Every finding on record at Powell Valley Care Center

Based on medical record review, staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 11 sample residents (# 2, #4) reviewed for allegations of abuse. This failure resulted in actual harm to resident #2 and resident #4. The findings were: 1. Review of the 10/21/25 annual MDS assessment showed resident #1 had a BIMS score of 0, indicating severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression. Review of the care plan, initiated 5/23/23, showed the resident had impaired thought processes and impaired decision making. Review of the 10/28/25 quarterly MDS assessment showed resident #2 had a BIMS score of 0, indicating severe cognitive impairment, and diagnoses that included Alzheimer's disease, non-Alzheimer's dementia, and depression. Review of the care plan, initiated 11/12/24, showed the resident had the potential for a behavioral problem due to severely impaired cognition. The following concerns were identified:a. Review of an incident dated 10/28/25 showed resident #2 was found outside of the staff bathroom and was heard yelling You fucking bitch! You pinched me! I oughta lay you out! I should kick your ass!. Resident #1 was found with his/her hands near resident #2's neck. Staff intervened and redirected the residents. After examining resident #2, nurse #1 noticed a 0.6 cm open wound on the right side of his/her neck. The wound was cleansed with wound wash and dressed with a band aid. b. Interview with RN #1 on 12/1/25 at 3:25 PM revealed she had been in the restroom when she heard yelling and quickly left the restroom, where she found resident #1 behind resident #2, and she noticed a small mark on resident #2's neck. Resident #1 had yelled obscenities at the time. RN #1 took resident #2 to the DON who cleaned up the scratch on resident #2's neck.c. Interview with the DON on 12/2/25 at 2:12 PM confirmed she cleaned the area on resident #2's neck, and the skin was broken but did not require a dressing. 2. Review of the 11/4/25 annual MDS assessment showed resident #3 had a BIMS score of 8, indicating moderate cognitive impairment, and diagnoses that included non-Alzheimer's dementia, depression, and cerebrovascular accident (CVA). Review of the care plan, last revised on 9/14/22, showed I can be verbally aggressive (calling people fat/mean and hateful comments, cussing and yelling). Review of the 9/30/25 quarterly MDS assessment showed resident #4 had a BIMS score of 0, indicating severe cognitive impairment, and diagnoses that included vascular dementia and CVA. The following concerns were identified:a. Review of an incident dated 11/25/25 showed RN #1 was notified by CNA #1 that resident #3 had hit resident #4 in the face with a spiral notebook. When resident #4 was assessed there were no visible injuries. Resident #4 stated s/he was not hurt, was crying and visibly upset, and asked why would somebody do that? When staff asked resident #3 why s/he hit resident #4, s/he stated [s/he's] a bitch. Resident #3 was removed from the area and staff assisted him/her to the toilet, where s/he was combative with cares. Resident #3 was then left in his/her room to try and calm down. About 30 minutes later, RN #1 was in the kitchen with another resident when she heard screaming. She saw resident #4's head being pulled back and ran over to assess the situation, and found resident #3 grabbed resident #4's hair hard and yanked it backwards with force. It took nurse #1 and CNA #1 to get resident #3 to let go of resident #4's hair. Resident #3 again started calling resident #4 names. Resident #4 was assessed and asked if s/he was okay, and staff reported s/he had a clump of about 30 hairs pulled out of his/her head, and s/he cried and stated why did [s/he] do that? Staff reassured resident #4 they would handle the situation. Resident #3 was removed from the unit and taken to RN #2's office to separate residents. b. Interview with RN #1 on 12/1/25 at 3:25 PM revealed she heard yelling and saw resident #3 hit resident #4 in the face with a spiral notebook. Resident #4 stated why did [s/he] do that? after s/he was hit. RN #1 took resident #3 to the restroom in an attempt to calm him/her down. During the toilet transfer, resident #3 grabbed RN #1's scrub top, and it took several people to get him/her to let go. 30 minutes after resident #3 was toileted, s/he wheeled his/her wheelchair across the unit and grabbed resident #4 by the hair. c. Interview with RN #2 on 12/2/25 at 1:38 PM revealed the NHA and DON were in a meeting, and she had been asked to let them know that there had been an incident between resident #3 and resident #4. She reported resident #3 was in his/her room, and resident #4 was in the common hallway after s/he had been hit in the face. She reported she assisted RN #1 and CNA #1 to help resident #3 use the lift to transfer to the toilet, and then left the room so there would not be so many people to increase agitation from resident #3. She reported she supervised resident #3 in the administration office after the incident.d. Interview with CNA #1 on 12/2/25 at 2:18 PM revealed she had been in another resident's room when resident #3 hit resident #4 in the face with the notebook. Further interview revealed resident #3 started crying and the staff separated resident #3 from resident #4. When she asked resident #4 what happened, she was told [s/he] hit me in the face with a notebook and told me 'you're ugly and should go kill yourself'. She reported that approximately 30 minutes after resident #3 hit resident #4, she heard resident #4 yell ow!, she saw resident #3 had a handful of resident #4's hair, and it took 2 staff members to get them separated. Resident #4 would not let anyone else touch him/her or brush his/her hair for the rest of the night. 3. Review of the facility policy titled Abuse: Recognizing and Reporting updated March 2023, showed Abuse is identified as physical abuse, sexual abuse, mistreatment, neglect, or misappropriation of patient/resident property. This includes violations against spouses, vulnerable adults, and children. A vulnerable adult means any person eighteen (18) years of age or older who is unable to manage and take care of him or herself or his or her property without assistance as a result of advanced age or physical or mental disability.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents received services to maintain or improve their ability to carry out activities of daily living for 1 of 3 residents (#21) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #21 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease. The review showed the resident required substantial/maximal assistance with oral hygiene, toileting hygiene, upper and lower body dressing, rolling left and right, sitting to standing, sitting to lying, lying to sitting, and transfers. Further review showed during the look-back period the resident had 2 or more falls with no injury, a fall with minor injury, and did not receive therapy services or restorative nursing programs. Review of the ADL self-care performance deficit care plan last revised on 11/26/24 showed .restorative staff to encourage and assist me with walking. Weather and behaviors permitting I would like to go outside. Three times a week as tolerated . The following concerns were identified: a. Review of the resident's record from 1/1/25 to 1/30/25 showed a restorative task for active range of motion and a program for ambulation two to three times per week. Further review showed no evidence the ambulation program was performed, offered, or refused and the active range of motion was only performed once, on 1/22/25, during the 30-day period. b. Interview with the restorative nurse on 1/31/25 at 8:37 AM revealed restorative CNAs should offer restorative programs 2 to 3 times per week and should document refusals. The restorative nurse revealed she tries to evaluate programs quarterly with the MDS assessments and she may have forgotten to change the resident's program to as needed. Further interview revealed sometimes restorative aides got pulled to work the floor if there was an opening; however, that was not an issue during the last 30 days. 2. Review of the policy titled Restorative Program dated 2/2024 showed .Maintenance and restorative programs will be provided to residents as indicated by the resident's comprehensive assessment: I. To ensure the resident receives the care and services because he/she is unable to perform Activities of Daily Living, (ADL) independently. II. To promote resident wellness and maintenance or restoration of ADL functions .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to implement interventions to ensure resident safety for 1 of 3 sample residents (#100) reviewed for falls. This failure resulted in actual harm to resident #100 who sustained fractures and was hospitalized . The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #100 had a brief interview for mental status (BIMS) score of 3 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and anxiety disorder. Further review showed the resident required extensive physical assistance of 2 or more people for transfers and extensive physical assistance of 1 person for toileting and personal hygiene. Review of the self-care deficit care plan last revised on [DATE] showed interventions which included .Transfer: I recently sustained major injury post fall and am now an extensive/total assist of two staff members at all times. Staff may use Sara lift [sit-to-stand type mechanical lift] for transfer with two person assist or staff can pivot transfer me as tolerated by me . Review of the mobility deficit care plan last revised on [DATE] showed and intervention of .Transfer: I am no longer able to transfer independently with my four wheeled walker. I am currently using a wheelchair related to recent injury . which was revised on [DATE]. Review of the care plan titled I am a high risk for falls r/t [related to] memory impairment and history of falls care plan last revised on [DATE] showed interventions which included .Ensure that I am wearing appropriate footwear (specify and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks) when up ambulating . The following concerns were identified: a. Review of a progress note dated [DATE] and timed 7:41 PM showed the resident had a fall that day at 6:30 PM, had been assisted to the bathroom by 1 staff without a mechanical lift or gait belt, and the resident was not wearing any footwear. Further review showed the resident had complaints of bilateral knee pain. b. Review of a progress note dated [DATE] and timed 11:15 PM showed the emergency room nurse contacted the facility to notify them of the resident transfer by helicopter flight to [NAME] due to bilateral displaced femur fractures. c. Review of a progress note dated [DATE] and timed 3:51 PM showed the resident's representatives had decided a non-operative care approach with a focus on comfort. Further review showed the resident was placed on comfort measures and was being medically stabilized for return to the facility at an unknown date. d. Review of a progress note dated [DATE] and timed 9:15 AM showed the resident was given Morphine IR (pain medication) 15 mg and transferred to the facility without immobilizers and with a Foley catheter present. e. Review of a progress note dated [DATE] and timed 11:36 AM showed the resident returned to the facility with several new wounds which included 2 skin tears, 2 deep tissue injuries on his/her left buttocks/coccyx, a deep tissue injury to his/her right gluteal fold, and a deep tissue injury to his/her right mid back. f. Review of a progress note dated [DATE] and timed 3:46 PM showed the resident was pronounced deceased at 11:55 AM. g. Review of a root cause analysis provided by the administrator on [DATE] showed [Resident] s/p [status post] fall on [DATE] at 1830 [6:30 PM], assisted fall. [S/he] was transferred to ER. [S/he] X-ray [sic] results stated comminuted periprostehetic [sic] fractures distal right femur with displacement of the right total knee prosthesis and boney fragments posteriorly and comminuted displaced periprostehetic [sic] fracture distal left femoral shaft with the prosthesis and distal femur displaced medially. Large joint effusion and prepatellar swelling Under the section describe what happened the document showed [Resident name] was being assisted with toileting by the CNA, resident was trying to sit on the toilet, and slid off the toilet and onto the floor. Legs were bent under and to the side of [him/her], assessment completed noted deformity to right knee prior to moving, 911 called to sent [sic] to ER. Further review showed the statement of cause included the resident was not wearing socks or shoes, a gait belt was not used, the staff member was not aware of the resident's transfer status, and the resident's care plan was not followed. 2. Interview with CNA #1 on [DATE] at 6:07 PM confirmed she assisted resident #100 to the bathroom without assistance on [DATE], a gait belt or mechanical lift was not used, and the resident was not wearing any footwear. Further interview revealed the resident attempted to stand without assistance, fell to the ground, and reported pain in his/her legs. 3. Interview with the infection preventionist, DON, restorative nurse, MDS coordinator, nurse manager #1, and the administrator on [DATE] at 8:37 AM revealed resident #100 was very independent prior to a fall on [DATE] which resulted in a fibula fracture. Following the [DATE] fall, the resident had a decline in ability and required a mechanical lift for transfers. During the 2 months prior to the [DATE] fall, the residents was able to transfer with a sit-to stand type mechanical lift transfer or a gait belt and stand and pivot procedure; however, the resident required 2 staff members for all transfers. They confirmed the resident declined after the fall on [DATE] and passed away on [DATE]. Further interview revealed staff were expected to use a gait belt for all physically assisted transfers, were expected to identify the resident's transfer status prior to transfer, and follow the resident's care plan when assisting residents. 4. Review of the Gait Belt procedure last revised [DATE] showed .1. A gait belt must be used by all nursing staff in the following situations: a. When transferring residents who are cooperative, able to bear weight, partially independent. b. When assisting a patient/resident to the floor, or off of the floor if a fall occurred. c. When ambulating with patient/resident who requires a minimum of stand by assistance . 5. Review of the policy titled Care Plan: Initiating Individualized Patient/Resident Care Plans last revised on [DATE] showed Nurses caring for the patient/resident are responsible for ensuring that the multi-disciplinary plan of care is implemented and updated as appropriate .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure care plans were implemented for 1 of 3 sample residents (#100) with falls. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #100 had a brief interview for mental status (BIMS) score of 3 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and anxiety disorder. Further review showed the resident required extensive physical assistance of 2 or more people for transfers and extensive physical assistance of 1 person for toileting and personal hygiene. Review of the self-care deficit care plan last revised on 8/10/23 showed interventions which included .Transfer: I recently sustained major injury post fall and am now an extensive/total assist of two staff members at all times. Staff may use Sara lift [sit-to-stand type mechanical lift] for transfer with two person assist or staff can pivot transfer me as tolerated by me . Review of the mobility deficit care plan last revised on 8/10/23 showed and intervention of .Transfer: I am no longer able to transfer independently with my four wheeled walker. I am currently using a wheelchair related to recent injury . which was revised on 5/11/23. Review of the care plan titled I am a high risk for falls r/t [related to] memory impairment and history of falls care plan last revised on 5/17/23 showed interventions which included .Ensure that I am wearing appropriate footwear (specify and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks) when up ambulating . The following concerns were identified: a. Review of a progress note dated 11/11/23 and timed 7:41 PM showed the resident had a fall that day at 6:30 PM, had been assisted to the bathroom by 1 staff member without a mechanical lift or gait belt, and the resident was not wearing any footwear. Further review showed the resident had complaints of bilateral knee pain. b. Review of a root cause analysis provided by the administrator on 12/6/23 showed [Resident] s/p [status post] fall on 11/11/2023 at 1830 [6:30 PM], assisted fall. [S/he] was transferred to ER. [S/he] X-ray [sic] results stated comminuted periprostehetic [sic] fractures distal right femur with displacement of the right total knee prosthesis and boney fragments posteriorly and comminuted displaced periprostehetic [sic] fracture distal left femoral shaft with the prosthesis and distal femur displaced medially. Large joint effusion and prepatellar swelling Under the section describe what happened the document showed [Resident name] was being assisted with toileting by the CNA, resident was trying to sit on the toilet, and slid off the toilet and onto the floor. Legs were bent under and to the side of [him/her], assessment completed noted deformity to right knee prior to moving, 911 called to sent [sic] to ER. Further review showed the statement of cause included the resident was not wearing socks or shoes, a gait belt was not used, the staff member was not aware of the resident's transfer status, and the resident's care plan was not followed. c. Interview with CNA #1 on 12/6/23 at 6:07 PM confirmed she assisted resident #100 to the bathroom without assistance on 11/11/23, a gait belt or mechanical lift was not used, and the resident was not wearing any footwear. 2. Interview with the infection preventionist, DON, restorative nurse, MDS coordinator, nurse manager #1, and the administrator on 12/7/23 at 8:37 AM revealed resident #100 was able to transfer with a sit-to stand type mechanical lift transfer or a gait belt stand and pivot procedure; however, the resident required 2 staff members for all transfers. Further interview revealed staff were expected to use a gait belt for all physically assisted transfers, were expected to identify the resident's transfer status prior to transfer, and were expected to follow the resident's care plan when assisting residents. 3. Review of the policy titled Care Plan: Initiating Individualized Patient/Resident Care Plans last revised on August 2020 showed Nurses caring for the patient/resident are responsible for ensuring that the multi-disciplinary plan of care is implemented and updated as appropriate .

