provide bag as indicated. On 9/8/25 at 11:50 AM, Resident #41 was awake in bed. An oxygen concentrator was observed at her bedside with oxygen tubing attached to it and was dated 7/23. On 9/8/25 at 11:14 AM, the DON asked LPN #1 to check the date on Resident #41's oxygen tubing. LPN #1 checked Resident #41's oxygen tubing and stated it was dated 7/23. The DON stated the oxygen tubing should be changed weekly. 2. Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by increasing breathlessness). A physician's order dated 8/22/24, documented Resident #53 was to receive oxygen at 2 liters per minute via nasal cannula intermittently for shortness of breath. Resident #53's September 2025 MAR directed staff to change her oxygen and nebulizer tubing, humidification bottle, clean the filter every week, date and provide bag as indicated. On 9/8/25 at 10:08 AM, Resident #53 was observed receiving oxygen at 2 liters per minute via nasal cannula. Resident #53's oxygen tubing was dated 8/20. On 9/8/25 at 11:11 AM, the DON checked Resident #53's oxygen tubing and stated it was 8/20. The DON stated the oxygen tubing should be changed weekly.

Based on record review and staff interview, it was determined the facility failed to ensure services provided met professional standards. This was true for 1 of 13 residents (Resident #2) whose records were reviewed. This failure placed Resident #2 at risk for harm from obstruction or over medication when her bowel medication administration was not documented in the medication administration record (MAR). Findings include: The American Nurses Association Principles for Nursing Documentation, dated 2010, accessed on 9/17/25, documented Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. It includes Documentation entries must be: Accurate, valid, and complete; Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; Dated and time-stamped by the persons who created the entry; Legible/readable; and Made using standardized terminology, including acronyms and symbols. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including atrial fibrillation (irregular heartbeat preventing the heart from pumping efficiently), heart failure, and diabetes. Resident #2's medical record documented the following physician orders dated 5/5/25:-Milk of Magnesia 1200 MG/ 15 ML, give 30 ML orally as needed for no BM in 72 hours. Give 1 dose, if no results within 24 hours, see Dulcolax suppository order. -Dulcolax suppository 10 MG, insert 1 suppository rectally as needed for bowel care if no results from MOM [Milk of Magnesia]. If no results in 24 hours, see Fleet enema order. -Fleet enema 7-19 GM/ 118 ML, insert 1 unit rectally as needed for bowel care if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results. On 9/12/25 at 10:40 AM, Resident #2's medical record documented she had no BM on the following dates:-8/18, 8/19, 8/20 -8/23, 8/24, 8/25-8/28, 8/29, 8/30-9/1, 9/2, 9/3, 9/4, 9/5 Resident #2's MAR for August and September 2025 documented she received her Milk of Magnesia order on 8/25/25. Resident #2's MAR for August and September 2025 did not include documentation her bowel care medications were administered on 8/20, 8/30, 9/3, 9/4, or 9/5. On 9/12/25 at 11:38 AM, the DON provided handwritten documentation the nurses use to monitor who may need as needed bowel medications. The handwritten records document Resident #2 received MOM on 8/20, 8/30, 9/3, and 9/5, and she refused a suppository on 9/4. On 9/12/25 at 12:48 PM, the DON stated, she could not explain why the nurses who administered the bowel medications did not document the administration or refusal of doses in the MAR.

Based on record review and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 1 of 13 residents (Resident #9) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident needs changed. Findings include:The CMS SOM, Appendix PP, dated 4/25/25, documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including, sepsis (a life-threatening, extreme response to an infection that causes the immune system to damage the body's own organs and tissues), diabetes, and was dependent on hemodialysis (a treatment using a machine to replicate kidney function, removing waste from the bloodstream) for end stage renal (kidney) disease. Resident #9's medical record documented a physician order, dated 8/1/25, for a fluid restriction of 1800 ML of fluids per day. Resident #9's care plan documented the following: -Initiated 7/16/25, for bowel care, encourage fluids-Initiated 8/5/25, for bladder care, encourage fluids-Initiated 8/5/25, for nutrition care, encourage fluids Resident #9's care plan did not include the physician order for a fluid restriction. On 9/10/25 at 3:27 PM, the DON stated, Resident #9's care plan was not accurate and should have been updated when the fluid restriction was ordered on 8/1/25.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview it was determined the facility failed to ensure residents' Minimum Data Set (MDS) assessments reflected the residents' status. This was true for 2 of 13 residents (#2 and #27) whose MDS assessments were reviewed for accuracy. This deficient practice created the potential for negative outcomes if residents' were not assessed and/or monitored due to inaccurate assessments. Findings include:1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (irregular heartbeat preventing the heart from pumping efficiently), heart failure, and diabetes. Resident #2's Admissions MDS Assessment (a standardized assessment tool that measures health status in nursing home residents) dated 5/11/25, documented at section M0300 Current Number of Unhealed Pressure Ulcer/Injuries at Each Stage, at item F1, F2, G1, and G2, Resident #2 had two unstageable pressure injuries (the full depth of the damage is hidden by a covering of dead tissue) and they were present when she admitted to the facility. Resident #2's Quarterly MDS Assessment, dated 8/11/25, documented at section M0300, items F1, F2, G1, and G2, Resident #2 had two unstageable pressure injuries and those injuries had not been present when she admitted to the facility. On 9/11/25 at 1:27 PM, the MDS Coordinator stated, when he completed Resident #2's Quarterly MDS Assessment on 8/11/25 he marked zero present on admission in error at F2 and G2 regarding her pressure injuries. He added, Resident #2's pressure injuries were not facility acquired. 2. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including post-traumatic stress disorder (PTSD), depression, anxiety and agoraphobia (an intense anxiety that involves fearing and avoiding places of situation that might cause panic and feeling being trapped, helpless or embarrassed). A PASRR Level 1 dated 2/11/25, documented Resident #27 had bipolar disorder, PTSD, anxiety and depression. In addition, the PASRR Level 1 also documented Resident #27 had diagnoses of agoraphobia, claustrophobia (intense fear of confined spaces that interferes with daily life), bulimia (an eating disorder, characterized by eating a large amount of food in a short amount of time), panic disorder and ADD (Attention Deficit Disorder). Resident #27's PASRR Level II dated 2/12/25, documented Resident #27 had Multiple mental health diagnoses. Sent to MHA (Mental Health Association) to review prior SNF (Skilled Nursing Facility) admission. Resident #27's admission MDS assessment, dated 2/24/25, documented in A1500 Preadmission Screening and Resident Review documented No for the question Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? On 9/11/25 at 10:08 AM, the MDS Coordinator reviewed Resident #27's MDS and stated the A1500 question should have been answered Yes.

Based on record review and staff interview, it was determined the facility failed to provide hospital transfer documents for 3 of 5 residents (#3, #5, and #59) whose records were reviewed for hospitalization. This deficient practice created the potential for the residents to experience harm if the residents were not treated in a timely manner due to lack of information. Findings include:The CMS State Operations Manual, revised 4/25/25, documented when a facility transfers or discharges a resident under any circumstances, the facility must ensure that the transfers or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cancer of pyriform sinus (part of the larynx), heart failure and pneumonia.A Nursing Note dated 5/31/25 at 2:24 PM, documented a nurse received a report Resident #3 was feeling sick, nauseated and wanted to go to the hospital. The provider was notified and Resident #3 was transferred to the hospital.There was no documentation in Resident #3's record the hospital was provided of his current medical information when he was transferred to ensure a safe and effective transition of care. 2. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including end stage renal disease and diabetes. A Nursing Note dated 4/26/25 at 3:08 PM documented Resident #5 complained of belly pain, fever and was shaking. The provider and DON were notified, and Resident #5 was transferred to the hospital. There was no documentation in Resident #5's record the hospital was provided his current medical record when he was transferred to the hospital to ensure a safe and effective transition of care. 3. Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including apraxia (an inability to perform purposeful movements or gestures) and aphasia (a communication disorder that makes it hard to use words) following a stroke. A Nursing Note dated 11/4/24 at 12:12 PM, documented Resident #59 was sent to the hospital for further evaluation of his elevated laboratory results. There was no documentation in Resident #59's record the hospital was provided his current medical record when he was transferred to the hospital to ensure a safe and effective transition of care. On 9/12/25 at 1:06 PM, the DON reviewed Resident #3, Resident #5, and Resident #59's records and stated she was unable to find documentation their medical information was sent with them when they were transferred to the hospital.

