Every finding on record at Quinn Meadows Rehabilitation and Care Center

Based on interview and document review, the facility failed to report 2025 4th quarter Payroll Based Journal (PBJ) information for the facility as required. This failure created the potential for CMS not to confirm adequate nurse staffing and potential for residents to experience longer waiting times for needed cares. Findings include:On 2/23/26 at 8:00 AM, the surveyor noted the lacked submission of 2025 4th quarter PBJ data to CMS.On 2/23/26 at 10:33 AM, the Executive Director stated the facility failed to submit 2025 4th quarter PBJ data to CMS as required.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 1 of 14 residents (Resident #47) reviewed for resident rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include:The facility's Call Lights: Accessibility and Timely Response policy, revision date 12/31/25, documented.staff will ensure the call light is within reach of resident and secured, as needed. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (muscular impairment on one side of the body) and diabetes. On 2/24/26 at 10:11 AM, observed Resident #47 reclining in her bed and her call light pinned to the headwall cord and not within her reach. On 2/24/26 at 10:12 AM, RN #2 stated Resident #47's call light should be within reach and had not been. On 2/24/26 at 12:24 PM, the RSN stated resident call lights should be within the resident's reach and had not been.

Based on record review and staff interview, it was determined the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC CMS-10123) within the CMS required timeframe to 1 of 3 residents (Resident #54) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include:Resident #54 was admitted to the facility 10/2/25, with multiple diagnoses including open wound to lower left leg and muscle weakness.Resident #54's medical record documented the NOMNC form was signed on 10/13/25, with her Medicare coverage of skilled nursing services ending on 10/14/25. CMS requires beneficiaries to have at least 2 days' notice before skilled nursing services end.On 2/24/26 at 11:34 AM, the Executive Director stated the facility had not provided Resident #54 with the NOMNC document at least 2 days prior to the end of her Medicare coverage of skilled nursing services and should have.

Based on facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing orders for delivering specific medications when residents do not have BM for over 72 hours for 2 of 4 residents (#5 and #7) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The facility's routine standing orders and bowel protocol documented the following:- Bisacodyl Delayed Release Tablet: 10 mg as needed for no BM in 3 consecutive days. Do not crush or chew. Do not give within 1 hour of antacids or milk ingestion.- Bisacodyl Suppository: 10 mg rectally as needed, if no results within 24 hours from Bisacodyl Tablet.- Fleet Natural Cleaning Enema: 1 dose rectally as needed, if no results from Bisacodyl Suppository within 24 hours. If no results after enema, then notify Provider for further instructions.Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including fracture of left arm and repeated falls.Resident #5's medical record documented the following related to BM data: - a BM on 1/30/26, and not again until 2/4/26 at 21:36, around 84 hours later.- a BM on 2/16/26 at 21:12, and not again until 2/20/26 at 21:52, about 96 hours later. Resident #5's physician order related to constipation were as follows:- MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350), give 17 grams by mouth one time a day for Constipation -Start Date: 1/14/26, (Note; this was given each day as ordered). - Bisacodyl Tablet Delayed Release, give 10 mg by mouth as needed for constipation, take one tablet PRN for no bowel movement in 3 consecutive days. FYI do not crush or chew. Do not give within 1 hour of antacids or milk ingestion -Start Date 1/7/26, (Note; this was not given in [DATE]). - Bisacodyl Suppository Insert 10 mg rectally as needed for constipation, If no results within 24 hours from Bisacodyl tablet, may give Bisacodyl Suppository per rectum -Start Date 1/7/26, (Note; this was not given in [DATE]).- Fleet Naturals Cleansing Enema (Rectal Cleansers), Insert 1 dose rectally as needed for constipation, If no results from Bisacodyl Suppository within 24 hours, may give one fleet type cleansing enema. If there is still no results, contact/notify MD for further instructions -Start Date 1/7/26, (NOTE; this was not given in [DATE]).Resident #7 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including cellulitis of right lower limb (a common, potentially serious bacterial infection of the skin's deep layers, characterized by rapid spreading of red, hot, swollen, and painful skin, usually in one leg) and pulmonary fibrosis (a chronic, progressive lung disease where tissue deep in the lungs becomes scarred, thick, and stiff, making it difficult to breathe and transfer oxygen into the bloodstream).Resident #7 medical record documented the following related to BM data:- a BM on 2/10/26 at 13:38, and not again until 2/15/26 at 21:10, over 120 hours without a documented BM.