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days for 1 of 5 sample residents (#42) and failed to ensure appropriate target symptoms were identified and monitored, and gradual dose reductions were performed for 1 of 5 sample residents (#4) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #42 had a brief interview for mental status score (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included non-alzheimer's dementia. Further review showed the resident had behaviors of delusions and hallucinations and received an antidepressant medication. The following concerns were identified: a. Review of the physician's orders showed the resident received an order for Ativan (antianxiety) 0.5 mg as needed one time per day for body spasms on 11/21/23 and no stop date or physician's rationale was indicated. b. Observation of the medication administration on 12/6/23 at 8:45 AM showed RN #1 administered Ativan 0.5 milligrams (mg) by mouth, 15 days after the Ativan order was obtained. c. Review of the November 2023 medication administration record (MAR) showed the Ativan 0.5 mg order was started on 11/21/23 and administered to the resident on 11/30/23. Review of the December 2023 MAR showed the Ativan 0.5 mg was administered to the resident on 12/6/23. d. Interview with RN #1 on 12/7/23 at 8:30 AM revealed she was unaware PRN Ativan should not exceed a 14 day duration and confirmed she administered the medication to the resident on 12/6/23. Interview with the RN on 12/7/23 at 8:50 AM revealed she spoke with the resident's physician and the physician was aware of a 14 day rule; however, the physician had not received a notice to change the order as of that time. e. Interview with the DON and nurse manager #1 on 12/7/23 at 9:35 AM revealed there was no evidence a request was sent to the physician for a stop date or a physician rationale for the long term use of the as needed Ativan order. 35081 2. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 8 out 15, which indicated moderate cognitive impairment, and diagnoses which included anxiety disorder and depression. Further review showed the resident had a patient health questionaire-9 (PHQ-9) score of zero, which indicated no depression symptoms, and no behaviors were exhibited. Review of the physician orders showed the resident received sertraline (anti-depressant) 150 mg by mouth daily for depression related to other specified anxiety and trazadone (anti-depressant) 75 mg by mouth at bedtime for insomnia. The following concerns were identified: a. Review of the care plan last revised on 11/30/22 showed I'm having psychosocial well-being problem [sic] r/t [related to] s/s [signs and symptoms] of depression and interventions which included Monitor/document/report PRN [as needed] adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes .Not being able to see or hear very well is hard and makes me sad. Please be patient with me and speak up when talking .Social services to monitor my mood/behavior every quarter and as needed . Further review showed no specific target symptoms were identified for the use of sertraline or trazadone. b. Review of the I use two antidepressant medications r/t [related to] depression and insomnia care plan last revised on 5/31/23 showed interventions which included Monitor/document/report PRN [as needed] adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes .Not being able to see or hear very well is hard and makes me sad. Please be patient with me and speak up when talking .Social services to monitor my mood/behavior every quarter and as needed . and no specific target symptoms were identified for the use of sertraline or trazadone. Further review showed follow guidelines for GDR [gradual dose reduction] attempts unless contraindicated by my physician. b. Review of the physician orders for December 2023 showed .Behaviors-Monitor for the following: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. For antidepressant use. There was no evidence of behavior monitoring related to the use of trazadone. c. Review of a pharmacy services communication dated 5/3/23 showed .This note is in reference to you resident, [resident's name], who is currently on the anxiolytic/hypnotic medication trazadone 75 mg po [by mouth] at bedtime for insomnia. Please review and indicate below if you think we could trial a lower dose or if [s/he] should remain where [s/he] is at . A facility RN added In talking with [resident's name] [s/he] doesn't want any changes to this as [s/he] feels this helps [him/her] sleep at night and feels the current dose is effective . Further review showed the physician marked a box which stated I consider a dosage reduction to be clinically contraindicated; however, the rationale section was not completed. d. Review of a pharmacy services communication dated 5/3/236/2/22 and signed by the physician on 7/25/23 showed This note is in reference to your resident, [resident's name] who is currently on Sertraline 100 mg daily for depression. Please review and indicate below if you think we could trial a lower dose or if [s/he] should remain where [s/he] is . A facility RN added In talking with [resident's name] [s/he] feels this medication is helping [him/her] and [s/he] doesn't want any changes made to it. Also [resident's name]'s Sertraline was increased to 150 mg [by mouth] daily on 5/25/23. No changes are requested at this time. Further review showed the physician marked a box which stated I consider a dosage reduction to be clinically contraindicated; however, the rationale section was not completed. e. Interview with the DON, infection preventionist, MDS coordinator, social services/recreation coordinator, and nurse manager on 12/7/23 at 9:36 AM revealed the pharmacy sends the communication to the nursing facility, it was reviewed and updated, and sent to the doctor. Staff members talk to the resident and evaluate how they feel about the medication and add the information to the communication. The revealed the target symptoms the resident displayed were tearfulness and negative self-talk. They revealed the resident used trazadone for insomnia and had the insomnia related to a response in changes resulted in difficulty sleeping because s/he gets upset; however, they did not monitor the resident's difficulty sleeping or specific sleeping patterns and they confirmed the care plan indicated insomnia may be an adverse reaction of anti-depressant therapy. Further interview confirmed the facility did not monitor resident specific identified target symptoms for the use of psychotropic medications or the medication effectiveness, and confirmed the physician did not provide a resident specific rationale for not performing a gradual dose reduction. 3. Review of the policy titled Monthly Resident Drug Regimen Review dated October 2017 showed .Management of Psychotropic Drugs and Gradual Dose Reductions (GDR) .C. Each resident must be evaluated by the attending physician to determine whether a GDR is clinically contraindicated. If a GDR is clinically contraindicated the physician is required to document this specifically in the medical record .B. Antidepressants 1 .After the first year, a tapering should be attempted annually, unless clinically contraindicated. The tapering may be considered clinically contraindicated if: 2. The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale why an attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder, or 3. The resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why an attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder . Further review showed .III, Orders for psychotropic drugs as needed or PRN A. All PRN orders for antidepressants, anxiolytics, or hypnotics will have a limited duration of 14 days. PRN orders for these medications will be discontinued 14 days from the date written. 1. If the resident's primary care providers believes [sic] a PRN order for longer than 14 days is needed or appropriate, the physician can extend the order beyond 14 days by documenting their rationale on the order and the resident's medical record .