Based on staff interview, record review, and review of the State Long Term Care Reporting System, it was determined the facility failed to ensure residents were free from abuse. This was true for 1 of 3 residents (Resident #24) reviewed for abuse, neglect, misappropriation of resident property and exploitation. The facility failed to protect Resident #24 when she experienced abuse from CNA #1 during a shower and created the potential for all residents in the facility to experience abuse. Findings include:The facility's Abuse Policy, revised 3/2024, documented the facility would prevent all types of abuse, neglect, misappropriation of residents' property and exploitation. The CMS SOM, Appendix PP, dated 4/25/25, defined:- Abuse, as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.- Willful, in the definition of abuse as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Resident #24 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including diabetes, atrial fibrillation (an irregular heart rate), morbid obesity, and muscle weakness.Resident #24's Quarterly MDS Assessment, dated 4/23/25, documented this resident required total assistance to shower. On 9/9/25 at 9:59 AM, Resident #24 stated she believed CNA #1 had a look like I'm going to do something to you then sprayed her in the face with the shower hose. She also stated CNA #1 was never nice to anybody and she had informed the facility that she didn't want this person working with her anymore. A Facility Reported Incident, dated 5/6/25, included an investigation summary which documented on 4/29/25, CNA # 1 did spray water into [Resident #24's] face intentionally and didn't stop when asked to stop.The investigative summary documented, as a result of a verified finding of abuse, such as physical, sexual or mental abuse, identify counseling or other interventions planned and implemented to assist the resident: [Resident #24] accepted counseling and is being seen.The facility's investigation substantiated abuse when CNA #1 intentionally sprayed Resident #25 in the face with water and did not stop when asked to.On 9/12/25 at 11:48 AM, the Administrator stated, this was not an incident of abuse, it was an incident of poor customer service, and the CNA was terminated for that. These findings represent past non-compliance with this regulatory requirement. The facility did the following:-Resident #24 was her own representative-Resident #24 was provided counseling-CNA #1's employment was terminated-All staff were given an in-service training on abuse and customer service. Training completed on 5/2/25.There was sufficient evidence the facility corrected the non-compliance as of 5/2/25 as there was no further resident abuse after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on observations, staff interview and record review, it was determined the facility failed to ensure physician's orders were clarified for bowel medications and respiratory treatment. This was true for 2 of 13 residents (#8 and #28) whose records were reviewed for quality of care. This deficient practice had the potential for adverse effects and harm for residents whose care and services were not delivered according to accepted standards of practice. Findings include:1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including a complete intestinal obstruction and had a colostomy (a surgical opening from the intestine through the abdominal wall to bypass the rectum). A. Resident #28's physician orders documented the following:-bisacodyl rectal suppository 10 MG, insert 1 suppository rectally as needed for constipation, dated 9/1/23-Dulcolax suppository 10 MG, insert 1 suppository rectally as needed for bowel care, dated 9/1/23-Fleet enema 7-19 GM/118 ML, insert 1 unit rectally as needed for bowel care, dated 9/1/23 On 9/12/25 at 10:48 AM, the DON stated, Resident #28 had a colostomy and should not have any medications administered rectally. She added, the route of administration on the orders were wrong and should have been corrected. B. Resident #28's physician orders documented the following:-magnesium hydroxide oral suspension 400 MG/5 ML, give 30 ML by mouth as needed for constipation, dated 9/1/23-Milk of Magnesia suspension 1200 MG/15 ML, give 30 ML orally as needed for no BM for 2 days, dated 9/1/23-Miralax powder 17 GM, give 17 GM by mouth as needed for bowel care in PM, give after 48-72 hours of no BM, mix with at least 4 oz fluid of choice, dated 6/5/25 On 9/12/25 at 10:50 AM, the Clinical Resource Nurse stated, Resident #28's as needed bowel medication orders were not clear and the orders should have been clarified to minimize risk for error. 2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including end of life care, chronic obstructive pulmonary disease (COPD- a progressive lung disease characterized by increased breathlessness), and diabetes.Resident #8's physician orders dated 3/31/25, documented, oxygen at 4 LPM (liters per minute) continually per nasal cannula via oxygen concentrator for chronic respiratory disease.Resident #8's Hospice Plan of Care dated 7/31/25, documented Oxygen at 4 LPM PRN (as needed) Resident #8's TAR (Treatment Administration Record) for September 2025 documented an order for oxygen 4 LPM continuously per nasal cannula via oxygen concentrator or tank every shift for chronic respiratory failure. On 9/8/25 at 11:56 AM, Resident #8 was observed in his room, there was no oxygen concentrator or equipment observed in his room. Resident #8 stated he refuses to wear his oxygen if his oxygen saturation is above 90% because the machine is too loud. On 9/11/25 at 2:00 PM, the DON stated resident #8's orders should have been updated to reflect his current order for oxygen as needed per the Hospice Plan of Care, and they were not.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, homelike environment. This was true for 1 of 4 residents (Resident #36) who were observed in power wheelchairs, and for all 44 residents who resided in the facility whose overall environment was observed. This deficient practice created the potential for harm if: a) residents were injured when the privacy curtains in the resident's rooms prevented the resident from moving around in their room safely and the holes in the floors caused a resident to fall, b) residents were embarrassed by dirty equipment and/or felt the lack of cleanliness in the facility was unacceptable, disrespectful, or undignified, and c) cross-contamination from spread of microorganisms. Findings include: The facility's General Environmental Condition policy, revised 9/1/18, documented a safe, functional, sanitary, and comfortable environment is provided for residents, staff, and the public. 1. Resident #36 was admitted to the facility 12/29/23, with multiple diagnoses including incomplete quadriplegia (characterized by weakness or paralysis of all four limbs), diabetes with diabetic polyneuropathy (affects multiple peripheral sensory and motor nerves that branch out form the spinal cord into the arms, hands, legs, and feet), and muscle weakness. On 8/4/24 at 2:08 PM, Resident #36 stated he had difficulty maneuvering his power wheelchair in his room due to the 2 ceiling curtains which often tangled up in the wheelchair when going between the 2 beds and going to the bathroom. At the time of this visit, Resident #36 was the only resident assigned to this room. He stated staff did not let him put the curtain material on the extra bed because that bed may be assigned to another resident at some point. 2. Resident #33 was admitted to the facility 3/24/23, with multiple diagnoses including diabetes, Crohn's disease (a chronic inflammatory bowel disease that affect the lining of the digestive tract), and depression. On 8/5/24 at 8:30 AM, Resident #33 stated the fan in his bathroom was not working. Additionally, he said he had reported this over several months, to a CNA, housekeeping staff, and the floor nurse but the fan had not been repaired. On 8/6/24 at 9:49 AM, the MS stated all staff who have access to PCC TELS (maintenance managment system) can report maintenance related issues. The PCC TELS system sends a note right to the MS for quick notice. The MS explained that staff who do not have PCC access can submit maintenance relate issues via a notebook located in the facility copier room. When reviewed, the last entry in the maintenance request notebook was 3/2023. A review of the PCC TELS system maintenance log for the last 3 months did not identify any maintenance requests for Resident #33's non-function bathroom fan. 3. The following common residential environment area were observed as unsafe and unsanitary: a. On 8/4/24 at 12:15 PM, a 5 inch long by 2 inch wide, and 1/2 deep hole in dining room floor tile with lifted edges creating a potential fall or trip hazard was observed. On 8/6/24 at 9:44 AM, the DON stated she did not remember seeing the hole in the dining room tile. On 8/6/24 at 9:46 AM, the MS stated he did not remember seeing the hole in the dining room tile but agreed it is a potential trip hazard and should have been repaired. b. On 8/7/24 at 10:00 AM, the west side shower room was observed with: - at the entrance of the shower room an area approximately 6-inch x 5-inch with missing floor tiles was observed. - in front of the cupboards on the shower room wall, the floor tile had a crack, approximately 12-inch long. - the right side of the floor was observed with a floor tile that was cracked and dipped inward, approximately 14-inch x 2-inch x 1/4-inch deep. - to the left side of the entrance into shower area, observed a screw hanging loose from the base board. On 8/7/24 at 10:05 AM, the west side shower room was observed with: - the air vent had a layer of dust on it. - the top left side of the window had large, thick, white cobweb. c. On 8/7/24 at 12:14 PM, observed west hall flooring was missing between: - room [ROOM NUMBER] and room [ROOM NUMBER], approximate size, 11-inch x 1-inch. - room [ROOM NUMBER] and 117, approximate size, 2-inch x 4-inch triangular shape. On 8/7/24 at 4:14 PM, the Maintenance Supervisor (MS), stated the floor in the west side shower room was a fall hazard and the facility had gotten a bid on the repair but, the bid was not approved to have it replaced. d. On 8/7/24 at 10:14 AM, the east side shower room was observed with: - the air vent had a layer of dust on it. - a shower chair had a large pink substance on the seat. CNA #4 attempted to clean the pink substance off the shower chair, but was unable to remove it. On 8/7/24 at 10:20 AM, CNA #4 stated she was not sure who cleans the air vents, but maintenance probably will clean the vents. She also stated she was not sure what the pink substance was on the shower chair seat. On 8/7/24 at 4:14 PM, the MS stated housekeeping should clean the shower rooms everyday by wiping things down and dusting the vents. On 8/8/24 at 10:16 AM, housekeeper #1 stated the shower rooms should be cleaned daily. She also stated, cleaning of the shower room consists of sanitizing the room, sweep and mop the floor, and cleaning the shower walls. 51121

Based on observation and staff interviews, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment, when staff did not follow hand hygiene protocols, properly clean Hoyer lift equipment, and follow proper protocol during tube feeding. These failures had the potential to impact 4 of 4 residents (Residents #8, #15, #16, and #21) for hand hygiene, Hoyer lift use for transfers, and 1 of 1 resident (Resident #156) during G-tube feeding, placing them all at risk for cross-contamination and infection. Findings include: The CDC Long-term Care Facilities Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions (EBP) in Nursing Homes, dated 6/28/24, documented indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. 1. The following were observed for hand hygiene: On 8/4/24 at 11:51 AM, the surveyor observed in the dining room CNA #4 picked up dirty washcloths without gloves. Then without performing hand hygiene, CNA #4 washed Resident #2's hands and face. On 8/8/24 at 9:26 AM, during a interview, CNA #4 stated she should not have placed the dirty washcloths on the residents dining table and she should have washed her hands prior to helping Resident #2 wash her hands and face before the lunch meal. On 8/4/24 at 12:29 PM, the surveyor observed food trays being delivered and set up on over-bed tables in resident rooms. CNA #1 and CNA #2 had not offered to help residents wash hands before eating. One 8/4/24 at 12:32 PM, CNA #1 stated she thought the CNAs working the floor provide oral care and offered residents, eating in their rooms, hand hygiene before their meal arrives. On 8/4/24 at 12:38 PM, RN #1 stated the residents that choose to eat in their rooms are able to wash their own hands. On 8/6/24 at 10:27 AM, the DON stated staff are to encourage residents to wash their hands prior to meals in their rooms. 2. The following was observed for clean equipment: On 8/4/24 at 2:35 PM, observed CNA #7 replace Hoyer lift back in storage room without cleaning after resident transfer. CNA #7 stated she had just completed a resident transfer with the Hoyer lift. On 8/6/24 at 9:43 AM, the DON stated if the Hoyer lift was not cleaned after use, that was wrong. 49552 3. The following were observed for G-tube feeding: Resident #156 was admitted to the facility on [DATE], with multiple diagnoses including stroke and dysphagia (difficulty swallowing). A physician's order, dated 7/8/24, documented Resident #156 was to be placed on enhanced barrier precautions for PEG tube. Gown and gloves required for high-contact patient care (dressing, bathing, transferring, incontinence or toileting care, dressing, changing, linens, or device or wound care). On 8/7/24 at 10:30 AM, observed Resident #156's door to his room, with signage directing staff to wear gloves and a gown for the following high-contact resident care activities: -Dressing -Bathing/showering -Transferring -Changing linens -Providing Hygiene -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, tracheostomy -Wound Care: any skin opening requiring a dressing. On 8/7/24 at 12:00 PM, observed RN #2 administer Resident #156's G-tube feeding without donning PPE. On 8/7/24 at 12:19 PM, RN #2 stated he should have donned PPE to give Resident #156 his feeding.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #156) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice. Finding include: The facility's Enteral Feeding: Gravity/Bolus policy, revised 3/10/21, directed staff to label and date opened containers of formula and refrigerate as soon as possible. Resident #156 was admitted to the facility on [DATE], with multiple diagnoses including stroke and dysphagia (difficulty swallowing). A physician's order, dated 8/1/24, documented Resident #156 was to receive Jevity 1.5 (a type of feeding formula that provides complete, balanced nutrition) or equivalent 240 ml via pump or syringe per PEG (Percutaneous endoscopic gastrostomy) tube every 4 hours. On 8/5/24 at 9:13 AM, an opened bottle of Ready-To-Hang Jevity 1.5 was observed in Resident #156's room on his bedside table. The bottle was labeled, opened 8/5/24 at 2330, 60ml/hour. On 8/7/24 at 12:00 PM, RN #2 was observed administering Ready-To-Hang Jevity 1.5 to Resident #156. RN #2 did not label the opened bottle of Ready-To-Hang Jevity 1.5. The opened bottle of Ready-To-Hang Jevity 1.5 was left on Resident #156's bedside table. On 8/7/24 at 12:19 PM, RN #2 stated, the Ready-To-Hang Jevity 1.5 bottle is used in a day, so it stays at the bedside until used. On 8/8/24 at 9:21 AM, the Clinical Resource Nurse stated the Ready-To-Hang Jevity 1.5 should have been refrigerated after it was opened.

Based on staff interview and review of annual competency evaluations, it was determined the facility failed to ensure each CNA's performance was evaluated at least once every 12 months and annual evaluations were performed. This was true for 1 of 5 CNAs (CNA #3) whose personnel records were reviewed. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for 44 of 44 residents living in the facility. Findings include: Annual performance evaluations were requested for 5 CNAs. On 8/7/24 at 2:22 PM, review of CNA #3's employee file documented her hire date as 5/1/20. CNA #3's employee file did not have an annual evaluation for 2022 or 2023. On 8/8/24 at 10:22 AM, the DON stated the CNA's evaluations should be done annually. She also stated CNA #3's evaluation had not been done; she had missed some of the employees annual evaluations.

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #14) received continuous oxygen via nasal cannula prescribed by the physician. This created the potential for Resident #14 to experience respiratory difficulties/impaired breathing. Findings include: Resident #14 was admitted to the facility 7/17/19, with multiple diagnoses including stroke, dysphagia (difficulty swallowing), and dependence on supplemental oxygen. Resident #14's oxygen was ordered at 2 liters per minute, via nasal cannula continuously. On 8/4/24 at 12:03 PM, CNA #2 removed Resident #14 from the portable liquid oxygen and stated she was going to top off the unit with liquid oxygen. Resident #14 was without her oxygen for over 4 minutes. Upon return CNA #2 reconnected Resident #14 nasal cannula to the portable liquid oxygen unit. On 8/7/24 at 12:15 PM, CNA #2 stated she should not have removed Resident #14 from her oxygen without first providing a backup oxygen source.

Based on record review and staff interview, it was determined the facility failed to ensure residents were provided with the pneumococcal vaccine when residents requested it. This was observed in 1 of 5 resident medical records reviewed (Resident #41). This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: Resident #41 was admitted to the facility 6/19/24, with multiple diagnoses including metabolic encephalopathy (a disturbance of brain function), chronic fatigue, and repeated falls. A review of Resident #41's medical chart showed on admission, Resident #41 requested a pneumonia vaccine. A review of Resident #41's record had no documentation the vaccine had been given. On 8/6/23 at 3:20 PM, the DON stated the pneumonia vaccine had not been given to Resident #41, and there was no documentation in her chart explaining why the vaccine had not been given.

Based on observation, interviews, and facility policy review, it was determined the facility failed to ensure wound care products and resident prescribed wound care cream were secured in a locked treatment care. This was observed in 1 of 2 treatment carts. This failure created the potential for residents to obtain prescribed wound care cream used for other residents and presented the risk for cross-contamination of wound care products stored in the cart. Findings include: The facility's Medication Management policy, revised 10/15/22, stated in part Medications and biologicals are stored appropriately according to manufacturer's guidelines and to prevent unauthorized access. Unlocked medication/treatment carts are under nurse control at all times. On 8/4/24 at 11:03 AM, west hall wound care treatment cart was observed to be unlocked when the nurse was not present. On 8/4/24 at 11:13 AM, LPN #1 stated she thought the cart needed to be closed and locked when she was not near it. On 8/8/24 at 10:10 AM, the DON stated treatment carts should be locked when a nurse is not present.