- a BM on 2/18/26 at 21:42, and not again until 2/22/26 at 21:59, over 96 hours without a documented BM. Resident #7's physician order related to constipation were as follows:- Bisacodyl Tablet Delayed Release Give 10 mg by mouth as needed for constipation. Take one tablet PRN for no bowel movement in 3 consecutive days. FYI do not crush or chew. Do not give within 1 hour of antacids or milk ingestion -Start Date 1/23/26 (NOTE; one dosage given on 2/15/26). - Bisacodyl Suppository Insert 10 mg rectally as needed for constipation If no results within 24 hours from Bisacodyl tablet, may give Bisacodyl Suppository per rectum -Start Date 1/23/26 (NOTE; not given in [DATE]).- Fleet Naturals Cleansing Enema (Rectal Cleansers) Insert 1 dose rectally as needed for constipation If no results from Bisacodyl Suppository within 24 hours, may give one fleet type cleansing enema. If there is still no results contact/notify MD for further instructions -Start Date 1/23/26 (NOTE; not given in [DATE]).On 2/24/26 at 10:08 AM, the DNS stated Resident #5 and Resident #7 had no documented BM for over 72 hours without any nursing intervention with prescribed medications ordered by their physicians and should have.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 2 residents (Resident #52) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue. Findings include:Resident #52 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic obstructive pulmonary disease (progressive, incurable respiratory condition-primarily caused by smoking-that restricts airflow, causing chronic bronchitis (inflamed airways) and emphysema (damaged air sacs)).On 2/23/26 at 11:22 AM, observed Resident #52's oxygen concentrator was set at 4 lpm and resident was asleep in his bed with the oxygen cannula in his nose.Resident #52's physician oxygen order dated 2/12/26, documented O2 at 2 L/M via NC continuous to keep sats equal or greater than 88%. Check O2 SATS every shift. On 2/24/26 at 10:20 AM, observed with RN #1, Resident #52's oxygen concentrator was set at 4 lpm. RN #1 stated the oxygen concentrator should not have been at 4 lpm and she turned it back down to 2 lpm.On 2/24/26 at 11:00 AM, the Regional Support Nurse stated someone should have caught the increased oxygen lpm and had not.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were assessed appropriately for adequate indications for the use of opioid pain medications. This was true for 1 of 4 residents (Resident #23) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse consequences or increased risk of death. Findings include:The facility's Pain Management policy, revision date12/29/25, documented under Pain Management and Treatment: 7. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain.The following are general principles the facility will utilize for prescribing analgesics.c. Consider evidence-based practice tools to assist in the assessment analgesic therapy for pain.Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including osteomyelitis (a serious infection of the bone or bone marrow) and sepsis (a life-threatening condition caused by the body's extreme response to an infection).Resident #23's medical record included physician orders for pain medication:Oxycodone HCl Oral Tablet 5 MG - Give 1 tablet by mouth every 4 hours as needed for Pain - Moderate. Start Date - 1/30/26Oxycodone HCl Oral Tablet 5 MG - Give 2 tablets by mouth every 4 hours as needed for Pain - Severe. Start Date - 1/30/26The following was documented on Resident #23's MAR for administration of Oxycodone HCl 2 tablets - Severe Pain: - 2/6/26 at 15:15 for pain level of 6- 2/7/26 at 09:27 for pain level of 6-2/7/26 at 17:40 for pain level of 6-2/9/26 at 02:55 for pain level of 6-2/12/26 at 14:31 for pain level of 6-2/12/26 at 19:30 for pain level of 2-2/13/26 at 17:42 for pain level of 5-2/17/26 at 15:56 for pain level of 5-2/19/26 at 17:37 for pain level of 5-2/20/26 at 20:14 for pain level of 4-2/21/26 at 09:33 for pain level of 6-2/21/26 at 16:13 for pain level of 6-2/22/26 at 07:55 for pain level of 6-2/22/26 at 17:34 for pain level of 6On 2/23/26 at 5:10 PM, the DNS stated the facility uses the standard pain scales for resident pain assessments (1-3 = mild, 4-6 = moderate, 7-10 = severe) and the pain medication should have been administered as ordered according to the pain level and had not been.