Based on observation, medical record review, staff interview, facility incident report review, and facility policy review, the facility failed to protect the resident's right to be free from physical and mental abuse by residents for 1 of 3 sample residents (#7) reviewed for abuse allegations. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #7 had a BIMS score of 4 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and depression. The following concerns were identified related to one incident of abuse: a. Review of the facility incident report dated 10/25/23 and timed 6:40 PM showed resident #5 had removed a puppy from the room of resident #7. When the stuffed animal was returned to resident #7 in his/her room, resident #5 returned to the room and staff found resident #5 with his/her hands around resident #7's throat and coffee had been spilled on resident #7. Further review showed the residents were separated and neither had noted injuries. b. Review of the nursing progress note for resident #7 dated 10/25/23 and timed 7:08 PM showed resident #7 was sitting in a recliner when resident #5 came up to [him/her] and placed his/her hands on resident #7's throat. The note indicated resident #7 screamed for help and no physical injury was noted; however, resident #7 continued to be shaken by the incident. c. Review of the nursing progress note for resident #5 dated 10/25/23 and timed 7:13 PM showed resident #5 had entered resident #7's room and removed a stuffed puppy. The puppy was carried into the common area where resident #7 observed resident #5 with the puppy and asked for it. The puppy was retrieved and given to resident #7; however, 10 minutes later resident #7 yelled s/he was being choked and needed help. Staff found resident #5 with his/her left hand on resident #7's throat, right hand grabbing resident #7's left wrist, and screaming at resident #7. After releasing resident #7, it was noted the resident's throat was red. 2. Interview with nurse #2 on 11/14/23 at 2 PM confirmed resident #5 wandered which resulted in resident to resident altercations at times and the residents in the secure unit had their favorite stuffed animal or blanket which can cause negative interactions. 3. Interview with the facility administrator on 11/14/23 at 4:15 PM confirmed the altercation occurred and revealed it seemed much worse at the time of occurrence than it really was. Further interview revealed neither resident remembered the incident two hours later. 4. Review of the facility policy and procedure titled Abuse: Recognizing and Reporting dated 3/2023 showed .Abuse is identified as physical abuse, sexual abuse, mistreatment, neglect, or misappropriation of patient/resident property .VULNERABLE ADULT ABUSE .I. Inspect injured vulnerable adult patient's/resident's body upon admission and throughout the course of care for evidence of physical and/or sexual abuse, for unexplained signs and symptoms that might include bruises, welts, abrasions, contusions, lacerations, punctures, burns, scalding, bone fractures, sprains, dislocations, subdural hemorrhage, retinal hemorrhage, brain damage, internal injuries, poisoning, malnutrition (deliberately intended), freezing, or exposure. II. Describe, on the medical record, all unexplained bruises, lacerations, etc., as to location and state of healing .

Based on medical record review, facility investigation record review, staff interview and review of the State Agency incident report logs, the facility failed to report allegations of abuse for 1 of 8 allegations (affecting residents #3 and #4) reviewed. The findings were: Review of the nursing progress notes dated 2/15/23 at 9:30 PM showed [resident #3] was found in the hallway with [his/her] hand up a resident's shirt. Review of the facility investigation showed the contact occurred in the hall and the video surveillance (which could not be accessed by the investigative team for nearly 2 days) recorded the interaction of the two residents meeting in the hall lasted less than 10 seconds. The video did not confirm any sexual contact occurred. The reporting CNA did not have a clear view, and could state only that it looked like resident #3 had his/her hand up resident #4's shirt. Further investigation review showed the investigative team concluded that contact of a sexual nature had not occurred. Resident #3 was moved to a room on another hall as a protective precaution. The following concerns were identified: a. Review of the State Agency incident report logs failed to show evidence the allegation was reported. b. Interview with the facility Administrator on 3/7/23 at 5:10 PM revealed the allegation had not been reported because there was no visible harm to either resident and the investigative team determined there had not been abuse. The administrator confirmed the regulation required all alleged violations involving abuse be reported no later than 2 hours after the allegation was made, and that had not been done.

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to provide services to ensure residents maintained acceptable parameters of nutritional status for 1 of 4 sample residents (#40) with weight loss. This failure resulted in harm to resident #40, who experienced an avoidable 7.6% loss of body weight in a 53 day period. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #40 had a BIMS score of 8 out of 15, indicating the resident had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS assessment showed the resident had no identified weight loss, no swallowing issues, and required supervision of 1 person for eating. Review of the self-care performance deficit care plan last revised on 6/14/21 showed interventions which included .Eating: I am able to eat with supervision and set up by one staff member. Further review of the care plan showed a focus area dated 6/15/21 indicating the resident had the potential for chewing difficulties due to a lack of teeth or dentures, and a focus area dated 6/22/21 that indicated the resident was at risk for dehydration and was to be weighed every Wednesday. The following concerns were identified: a. Further review of the resident's medical record showed between 6/14/21, when the resident's weight was recorded as 122.4 pounds, and 8/6/21, when the resident's weight was recorded as 113 pounds, the resident lost 9.4 pounds (7.6% of body weight) over the 53-day period. b. Review of the nutrition/dietary note dated 6/24/21 showed WT. LOSS: [resident's] most current wt. [weight] on 6/23/2021 was 118.0 Lbs. This is a -5.8% & -7.2 Lb. wt. decline in 2 weeks from a wt. of 125.2 Lbs on the 9th. [The resident] has pain daily and has experienced a fall in addition to [his/her] dementia. Wrote order for approved nutrition supplement BID [twice daily] between meals. Monitor weekly wts and follow as needed. c. Review of the nutrition/dietary note dated 7/29/21 showed SIGNIFICANT WEIGHT LOSS: [resident's] weight on 7/15/21 was 118.4#. This is a weight loss of 6.8#/5.4% since 6/9/21. Average meal intake for the last 4 weeks have declined from 53% to 17%. Nursing staff report due to [his/her] declining health condition, [resident] is eating and drinking very little. Current diet order is mechanical soft, nectar thickened liquids. Nutrition supplement order for BID between meals. d. Further review of progress notes and the resident's care plan showed no other interventions related to the resident's weight loss, and no change or update to the assessment the resident required only supervision and set up with meals. e. Observation on 8/9/21 at 5:27 PM showed the resident was in his/her wheelchair, seated at a table with two other residents in the common dining area. The resident was slumped forward in his/her chair, leaning to the left. It was noted a spoon was on the plate; however, minimal food had been eaten. f. Observation on 8/10/21 at 12:03 PM showed a CNA positioned the resident up to the table and left the room. The resident's head was leaned forward and his/her eyes were closed. The resident's meal tray was uncovered and positioned on the table in front of the resident. Observation at 12:08 PM showed dietitian #1 attempted to wake the resident without success. The dietitian notified a CNA the resident was not eating. Observation at 12:13 PM showed the dietitian obtained a drink that was orange in color and attempted to assist the resident to eat. g. Observation on 8/10/21 at 5:22 PM showed the resident was seated at an assisted dining table, which was a different location than his/her previous meals, and was being assisted by staff to eat the meal. h. Observation on 8/11/21 at 12:01 PM showed the resident was seated at an assisted dining table and was eating independently. i. Interview with the dietitian on 8/12/21 at 8:49 AM revealed when the resident's initial assessment was performed, his/her actual weight was 122.4 pounds. The dietitian revealed when residents were identified for weight loss, they were reviewed monthly, and weights were also discussed during team meetings. Further interview revealed the dietitian had noticed the resident was slumped over in the chair and was not receiving assistance on 8/10/21, so she attempted to assist him/her. She revealed one of the CNAs reported she could not get the resident wake up; however, the dietitian was able to wake the resident and helped him/her eat. The dietitian confirmed the resident's meal intakes were low, and the resident was placed at the assisted table due to the low intake averages. The dietitian revealed the resident's dining assistance needs should be indicated on the care plan, and she felt the resident needed someone to sit with him/her to help during meals. j. Review of the policy titled Resident Weight Maintenance dated 8/19 showed .Every effort will be made within the range of resident wishes/rights to maintain a healthy weight for each resident .III. The charge nurse responsible for the resident with weight loss will be notified. Nursing will be asked to notify CNAs responsible for the day to day care of the resident. VII. Staff will review consumption records and eating pattern will be reviewed .IX. The nutrition care plan will be revised to reflect any new interventions or changes .