Based on policy review, observation, record review, and interviews, it was determined the facility failed to ensure a resident was initially assessed to determine if they were safe to self-administer medications for 1 of 2 residents (Resident #36). This failure created the potential for adverse effects if Resident #36 self-administered medications inappropriately. Findings include: The facility's Self-Administration of Medications policy, dated 11/28/17, stated in part 2. The interdisciplinary team determines that it is safe for the resident to self-administer drugs before the resident is allowed to do so, and the decision is periodically reviewed according to the resident's status. 2a. Qualify nursing staff administers drugs until the determination is made. Resident #36 was admitted to the facility 12/29/23, with multiple diagnoses including incomplete quadriplegia (characterized by weakness or paralysis of all four limbs), diabetes with diabetic polyneuropathy (affects multiple peripheral sensory and motor nerves that branch out form the spinal cord into the arms, hands, legs, and feet), and gastro-esophageal reflux. On 8/4/24 at 2:12 PM, Resident #36 stated he was given calcium carbonate oral chewable tablets at bedside to use when he thought he needed them. He stated his nurse had given him 6 tablets and he already had taken two and still had 4 additional tablets in his dresser drawer. No self-administration medication assessment was documented in his medical records. An email from the DON on 8/7/24 at 2:52 PM, documented the self-administration medication assessment was not completed for Resident #36. During a follow-up interview with the DON on 8/7/24 at 4 PM, she confirmed the self-administration medication assessment had not been completed for Resident #36.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 4 of 10 residents (#5, #6, #7, and #10) observed for infection control prevention practices. These failures created the potential of exposing residents to the risk of infection and cross contamination including COVID-19. Findings include: 1. The facility's Screening and Management of Coronavirus COVID-19 policy and procedure, dated 5/19/20, directed staff to place their newly admitted residents in quarantine precautions and to place a sign outside of the rooms indicating they were under quarantine. According to the U.S. Department of Health and Human Services, website accessed 6/23/20, quarantine is defined as separation and restriction of movement of people who may have been exposed to a contagious disease to see if they become sick. A facility in-service Transmission Based Precautions, dated 6/10/20, directed staff to post the appropriate precaution signage outside the resident's room and to place and maintain an adequate supply of appropriate PPE at the door. On 6/16/20 at 8:30 AM, during the initial tour of the facility's quarantine unit, PPE carts were observed outside the rooms of Residents #5, #6, #7, and #10. There were no signs posted outside their rooms. On 6/16/20 at 8:45 AM, NA #1 entered Resident #10's room. NA #1 wore a mask but did not don a gown or gloves when she entered Resident #10's room. On 6/16/20 at 10:38 AM, RN #1 said resident rooms in the quarantine unit with a PPE cart outside their doors were newly admitted residents whose COVID-19 test results were still pending. RN #1 said staff should wear a facial mask, gown, and gloves when they enter residents' rooms with PPE carts outside their doors. On 6/16/20 at 12:05 PM, UM #1 together with the ICP, said resident rooms in the quarantine unit with a PPE cart outside their doors were newly admitted residents whose COVID-19 test results were still pending, residents on [MEDICAL TREATMENT], or residents who had frequent medical appointments such as wound clinic visits. UM #1 said there should be a sign which stated STOP please see the nurse outside the residents' doors in the quarantine unit. UM #1 said staff entering resident rooms with a PPE cart outside their door should wear a facial mask, gown, and gloves before entering these rooms. When asked why there were no signs posted outside of the resident rooms in the quarantine unit, UM #1 said the facility had a recent change of management and all of the signs had the name of their former corporation. On 6/16/20 at 12:45 PM, NA #1 said she knew she had to wear a gown before entering Resident #10's room but there were no gowns in the PPE cart. NA #1 said she just wanted her job done and she made a poor choice. 2. The Centers for Disease Control and Prevention's website, accessed on 6/17/20, stated hand hygiene should be performed before donning PPE. On 6/16/20 at 1:45 PM, NA #1 walked toward Resident #6's room and opened the PPE cart, then took a gown out and put it on over her clothes. NA #1 then put on a pair of gloves and entered Resident #6's room. NA #1 did not perform hand hygiene before donning her PPE. On 6/16/20 at 2:00 PM, NA #1 said she did not perform hand hygiene before donning her PPE when she entered Resident #6's room because there was no hand sanitizer of top of the PPE cart. 3. A facility in-service Transmission Based Precautions, dated 6/10/20, documented isolation and quarantine interventions were to be communicated to staff through clinical alerts, communication boards, signage, and stand-up meetings. On 6/16/20 at 12:55 PM, CNA #1 stepped out of Resident #6's room carrying a food tray and placed it inside the food cart. CNA #1 was not wearing a gown when she stepped out of Resident #6's room. NA #1 was heard saying to CNA #1 I am confused now, are we supposed to wear gowns when we enter residents' rooms with a PPE cart outside their rooms? CNA #1 said she was told she did not need to wear a gown to enter residents' rooms if she was only collecting food trays. On 6/16/20 at 1:05 PM, the ICP said she was appointed as Infection Control Nurse four days ago and had recently started training the staff regarding hand hygiene and infection control and prevention practices.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents and/or their representative received written notification regarding transfer to the hospital, and the state ombudsman was notified of the transfer. This was true for 2 of 3 residents (#31 and #33) reviewed for transfer/discharge. This failure created the potential for harm if residents were unable to exercise their rights related to transfers due to lack of notification. Findings include: The facility's policy for Discharge and Transfer, revised 2/1/19, documented the following: * The facility must immediately inform the resident/representative when there is a decision to transfer or discharge the resident. * The resident and their representative must be notified in writing and in a language and manner they understand. * For unplanned, acute transfers when it was expected for the resident to return to the facility, the resident and/or their representative were notified verbally followed by written notification using the Notice of Hospital Transfer or state specific form. * A copy of the notices for emergency transfer must be sent to the ombudsman, and may be sent when practicable, such as a list sent on a monthly basis or per the state's requirements. The policy was not followed. 1. Resident #31 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #31's discharge MDS assessment, dated 8/1/19, documented he had an unplanned discharge to the hospital, and he had problems with short term memory. A Change in Condition Evaluation, dated 8/1/19 at 9:02 PM, documented Resident #31 was found on the floor in his room, and he stated he rolled over in bed and fell to the floor. Resident #31 complained of back pain rated as 8 or 9 (on a scale from zero to 10), and an order was received to send him to the emergency room for evaluation. A voice message was left for both of his daughters. Resident #31's record did not contain documentation that written notification was provided to him and/or his representative, or the state ombudsman was notified when he was transferred to the hospital on [DATE]. On 9/5/19 at 12:47 PM, the Administrator said the facility just recently started sending notices to the local ombudsman regarding transfers because they did not know whom to contact. The Administrator said there would probably not be much documentation that notification was provided to the ombudsman regarding resident transfers. On 9/6/19 at 8:39, the MSW said the facility had not been notifying the local ombudsman or providing written notification to the resident and/or their representative when they were transferred out of the facility. On 9/6/19 at 9:58 AM, RN #2 said she assisted in completing the transfer form when a resident was transferred to the hospital, and she thought it was the facility's policy to provide the resident and/or their representative with written information regarding the transfer at the time of the transfer. 2. Resident #33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A hospital History and Physical, dated 6/6/19, documented Resident #33 was transported to the emergency roiagnom on [DATE] after a fall from a transport van resulting in a superficial [MEDICAL CONDITION]. Resident #33's record did not contain documentation that he, his representative and the state ombudsman were provided written notice of transfer to the hospital. On 9/6/19 at 8:15 AM, the MSW stated the facility had not been providing written notifications of transfers to the residents, their representatives or the ombudsman.