Based on observation, policy review, and staff interview, it was determined the facility failed to maintain the kitchen in a sanitary manner. This deficiency had the potential to affect the 37 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. The facility's Sanitation Inspection policy revision date 12/3/24, documented it was the policy of the facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. On 2/3/25 at 8:10 AM, during the initial kitchen tour, the following was observed in the kitchen: - dust between handles of the refrigerator and freezer. - the ice machine floor drain had a large hard water stain. The drain pipes for the ice machine had a thick, dark gray, dry, substance. - the right side of the ice machine had a build up of a white substance. - the inside lip of the ice machine had a red, dry substance. - under the handwashing sink observed a fuzzy, gray substance on the pipes/tubing and hard water stain on the floor. - the dish rack was observed with a thick, fuzzy, gray, and yellow substance around the base and wheels. Observed dried chunks of different colors one the poles of the rack. - the serving table was observed with a white substance on the lower edge. - the wheels and lower part of the poles of the dish racks had a thick, gray, fuzzy substance covering them. - the front of the stove, on the bottom, observed a brown/orange, thick substance. - the vents in dish room and above the serving table were observed with a black substance. - the inside of the refrigerator, the left corner was observed with a dry, yellow substance. The right side of refrigerator wall was observed to have a dry, white substance. On 2/5/25 at 8:29 AM, the DM stated the kitchen has a daily and weekly cleaning schedule and the kitchen equipment should have been cleaned. On 2/5/25 at 12:59 PM, the Administrator stated the kitchen equipment and floor should have been clean.

Based on review of the State Operations Manual, record review, and staff interviews, it was determined the facility failed to ensure a Significant Change of Status Assessment (SCSA) MDS was completed when residents were newly diagnosed with a major mental disorder. This was true for 2 of 12 residents (#27 and #33), whose MDS records were reviewed for accuracy. This had the potential for harm if the facility staff did not recognize changes in the resident's health status and mental health needs. Findings include: Appendix PP of the State Operations Manual dated 8/8/24, documented a SCSA must be completed within 14 days after a determination has been made that a significant change in the resident's status from baseline occurred. 1. Resident #27 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including primary adrenocortical insufficiency (a condition where the adrenal glands fail to produce sufficient amounts of the hormones cortisol and aldosterone) and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Resident #27's Level 1 PASARR dated 8/21/24, documented he had schizophrenic disorder. The quarterly MDS dated [DATE], had not documented Resident #27 had a schizophrenic disorder. On 2/5/25 at 2:31 PM, the DON and the RSN stated Resident #27's MDS should have been updated within 14 days of the schizophrenic disorder diagnosis identified on 8/23/24 PASARR I but was not. 2. Resident #33 was admitted on [DATE], with multiple diagnoses including fractured pelvis, anxiety disorder, and depression. Resident #33's Level I PASRR screening dated 12/30/24, documented she was suspected to have a mental disorder of mild/situational depression. Resident #33's Level II PASRR evaluation dated 12/30/24, documented her depression and anxiety diagnosis was identified as mild or situational and does not meet the criteria for major mental illness. Resident #33's medication orders dated 1/2/25, documented the following. - Quetiapine Furnate (antipsychotic medication) 25 MG. Give 1 tablet by mouth at bedtime for depression. - Citalopram Hydrobromide Oral Tablet (antidepressant medication) 20 MG. Give 1 tablet by mouth one time a day for depression. Resident #33's Admission MDS dated [DATE], documented in section A1500, Resident #33 was not considered to have a serious mental illness. Resident #33's physician documented on 1/11/25, Resident #33 had a diagnosis of major depressive disorder (a major mental illness) and she will continue to meet with Resident #33 on a regular basis to provide supportive counseling and monitor medication need. On 2/5/25 at 2:14 PM, the DON and RSN stated a SCSA MDS was not completed for Resident #33 after her newly identified diagnosis of major depressive disorder, and there should have been one completed. 51121