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure 1 of 19 sample residents (resident #68) were treated with dignity and respect. The findings were: 1. Review of the 7/13/21 quarterly MDS assessment showed resident #68 was admitted to the facility on [DATE], had a BIMS score of 3 showing severely impaired cognition, was frequently incontinent, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan, last revised 7/20/21, showed the resident had . FUNCTIONAL [sic] bladder incontinence r/t Impaired Mobility and the resident was . totally dependent on one staff for toilet use. Please check and change me every 2 hours and PRN. Further review showed the resident had communication difficulties, but could answer basic or yes/no questions. The following concerns were identified: a. Observation on 8/11/21 at 11:49 AM showed the resident was seated in his/her wheelchair in the common area of the unit, along with two other residents. The resident was calling out help with each breath exhalation, indirectly asking who are you?, as well as stating I have to go to the bathroom. After stating a few times s/he had to use the bathroom, RN #1 approached the resident to acknowledge the request. The nurse appeared confused and turned to ask CNA #1 about how to care for the resident. CNA #1 was seated at the nurse's station across the room; she then stood up and loudly expressed [S/he]'s a check and change. [S/he] can just go in [his/her] pants since [s/he] has depends on, and they'll change [him/her] later. RN #1 said okay, and returned to the medication cart, and CNA #1 returned to the nurses station. The resident continued to call out, stating again s/he needed to use the bathroom at 11:51 AM and 11:54 AM. RN #1 again approached the resident, moved the resident to a table, and sat down next to the resident to assist him/her with lunch. The resident again began stating s/he needed to go to the bathroom, to which RN #1 responded You can just go right here. You can just go in your pants and we'll change you after lunch. Just go. b. Observation on 8/11/21 at 6:00 PM showed CNA #2 transferred the resident to his/her bed using a mechanical lift. She then removed the resident's brief, and it was noted the resident had been incontinent of both bowel and bladder. Interview with CNA #2 at the time revealed she did not usually work in that area of the facility and did not know if the resident was always incontinent. c. Interview with CNA #1 on 8/12/21 at 10:55 AM revealed residents designated a check and change were residents who were incontinent, and required staff to change their brief every 2 to 4 hours because these residents don't use the toilet. She then provided the basic care sheets the staff use as a reference during their shifts; it contained guidance for transfers, notes, and resident-specific accommodations. It was noted that 6 other residents were noted as being Ck & chg; CNA #1 confirmed this stood for check and change. She stated staff . know [the residents] are incontinent so [staff] only change their briefs, so we don't actually toilet residents with briefs, because that's considered [the resident's] toileting. d. Interview with the DON on 8/12/21 at 12:36 PM revealed all residents should be asked or assessed for toileting needs at least every 4 hours. She further stated if a resident is physically able to sit on the toilet, then the resident should be toileted; a resident who was unsafe or physically unable to sit on the toilet would be a check and change. She also stated her expectation was for staff to assist a resident to the bathroom if the resident requested. The DON stated it would not be appropriate to tell residents to soil themselves and they would change them later, nor to refer to residents as a check and change. e. Review of facility policy Patient and Resident Rights, last revised February 2019, showed residents have the Right to Participate in One's Own Care: Receive adequate and appropriate care ., Right to Privacy and Confidentiality: During treatment and care of one's personal needs . , and the Right to Dignity, Respect ,and Freedom: To be treated with consideration, respect, and dignity .

Based on resident representative and staff interview, medical record review, and policy and procedure review, the facility failed to ensure resolution to grievances for 1 of 1 sample residents (#11) who reported lost items. The findings were: 1. Review of a psychosocial note dated 3/10/21 and timed 10:57 AM showed resident #11's plain gold wedding band was missing and the resident's spouse was very upset. Interview with the resident's son on 8/10/21 at 4:27 PM revealed the wedding ring remained missing and there was no resolution at that time. Review of the grievance log showed no evidence a grievance form was completed for the missing ring. Interview with the social services director on 8/12/21 at 8:17 AM confirmed she was aware of the missing ring and the facility had not resolved the grievance. Further interview revealed the facility would consider anything that bothered a resident to be a grievance. 2. Review of the policy titled Patient Complaints/Grievances dated 08/2020 showed .Definitions: .II. Patient/Resident Grievance A. A grievance is defined as a formal or informal written or verbal complaint that is made by a patient/resident or the patient/resident's representative when a patient/resident issue cannot be resolved promptly by staff present .V. Timelines for Grievance Response .D. If the grievance is not complete and/or corrective action is still being evaluated, the facility response should communicate the status of the resolution process and will provide a follow-up date in writing within 14 days after submission. PVHC should attempt to resolve all grievances as soon as possible .

Based on medical record review, staff interview, and review of the CMS MDS 3.0 Resident Assessment Instrument (RAI) manual, the facility failed to ensure a significant change assessment was completed for 1 of 3 sample residents (#41) with an identified change in condition. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #41 had a BIMS score of 6 out of 15 indicating the resident had severe cognitive impairment. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident weighed 181 pounds with no weight loss greater than 5 percent in the last month or 10 percent in the last 6 months and was able to eat independently. The following concerns were identified: a. Review of the quarterly MDS assessment dated [DATE] showed the resident had a BIMS score of 4 out of 15 indicating severe cognitive impairment and required total physical assistance of 1 person for eating. Further review showed the resident weighed 162 pounds, a 10 percent weight loss since the annual assessment, and was shown to have weight loss which was not physician prescribed. b. Interview with the MDS coordinator on 8/12/21 at 8:57 AM revealed she had missed the resident's weight loss and with the decline in eating the quarterly MDS assessment should have been a significant change assessment instead, since there were 2 identified areas decline. c. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual version 1.17.1 last revised October 2019 showed .A significant change is a major decline or improvement in a resident ' s status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan .

Based on medical record review, staff interview, and CMS MDS 3.0 Resident Assessment Instrument (RAI) review, the facility failed to ensure MDS assessments were completed a minimum of every 92 days for 1 of 20 sample residents (#1). The findings were: 1. Review of the admission MDS assessment for resident #1 showed the assessment was completed on 3/28/21. Review of the following quarterly MDS assessment showed the assessment was completed on 7/27/21, 121 days after the completion of the admission assessment. 2. Interview with the MDS coordinator on 8/12/21 at 9:01 AM revealed she was aware the resident's quarterly MDS assessment was completed late. The MDS coordinator revealed the resident was left off the planning schedule at the time the quarterly assessment was due. 3. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1 last revised October 2019 showed .The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD [assessment reference date] (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .

Based on observation, resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure treatment and services were provided to promote healing of pressure injuries for 1 of 6 sample residents (#228) with pressure injuries. The findings were: 1. Review of the 7/22/21 admission MDS assessment showed resident #228 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident was cognitively intact with a BIMS score of 15, required supervision with bed mobility, and limited assistance of 1 person with transfers and toilet use. Review of the 7/16/21 Braden Scale assessment showed the resident was at risk for pressure sore development with a score of 18. Review of the resident's current care plan, last updated 8/3/21, showed the resident was at risk for pressure ulcer development, with interventions that included Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] &D cream applied after peri-care to help maintain my skin integrity. Review of an admission summary progress note dated 7/16/21 and timed 3:46 PM showed . Over all skin is dry and intact . Coccyx is pink as she sits a lot . Review of a skin/wound progress note dated 7/26/21 and timed 5:03 PM showed . [the resident's] skin was clean, dry, and intact . The following concerns were identified: a. Review of a nursing 8/4/21 skin/wound progress note timed 6:02 AM showed pt has a stage 2 pressure ulcer on coccyx . Area was clean, dried, and barrier cream applied. Review of another nursing skin/wound progress note, documented by a second nurse, dated 8/4/21 and timed 3:37 PM showed Resident has Stage 2 open ulcer to L side of coccyx, and redness to R side of coccyx. [MEDICATION(S)] [antibiotic ointment] applied to open sore and covered with Mepelex [padded wound bandage]. Wound Care RN was notified of the ulcers. b. Review of an Initial Wound Assessment progress note dated 8/7/21 and timed 3:18 PM documented a left buttock pressure ulcer measuring 3 [by] 3 [by] 0, with no units of measure indicated. The wound was described as having a Pink/beefy Red Tissue wound bed, and macerated wound edges/surrounding tissue. Documented wound treatments initiated included . cleansed with wound wash, A&D and [MEDICATION(S)] applied, [MEDICATION(S)] . The note further showed the physician was notified on 8/7/21 at 3:00 PM, and wound care was notified on 8/7/21 at 2:00 PM. The note also showed Wound Treatment Added to TAR and Weekly Wound Assessment Added to TAR were both documented as No. c. Observation of wound care performed by wound care nurse on 8/12/21 at 11:23 AM showed the nurse approached the resident, who had just finished using the toilet, and assisted him/her to his/her feet. Upon standing, two open wounds were observed on the inner side of both of the resident's buttocks. The wound on the left buttock was noted to be approximately three inches across, was open with a visible wound bed, and very raw and reddened. The wound on the right buttock cheek was smaller, was very reddened, and appeared to have minor skin breakdown. The resident stated at the time the wounds were painful and irritated. Both wounds were cleansed and had ointment applied, and a Mepelex covering was applied to the wound on the left buttock; the wound on the right was not covered with a dressing. Interview with the wound care nurse at that time revealed she was aware of the wounds, but had not assessed or intervened immediately after she was notified of their presence; she was unable to recall the exact date of the notification. d. Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 and August 2021 MAR and TAR showed no documentation of orders or treatments provided to the identified wounds. e. Review of the medical record showed after discovery on 8/4/21, no documented monitoring or assessments were performed on the wounds until 8/7/21; further review showed no additional documentation was noted after the initial wound assessment on 8/7/21. 2. Review of the policy titled Wound Care Guidelines-Prevention of Pressure Ulcers and Skin Tears dated 8/2019 showed .A. Acute Care: When a nurse identifies a wound or pressure ulcer, he/she should obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B. The wound care nurse, or other qualified RN, will do an initial assessment. Documentation to include: photographs of the wound, wound measurement, wound description and treatment recommendations. This nurse will collaborate with the physician for treatment orders .