Based on record review, staff and resident interview, review of the facility's hyperglycemic policy procedure, and review of diabetic menus, it was determined the health and safety of two of six residents sampled for management of diabetes mellitus (#s 4 and 11) were in Immediate Jeopardy and at risk for serious harm, impairment, or death when the facility: *Failed to follow its policy and procedures related to physician notification of blood sugars in excess of 300 mg/dl (milligrams per decaliter); *Failed to clarify physician-ordered hyperglycemic parameters and ensure those parameters were consistent with recognized professional standards of practice; *Failed to provide appropriate diabetic meals; *Failed to provide risks and benefits education related to non-compliance with dietary restrictions; and *Failed to assess residents for signs and symptoms of acute [MEDICAL CONDITION], such as diabetic ketoacidosis (DKA). The American Diabetes Association (ADA), in an article entitled [MEDICAL CONDITION], (last edited 9/16/14), defined [MEDICAL CONDITION] as .high blood glucose (blood sugar that) . happens when the body has too little insulin or when the body can't use insulin properly . [MEDICAL CONDITION] can be a serious problem .fail(ure) to treat [MEDICAL CONDITION], (may result in) a condition called ketoacidosis . Ketoacidosis is life-threatening and needs immediate treatment . ADA Standards of Medical Care in Diabetes (2015), documented, Patients with poorly controlled diabetes may be subject to acute complications .including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma. The ADA identified the following treatment goals for glycemia in older adults with intermediate remaining life expectancy and three or more chronic illnesses. *Hemoglobin A1C goal of less than 8.0%; *Fasting (no caloric intake for 8 hours) or preprandial (before meals) blood sugar goal of 90-150 mg/dl; and *Bed time glucose goal of 100-180 mg/dl. On 10/9/15 at 3:30 p.m., the Administrator, DNS, and the Regional Nurse Consultant were notified verbally and in writing of the Immediate Jeopardy involving the facility's failure to: *Ensure, diabetic residents had parameters for high blood sugars which required physician notification; *Educate licensed nurses to the facility's hyperglycemic protocol; and, *Assess diabetic residents for signs and symptoms of [MEDICAL CONDITION]. On 10/15/15, the facility was informed in writing the Immediate Jeopardy also encompassed the facility's failure to: *Provide ongoing dietary assessments; *Provide consistent carbohydrate meals per the facility's Diet Manual; *Provide residents with risks and benefits education related to non-compliance with dietary restrictions. The facility submitted an acceptable Abatement Plan to the Bureau of Facility Standards on 10/19/15 and an on-site survey on 10/26/15 confirmed the conditions of the IJ had been abated. The abatement plan included a review of diabetic residents' blood glucose levels, medication regimen, and physician-set hyperglycemic parameters for individual residents that would require physician notification. The [MEDICAL CONDITION] protocol was revised and nursing staff were educated on the new protocol. Diabetic residents' care plans were also individualized to reflect physician notification parameters, as well as specific preferences regarding a diabetic diet. Findings included: The facility's Diabetic Care Protocol in effect at the time Immediate Jeopardy was determined documented the following parameters for physician notification for a resident without individualized parameters: *Immediate physician notification of blood glucose levels greater than 400 mg/dl; *Physician notification as soon as possible during normal business hours of blood glucose levels greater than 350 mg/dl or greater than 300 mg/dl on two consecutive readings. The protocol did not define consecutive and it was unclear whether it would apply to two blood glucose checks in a 24 hour period, two blood glucose checks minutes apart, and/or bedtime and morning blood glucose assessments. 1. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's July 2015 MAR indicated [REDACTED]. The August 2015 MAR indicated [REDACTED]. The September 2015 MAR indicated [REDACTED]. The facility failed to notify Resident #4's physician of any of the 41 hyperglycemic episodes during this three month period and the resident's medical record did not include evidence she was assessed for signs/symptoms of [MEDICAL CONDITION]. On 10/8/15 at 3:45 p.m., the DNS and RCM stated there was no evidence Resident #4's physician was notified when the resident's blood glucose levels exceeded either 300 mg/dl or 400 mg/dl. The resident's October 2015 recapitulated physician orders [REDACTED]. No further individualized blood glucose parameters with physician notification were documented. It could not be determined from the resident's medical record whether any monitoring of the resident's blood glucose level was faxed to the physician who, on 10/9/15, stated he did not know whether blood glucose monitoring results had been faxed to him as he had ordered. A 10/21/14 physician visit/progress note documented Resident #4's blood glucose was running in the 300's with no new interventions initiated after the physician's visit. A 1/15/15 physician progress notes [REDACTED]. No new interventions were initiated at this time. A 4/6/15 physician's note documented the resident's diabetes was poorly controlled. No further interventions for diabetic management were initiated during the physician's 4/6/15 visit. A 6/30/15 physician's note documented the resident's blood glucose was assessed in the 200-300 range; no new interventions were initiated after the June physician visit. Resident #4's diabetic care plan, initiated 7/30/15, documented staff were to provide and encourage consumption of a consistent carbohydrate diet. On 10/9/15 at 9:30 a.m., the resident's physician stated he let her eat what she wanted to eat . and just gave up and that he was ignoring high blood glucose to keep her quality of life . let her eat what she wants. The physician also stated he would wait until Resident #4's blood glucose levels were in the 600-700 (mg/dl) range before doing something more about it . (it's a) judgment thing. The resident's physician added that it was a waste of time and energy for the facility to send me (weekly) blood sugars on (Resident #4) because I'm not going to do anything about them. Resident #4's medical record did not document the resident received continuing education and/or risk vs. benefit discussion regarding her diabetic diet. It could not be determined from the resident's medical record whether she was asked for nutritional preferences, needs, or goals. Additionally, physician progress notes [REDACTED]. On 10/9/15 at 12:50 p.m., the RD stated the facility's diabetic education wasn't intensive, but did include notification that residents could make food choices as well as information on snacks that were consistent with diabetic restrictions. She stated diabetic nutritional approaches were tailored to diabetic residents' quarterly HgA1c labs and reviewed when any problems arose. The RD noted that Resident #4's HgA1c labs had been reviewed. 2. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses, including Type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION] hypertension, heart failure, and hypertension. On 2/22/15 the resident was sent to the emergency room and diagnosed with [REDACTED]. While in the emergency room (ER), the resident received insulin intravenously for elevated blood glucose levels. The following blood sugars were documented in the emergency room from 2/22/15 to 2/23/15: 387 mg/dl, 459 mg/dl, 436 mg/dl, and 262 mg/dl. A physician visit dated 2/25/15 documented concerns related to fasting glucose levels over 200 mg/dl (often greater than 300 mg/dl or more). The Assessment/Plan after the 2/25/15 physician's visit did not include any changes to the resident's diabetic medications or management plan. Resident #11's medial record from 4/15/15 to 8/19/15 did not document individualized parameters had been established for the resident's blood sugars. On 8/20/15, five months after the resident was treated in the emergency room for [MEDICAL CONDITION], the facility requested hyperglycemic parameters from the physician. The physician documented he wanted to be notified only when the resident's blood glucose levels were greater than 500 mg/dl. The physician did not document a rationale for that notification requirement given that the resident had required emergent treatment in February 2015 for a blood glucose in the 500 range. The June, July, and August 2015 recapitulated physician orders [REDACTED].#11's blood glucose every morning and at bedtime, however individualized parameters were not specified at this time. An 8/20/15 order directed staff to assess the resident's blood glucose every morning and at bedtime, and to notify the physician for blood glucose levels greater than 500 mg/dl. Resident #11's July 2015 MAR indicated [REDACTED]. The August 2015 MAR indicated [REDACTED]. The physician was not notified of the identified occurrences, and signs and symptoms of [MEDICAL CONDITION] were not assessed per the medical record when the resident's blood glucose was elevated. The resident's October 2015 recapitulated physician orders [REDACTED]. A Medical Nutrition Therapy Assessment note documented upon admission the resident did not want to be on a diabetic diet, but rather followed a limited sugar diet. It could not be determined from the resident's nutritional record, care plan, or kitchen spreadsheets that any further risk/benefit education was provided to the resident regarding a regular diet or incorporation of her preference of a limited sugar diet. The resident's October 2015 care plan documented her refusal to follow dietary recommendations and prescribed diet (initiated 12/24/14). An intervention was initiated on 12/24/14 to educate the resident on risks associated with non-compliance, for social services to assess reasons for non-compliance, and for social services to make routine visits to provide support. The resident's diabetes care plan documented on 3/4/15 that staff were to provide diabetes education and education related complications as appropriate. Resident #11's record did not include documentation that these education and social work interventions were completed. Physician's notes from 2/25/15, 4/15/15, 6/10/15, & 8/12/15 documented the resident's diabetes was uncontrolled and that the resident was non-compliant with glucose checks and diet. The 6/10/15 physician note documented the resident's most significant obstacle related to diabetic management was non-compliance, but that staff would continue to encourage adherance to a diabetic regimen. No further education of risks/benefits was documented and no further discussion of the resident's preferences, needs, or goals in relation to diabetic management was documented. On 10/7/15, LN #1 stated the facility's hyperglycemic protocol allowed physicians to determine at what point a hyperglycemic blood glucose assessment required physician notification. LN #1 also stated physician notification requirements were predetermined for those residents with sliding scale parameters (not all diabetic residents in the facility had a sliding scale for insulin administration). She stated she did not know when to notify the physician of a hyperglycemic blood level if a resident did not have a sliding scale. When asked, LN #2 stated she did not know when to notify the physician if a resident was assessed with [REDACTED]. On 10/8/15 the Regional Nurse Consultant was asked to provide the facility's policy and protocol for [MEDICAL CONDITION]. She stated there was no such policy or protocol. The facility's [DIAGNOSES REDACTED] policy and protocol, dated (revised 1/2/14) was later provided, which included a [MEDICAL CONDITION] policy and protocol. On 10/8/15 at 3:45 p.m., the DON stated she was unsure of what to do if a resident had increased blood glucose readings that indicated [MEDICAL CONDITION]; the Regional Nurse Consultant stated the nurses should follow facility protocol and notify the physician. She was unsure if the current Medical Director was aware of the facility's protocol for notification. Meals served to residents from 10/5/15 to 10/9/15 were observed to lack vegetables and there was a significant amount of carbohydrate food items. The facility failed to: *Assess residents who experienced repeated and frequent hyperglycemic episodes; *Develop and implement policies and procedures for hyperglycemic management that were consistent with professional standards; *Follow its own hyperglycemic policy and protocol by notifying the physician of blood glucose levels over 300 mg/dl or 400 mg/dl; *Staff were not aware of hyperglycemic protocol; *Staff failed to provide risk/benefit education for residents regarding non-compliance with diabetic restrictions; *Residents were not assessed and/or provided a carbohydrate-consistent diet that was compatible with policy-defined diet sample menus; *Resident goals for diabetic management and diet choice were not identified and incorporated into plans of care; *Residents were not educated about potential risks and consequences of their dietary choices;

Based on observation, staff interview, and record review, it was determined the facility failed to ensure 1 of 15 sampled residents (Resident #7) did not develop pressure ulcers. The failure resulted in harm when the resident developed two stage II pressure ulcers after the facility did not address all identified risk factors for skin breakdown; initiatate interventions for prevention; implement interventions when they were ordered; or initiate/revise skin breakdown care plans in a timely manner. Findings include: Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A 9/9/15 risk management form documented the resident developed two stage II pressure ulcers, one on each heel laterally. It documented the pressure sores were avoidable, and that it could not be verified that heels were floated upon admission. It documented pressure ulcers developed within 5 days of admit, the resident was compromised nutritionally, mobility was impaired, was unable to make even slight position changes without assistance to offload pressure, and had [MEDICAL CONDITION] to bilateral lower extremities. The 9/9/15 Skin Integrity Report for the left lateral heel documented the resident had a stage II pressure ulcer, with pain, and was a blister that measured 3.6cmx3cm and surrounding tissue was boggy, red, and non-blanchable. The 9/15/15 assessment of the wound documented the resident had pain, the wound measured 3.6cmx3cm with surrounding tissue unchanged. The 9/9/15 Skin Integrity Report for the right lateral heel documented the resident had a stage II pressure ulcer with pain, and was a blister, that measured 4cmx4.6cm and surrounding tissue was boggy, red, and non-blanchable. The 9/15/15 assessment of the wound documented the resident had pain, and that the wound was unchanged. An assessment of the wound was not documented for the week of September 21, 2015. No new interventions were ordered at this time. The resident's recapitulated physician's orders [REDACTED].>*Monitor and apply skin prep to bilateral heels twice daily for heel blisters (ordered and started 9/12/15); *Pressure-redistribution cushion to chair (ordered 9/4/15); *Pressure-redistribution mattress to bed (ordered 9/4/15); and, *Skin check weekly on Wednesday (ordered 9/11/15 and started 9/16/15). The resident's ADL care plan, initiated 9/5/15, documented the resident required 2 person extensive assistance with bed mobility and transferred with a front wheel walker. The skin breakdown risk care plan documented the interventions (initiated 9/9/15): *Assist with repositioning approximately every 2 hours and prn; *Float heels while in bed; *If resident refuses care re-approach and use alternate staff prn; *Observe skin condition with ADL care daily and report abnormalities; *Pressure redistribution surfaces to chair as per protocol; and *Pressure reducing mattress to bed as per protocol. The resident's 9/11/15 admission MDS assessment documented the resident was severely impaired cognitively, had no refusals of care, required two person extensive assist to move in bed and to transfer, had 2 stage II pressure ulcers (not present on admission to the facility), had pressure reducing devices on the chair and bed, a turning/repositioning program, pressure ulcer care, and did not have a condition that would result life expectancy less than 6 months. The resident's skin breakdown care plan added the following interventions on 9/17/15: *Monitor skin for signs/symptoms of skin breakdown; *Norton/Braden assessment per policy; *Provide wound treatment as ordered; *Skin check per policy; and, *Weekly skin assessment by license nurse. The resident's non-compliance care plan, initiated 9/21/15, documented the resident refused cares including refusals of repositioning, heel offloading, bathing and cares. Interventions included checking during rounds to ensure heels were offloaded. The resident's skin breakdown risk care plan was initiated 9/9/15, the day the pressure ulcers were identified, and the care plan for the pressure ulcers was initiated 9/17/15, 8 days after the breakdown was identified. Interventions and weekly skin assessments were not started until after pressure ulcers were identified. The September 2015 TAR documented the resident's heels were to be monitored and skin prep applied to bilateral heels two times a day starting on 9/12/15. It documented this was completed 15 of 38 opportunities. The resident's ADL record documented the resident transferred with extensive assistance of two people. The record documented the resident was not transferred out of bed during the night or evening shift for 12 days; evening shift transferred the resident 8 of the 12 days and the resident did not transfer for 4 consecutive days. Not applicable was documented for all locomotion opportunities in September 2015. The resident was not observed out of bed the week of the survey 10/5/15-10/9/15. On 10/8/15 at 6:00 p.m., the RCM and DNS were interviewed regarding the resident's pressure ulcers. The RCM was asked about skin assessments before 9/9/15, an interim care plan for the resident's skin upon admission, and alternative interventions offered to get the resident out of bed. She was also asked about attempts made to identify the resident's objectives to floating her heels or getting out of bed, and how these barriers were addressed. There was no documentation regarding skin assessments before 9/9/15, an interim skin care plan, alternative interventions offered to get the resident off loaded and out of bed, or documentation of refusals and how this barrier was addressed. On 10/9/15 at 10:30 a.m., the resident's heels were observed. On both heels laterally, pressure ulcers were 2.5cmx2.5cm without depth. The skin was intact and continuous throughout, and the pressure ulcers were dark red/purple in color with no blanching. The resident was laying on an air mattress and heels were floated. The resident experienced harm when she developed 2 avoidable stage II pressure ulcers on her heels while residing in the facility. The facility did not recognize and assess factors that put the resident at risk of developing pressure ulcers upon admission. The resident did not have an interim care plan upon admission to protect her skin or skin assessment until the identification of the two pressure ulcers. Interventions to prevent pressure ulcers were not implemented as ordered. Mobility was identified as a risk factor for the resident's skin breakdown; the resident was transferred out of bed 9 of 38 opportunities. The skin breakdown risk care plan was created when skin had already broken down. The care plan was not revised to modify the prevention strategies and to address the presence and treatment of [REDACTED].