Based on policy review, Up-To-Date review, observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 2 residents (Resident #189) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue, poor sleep quality, and low oxygen levels. Findings include: The facility's Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) policy dated 12/16/24, documented under Policy Explanation and Compliance Guidelines, document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s). Up-To-Date (Sleep-related breathing disorders in COPD - Up-To-Date), Sleep-related breathing disorders in COPD dated 12/8/23, documented heated humidification is generally recommended for patients receiving CPAP. Resident #189 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing). On 2/3/25 at 2:43 PM, Resident #189 stated she had not used the CPAP since the humidifier water ran dry 3 days ago. Additionally, Resident #189 stated no one had been back to help her with the CPAP. Resident #189's physician's orders documented CPAP with setting of 6 to 15 cmH20 at bedtime. Add distilled water every night and as needed every night shift. On 2/5/25 at 10:15 AM, with RN #2 present, Resident #189 stated she had not used her CPAP the last three nights because they had not filled the CPAP humidifier with distilled water. On 2/5/25 at 11:06 AM, the DON stated nursing staff should have been filling the humidifier each night and as needed but nursing staff had not.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 12 residents (Resident #16) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Comprehensive Care Plans policy, dated 12/13/24, documented the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Resident #16 was initially admitted to the facility on the 11/23/22, and readmitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (spinal narrowing) and heart failure. a) A Progress Note dated 1/23/25 at 1:27 PM, documented the staff were called outside to the front of facility. Resident #16 was observed laying on the driveway near the sidewalk, on his left side. Resident #16 stated his wheelchair tire went off the curb and he fell out of the wheelchair. Resident #16 received a bruise and a cut to his left elbow, a cut to the bridge of his nose and forehead. Resident #16's care plan was not updated with new fall interventions. On 2/5/25 at 11:11 AM, the DON stated there was no interventions for Resident #16's fall on 1/23/25, in his care plan. The care plan should have been updated. b) Resident #16's TAR documented he did not have skin breakdown/wounds. On 2/4/25 at 11:44 PM, Resident #16's care plan documented he recently had lumbar spinal fusion surgery. Resident #16's goal was for his surgical site to heal without signs and symptoms of complications by next review date. His care plan directed the facility staff to: - Allow me to rest when my pain is worse. - Assist me with turning and repositioning. - Encourage me to report pain. - Encourage me to turn, cough and breathe deeply to help prevent pneumonia. - Ensure I am eating to promote healing. - Diet per my physician order. - Encourage diet high in protein to promote healing. - Monitor my intake. - Offer snacks. - Have dietician assess my nutritional status. - Assess for my likes and dislikes. - Monitor and change my bandages per my physician orders. - Monitor my pain. Perform pain scale every shift. Administer pain medication as ordered. Assist me to comfortable positions. - Monitor my surgical site for s/s of infection: redness, increased temperature, Drainage, etc. On 2/5/25 at 11:11 AM, the DON stated Resident #16 does not have any wound issues, his lumbar surgery was a while ago, and his care plan should have been updated.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 37 residents who resided in the facility whose equipment and environment were observed for cleanliness and proper lighting in their rooms. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or residents were injured due to inadequate lighting in resident rooms. Findings include: The facility's Cleaning and Disinfecting of Resident-Care Equipment policy dated 12/6/24, documented direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule. The following areas were observed: a) On 2/3/25 at 9:21 AM, in room [ROOM NUMBER]A, the right bed rail was observed with a dried brown substance in the curve of the railing and across the railing. The bedside table base was observed with a dry white substance. On 2/5/25 at 10:46 AM, the Director of Housekeeping/Laundry stated the bed rail, and the bedside table are to be cleaned daily and should have been cleaned. b) On 2/3/25 at 8:28 AM, observed a Hoyer lift stored in the hallway in front of room [ROOM NUMBER] with a dirty cushion on the cross bar. On 2/3/25 at 8:32 AM, the ADON stated the cushion was dirty and should have been getting changed or cleaned between resident transfers. On 2/3/25 at 10:04 AM, observed CNA #2 remove a Hoyer lift from room [ROOM NUMBER] and did not clean/disinfect the Hoyer lift. On 2/3/25 at 10:08 AM, CNA #2 stated there is no set time frame for cleaning the Hoyer lifts. On 2/3/25 at 10:13 AM, CNA #1 stated he didn't know who cleans the Hoyer lift or when it gets cleaned. c) Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and diabetes. On 2/3/25 at 1:41 PM, Resident #32 stated the lights were off in his room because he could not reach any of the light switches in the room when in bed. On 2/4/25 at 10:30 AM, the Administrator stated that residents might have problems with room light access due to the location of room light switches. On 2/4/25 at 11:45 AM, the Administrator provided the results of a Potential Building Wide Grievance survey he had just completed. This survey documented four residents stated access to the light switch from their bed was identified as a potential barrier at times. On 2/4/25 at 11:48 AM, the Administrator stated the light switches in resident rooms seemed to be an issue for some residents and needed to be addressed. 51121

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents resuscitation code status was up to date in their medical records and residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 1 of 12 residents (Resident #188) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented. Findings include: The facility's Residents' Rights Regarding Treatment and Advance Directives policy dated [DATE], documented under Policy Explanation and Compliance guidelines: On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Any decisions made regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Resident #188 was admitted to the facility on [DATE], with multiply diagnoses including chronic respiratory failure with hypoxia (a condition where the body is unable to effectively exchange oxygen and carbon dioxide in the lungs over a prolonged period, leading to persistently low levels of oxygen in the blood) and multiple fractures of bilateral ribs. Resident #188's medical record had conflicting documentation related to his resuscitation status as listed below. - Resident 188's face sheet documented DNR. - His POST (Physician Orders for Scope of Treatment) dated [DATE], documented YES to CPR, attempt resuscitation. - His care plan dated [DATE], documented DNR. Resident #188's medical record did not contain documentation of the following; - an advance directives. - of the facility offering to assist the resident to formulate an advance directive. - the resident declined to formulate an advanced directive. On [DATE] at 2:25 PM, the DON and Regional Support Nurse stated the POST was the most up to date document and it did conflict with the other documents in Resident #188's record and should not have. On [DATE] at 2:30 PM, the DON and Regional Support Nurse stated Resident #188 did not have an advance directive in the medical record and should have.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: The facility's Controlled Substance Administration & Accountability policy dated 12/16/24, documented it is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. On 2/4/25 at 12:26 PM, during hall 100's medication cart audit, observed the narcotic accountability record, dated 1/1/25 to 2/4/25, did not document a licensed nurse signature on each shift for 11 out of 35 days. On 2/4/25 at 12:33 PM, RN #1 stated the nurses should have signed the sheet when they accepted or released the medication cart.

Based on record review, policy and State Operations manual review, and staff interview, the facility failed to ensure physician ordered psychotropic medications were necessary to treat a specific diagnosed condition documented in resident's medical records. This was true for 1 of 6 residents (Resident #27) reviewed for psychotropic medication administration. This failure created the potential for Resident #27 to experience negative side effects related to receiving psychotropic medication without a proper diagnosis. Findings include: The facility's Unnecessary Drugs-Without Adequate Indication for Use policy dated 12/16/24, documented under Policy Explanation and Compliance Guidelines, documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed. State Operations Manual Appendix PP S483.45(e)(1) documented residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident #27 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including primary adrenocortical insufficiency (a condition where the adrenal glands fail to produce sufficient amounts of the hormones cortisol and aldosterone) and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Resident #27's physician's order documented Risperdal (antipsychotic medication) oral tablet 1 mg at bedtime for schizophrenia. Resident #27's medical record had not documented schizophrenia as a medical diagnosis. Resident #27's MDS dated [DATE], under I6000 documented NO for schizophrenia. On 2/5/25 at 2:28 PM, the DON and the RSN stated the schizophrenic diagnosis should have been in the record before the Risperdal was ordered and administered but was not.