Based on observation, medical record review, and staff interview the facility failed to ensure indications of pain were acted on for 1 of 6 sample residents (#42) reviewed for pain. The findings were: Review of the 6/15/21 quarterly MDS assessment showed resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 12/22/20 care plan showed the resident had potential for pain related to a history of a lumbar compression fracture. The interventions included assessing for pain every shift and as needed and documenting the assessment in the MAR. If I [the resident] show signs or symptoms of pain ask if I [the resident] would like something for it, either pharmacological or non-pharmacological. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other orders for pain medications. Interview with RN #2 on 8/12/21 at 9:20 AM revealed the resident was able to use words and verbalize how s/he was feeling. However, due to the resident's dementia the Pain Assessment in Advanced Dementia (PAINAD) tool was used to determine a number for the pain rating. The tool allowed the staff to identify current behaviors that could indicate pain. Review of the scale for the PAINAD tool showed 1-3 was mild; 4-7 was moderate and 8-10 was sever pain. The following concerns were identified: a. Observation on 8/10/21 at 9:32 AM showed the resident was grinding his/her teeth while seated in the recliner in the main area. Interview with RN #3 at that time revealed the resident was known to grind his/her teeth, and had been to the dentist recently. She further stated they checked with the resident routinely to rule out pain. Observation on 8/10/21 at 2:52 PM showed the resident was seated in a recliner in the main area, again grinding his/her teeth. The grinding could be heard from across the room. b. Review of an order administration note dated 7/31/21 at 8:08 AM showed Tylenol Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed .resident is grinding his teeth more than normal. When asked [s/he] stated 'I just hurt a little.' c. Review of the July 2021 MAR showed the resident was assessed for pain three times per day (each shift). It was noted there were 21 separate assessments in which pain was indicated. The pain was indicated with a number from the (PAINAD rating tool) the numbers ranged from 1 to 6. Continued review showed the resident received the Tylenol on 5 of the 21 occasions pain was indicated. Further review or the MAR and the progress notes showed the resident did not receive any other pain medications or non-pharmacological pain interventions for the other 16 occurrences of documented pain. d. Review of the August 2021 MAR showed the resident was assessed for pain three times per day (each shift). From 8/1/21 to 8/11/21 it was noted there were 14 separate assessments in which pain was indicated. The pain was indicated with a number from the (PAINAD rating tool) the numbers ranged from 2 to 5. Continued review showed the resident received the Tylenol on 1 of the 14 occasions pain was indicated. Further review or the MAR and the progress notes showed the resident did not receive any other pain medications or non-pharmacological pain interventions for the other 13 occurrences of documented pain. e. Interview with the DON on 8/12/21 at 12:39 PM verified there should have been follow through when pain was indicated on the shift assessments. Further, she was planning to complete an audit regarding the pain evaluation system.

Based on observation, staff interview, and medical record review, the facility failed to ensure bed rail assessments indicated safe use for 1 of 3 sample residents (#11) with bed rails. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #11 had a BIMS score of 7, indicating severe cognitive impairment, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required total physical assistance of 1 person for bed mobility, locomotion on and off the unit, dressing and personal hygiene and required total physical assistance of 2 or more people for transfers and toilet use. Review of the ADL self-care performance deficit care plan last revised on 2/18/21 showed interventions which included .Bed Mobility: I require total assistance of one staff to turn and reposition in bed as necessary . Further review showed the resident was .a High risk for falls r/t [related to] Gait/balance problems and weight bearing as tolerated. The following concerns were identified: a. Observation on 8/10/21 at 9:32 AM showed the resident was in bed with a mattress on the floor to the right side of the bed, and half bed rails were in use to the bilateral upper portion of the bed. b. Observation on 8/11/21 at 5:27 PM showed the bed rails were in use on the bilateral upper portion of the bed. c. Observation on 8/12/21 at 8:53 AM showed the bed rails were designed with 5 gaps. Maintenance staff member #1 measured the gaps to be 3 3/4 inches by 12 inches, 2 1/4 inches by 12 inches, 6 inches by 4 inches, 6 inches by 2 1/2 inches, and 4 3/4 by 2 1/2 inches. d. Review of a side rail assessment form dated 6/4/21 showed the resident had an alteration in safety awareness, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed side rails should not be used and were not indicated at that time. e. Interview with nurse manager #1 on 8/12/21 at 9:52 AM revealed the resident was getting stronger and used the rails to sit up and reposition in bed. Further interview revealed she believed the rails were appropriate; however, she was unsure why the assessment indicated the resident did not need them.

Based on medical record review, facility investigation review, family and staff interviews, and review of facility incident reports, the facility failed to ensure residents were free from abuse for 1 of 4 sample residents (#1). The findings were: 1. Review of the care plan for resident #1, last revised on 3/27/18, showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed a focus of I wander the Heart Mountain/West unit, wander with disregard to safety when unsupervised, and often intruding on others privacy or into others rooms related to dementia. Interventions included distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, I prefer playing piano, listening to music, social events with music and exercising and I will be verbally redirected if/when I wander into another resident's room. Behavioral charting should be completed when this occurs. Review of the quarterly minimum data set (MDS) assessment dated [DATE] for resident #3 showed the resident was unable to complete the brief interview for mental status and was severely cognitively impaired. Review of the care plan for resident #3, last revised on 8/13/19, showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review showed a focus of The resident is physically aggressive (hitting, punching, and slapping) staff and residents related to anger, dementia and poor impulse control. Interventions included When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later. The following concerns were identified: a. Review of the Facility Investigation of Incident Report dated 11/5/19 at 3:31 PM showed RN heard someone cry out and heard a thump, went to investigate and found (resident #1) on the floor. (Resident #1) was lying on the floor on right side in another resident's room with another resident (Resident #3) standing above (him/her) rubbing (his/her) hand acting remorseful. (Resident #1) had a bloody and swollen lip. Further review showed (Resident #3) did not have any bruises to hands at the time of assessment on 11/3/19, but assessment on 11/4/19 revealed (his/her) right hand had a light bruised area between knuckles of pointer finger and middle finger with no other problems noted. Review of the facility incident report dated 11/4/19 showed the incident was believed to be an unwitnessed resident-to-resident altercation. b. Interview with RN #1 on 11/13/19 at 1:20 PM revealed she heard resident #1 fall and went immediately to resident #2's room. She revealed resident #3 had a history of [REDACTED]. c. Interview with RN #2 on 11/13/19 at 4:30 PM revealed resident #3 had always been a difficult resident and a recent assessment by a psychiatric specialist resulted in an increase in the resident's [MEDICAL CONDITION] medication. d. Interview with resident #1's representative on 11/13/19 at 2:33 PM revealed they were very pleased with the resident's care, stating, There has been a couple incidents of falls and altercations with other residents, but nothing bad.