Based on observation, record review and staff interviews, it was determined the facility failed to ensure residents who entered the facility without pressure ulcers did not develop unstageable pressure ulcers. Additionally, the facility failed to provide the necessary nursing care and services to promote healing of pressure ulcers. This was true for 1 of 9 (#3) sampled residents reviewed for pressure ulcers. This deficient practice caused harm when the facility failed to recognize and assess Resident #3's wounds as pressure ulcers and failed to treat and promote wound healing. Findings included: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. An Incident/Accident Report (I&A), initiated at the facility on 3/7/14 at 12:00 PM, documented the resident fell , fractured her left ankle and was transferred to a local hospital. An Operative/Procedure Report by a local orthopaedic surgeon, dated 3/8/14, documented the resident required surgical intervention. The resident's 14 day admission MDS assessment, dated 3/23/14, coded: *Moderately impaired decision making skills. *No rejection of cares. *Dependent on 2+ persons for bed mobility, transfers, dressing and toilet use. *At risk for developing pressure ulcers. *No pressure ulcers present on admission. The Recapitulation Orders, dated 3/12/14, documented the following: *Wound dressing site to be observed every shift every day; *Float heels with pillows while in bed every shift every day; *Pressure reducing mattress to bed; *Pressure redistribution cushion to chair; *Trapeze over bed for bed mobility; and, *Weekly skin assessments by LN on Tuesday. The March 2014 TAR (Treatment Administration Record) did not document Resident #3's heels were floated on: *Day Shift - 3/12, 3/19 and 3/20. *Evening Shift - 3/25. *Night Shift - 3/12, 3/14-15, 3/20-22, 3/27-29. The March 2014 TAR did not document Resident #3's wound dressing site was observed every shift: *Day Shift - 3/12, 3/19, and 3/20. *Evening Shift - 3/25. *Night Shift - 3/12, 3/14-15, 3/20-22, and 3/27-29. The resident's care plan for skin integrity related to surgical wound, initiated on 3/13/14, documented: *"CMS (color, motion, sensation) checks to LLE (left lower extremity). *Elevate legs as much as possible and as resident will allow. *Observe wounds under Podus boot every shift and PRN. *Report worsening of s/sx (signs and symptoms) of infection to MD. *Vascular studies/consults per MD orders. *Wound care per MD orders. *Wound check every other day." A progress note, dated 3/19/14, documented the resident was first seen post operatively by the orthopaedic surgeon for a follow up visit of the left ankle. The progress note documented the resident was having "significant pain"...and had "been in a splint non-weight bearing." The splint was removed and there were "some resolving fracture blisters on both sides of the ankle." The resident was started on an antibiotic with the plan to "ice and elevate her ankle as much as possible. Continue non-weight bearing in the splint." The resident was to be seen in one week for follow up. A progress note, dated 3/26/14, the resident was seen by the orthopaedic surgeon for a two week follow up visit of her left ankle. The progress note documented the "incisions looked good" but the resident appeared to have a heel ulcer with "some black, necrotic tissue." The plan included transitioning the resident into a heel off-loader brace. The resident was given a new splint in the physician's office "with a significant amount of heel padding" until a heel off-loader brace could be set up. The resident was to be seen in one week for follow up. The Recapitulation Orders documented an order, dated 3/26/14, to ensure an off loading Podus boot was in place every shift, everyday. A care review progress note, dated 3/27/14, documented the resident went yesterday and the physician "noted a pressure ulcer on the left heel. Physician did not write anything about it but van driver stated physician saw it." The note documented the "Wd (wound) nurse will evaluate and ask for orders. Res(ident) is getting up 3 X (times) a day and encouraged to stay up for as long as possible." The April 2014 MAR indicated [REDACTED] *Evening Shift - 4/28. *Night Shift - 4/3-5, 4/10-12, 4/17-18, 4/24-25 & 4/30. Additionally, the April 2014 MAR indicated [REDACTED] *Evening Shift - 4/28. *Night Shift - 4/3-5, 4/10-12, 4/17-18, 4/24-25 & 4/30. The April 2014 MAR indicated [REDACTED] *Day Shift - 4/10, & 4/12. *Evening Shift - 4/28. Night shift - 4/3-5, 4/10-12, 4/17-18, 4/24-25 & 4/30. A physician progress notes [REDACTED]. The progress note documented the "heel wound had not worsened. She has developed a blood filled blister on the ball of her foot, as well as on the lateral aspect of her foot." A care review progress note by the NPE, dated 4/4/14, documented the resident had a "DTI (deep tissue injury) to the left heel R/T (related to) the splint" and was "dark purple in color" but not open. In addition, it was documented the "Res(ident) states she would like to lose weight." NOTE: The resident's need for added nutrition for healing related to an ankle fracture and pressure ulcers was not addressed. A physician progress notes [REDACTED]. examined by the orthopaedic surgeon and was five weeks out from her surgery. The progress note documented the resident was "complaining of achiness and pain in her left foot and ankle." The physical examination documented: *Black eschar (dead tissue) at the heel. *Black eschar at the plantar surface (sole) of the first MTP (big toe) joint. *Black eschar along the lateral aspect (outer side) of the foot. *[DIAGNOSES REDACTED] (redness) at the top of the foot with a small dime-sized area of eschar over the first metatarsal. The plan documented to "Continue with daily wound care. I have started her on some Keflex 500 mg four times a day for seven days." On 4/14/14, a progress note documented, "air mattress placed today." NOTE: The pressure reducing mattress was ordered on [DATE], and was placed on the resident's bed a month after the facility received the physician's orders [REDACTED]. On 4/16/14, the resident was examined by the orthopaedic surgeon who documented: *Left ankle wounds draining; *Heel ulcer with eschar; *Lateral foot necrosis; * 4, 5 toes necrosis; and, *Dorsal (top) foot wound. The surgeon documented, "A/P (Assessment/Plan) Prognosis not looking good for foot. Will need arterial vascular studies and vasc (vascular) surgeon consult." On 4/17/14, the resident was examined by her family practice physician, for wound check and one month follow up. The physician documented, "L (left) foot was in cast after surgery, then had splint placed, was wrong kind, did not off-load. Unclear if this led to current problem. Now has correct boot on. Had developed some dark spots on foot, oozing, incision not healed. Called by staff 2 days ago, I asked her to come in to evaluate." The skin exam documented, "multiple dark patches on L foot, lateral is dripping some dark blood. No bad odor. Global [DIAGNOSES REDACTED], dusky, and non-blanching, quite tender in some spots, not in others." The Provider Plan documented, "Appears to be areas of necrotic and non-viable tissue of foot...Agree with vascular study." An Ultrasound Report, dated 4/18/14, documented, "...left ankle-brachial index is within normal limits." The Recapitulation Orders, dated 4/21/14, documented the following orders: *Check CMS to left lower extremity/foot/toes every shift - Every shift Everyday Assessment. *Remove Podus boot to left foot/ankle every shift for a skin check under boot. Ensure boot is replaced and left heel is fully suspended - Every Shift Everyday Assessment. The April 2014 MAR indicated [REDACTED] *Evening Shift: 4/28. *Night Shift: 4/24-25 & 4/30. The Vascular Report, dated 4/22/14, documented "there appears to be adequate perfusion to heal..." A progress note by the NPE, dated 4/22/14, documented a video conference with the NPE and head of the facility's ownership Skin Integrity Program. The head of the facility's Skin Integrity Program recommended a change of treatment to the lateral ankle wound. The NPE called and obtained an order from the orthopaedic surgeon's PA (physician's assistant) for the following: *Surgical incision wound care: Cleanse lateral incision area with 1/4% Dakins solution and cover with [MEDICATION NAME] silver (Ag) and rolled gauze BID (twice daily). If medial wound is draining, may use same treatment as lateral wound. If not draining or no s/sx of infection, may lightly cover with [MEDICATION NAME] of border gauze BID - Every 12 hours Everyday. Scheduled at 8 AM and 8 PM. The April 2014 MAR indicated [REDACTED] *4/28 at 8 PM. The Recapitulation Orders, documented the following order, dated 4/23/14: *[MEDICATION NAME] to black necrotic areas daily - Day Shift Everyday. The April 2014 MAR indicated [REDACTED] *4/24-27. NOTE: This order had a start date of 4/23/14 but was not started until 4/28/14. On 4/28/14 the resident was seen by the vascular surgeon who documented in his report, "The patient's foot certainly does not look good and she is a (at) risk to lose it. I do feel, however, that her blood supply is playing a significant role in this and based on an ultrasound examination and the clinical examination of her foot, I do not believe that revascularization given that she has mild vascular disease is likely to improve her healing. Therefore, I am recommending continued wound care. Clearly there is still a significant issue in the patient's healing, perhaps nutritional, perhaps infection, perhaps related to inadequate offloading. I encourage you to address all of these...her blood supply is not playing a significant role." The May 2014 MAR indicated [REDACTED]. *Night Shift - 5/2-3. The May 2014 MAR indicated [REDACTED] *Evening Shift - 5/6. *Night Shift - 5/2-3. The May 2014 MAR indicated [REDACTED] *Evening Shift - 5/6. *Night Shift - 5/2-3. The May 2014 MAR indicated [REDACTED] *Evening Shift - 5/6. *Night Shift - 5/2-3. The May 2014 MAR indicated [REDACTED] *Day Shift: 5/3, *Evening Shift: 5/6. *Night Shift: 5/2-3. The May 2014 MAR indicated [REDACTED] *5/3 - 8:00 AM. *5/6 - 8:00 PM. The Skin Integrity Report sheets documented the type of wound as vascular for all seven wounds and contained spaces to document at the date of each assessment - Pain, Appearance, Length (cm), Width (cm), Surrounding Tissue, Wound Edges and Care Plan Updated. a. Anatomical Location: Left heel 3/26/14 - painful, 100% black adherent eschar, 4.4 cm L (length) x 5.4 cm W (width), inflamed, dry, care plan updated. 4/4/14 - painful, 100% black adherent eschar, 4.2 cm L x 5.4 cm W, inflamed, dry. 4/11/14 - painful, 100% black adherent eschar, 4 cm L x 5.4 cm W, inflamed, dry. 4/14/14 - painful, 100% black adherent eschar, 4 cm L x 5.2 cm W, inflamed/red, dry. 4/22/14 - painful, 100% black adherent eschar, 4 cm L x 5.2 cm W, red, dry. 4/29/14 - painful, 100% black adherent eschar, 3.9 cm L x 5.2 cm W, red, dry. 5/6/14 - no pain, 100% black adherent eschar, 3 cm L x 6 cm W, healthy, healthy. NOTE: Wound edge choices were "healthy, calloused, macerated, rolled," but not "dry" as documented. b. Anatomical Location: Left dorsal foot 4/4/14 - no pain, 100% pink [MEDICATION NAME], 1 cm L x 1.2 cm W, scant serous, healthy, healthy. 4/5/14 - no pain, 100% black eschar, 1 cm L x 1.2 cm W, healthy, healthy, care plan updated. 4/11/14 - no pain, 100% black adherent eschar, 1 cm L x 1.2 cm W, healthy, healthy. 4/22/14 - no pain, 100% black adherent eschar, 1 cm L x 1.3 cm W, healthy, healthy. 4/29/14 - no pain, 100% black adherent eschar, 1 cm L x 1.2 cm W, healthy, healthy. 5/6/14 - no pain, 100% yellow eschar, 1 cm L x 1.2 cm W, healthy, healthy. c. Anatomical Location: Left lateral foot 4/4/14 - painful, 100% blood blister, 6.8 cm L x 3 cm W, inflamed, inflamed, care plan updated. 4/11/14 - painful, 100% black adherent eschar, 7 cm L x 3 cm W, inflamed, inflamed. 4/14/14 - painful, 100% black adherent eschar, 7 cm L x 3 cm W, pale, pale. 4/22/14 - painful, 100% black adherent eschar, 6.3 cm L x 4.5 cm W, pale, pale. 4/29/14 - painful, 100% black adherent eschar, 6.5 cm L x 4.5 cm W, pale, pale. 5/6/14 - painful, 100% black adherent eschar, 7 cm L x 6 cm W, healthy/pale, healthy/pale. NOTE: Wound edge choices were "healthy, calloused, macerated, rolled," but not "inflamed" or "pale" as documented. d. Anatomical Location: Left medial ball of foot 4/4/14 - painful, 100% blood blister, 2 cm L x 2.5 cm W, inflamed, red, care plan updated. 4/11/14 - painful, 100% black eschar, 1.6 cm L x 2.1 cm W, healthy, red. 4/14/14 - painful, 100% black adherent eschar, 1.6 cm L x 2.1 cm W, healthy, red. 4/22/14 - painful, 100% black adherent eschar, 1.6 cm L x 2.1 cm W, healthy, red. 4/29/14 - painful, 100% black adherent eschar, 1.5 cm L x 2.1 cm W, healthy, red. 5/6/14 - not painful, 100% black adherent eschar, 1.5 cm L x 1.5 cm W, healthy, healthy. NOTE: Wound edge choices were "healthy, calloused, macerated, rolled," but not "red" as documented. e. Anatomical Location: Left 4th toe, top 4/4/14 - painful, intact purple, 2 cm L x 0.5 cm W, inflamed, healthy. 4/11/14 - painful, intact purple, 1.8 cm L x 0.5 cm W, inflamed, healthy. 4/14/14 - painful, intact purple, 1.8 cm L x 0.5 cm W, inflamed, healthy. 4/29/14 - painful, intact purple, 1.9 cm L x 0.5 cm W, inflamed, healthy. 5/6/14 - painful, intact purple, 1.9 cm L x 0.5 cm W, healthy/pale, healthy. f. Anatomical Location: Left lateral ankle/surgical incision/[MEDICAL CONDITION] 4/4/14 - painful, 75% dark scab 25% slough, 8 cm L x 1.8 cm W, moderate serosanguineous, inflamed, red, care plan updated. 4/11/14 - painful, 50% [MEDICATION NAME] (ex:stg 2) 50% slough, 8 cm L x 2.3 cm W, minimum serosanguineous, inflamed, red. 4/14/14 - painful 75% [MEDICATION NAME] (ex:stg 2) 25% slough, 7.8 cm L x 2.5 cm W, moderate serosanguineous, inflamed, red. 4/22/14 - painful, 75% [MEDICATION NAME] (ex:stg 2) 25% slough, 8.8 cm L x 1.4 cm W, moderate heavy serosanguineous, inflamed, red. 4/29/14 - painful, 75% [MEDICATION NAME] (ex:stg 2) 25% slough, 8.2 cm x 1.7 cm W, moderate serosanguineous, inflamed, red. 5/6/14 - painful, 25% yellow eschar 25% black eschar, 50% [MEDICATION NAME] (ex:stage 2), 7 cm L x 2.6 cm W, moderate serosanguineous, inflamed, fragile. NOTE: Wound edge choices were "healthy, calloused, macerated, rolled" but not "red" as documented. g. Anatomical Location: Left medial ankle/surgical incision 4/4/14 - painful, 50% dark scab 50% slough, 6 cm L x 0.5 cm W, minimal serosanguineous, inflamed, red, care plan updated. 4/11/14 - painful, 50% [MEDICATION NAME] (ex:stg 2) 50% slough, 5 cm L x 0.5 cm W, healthy, healthy. 4/14/14 - painful, 75% [MEDICATION NAME] (ex:stg 2) 25% slough, 5 cm L x 0.5 cm W, healthy, healthy. 4/22/14 - not painful, > 75% [MEDICATION NAME] (ex:stg 2) < 25% slough, 5 cm L x 0.5 cm W, healthy, healthy. 4/29/14 - not painful, > 75% [MEDICATION NAME] (ex:stg 2) < 25% slough, 5 cm L x 0.5 cm W, healthy, healthy. 5/6/14 - not painful, 75% granulation 25% slough, 1.5 cm L x 0.5 cm W x 0.1 cm depth, healthy, healthy. On 5/7/14 at 3:55 PM, the surveyor observed the wounds to the resident's left foot with the NPE. The NPE stated she first became involved with the resident's care on 4/4/14. The NPE took the following measurements: *left heel - 3.6 cm L x 6.5 cm W - eschar present. *left dorsal - 1.4 cm L x 1 cm W - eschar present. *left lateral foot - 8 cm L x 6 cm W - eschar present. *left medial ball of foot - 1.3 cm L x 1.5 cm W - eschar present. *left 4th toe - 2.1 cm L x 0.7 cm W, eschar present. *left lateral ankle incision site had healed, approximately 1" below the incision site an open area measured 8 cm L x 2.4 cm W. *left medial incision - 1.9 cm L x 0.4 cm W with inflamed wound edges On 5/9/14 at 10:20 AM, the NPE and the MCO were interviewed regarding the resident's left foot wounds. The surveyor questioned the NPE regarding the missing data in documentation on the March, April and May 2014 TARs in which heels were not consistently floated, wound dressing site not observed every shift, CMS not performed, Podus boot not removed, Podus boot not offloaded or replaced and the left heel not fully suspended. The NPE confirmed that information was missing in the MARs and stated the "holes" were a "problem." When asked about the 4/23/14 order for [MEDICATION NAME] to black necrotic areas daily and why there was no documentation on the April 2014 MAR for 4/26 and 4/27, the NPE stated the facility didn't have [MEDICATION NAME] available, that it had been ordered on [DATE] but was not started until 4/28/14. She stated there was "some confusion" with the pharmacy related to preparation. When asked why the facility waited 4 days in letting the pharmacy know staff did not have the [MEDICATION NAME], the NPE did not have an answer. She then stated she was responsible for the missing 4/28/14 documentation on the evening shift but could not explain the cause for the other missing documentation. She stated it looked like there was a "pattern." When asked about the documentation on 4/17/14 in which the physician stated the resident received the "wrong" boot, the NPE and MCO both stated there was not a significant difference between the two types of boot. Both the NPE and MCO stated the orthopaedic surgeon's office ordered the boot and it was fitted by the company representative. They both stated the resident would have the same skin issues even if she had been fitted with the correct boot. The MCO stated the boot did not contribute to the ulcers originally documented as "pressure" but been changed to "vascular" after consulting with the orthopaedic surgeon. When asked about the vascular report which documented, "there appears to be adequate perfusion to heal" (wounds), the NPE stated, "there was a lot of gray area in the report and wasn't sure exactly what that pertained to." When asked about the vascular surgeon's report in which he documented the resident's left foot "did not look good" and she was at risk to lose it, the NPE stated she agreed with the physician. On 5/9/14 at 11:30 AM, the NPE stated she consulted with the corporate wound care specialist who gave the recommendation for a new treatment order. It was after this change of treatment on 4/22/14 that the wounds started to improve. The facility consistently failed to: *Adequately assess the left foot wounds as pressure ulcers instead of vascular ulcers. The pressure ulcer to the heel was first noticed on 3/26/14, however, a wound specialist was not consulted until 4/22/14; *Float the resident's heels; *Observe the wound dressing site; *Offload the Podus boot every shift; *Check the CMS of the left lower extremity every shift; *Remove the Podus boot every shift for a skin check under the boot, replace the boot and ensure the left heel was fully suspended every shift; *Order an air mattress in a timely matter; *Follow up with the pharmacy for the order of [MEDICATION NAME] and the resident had to wait 4 days for the medication.