Based on observation, interview, Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator. U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled. On 2/3/25 at 8:10 AM, observed in the kitchen, next to the clean dish rack, a large garbage can without a lid. On 2/5/25 at 1:13 PM, the cook stated they had never had a lid on their garbage can. He did not know they needed one. On 2/5/25 at 2:54 PM, the RSN stated the garbage can should have had a lid on it.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 6 residents (Resident #28) reviewed for IV medication administration. This failure had the potential of placing residents at risk for cross-contamination and infection. Findings include: The facility's Intravenous Therapy policy dated 12/13/24, documented under IV push. - Disinfect needleless connector/IV port with appropriate antiseptic agent (e.g., chlorhexidine, povidone iodine, an iodophor, or 70 percent alcohol) as per facility protocol. - Attach 10mL syringe normal saline and confirm patency of vascular access device as per protocol. - Disinfect needleless connector again with appropriate antiseptic agent. - Attach medication/solution syringe and administer slowly as per medication guidelines. - Observe infusion site for any adverse reactions and stop infusion, if so noted, and notify practitioner. - Detach medication syringe and disinfect needleless connector with appropriate antiseptic agent again. - Flush vascular access device with normal saline at same rate drug was injected. - Disinfect the needleless connector again and attach locking solution and inject into device, if warranted. On 2/3/25 at 11:01 AM, observed RN #1 during IV push medication administration do the following. - use Resident #28's bedside table without cleaning or disinfecting it before putting the IV push antibiotics syringe and flush syringes on the bedside table without any protective barrier. - uncap and clean first IV port with an alcohol pad before connecting the flush syringe to the port and recap the port. - uncap and clean the second IV port with an alcohol pad before connecting the flush syringe to the port. - without wiping the second IV port with an alcohol pad, connected the antibiotic syringe and instill the antibiotic. - After the antibiotic syringe was empty, RN #1 again wiped the second port with an alcohol wipe and connected the flush syringe to the port. On 2/3/25 at 11:19 AM, RN #1 stated she should have disinfected the bedside table before using it and she should have cleaned the second IV port before connecting the antibiotic syringe to the port, but did not. On 2/5/25 at 3:08 PM, the RSN stated RN #1 should have cleaned Resident #27's bedside table and the IV port prior to connecting each syringe to the IV port.