Based on observation, medical record review, and staff interview, the facility failed to ensure bed rails were assessed for safety, and failed to obtain informed consent prior to installation for 4 of 4 sample residents (#12, #13, #19, #47) with bed rails. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #12 had [DIAGNOSES REDACTED]. Review of the care plan last revised on 4/23/19 showed I have impaired mobility r/t (related to) a disability in my lower extremities and confusion and interventions included Bed Mobility: I need extensive assistance with bed mobility and I will use two half side rails to assist with turning and repositioning. The following concerns were identified: a. Observation on 7/9/19 at 8:13 AM showed the resident had bilateral bed rails attached to the upper portion of his/her bed, which were designed with 5 gaps. The gaps measured 5 inches by 4 1/2 inches, 4 inches by 6 inches, 2 1/2 inches by 6 inches, 4 inches by 12 inches, and 2 1/2 inches by 12 inches. b. Review of the side rail assessment dated [DATE] showed no evidence the bed rails were assessed for risk of entrapment. c. Review of the medical record showed no evidence the resident signed a consent for bed rail use. 2. Review of the annual MDS assessment dated [DATE] showed resident #13 required extensive physical assistance of 1 person for bed mobility and had [DIAGNOSES REDACTED]. Review of the care plan last revised on 4/20/19 showed I have mobility impaired r/t (related to) declining strength, balance, and coordination. The interventions included Bed Mobility: Provide extensive assist with bed mobility especially helping with my legs in and out of bed. I does (sic) not use side rails. I has (sic) a grab bar. The following concerns were identified: a. Observation on 7/9/19 at 11:19 AM showed the resident had bilateral bed rails attached to the upper portion of his/her bed, which were designed with 5 gaps. The gaps measured 5 inches by 4 1/2 inches, 4 inches by 6 inches, 2 1/2 inches by 6 inches, 4 inches by 12 inches, and 2 1/2 inches by 12 inches. b. Review of the side rail assessment dated [DATE] showed no evidence the bed rails were assessed for risk of entrapment. c. Review of the medical record showed no evidence the resident signed a consent for side rail use. 3. Review of the annual MDS assessment dated [DATE] showed resident #19 had [DIAGNOSES REDACTED]. The following concerns were identified: a. Observation on 7/9/19 at 9:05 AM showed the resident had bilateral side rails attached to the upper portion of his/her bed, which were designed with 5 gaps. The gaps measured 5 inches by 4 1/2 inches, 4 inches by 6 inches, 2 1/2 inches by 6 inches, 4 inches by 12 inches, and 2 1/2 inches by 12 inches. b. Review of the side rail assessment dated [DATE] showed no evidence the bed rails were assessed for risk of entrapment. Further review showed the side rails were not used to promote independence, were not requested by the resident, and did not appear to be indicated. c. Review of the medical record showed no evidence the resident signed a consent for bed rail use. d. Interview with the DON on 7/10/19 at 2:17 PM revealed the bed rails should not have been in use for the resident. 4. Review of the quarterly MDS assessment dated [DATE] showed resident #47 had [DIAGNOSES REDACTED]. Review of the care plan last revised on 5/22/19 showed I have mobility impairment r/t (related to) advanced age, compromised breathing effectiveness and [MEDICAL CONDITION] and interventions which included Bed Mobility: I can use some supervision with my bed mobility and use one half side rail. The following concerns were identified: a. Observation on 7/9/19 at 8:06 AM showed the resident had bilateral side rails attached to the upper portion of his/her bed, which were designed with 6 gaps. Two of the gaps measured 4 inches by 4 inches, two of the gaps measured 4 inches by 7 3/4 inches, and 2 of the gaps measured 4 inches by 11 inches. b. Review of the side rail assessment dated [DATE] showed the facility did not assess the bed rail for risk of entrapment. c. Review of the medical record showed no evidence the resident signed a consent for bed rail use. 5. Interview with the DON on 7/10/19 at 2:06 PM revealed the facility did not evaluate resident side rails for entrapment risk.

Based on resident and staff interview, medical record review, and review of facility bathing schedules, the facility failed to honor resident preferences for 1 of 1 sample resident (#45) related to bathing. The findings were: Interview with resident #45 on 7/9/19 at 10:11 AM revealed residents were not able to choose bath days. The resident was scheduled for showers on Thursdays and Sundays and said the bathing schedule interfered with participation in church services. Further interview revealed the resident had to get up as early as 5:30 AM at times to receive a bath. Review of the admission MDS assessment dated [DATE] showed the resident felt it was very important to choose his/her bath, shower, bed bath, or sponge bath and attend religious services. Review of the facility's bathing schedule showed the resident was to receive a bath during the day shift on Thursday and Sunday. Further review showed the facility provided showers on the evening shift 7 days per week. Review of the resident's care plan initiated on 11/20/18 showed I have a self care deficit r/t (related to) impaired cognition and chronic pain from my osteoarthitis. Interventions included Bathing: I need help with my bath twice per week. There was no evidence the resident's preferences were identified on the care plan. Review of the resident's admission document dated 10/29/18 showed on the Resident's Choices and Preferences document the resident preferred bathing in the afternoon or evening. Interview with the DON on 7/10/19 at 2:22 PM revealed residents were asked about bathing preferences at the time of admission and the facility placed them on the schedule based on the other facility residents' bathing schedules.

Based on medical record review and staff interview, the facility failed to ensure residents' right to formulate an advanced directive for 3 of 21 sample residents (#12, #13, #47). The findings were: 1. Review of the medical record for resident #12 showed the resident was listed as do not resuscitate (DNR). The following concerns were identified: a. Review of a physician note, which was undated and untimed, provided by the facility on 7/10/19 at 8:38 AM showed the resident was marked as DNR with an advanced directive on file. b. Review of the medical record showed the facility had no document signed by the resident or resident's representative to identify the resident's code status election. 2. Review of the medical record for resident #13 showed the resident was listed as DNR. The following concerns were identified: a. Review of a physician note, which was undated and untimed, provided by the facility on 7/10/19 at 8:38 AM showed the resident was marked as DNR with an advanced directive on file. b. Review of the medical record showed the facility had no document signed by the resident or resident's representative to identify the resident's code status election. 3. Review of the medical record for resident #47 showed the resident was listed as DNR. The following concerns were identified: a. Review of a physician note, which was undated and untimed, provided by the facility on 7/10/19 at 8:38 AM showed the resident was marked as DNR with an advanced directive on file. b. Review of the medical record showed the facility had no document signed by the resident or resident's representative to identify the resident's code status election. 4. Interview with unit ward clerk #1 on 7/10/19 at 1:23 PM revealed some residents admit with documents indicating their advanced directives; however, often times residents admit with a transfer document signed by the physician which indicates code status. Further interview revealed the facility did not have signed elections for residents.

Based on observation and staff interview, the facility failed to ensure furniture utilized by residents was clean and in good repair in 1 of 3 units (South). The findings were: 1. Observation of the South common area on 7/10/19 at 1:10 PM showed the following concerns. a. A brown vinyl recliner chair located on the south side of the common room had an area on the right arm rest which measured 7 inches by 5.5 inches; an area on the left arm rest which measured 8 inches by 6 inches; and an area on the headrest which measured 5.5 inches by 4 inches with the outer vinyl missing, and the underlying padding exposed. These areas created a surface that could not be effectively cleaned. b. A brown vinyl recliner chair located on the north side of the common room had an area on the right arm rest which measured 6.5 inches by 7 inches and an area on the left arm rest which measured 8 inches by 5.5 inches with the outer vinyl missing, and the underlying padding exposed. In addition, the headrest had 3 cracks measuring 3 to 5 inches long with the vinyl peeling away from the edges. These areas created a surface that could not be effectively cleaned. 2. Interview with the infection prevention nurse on 7/10/19 at 3:26 PM confirmed the recliners could not be effectively cleaned.

Based on medical record review, resident and staff interview, review of facility investigations, and policy and procedure review, the facility failed to ensure residents were free from abuse or neglect for 2 of 4 residents (#2, #3) reviewed. This failure resulted in harm to resident #2, who sustained injuries that required transfer to the emergency room and stitches. The findings were: 1. Review of the medical record showed resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] showed a brief interview for mental status (BIMS) score of 0 (indicating severe cognitive impairment), the resident required the extensive assistance of one staff member for transfers and dressing, did not ambulate, and was incontinent of bowel and bladder. The following concerns were identified: a. Review of nursing progress notes dated 4/18/19 showed the resident fell out of bed and sustained facial injuries which included a laceration to the ear. The resident was transferred to the emergency room and received stitches. b. Interview on 5/14/19 at 1:52 PM with CNA #3 revealed the CNA who cared for resident #3 on that day (CNA #1) asked for her help to transfer the resident from the bed, because the resident was wiggling and kicking his/her legs. She stated when they got to the resident's room, the resident was on the floor facing the wall. She stated she also noticed the bed was at a high level and the fall mat was not by the bed. She confirmed the bed should have been in the low position and the fall mat by the bed prior to getting help. She stated CNA #1 did not push the call light for help, because it was dinner time and it would have taken longer to get help because they were busy. c. Interview on 5/14/19 at 4:31 PM with the resident's roommate, who was cognitively intact, revealed s/he heard CNA #1 with the resident, and the resident was acting out by thrashing and kicking his/her feet out. The roommate stated the CNA left the resident and the next thing s/he heard was a thump. The roommate stated s/he pulled the curtain back and the resident was on the floor. The roommate further stated the bed was in a high position and the fall mat was not by the bed. d. Review of the resident's care plan showed a care area of [MEDICAL CONDITION] with interventions that included bed in lowest position and wheels locked. Further review of the care plan showed the resident was at high risk for falls with interventions that included Follow facility fall protocol. Review of the facility's High Risk Fall Interventions sheet showed, bed low position, padded floor mat . e. Review of the Falls/Fall Risk Assessment revision date of 6/18 showed .If the patient/resident is determined to be at risk for falls, interventions will be initiated in the Nursing Care Plan. f. Interview with the DON on 5/14/19 at 4:14 PM revealed when he talked to CNA #1 about the incident on 5/6/19, she confirmed she left the bed in high position and did not put the fall mat by the bed. The CNA resigned from her position effective immediately at the conclusion of her 5/6/19 interview with the DON. g. An attempt to interview CNA #1 by phone was made on 5/14/19 at 1:15 PM, but there was no answer. 2. Medical record review showed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] showed the resident had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact, had impaired vision with corrective lenses, and required the extensive assistance of 1 staff member for toilet use. The following concerns were identified: a. Interview on 5/13/19 at 4:00 PM with the NHA revealed the facility had investigated an incident that occurred on 5/7/19. He stated resident #3 alleged a CNA threw a call light at him/her. b. Review of the facility's investigation showed the DON interviewed resident #3 on 5/8/19. The resident revealed CNA #2 hollered something and threw my call light. Further review of the facility's investigation showed the resident was not injured. c. Interview with the DON on 5/14/19 at 4:14 PM revealed CNA #4 had sent him an email on 5/11/19 at 12:45 AM about the incident. The email revealed a conversation the CNA had with NSA #1 about CNA #2. After receiving the email, the DON talked with NSA #1 on 5/11/19. The NSA told him CNA #2 told her she ripped the call light out of the resident's hand. The DON stated he called the police and placed CNA #2 on suspension pending the investigation. d. Interview on 5/15/19 at 7:07 AM with NSA #1 revealed she worked on 5/7/19, the night of the incident. She stated the resident had nights where s/he would ring the call light constantly, and that night the resident held the call button down. The NSA further revealed CNA #2 came to her and was upset. CNA #2 told the NSA she ripped the call light out of the resident's hand, told him/her to quit ringing it, and threw it at him/her. The NSA stated she did not report the incident because she did not think about it. e. Interview on 5/15/19 at 7:10 AM with CNA #4 revealed she and NSA #1 went into the resident's room after the incident occurred. The resident was upset and told them to get out if they couldn't help. She stated the resident reported the incident to the nurse. She also stated she sent an email about the incident to the DON on 5/11/19, 4 days after the occurrence. f. Interview on 5/14/19 at 7:30 AM with the resident revealed the resident did not recall the event and had no complaints about the facility. g. Attempts to interview CNA #3, who was on suspension from the facility, by phone were made on 5/14/19 at 10:35 AM and 1 PM, and a message was left for a return call. The CNA did not return the phone call. h. Interview with the NHA on 5/15/19 at 7:33 AM revealed the nurse did not conduct a skin assessment. He also stated his expectations when residents excessively used the call light were that staff would provide one to one care, redirect the resident, and have 2 staff care for the resident to help the resident. He also stated they would look at other issues that would cause the excessive call light use like an underlying illness, or pain. He stated staff were encouraged to confront staff who seemed frustrated, and find out what was going on. He stated staff were encouraged to change assignments if needed, and let that staff member take a break. He stated they had been working on strategies in the Nursing Practice Council to recognize and help with staff burnout. He stated they have free massages one day a week, and will do cook-outs. He stated they just had a training in (MONTH) on harassment and employee conduct. He further stated they did not let staff who liked to work extra put in too many shifts. i. Interview on 5/14/19 at 4:14 PM with the chief operations officer revealed staff received abuse training through human resources upon hire and before resident contact. Abuse training was also provided annually. j. Review of the Abuse: Recognizing and Reporting policy revised 6/15 showed, I. Any employee or member of the medical staff, who suspects, after assessment of the patient/resident, that the patient/resident may be a victim of abuse, will proceed according to policy and the laws established for reporting abuse .