Based on medical record review, policy review, and staff and resident interview it was determined the facility failed to ensure residents received adequate supervision and staff assistance to prevent falls with injuries. This was true for 2 of 3 (#s 3 & 4) residents sampled for falls. Resident #3 was harmed when she fell and suffered a left ankle fracture and Resident #4 was harmed when she fell and suffered a left hip fracture. Additionally, the facility failed to ensure siderails were assessed as safe for 3 of 5 (#s 1, 3, & 4) residents sampled for siderails use. Findings included: The facility's Policy and Procedure for, "Falls Management," documented the following: - "Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury." - Purpose of the policy is "to reduce the risk for falls and minimize the actual occurrence of falls and to address injury and provide care for a fall." - Patients with a score of 12 and above on the Fall Risk Evaluation are "at risk" of falls. - Develop individualized plan of care. - Review and revise care plan regularly. 1. Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's Quarterly MDS assessment, dated 1/14/14, coded the following: - Extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. - Limited assistance of one person to walk in room and for locomotion on and off the unit. - Upper and Lower extremity impairment (limitation). Resident #4's most recent Quarterly MDS assessment, dated 4/7/14, coded the following: - Extensive assistance of two people for bed mobility, transfers, dressing, and toileting. - Walking in her room, locomotion on and off the unit did not occur. - Upper and Lower extremity impairment (limitation). Resident #4's Care Plan, Incident/Accident Reports, Physical Therapy Notes, Occupational Therapy Notes, Nursing Notes, hospital History & Physical, facility faxes, and x-ray results were reviewed and documented the following: * Fall Risk Evaluation, dated 10/25/13, documented a score of 12 or above indicated the resident was at high risk for falls; the resident scored a "16." * The resident's Fall Care Plan (CP), initiated on 10/27/13, documented, "pressure alarm when in bed and tab alarm when up in w/c; mats on floor next to both sides of bed; assist resident getting in and out of bed with 2 person assistance; have commonly used articles within easy reach; resident to wear non slip footwear" with the hand written words, "for assisted transfers." * An Incident/Accident Report (I&A), initiated on 10/30/13 at 4:45 PM, and completed on 5/12/14, documented: - "Resident is alert, poor safety awareness, with left sided weakness. She was in her room going through the night stand drawers. A CNA had been in the room just prior to fall and had moved some items so the resident could search drawers without reaching. CNA left the room and a few moments later, the residents alarm was sounding. She was on the floor facing the door with her buttocks pushed against drawer. - Care Plan updated - No. - Newly admitted s/p CVA with left sided deficit. - Interventions initiated after the fall - Assessed resident for new onset pain or injury, assisted resident up from the floor with 2 person extensive assist and assisted to bed. Alarm re-applied to resident and placed on increased staff supervision. - Recommendations to prevent further falls - continue with alarm on at all times. Increase staff supervision. - Root Cause Inclusion - Resident's poor safety awareness and generalized weakness secondary to CVA with left sided deficit. - Summary of staff interview - CNA had just left the resident's room after placing items within reach of resident." * The Fall CP, initiated on 10/30/13, documented, "increased staff supervision." NOTE: The facility documented increased supervision was implemented per the I&A and the Fall Care plan on 10/30/13; however, the facility failed to identify what increased supervision was to include, for example what specific times the resident would be observed. * An I&A Report, initiated on 11/6/13 at 3:15 PM, and completed on 5/12/14, documented: - "Resident found by CNA sitting on floor in front of her w/c. Alarm intact, no injuries noted. Two person extensive assist transfer back to w/c... - Care Plan updated - Yes. - Recent admit s/p CVA with left sided deficit. - How long since the resident had last voided - 2 hours. - Interventions initiated immediately after fall - Assessed for new onset of pain, assisted resident up with 2 person extensive assist and assisted back into w/c... - Recommendations to prevent further falls - Therapies to evaluate and treat as indicated. Summary of interview with witness(es) - NA - Root Cause Conclusion - Resident's poor safety awareness and general weakness secondary to CVA with left sided deficit." * The Fall CP, initiated on 11/6/13, documented: Neuro(ological) checks per facility protocol; therapy to continue tx (treatment) per MD orders for safety, strength, and cognition; and place call light within easy reach of resident. * Fall Risk Evaluation, dated 11/7/13, documented: A score of 12 or above indicated the resident was at high risk for falls, the resident scored a "15." * The Fall CP, initiated on 12/6/13, documented: low bed; use simple "yes/no" phrases and questions; and evaluate effectiveness and monitor for side effects of drug. * An I&A Report, initiated on 12/7/13 at 7:00 PM, and completed on 5/7/14: - "Resident was witnessed to have slid out of w/c to floor while in her room. Resident was assisted up from floor with 2 person extensive assist... - Care Plan updated - Yes. - How long since the resident last voided - unknown (resident) incontinent. - Interventions initiated immediately after fall - assisted resident up from floor with a 2 person extensive assist. Assessed resident for injuries, none noted. Resident shows no s/sx of any pain. - Family/Responsible party notified - No. - Recommendations to prevent further falls (document interventions below and on the Care Plan) - Therapy to eval(uate) for positioning. - Summary of Interview of witness(es) - Resident was noted to have slid out of w/c to floor. - Root Cause Conclusion - Resident's muscular deficit and poor cognition r/t CVA." NOTE: The resident's Fall CP was not evaluated after the fall on 12/7/14, to determine the effectiveness of the current interventions. Additionally, the facility failed to modify and replace current interventions in place. * An I&A Report, initiated on 1/3/14 at 1:30 PM, and completed on 5/7/14, documented: - "Resident attempted to transfer unassisted from w/c to bed while friend in her room. Turned to sit on bed and sat on the floor. CNA heard the noise and entered the room... - Care Plan updated - Yes. - Bed was in the low position. - Both 1/2 side rails were up. - Interventions initiated immediately after the fall - Neuro checks initiated per facility protocol. Assessed resident for any new injuries, none noted... - Recommendations to prevent further falls - Non skid foot wear. - Summary of interview with witness(es) - As stated previously. - Root Cause - Resident got up from w/c turned to sit on bed and sat onto the floor rather than the edge of bed." NOTE: It was difficult to determine how the resident would be able to transfer successfully from the w/c to the bed with the side rails up and the bed in the low position, the resident was 5 feet 9 inches tall. Additionally, the resident's Fall CP was not reviewed and revised after the fall on 1/3/14, to determine the effectiveness of the current interventions. * An I&A Report, initiated on 2/5/14 at 9:00 AM, and completed on 5/7/14, documented: - "Following the AM meal (breakfast), resident self propelled w/c back to her room and attempted to transfer to her bed and fell on to the floor. - Care Plan updated - Yes. - An alarm was being used for the resident, the alarm was in place, but the alarm was not turned on. - The resident's bed was in the low position and siderails were up. - Interventions initiated immediately after fall - Assessed res(ident) for any new onset of pain..., assessed for any injuries..., initiated Neuro checks... - Recommendations to prevent further falls - Educate staff on checking that alarms are in place and turned on. Staff to anticipate needs i.e.: toileting pre and post meals. - How long since the resident last voided - 1 hour. - Summary of interviews with witness(es) - NA." NOTE: It was difficult to determine how the resident would be able to transfer successfully from the w/c to the bed with the side rails up and the bed in the low position, the resident was 5 feet 9 inches tall. * The Fall CP, initiated 2/5/14, documented: provide education to staff to ensure that alarms are in place per plan of care and Neuro checks per facility protocol. Both interventions listed above had a line written through them and "D/C," (discontinued); however, there was not a date to indicate when the interventions had been discontinued. * The Fall CP, initiated on 2/18/14, documented: fall mat to left side of bed. *An I&A Report, initiated on 3/23/14 at 10:00 PM, and completed on 4/1/14, documented: - "...heard resident calling for help, opened door of resident's room to find resident lying on floor by sink...left leg appeared displaced, resident stated 'ouch, ouch, ouch' and pointing (to her left leg). Resident transported to local hospital. - Care Plan updated - Yes. - An alarm was being used for the resident, the alarm was in place, but the alarm was not turned on. - How long since the resident last voided - immediately. - Additional comments - Resident at times is compulsive and evidently ambulated independently to the bathroom, possibly disabled alarm system, unknown why resident did not use call light as she has in the past when waiting to use the bathroom at night. - Interventions initiated immediately after the fall - Resident was stabilized with a CNA at side from the time of the incident until transported via ambulance from the facility. - Recommendations to prevent further falls - Upon return from the hospital, the resident will have 30 minute checks for needs and to check alarm placement. - Summary of interview with witness(es) - CNA had checked on resident about 10 min(utes) prior to event and res(ident) appeared to be asleep in bed. - Root Cause Conclusion, Resident had always used call light to ask for assist to bathroom. On this occasion, she did not ask and evidently go up by herself to use the bathroom and was on her way to the sink to wash her hands when she fell . - Cause of injury, It is unknown to me if there are preexisting conditions to this hip fracture, but resident was in evident distress post fall." NOTE: On 3/23/14, at 10:15 PM, the resident was transported to a local hospital for evaluation and treatment of [REDACTED]. * X-ray results, dated 3/24/14, were reviewed and documented the following," Acute comminuted (a fracture in which the bone has broken into several pieces) intertrochanteric left hip fracture with mild shortening." The resident required surgical intervention to repair the left hip fracture. * The resident's Discharge from the hospital, dated 3/28/14, documented the following, "The patient is a...female with a history of right MCA stroke and residual left hemiparesis and expressive aphasia. She initially had a fall with fracture of the left hip in December of 2013, but could not have any surgical procedure as she recently had a stroke during the same time period. She presented to the emergency room (on 3/23/14) after suffering a fall with a new fracture superimposed to recent fracture, intertrochanteric..." NOTE: The resident was readmitted to the facility on [DATE]. * The Fall Risk Evaluation, dated 3/28/14, documented: A score of 12 or above indicated the resident was at high risk for falls, the resident scored a "19." * The Fall CP, initiated on 3/28/14, documented: pressure alarm and 30 min(ute) (checks). (This intervention was already on the care plan with an initiated date of 10/27/13). *Physical Therapy Evaluation, dated 3/31/14, documented: "Resident referred to PT following a hospitalization for a (Left) hip fracture and presents now with TTWB (Toe Touch Weight Bearing)to Left LE (lower extremity) and very dependent with transfers and mobility. PT interventions to include transfer training in light of Wt (weight) bearing restrictions to patient..." * Occupational Therapy Evaluation, dated 3/31/14, documented: " Pt (patient) was a long term care resident but due to fall and hip fx (fracture) she has declined in condition and now requires OT to (increase independence with) self care and return to her prior level of function..." NOTE: The ground level fall on 3/23/14 resulted in ADL decline and ability to ambulate. Prior to the fall, the resident required extensive assistance of one person for ADLs and limited assistance of one person for ambulation; after the fall, the resident required assistance of two people for ADL assistance and she was not able to ambulate due to her hip fracture and TTWB. On 5/9/14 at 12:00 PM, the MCO, Interim DNS, and SDC were interviewed. The surveyor asked the MCO why the Fall CP was not reviewed and revised after each fall to include increased supervision. The MCO said she did not have an answer for why that was not done, but would look into it. The MCO stated she and the RVP, in December 2013, had identified that the facility had concerns related to resident falls and were working with facility staff to decrease the facility's number of falls. No additional information was provided to resolve this concern. The facility failed to implement care plan interventions or provide adequate supervision to reduce Resident #4's risk for falls. The resident was harmed when she fell and fractured her left hip. 2. Resident #1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident's most recent Admission MDS, dated [DATE], coded the following: - Moderately impaired cognition. - Short Term/ Long Term memory, "OK." - Extensive assist of one person for transfers, dressing, toilet use, and bathing. - Independent with bed mobility. - Functional limitation in range of motion on both sides. - Restraints in bed, bed rail - "none." NOTE: The resident's Quarterly MDS was coded incorrectly under P0100, Physical Restraints, and did not trigger a Care Area Assessment to be considered (CAA) for restraints; consequently there were no areas on the resident's care plan related to the use of side rails. Resident #1's bed was observed to have side rails on the bed and in the upraised position on 5/5/14 - 5/8/14 at 8:30 AM, 10:00 AM, 1:00 PM, and 3:00 PM. The resident's medical record was reviewed and it was determined the record did not include documentation that an evaluation for the use of siderails was completed to assess whether or not the siderails were safe for Resident #1 to use. 3. Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's most recent Quarterly MDS assessment, dated 4/7/14, coded the following: - Short Term/Long Term memory impairment. - Extensive assistance of two people for bed mobility, transfers, dressing, and toileting. - Walking in her room, locomotion on and off the unit did not occur. - Functional limitation and impairment of upper and lower extremity on one side. - Restraint in bed, bed rail - "none." NOTE: The resident's Quarterly MDS was coded incorrectly under P0100, Physical Restraints, therefore it did not trigger a Care Area Assessment to be considered (CAA) for restraints; consequently there were no areas on the resident's care plan related to the use of side rails. Resident #1's bed was observed to have side rails on the bed and in the upraised position, on 5/5/14 - 5/8/14 at 8:40 AM, 10:10 AM, 1:10PM, and 3:00 PM. A Device Evaluation form, dated 10/27/13, documented: * "Cognitive Status - Memory impaired, decreased safety awareness, and short attention span. * Bed mobility - Assisted mobility. * Transfer - Assisted transfer. * Functional Limitation - Left arm, hand, leg, and foot, flaccid. * Balance/Posture - Imapaired balance, leans to the left, flaccidity, and uncontrolled body movements. * Fall History - fell within the last 30 days. * Side Rail evaluation = If side rails are in use, they are to be considered a positioning device. The summary of risk factors and interventions attempted to date, on page 2 of this form was blank. NOTE: Per the facility's policy and the directions on the Device Evaluation Form, the side rails were supposed to be evaluated quarterly. The quarterly evaluation portion of the form was blank. Resident #4's side rails had not been assessed since 10/27/13 or 6 months prior to survey. Additionally, it could not be determined the side rails had ever been assessed for safety. On 5/9/14, at 9:20 AM, the MCO, DNS, and SDC were interviewed related to the above concern. The MCO stated the maintenance supervisor had assessed the side rails throughout the building for safety to include gap assessment and whether the bed itself was safe for use; however, she stated the side rails in use for Resident #1 and #4 had not been individually assessed for safety. 4. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Annual MDS Assessment, dated 1/4/14, documented the following: *Resident was cognitively intact with a BIMS Score of 15. *Extensive assistance of one person for bed mobility, transfer, dressing, toilet use and bathing. *Walking in room and corridor did not occur. *Height = 64" (5'5"), Weight = 277# (pounds). The resident's most recent Quarterly MDS Assessment, dated 4/6/14, documented the following: *Cognitively intact with a BIMS Score of 13. *Extensive assistance of two 2+ persons for bed mobility, transfers, dressing, toilet use and bathing. *Walking in room and corridor did not occur. *Height = 64" (5'5"), Weight = 262 #. The CAA (Care Area Assessment) Worksheet, dated 1/4/14, documented in the analysis of findings for the ADL Functional/Rehabilitation Potential, "Resident has self care deficit r/t weakness to BLE (bilateral lower extremities). Resident states she needs extensive assist for her ADL's r/t her BLE that she has weakness and pain and cannot lift her legs for self transferring...needs extensive assist for lower body..." The resident's Fall Care Plan (CP), initiated on 6/23/09, documented: *"During transfers ensure client has appropriate fitting shoes or non skid socks to prevent slipping. *Instruct/teach client to wait for assistance and educate on fall preventions such as setting wheelchair brakes, use walker, etc. PRN. *Monitor frequently for safety issues, keep room clean and clutter free. *Use gait belt when transferring, as needed." (This intervention was discontinued on 1/18/14). The resident's Nursing Assistant Care Card (undated) documented the resident needed extensive assistance of 1-2 persons for transfers and assistance of 1 person for toilet use. An Incident/Accident Report (I&A), initiated on 3/7/14 at 12:00 PM and completed on 3/26/14 at 11:52 AM, (refer to F-225 as it relates to investigations) documented: *Event: Resident lowered to floor. *Injury: Fracture (left ankle). *Transported out of center: Yes. *admitted : Yes. *Date: 3/7/14. *Transferred to hospital: Yes. *Care Plan updated: Yes. *Footwear/Equipment at time of fall: Shoes, socks, walker, wheelchair, walker. *Did fall occur during a transfer: Yes. *Use of gait belt: No. *Activity engaged in at the time of fall: Resident had just finished voiding on BSC (bedside commode) when a CNA was assisting the resident up from commode and back into wheelchair. *Interventions initiated immediately after fall: Assisted to bed with use of Hoyer mechanical lift. Stabilized left ankle with pillows. Ice pack applied to left ankle. Pain medication given. *Recommendations to prevent further falls: Hoyer lift for all transfers. *Summary of interview with witness: CNA was assisting res(ident) up from BSC. Bottom of pant covered the bottom of resident's shoes. CNA and resident were attempting to pull pants up when resident began to slip down. Resident was then lowered to the floor with assistance. *Root cause conclusion: Resident's pants extended below her feet causing her to slip. Resident has history of osteoporosis, poor neuromuscular strength and morbid obesity. *Cause of injury: Pants became entangled around bottom of feet. Morbid obesity with long history of osteoporosis. On 5/6/14 at 10:10 AM, Resident #3 commented to the surveyor regarding her fall. She stated it happened on day shift, that CNA #1 was behind her and helped her off the BSC. She stated all of a sudden she went down and the CNA also went down. The resident stated she went to the hospital and had surgery on her left foot. On 5/8/14 at 1:15 PM, Resident #3 was interviewed. She stated before the fall she could stand without problems but was using a wheelchair instead of walking. She could physically do whatever she wanted, was able to tidy up her room, and enjoyed being involved with the activities program. She stated she didn't know what caused her fall. She said she didn't need pain medication before the fall but now needs pain medication "3-4 times per day." She stated that "some days the pain is worse than others." NOTE: Record review of the resident's MAR, dated February 2014, documented the resident did not receive any PRN pain medication. However, the MAR, dated March 2014, after the resident fell and fractured her left ankle, documented she requested PRN pain medication on March 16, 17, 18, 23, 24, and 30. The MAR, dated April 2014, documented the resident requested PRN pain medication a total of 18 times. Resident #3 stated she did not remember CNA #1 using a gait belt when transferring her from sitting to a standing position. She stated CNA #1 was behind her, and that she fell backwards on her. Resident #3 stated she is now bed bound and gets up for meals occasionally in the WC but then goes right back to bed. She stated "The fall has really messed up my whole life" due to pain and having to stay in bed. She stated she has "pain most of the day and night." On 5/8/14 at 1:45 PM, CNA #1 was interviewed regarding Resident #3's fall. She stated Resident #3 could stand and pivot before the fall. She stated the resident "was fairly mobile and was able to do a lot on her own." She stated the resident combed her own hair, put on cosmetics, attended numerous activities, washed the front parts of her body and private areas, and dried herself. Before the fall, CNA #1 stated the resident was a one person assist and that another aide had put her on the BSC (bedside commode). CNA #1 responded when the resident put on her call light. She stated Resident #3's walker was in front of the resident and that the resident held on to the walker as she stood up. The resident's WC was locked on the resident's right side, CNA #1 stated, and she was between the BSC and the resident. The resident lost her balance and landed on her, CNA #1 stated, as she was pulling the resident's pants up and the resident lost her balance. She stated she thought the resident's left leg bent backwards when she went to the floor. CNA #1 stated she thought the resident was standing on a string but didn't think the resident's pants were under her feet. When asked if she used a gait belt (device used for transferring people from one position to another) with Resident #3, CNA #1 stated she normally used a gait belt with most resident's but didn't have one large enough at the time. The facility's Policy and Procedure for Safe Resident Handling Equipment documented, "A Gait Belt is used with patients who can safely ambulate with assistance and/or perform greater than or equal to 50% of lift/transfer with stand pivot assistance with one staff member." On 5/9/14 at 9:15 AM, CNA #4 stated she worked with the resident before and after her fall on evening shift. CNA #4 stated she had noticed a change in Resident #3's attitude after the fall, who she said no longer wanted to get out of bed or shower, "usually because of pain." On 5/9/14 at 10:20 AM, the NPE and the MCO were made aware of the above concerns related to the resident's fall. The surveyor asked why the gait belt was discontinued on the resident's Fall Care Plan on 1/18/14. The MCO stated the DNS at the time discontinued the gait belt and stated, "I can't speak to that." Prior to the fall on 3/7/14, the resident was able to stand and pivot, helped with her activities of daily living, attended numerous activities and did not request PRN pain medication. After the fall, the resident had a decrease in her daily function, was non weight bearing and mainly stayed in bed. She had a change in attitude and does not want to get out of bed due to an increase in pain. She is not able to attend the activities program. Additionally, the resident stated the fall "really messed up her whole life due to pain and having to stay in bed." Prior to the fall on 3/7/14, the resident did not request PRN pain medication, however, since the fall the resident has requested PRN pain medication on a regular basis. The facility failed to identify interventions to replace the gait belt when it was discontinued from the care plan. CNA #1 stated she normally used a gait belt but didn't have one large enough for Resident #3 at the time of the 3/7/14 transfer, fall, and fracture. The resident was harmed due to the facility's failure to ensure the resident was safe when being transferred. Additionally, Resident #3's bed was observed to have side rails on the bed and in the upraised position throughout the survey on 5/5/14 - 5/9/14. The resident's medical record was reviewed and it was determined the record did not include documentation that the use of side rails had been assessed to be safe for this resident. On 5/9/14 at 11:45 AM, the NPE was interviewed regarding the side rail restraint evaluation. The NPE stated, "The floor nurse had assessed it incorrectly." 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's bed was observed to have a side rail on the bed in the upright position throughout the survey on 5/5/14 - 5/7/14. The resident's medical record was reviewed and it was determined the record did not include documentation that the use of side rails had been assessed to be safe for this resident. On 5/8/14 at 3:10 PM, the NPE was interviewed regarding the side rail restraint evaluation. The NPE stated, "I do not see that the side rail has been assessed to be safe." On 5/8/14 at 4:50 PM, the Administrator, MCO and NPE were made aware of the above side rail issues. No further documentation was provided.