Based on observation, medical record review and staff interview, the facility failed to provide the necessary services to promote healing for 1 of 1 sample residents (#41) with a pressure ulcer. The facility failed to monitor and assess the pressure ulcer, which worsened from a stage II to a stage IV resulting in harm for this resident. In addition, the facility failed to consistently implement interventions to prevent pressure ulcers for 1 of 8 sample residents (#39) who were at risk for the development of pressure ulcers. The findings were: 1. Review of the 11/26/13 annual MDS assessment showed resident #41 had [DIAGNOSES REDACTED]. Further, the care area assessment (CAA) for pressure ulcers showed the resident had a previous history of pressure ulcers. Review of the Braden Scale (tool used to determine the risk for developing pressure ulcers) showed the resident's score was 12, indicating a high risk for developing pressure ulcers. Review of the 2/19/14 photographic wound document sheet showed s/he had developed a stage II pressure ulcer. The pressure ulcer was located on the left buttock over the ischial tuberosity and measured 0.5 centimeters (cm) by 1.0 cm. Review of the nurse's notes dated 2/19/14 and timed 3:33 PM indicated a wound assessment was completed and the physician had been notified. The following concerns were identified: a. The nurse's note dated 4/4/14, timed 6 AM, showed the CNA had reported; "the wound on (his/her) buttock appeared larger, have pus and is bleeding." The note did not indicate the wound had been assessed at that time. Further review showed a nurses' note dated that same day, timed 7:22 PM, (13 hours, 22 minutes later) which indicated a wound assessment had been completed and showed the resident's "left tuberosity is completely opened red with some weeping and purulent discharge." Photographs and measurements were taken of the wound for the wound care nurse. Review of the nurses' notes from 2/20/14 through 4/3/14 (43 days) failed to show documentation concerning the appearance of the wound, including wound measurements until 4/4/14. b. Review of the photographic wound document dated 4/4/14 showed the wound measured 3.5 cm by 4.1 cm with a depth of 0.1 cm and showed it remained a stage II pressure ulcer. Neither the nurse's note nor the wound document, indicated the physician had been notified of the progression of the wound. c. Review of the nurse's note dated 4/9/14, timed 5:10 PM, revealed the wound had "deteriorated since previous assessment on 4/4/14." Further, the wound measured 5.5 cm by 4.0 cm and 2.5 cm deep with undermining of 4 cm (wound diameter is wider at the base than at the wound's skin edge). The 4/9/14 photographic wound document showed the wound was a stage IV pressure ulcer and that bone was evident. Review of the Physician Communication sheet dated 4/9/14 showed the physician was notified and wound care instructions were ordered. d. During an interview with the DON and wound care nurse on 4/24/14 at 10:25 AM revealed they would have expected documentation to show the resident's wound had been assessed weekly and that there was ongoing communication with the physician after the development of the stage II pressure ulcer. 2. Review of the 12/31/13 annual and 4/1/14 quarterly MDS assessments showed resident #39 was at risk for pressure ulcers. The assessments further indicated a pressure reducing device was used in the chair. According to the 3/31/14 Braden Scale, the resident was at moderate risk for pressure ulcers due to slightly limited sensory perception, slightly limited mobility, and chairfast (spending most of the time in a chair). The following concerns were identified: a. Observation of the resident on 4/22/14 at the following times revealed s/he was in a wheelchair with no cushion: 7:55 AM to 9:25 AM, 12 noon to 1:05 PM, and at 5:25 PM. b. Observation on 4/23/14 at 9:10 AM revealed the resident was seated on a cushion in the wheelchair. During an interview on 4/23/14 at 10 AM, CNA #5 stated the resident usually had a cushion in the wheelchair, and was not sure why the cushion was not used on 4/22/14. c. On 4/23/14 at 4:45 PM the DON stated the cushion should have been in the wheelchair the day before (4/22/14). He stated all residents who could not walk and were in a wheelchair should have a cushion.

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure residents were free from significant medication errors during 1 of 2 observed medication passes, affecting residents #46 and #70. This systems failure resulted in harm for resident #70. The findings were: 1. Observation of a medication administration pass on 4/23/14 at 3:37 PM with LPN #1 revealed resident #70 was administered [MEDICATION NAME] (medication used to prevent [MEDICAL CONDITION]) 32.4 mg. The following concerns were identified: a. Review of the April 2014 MAR indicated [REDACTED]=48.6 mg) at bedtime, ordered on [DATE]. Review of an electronically signed physician's progress note dated 3/20/14 with current medications listed showed another dose, "1. [MEDICATION NAME] 30 mg in the morning, 30 mg in the evening, 45 mg at bedtime". In addition, the "Physician Orders" dated March, 2014 showed the resident was supposed to receive, "[MEDICATION NAME] 32.5 mg twice daily for [MEDICAL CONDITION] disorder". b. Review of the medical record showed a nursing progress note dated 4/18/14 revealed the CNA had been performing pericare for the resident and the resident had a [MEDICAL CONDITION] that lasted approximately 4 minutes. Interview with the pharmacist on 4/24/14 at 10:25 AM revealed [MEDICATION NAME] was not available in 32.5 mg, however, it was available in 32.4 mg. The pharmacist was not aware of the physician's progress note that listed the [MEDICATION NAME] dose as 30 mg twice a day and 45 mg at bedtime. The pharmacist verified the medication dose should have been clarified and the MAR indicated [REDACTED]. Interview with the administrator at the same time verified medication reconciliation was performed by nursing staff on a month to month basis and medications listed on the MAR indicated [REDACTED]. 2. Observation of a medication administration pass on 4/23/14 at 3:50 PM with LPN #1 revealed resident #46 was administered carvedilol 6.25 mg (a medication that lowers heart rate and is used to treat heart failure and high blood pressure). The resident was also administered [MEDICATION NAME] 100 mg (used to treat [MEDICAL CONDITION]), [MEDICATION NAME] 160-4.5 mcg/act 2 inhalations for [MEDICAL CONDITION], and [MEDICATION NAME] 5 mg used to treat urinary urgency. The following concerns were identified: a. Review of the April 2014 MAR indicated [REDACTED]. There were no specific times recorded when the medication had been administered. LPN #1 was unable to verify the time the AM medications were given. Interview with the resident on 4/23/14 at 4 PM revealed s/he had taken his/her morning medicines around 10 AM because s/he didn't like to get up early. b. According to the 2013 Physician's Desk Reference Nurse's Drug Handbook carvedilol, [MEDICATION NAME], and [MEDICATION NAME] should be given over a 24 hour period in divided doses for the maximum effect of the drugs to control the signs and symptoms of diseases. In addition, carvedilol, "plasma concentrations are 50% higher in the elderly", and [MEDICATION NAME] should be administered, "12 hours apart in the AM/PM for maximum effectiveness". Also, [MEDICATION NAME], "duration of action is 6-10 hours", and to control symptoms of urinary frequency/urgency doses should be timed accordingly. Interview with RN #6 on 4/24/14 at 9 AM revealed AM meds were given from around 7 AM until noon, and PM meds were given after 3 PM. Interview with RN #5 on 4/24/14 at 9:05 AM showed AM meds were supposed to be administered between 7 and 10 AM and PM meds between 4 and 6 PM. Bedtime medications were administered when the resident went to bed. Interview with RN #4 on 4/24/14 at 9:15 AM revealed AM medications were supposed to be administered between 7 and 10 AM and PM medications between 3:30 to 6:30 PM. Bedtime medications were administered at different times according to when the resident went to bed. Interview with the pharmacist on 4/24/14 at 10:25 AM revealed the pharmacist was unable to verify the times that AM and PM medications were administered. The pharmacist agreed that medication dosing should be timed based on the individual medication that was being given for the resident to receive the maximum effect of the medication.

Based on medical record review and staff interview, the facility failed to ensure 3 of 6 sample residents (#2, #12, #58) at risk for pressure ulcers were assessed, monitored and treated with the appropriate nursing measures to prevent pressure ulcers. This lack of monitoring and implementation of nursing measures resulted in development of multiple pressure ulcers which required surgical debridement for resident #2. The findings were: 1. Review of the September 2011 physician's orders [REDACTED]. Review of the 7/25/11 annual MDS assessment for the resident revealed s/he was at risk for pressure ulcer development but had none at that time. Review of the July 2011 care plan showed interventions included: prevent skin to skin and direct contact with pads and pillows, use pressure-redistributing mattress and chair cushion, and encourage or provide small shifts in position while sitting every two to three hours. The following concerns were identified: a. Review of the 8/16/11 nursing notes written at 6 AM showed the CNA reported the resident had "several large open areas on the coccyx." Further review showed the nurse would like the day shift nurse to notify the wound care nurse about the open areas. Interview with the MDS coordinator and wound care nurse on 9/21/11 at 2:40 PM revealed the nursing staff had been notified the wound care nurse would be unavailable for two weeks. The wound care nurse said, in this interview, that staff nurses were supposed to follow through with notifying and working with the physician on treatment and monitoring of the pressure ulcers. Continued review of the nursing and interdisciplinary progress notes showed the next notation in regard to the development of multiple pressure ulcers was not written until 8/25/11 at 10:45 AM (nine days later). Review of these notes showed the open areas remained and they were tender when the [MEDICATION NAME] ointment was applied. b. According to the physician progress notes [REDACTED]. Due to the wound care nurse being on leave, the physician asked the MDS coordinator to assess the condition of the resident's pressure ulcers the following day, 8/30/11, at 10 AM. The MDS coordinator performed the assessment and the notes showed the pressure ulcers had 'worsened." Continued review of the nursing notes showed the physician consulted with an orthopedic surgeon about debridement of the necrotic ulcers on 8/30/11. Review of the 8/31/11 nursing notes written at 4 PM showed an additional new sore was noted on the resident's right buttock. On 9/1/11 the resident had surgical debridement of the multiple pressure ulcers and was admitted to the hospital for five days. c. Observation on 9/21/11 from 9 AM until 12 noon showed staff were re-positioning the resident and following the care plan in regard to pressure redistributing devices in the bed and the chair. However, interview with the wound care nurse and the MDS coordinator on 9/21/11 at 2:40 PM revealed there was no official log of pressure ulcer or wounds maintained for monitoring purposes, but nursing staff should know who had pressure ulcers. The wound care nurse said the nursing staff did not but should have followed through with assessing, monitoring, and treating the resident's pressure ulcers while she was unavailable. 2. Review of the 7/4/11 quarterly MDS assessment for resident #58 showed s/he was at risk for skin breakdown. Review further showed the resident currently had one stage I and one stage II pressure ulcer. Review of the 7/19/11 care plan showed interventions including repositioning, shifting points of pressure every one to two hours or more often, pressure relief in the bed and chair, and the resident to move in bed and to get up in the chair more frequently. The following concerns were identified: a. Review of the 2/23/11 nursing notes written at 8 PM showed the resident had two small open areas on the coccyx. Continued review of the nursing notes showed the next notation regarding skin was written on 3/31/11 (nearly one month later). This note showed there was an open area on the left buttocks the size of a dime and an additional open area just to the right side of the gluteal fold the size of a nickel. The next nursing note in regard to the resident's pressure ulcers was written at 2:53 PM on 4/3/11 (4 days later) and described the pressure ulcers as dark purple with poor blanching. At 9:16 PM on that same day, the nursing note described the area as being a large area that was open and bleeding on the coccyx. The 4/4/11 nursing notes written at 7 AM showed the resident had several open areas to the coccyx and upper buttocks. Review of the 4/24/11 nursing notes showed the sacrum had open areas and [MEDICATION NAME] ointment was applied. The wound nurse assessed the resident's pressure ulcers on 7/17/11 at 11:31 AM. Her notes indicated the resident continued to have Stage I and Stage II pressure ulcers bilaterally. She further indicated it was a challenge to get this resident to turn, reposition, move about in bed or get out of bed to take the pressure off the coccyx. The next nursing notes written in regard to the status of the pressure ulcers was on 6/14/11 (nearly one month later) at 11:12 AM. These notes indicated the pressure ulcer was still present. b. Review of the nursing notes showed no evidence the pressure ulcers were monitored or treated between 7/6/11 at 11:14 AM through 9/18/11. Interview with the MDS coordinator and the wound care nurse on 9/21/11 at 2:40 PM revealed the resident still had a Stage II pressure ulcer on the buttocks. c. Observation on 9/21/11 from 9 AM until 12 noon showed staff did turn and reposition the resident at intervals of one to one and one-half hours and followed the care plan in regard to pressure redistributing devices in the bed and the chair. However, interview with the wound care nurse and the MDS coordinator on 9/21/11 at 2:40 PM revealed there was no official log of pressure ulcers or wounds maintained for tracking purposes and therefore sometimes nursing staff did not follow through with treatments and monitoring the status of wounds. The wound care nurse was also the nurse manager of the south unit and therefore depended on the nursing staff to follow the pressure ulcers when she was unable to do so. 3. Review of the 9/19/11 quarterly MDS assessment for resident #12 showed s/he was at risk for developing pressure ulcers. Further review of that assessment showed the resident currently had one unhealed stage II pressure ulcer on the coccyx. Review of the nursing notes showed this pressure ulcer was identified on 1/15/11. At that time the ulcer measured 2 to 3 centimeters (cm) and was open according to the nursing notes. Review of the 9/20/11 care plan showed interventions included repositioning every one to two hours or more often, a pressure relieving cushion in the wheelchair, a pressure redistributing mattress on the bed, good nutrition, and to monitor and document the status of the wound. The following concerns were identified: a. Review of the nursing notes showed the pressure ulcer was identified on 1/15/11, was documented as to status on 1/16/11, 1/17/11, 1/22/11, 1/30/11 but not again until 2/24/11 (over three weeks) when the pressure ulcer was assessed by the wound care nurse. Further review of these wound care nursing notes showed the pressure ulcer was worse and the wound care nurse "...will change the treatment soon. [MEDICATION NAME] used at this time..." It was an additional five days before a different wound care nurse assessed the resident on 3/1/11. Review of her notes written on 3/1/11 at 10:12 AM showed there was also a "slit" in the gluteal fold which had gotten deeper. This wound care nurse changed the treatment to [MEDICATION NAME] dressing to protect the slit as well as the coccyx area. The next wound care notes written at 11:30 AM was by the facility's wound care nurse on 3/16/11 and review of those notes showed "Unfortunately, the dressing was not applied appropriately, and therefore was defeating the purpose....It needs to be occlusive so as not to allow fecal matter, etc. to the wound...This did not begin as a pressure wound, rather from excess moisture, and now..." that the resident was sitting more, the area has increased and worsened. b. Review of the 3/29/11 nursing notes written at 10:47 PM showed there was a reddened area below the dressing on his/her buttocks. Review of the nursing notes showed the next wound notes were written on 4/17/11 and indicated the gluteal cleft was closed. However, review of the 4/22/11 nursing notes written at 10:42 AM showed "...sore in the gluteal cleft continues to be an issue." Review of the 6/15/11 nursing notes written at 9:02 AM showed the "sacral slit" was unchanged, 54 days later. Review of the 6/17/11 wound care nursing notes timed at 11:36 AM showed the area on the coccyx was open and was determined to be a Stage II pressure ulcer that measured 1.5 cm by 2 mm (millimeters) by 0.3 mm and had scant drainage. The wound was packed with a small piece of Ag Mesh and was covered with [MEDICATION NAME]. Review of the 6/19/11 nursing notes written at 2:29 PM showed the coccyx area was red and had a small amount of yellow drainage. c. Review of the 6/23/11 nursing notes revealed the sacral wound was open and was approximately one-half inch long by one-fourth inches wide. Continued review of these notes showed the nurse would notify the wound care nurse of the status. Review of the 6/24/11 wound care nursing notes showed the wound bed was clean but slightly macerated and did not have the recommended dressing in place. The wound measured 2 cm by 0.1 cm by 0.2 cm. The wound care nurse packed the open area with [MEDICATION NAME] Ag Mesh and covered it with a strip of thin [MEDICATION NAME] and asked nursing staff to follow the wound. Review of the 6/26/11 nursing notes revealed the wound had no dressing on it at all. The wound was cleansed and [MEDICATION NAME] ointment was applied and covered by a [MEDICATION NAME] strip only because staff "was unable to locate the [MEDICATION NAME] Ag Mesh." d. Review of the nursing notes on 7/6/11, 7/13/11, 7/19/11, 7/27/11, and 8/6/11 showed the dressing was not in place as recommended. Review of the 8/7/11 nursing notes showed the pressure ulcer was unchanged. The next wound status note was written by the dietician on 9/15/11 and was the quarterly nutrition assessment. Review of that note showed the resident continued to have a stage II pressure ulcer. e. Observation on 9/20/11 from 1 PM until 5 PM showed staff did turn and reposition the resident at intervals of one to one and one-half hours and followed the care plan in regard to pressure redistributing devices in the bed and the chair. However, interview with the wound care nurse and the MDS coordinator on 9/21/11 at 2:40 PM revealed there was no official log of pressure ulcer or wounds maintained for tracking purposes and therefore sometimes nursing staff did not follow through with treatments and monitoring the status of wounds. The wound care nurse was also the nurse manager of the south unit and therefore depended on the nursing staff to follow the pressure ulcers when she was unable to do so.