Based on a complaint from the general public, record review, and staff interview, it was determined the facility failed to prevent residents from acquiring multiple pressure ulcers. This was true for 1 of 3 residents (#3) sampled for pressure ulcers and resulted in harm to Resident #3, who developed five Stage II and Stage III pressure ulcers on her buttocks, sacrum, and coccyx, as well as two pressure ulcers on the left foot. Additionally, it was determined that the facility failed to provide Resident #3 with physician ordered treatment for [REDACTED]. On 10/6/11, the Idaho Department of Health and Welfare, Bureau of Facility Standards, received a complaint from the general public that stated the identified resident (Resident #3) had developed a number of pressure ulcers while under the care of the facility, treatment for [REDACTED]. Resident #3 was admitted to the facility from an acute care hospital on [DATE] with [DIAGNOSES REDACTED]. The resident had sustained a pathological [MEDICAL CONDITION] leg at home prior to her admission to the hospital, and discharged from the skilled nursing facility on 10/4/11 with orders for hospice care at home. A physician's Clinic Visit Note, dated 8/31/11, documented, "Her (Resident #3) only other complaint is some skin breakdown in the peri area and on the buttocks. They have been using over-the-counter barrier creams for this and they have not helped. Skin breakdown related to the patient's incontinence and continuous sitting." A History and Physical from the hospital, dated 9/6/11, documented, "She (Resident #3) has had skin excoriation on the groin, upper thighs, and buttocks and under her pannus. The patient does have a lot of [DIAGNOSES REDACTED] and irritation in the groin, buttocks ..." A hospital Discharge Summary, dated 9/8/11, documented, "The patient does have a lot of [DIAGNOSES REDACTED] and irritation in the groin and buttocks. ... she was fitted with an immobilization boot to wear at all times when she was out of bed. With the patient's debilitated status with the fibular fracture as well as with the skin conditions, in the groin and buttocks, it is felt that it would be beneficial to keep her Foley catheter in until she is more ambulatory. On discharge, the patient is instructed to wear her immobilization boot at all times unless she is in bed." The resident's 14-day admission MDS assessment, dated 9/19/11, documented the following: * Cognitive skills intact for daily decision making * No behaviors, but felt tired and without any energy * Extensive assistance of at least two staff members required for bed mobility, dressing, personal hygiene, and bathing * Indwelling catheter * Always incontinent of bowel * Transfers and ambulation did not occur during the assessment period * Five Stage I pressure ulcers; no Stage II, III, IV, or unstageable pressure ulcers; and no venous or stasis ulcers * Pressure reducing device to chair * No pressure reducing device to bed * Ulcer care provided A Norton Pressure Ulcer Scale assessment, dated 9/9/11, documented a score of "10;" the Norton Scale designated scores of 10 or less as "High Risk" for pressure ulcers. Recapitulated physician's orders [REDACTED].. Resident #3's Skin Care Care Plan, dated 9/14/11, documented the following: * "Focus: Alteration in skin integrity r/t (related to): decreased mobility. Date initiated: 9/13/11." A handwritten note, dated 9/27/11, documented, "New onset pressure ulcers." * "Interventions: Report c/o (complaints of) pain to LN; report any new open areas to LN; administer medication as ordered; check for incontinence and provide pericare as needed ...; check pedal pulses as ordered ...; cut and trim toenails ...; document on flow sheet if skin is intact ... (or) ... is reddened or has open areas ...; follow center protocol/regime for treating breaks in skin integrity; inspect and monitor feet ...; keep resident's fingernails short ...; monitor s/s (signs and symptoms) of pain ...; observe for cause of skin tear ...; observe standard precautions; weekly skin assessment per protocol." All interventions included a start date of 9/13/11. Handwritten entries, all with start dates of 9/27/11, documented, "air bed, tx (treatment) per MD (physician) order, weekly measurements." A Medical Nutrition Therapy Assessment, dated 9/15/11, documented, "Has bruising on extremities, skin otherwise intact. Norton Score = 10 - at risk for skin breakdown." The resident's Nutrition Care Plan, however, was dated 9/22/11 and included no documentation related to the resident's skin condition or risk factors. Recapitulated physician's orders [REDACTED]. documented as 9/28/11), and "Weekly skin assessment" (Start date documented as 9/9/11). Resident #3's Nursing Progress Notes documented the following: * 9/12/11 - "Upon returning to bed a full skin assessment was completed. Noted large skin tear to (right) upper chest/neck area. Res(ident) also noted to have reddened areas under bilat(eral) breasts possibly from gait belt. Res(ident) had walking boot to LLE (left lower extremity). * 9/27/11 - "Dr. (name), Noted that resident has some pressure breakdown in skin integrity to her buttocks. (Left) buttock has a 5 cm X 3.1 cm (5 centimeter by 3.1 centimeter) Stage II ulcer as well as a 1.5 X 1.5 cm Stage II. (Right) buttocks has a 1.75 X 0.75 cm Stage II and a 2.25 X 1 cm Stage II. The sacral area also has a 0.5 X 0.25 cm Stage II ulcer. Applied mediseptic and covered. Could we get an order for [REDACTED]. Thank you." * 9/29/11 - "Resident reviewed for new wounds to buttocks ... MD (and) family notified of new wounds. Air bed has been implemented (and) request sent for tx. Will begin weekly measurements. Per hx (resident history) in chart she had a wound on 8/17/11 (at) home." NOTE: The facility provided documentation that a pressure relieving air bed had been ordered on [DATE] and received by the facility on 9/29/11. Pressure Ulcer Documentation Forms for Resident #3 documented the following: * 9/27/11: Right Lateral Buttocks - Stage II, 2.25 cm X 1 cm. No odor or tunneling. * 10/2/11: Right Lateral Buttocks - Stage II, 1.75 cm X 0.75 cm. No odor or tunneling. * 9/27/11: Sacral Crease - Stage II, 0.5 cm X 0.25 cm. No odor or tunneling. * 10/2/11: Sacral Crease - Stage II, 0.5 cm X 0.25 cm. No odor or tunneling. * 9/27/11: Right Medial Buttocks - Stage II, 1.75 cm X 0.75 cm. No odor or tunneling. * 10/2/11: Right Medial Buttocks - Stage II, 0.5 cm X 0.5 cm. No odor or tunneling. * 9/27/11: Left Medial Buttocks - Stage II, 1.5 cm X 1.5 cm. No odor or tunneling. * 10/2/11: Left Medial Buttocks - Stage II, 0.75 cm X 0.75 cm. No odor or tunneling. * 9/27/11: Left Lateral Buttocks - Stage II, 5 cm X 3.1 cm. No odor or tunneling. * 10/2/11: Left Lateral Buttocks - Stage II, 5 cm X 2.75 cm. No odor or tunneling. Resident #3's September 2011 MAR indicated [REDACTED] * "Apply [MEDICATION NAME] ointment to pressure ulcers on buttocks and sacral area, and cover BID until healed. Start date: 9/28/11. Twice a day everyday." The resident was to receive the treatment at 8:00 a.m. and 8:00 p.m., however the September 2011 MAR indicated [REDACTED]. The resident's October 2011 MAR indicated [REDACTED]. An Interdisciplinary Progress Note, dated 10/4/11, at 11:00 a.m., documented, "Res(ident) D/C'd (discharged ) home (with) hospice services. Hospice to provide wound care ..." A Transfer/Discharge Report, dated 10/4/11 at 11:00 a.m., documented, "Going home (with) hospice services. Wounds to buttocks. Educated on need for air bed (and) frequent position changes." Physician Orders, dated 10/3/11, included a list of "Additional Discharge Orders" that did not document any medications and/or treatments for Resident #3's pressure ulcers. A Resident's Recapitulation of Stay Discharge Plan and Instructions, dated 10/4/11, did not document any information related to Resident #3's pressure ulcers, other than the need for an air bed assistive device. Hospice Wound/Pressure Sore - Weekly Assessment forms, dated 10/4/11, documented that one of the resident's right buttock pressure ulcers measured 2.25 cm X 1 cm.; the second right buttock pressure ulcer measured 1.75 cm X 0.75 cm; the sacral pressure ulcer measured 0.5 cm X 0.25 cm; and that the first left buttock pressure ulcer measured 5 cm X 3.1 cm and the second left buttock pressure ulcer measured 1.5 cm X 1.5 cm. A Hospice Wound/Pressure Sore - Weekly Assessment form, dated 10/5/11, documented the resident had a Stage III pressure ulcer on her left heel that measured 1 cm X 1 cm and a Stage I pressure ulcer on the left lateral foot that measured 3 cm X 1 cm. A Hospice Skilled Nursing Visit form, dated 10/5/11, documented, "Bed sores X 7. No s/s of infection (with no complaints of) pain, but (with) Stage I had 5 on (pain rating scale) (with) grimacing/moaning when cleansing." On 10/13/11, at 3:40 p.m., the facility's DON was interviewed. When asked to explain the cause for Resident #3 developing five Stage II pressure ulcers to her buttocks and sacral area, the DON stated, "She wasn't participating a whole lot with getting up. She was a Hoyer (assisted transfer resident) and she sat a lot; she didn't like her off-loading and position changes." When asked to explain the facility's failure to document pressure ulcers to the resident's left foot, as documented by hospice staff on the day of discharge from the facility, the DON said that she was not aware that Resident #3 had wounds on her left foot, noted that the immobilizer boot on the resident's left foot was removed anytime the resident was in bed, and stated, "She only wore the boot to eat and for therapy, otherwise she was in bed without the boot (on)." When asked about staff's failure to provide treatment for [REDACTED]. to assume that we didn't have it ([MEDICATION NAME] ointment) yet because the pharmacy hadn't delivered it. I hope it's not just a hole (staff lack of documentation on the resident's MAR). Resident #3 was admitted to the facility following surgical repair to a fractured leg and with a known history of skin breakdown. The resident was assessed by the facility to be at high risk for the development of pressure ulcers. The facility failed to implement adequate preventative measures to protect the resident's skin, or treatment as physician ordered when the resident did develop multiple pressure ulcers during the 24 days that the resident was at the facility. The resident was harmed when she developed five Stage II ulcers to the buttocks and sacral area and two pressure ulcers, including a Stage III ulcer, to the left foot.