Based on observation and staff interview, it was determined the facility failed to monitor, discard outdated food items, and maintain the kitchen in a sanitary manner. These deficiencies had the potential to affect the 36 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. The facility's Date Marking for Food Safety policy, revised [DATE], stated the facility adhered to a date marking system to ensure safety of food. The policy also stated the food should be clearly marked to indicate the date by which the food shall be consumed or discarded. 1. a. On [DATE] at 1:20 PM, the following seasoning containers had a sticker with the following dates on it: - All Spice - [DATE] - Cream of Tartar: [DATE] - Whole Fennel seeds: [DATE] - Cayenne Pepper: [DATE] - Curry Powder: [DATE] - Ground Ginger: [DATE] - Dill Weed, [DATE] - Chives: [DATE] - Hungarian Paprika: [DATE] - Ground Nutmeg: [DATE] - Ground Mustard: [DATE] The above seasonings had a handwritten use by date which was one or two years from the date on the sticker except for the All Spice. Some of the seasonings had two different use by dates written on it. b. The following seasonings had no date on the sticker but had use by dates as follows: - Poppy Seed: use by [DATE] - Whole Oregano: use by [DATE] c. The following food items had an expiration date as follows: - Maple Flavor: [DATE] - Red Food Color: [DATE] - [NAME] Imitation Maple Flavor: use by [DATE] - [NAME] Red Food Color: [DATE] - Yellow Food Color (Egg Shade): [DATE] - Red Food Color: [DATE] - 2 bags of Couscous with best by [DATE] On [DATE] at 2:00 PM, the Chef stated the date on the sticker was the date it was received in their warehouse, and they would add one or two years from it for the use by date. The Chef also stated the expired food items should not be in the kitchen. On [DATE] at 1:59 PM, the DM stated the facility added one or two years from the date on the sticker as the use by date. When asked why some of the containers had two different use by dates written on them, the DM stated, I don't know why, unless we did a refill and mistakenly wrote two dates on it. The DM stated some of the spices are in their original container and some might have been refilled. When asked if the original container of the spices should be kept or thrown away when they have been consumed, the DM stated some of the containers were thrown away and some were refilled. The DM also stated some of the spices were hard to get so she would get them from the store and refill the container. 2. On [DATE] at 2:20 PM, during the kitchen tour with the DM, the following was observed in the kitchen: - The metal shelf where the oven was had a collection of dark debris along the sides of the oven and rusted areas were observed on the corners of the shelf. Food droppings were also observed on the shelf. - The oven door from the outside had whitish dried splatters. Both sides of the oven looked dirty. Also, a whitish splatter was observed on top of the oven. The inside of the oven was observed to be heavily soiled with grease. - The can opener was observed to have white splatter on its side. On [DATE] at 1:59 PM, the DM stated the shelves were being cleaned every three months and the oven was being cleaned every week. The DM was unable to provide documentation the oven and shelves were being cleaned as scheduled.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advanced Directive. This was true for 6 of 12 residents (Resident # 13, 14, 18, 22, 27, and 141) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include: The facility's Residents' Rights Regarding Treatment and Advanced Directives policy, dated 2/3/23, documented on admission the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. Should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. Any decision-making regarding resident's choices will be documented in the resident's medical record. 1. The following resident's records did not include an advanced directive or documentation information about an advanced directive was provided to the resident or the resident's representative. a. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure and hypertension. A Social Services assessment, dated 11/9/23, documented Resident #13 had an advanced directive and the facility had received a copy of her advanced directive. Resident #13's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her or [NAME] representative. b. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and Type 2 diabetes. A Social Services assessment, dated 9/13/23, documented Resident #14 had an advanced directive and the facility had received a copy of his advanced directive. Resident #14's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with him or his representative. c. Resident #22 was admitted to the facility on [DATE], with multiple diagnosis including cervical vertebra fracture and respiratory failure. A Social Services assessment, dated 3/11/24, documented Resident #14 had an advanced directive. Resident #22's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her or her representative. d. Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnosis including sepsis (a life-threatening complication of an infection) and respiratory failure. Resident #27's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her or her representative. e. Resident #141 was admitted to the facility on [DATE], with multiple diagnosis including acute respiratory failure and urinary tract infection. Resident #141's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her or her representative. On 4/16/24 at 2:16 PM, the SSD stated the residents' social services assessments documented a copy of their advanced directive was documented by mistake. She stated when she completed the assessment she was thinking of the POST (Physicians Orders for Scope of Treatment). The SSD also stated she did not document that she offered to assist residents or resident representatives with completing an advanced directive. 36193 2. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness) and diabetes. A Social Services evaluation, dated 2/5/24, documented Resident #18 had an advanced directive. Resident #18's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with him or his representative. On 4/17/24 at 10:24 AM, the SSD stated she discussed the advanced directive with Resident #18 and his family, and remembered asking for a copy of it, but did not document the conversation. The SSD stated she was unable to find Resident #18's advanced directive.

Based on record review, policy review, and staff interview, it was determined the facility failed to provide a summary of residents' baseline care plans to residents or their representative. This was true for 5 of 12 residents (#13, #14, #22, #27, and #141) reviewed for baseline care plans. This failure placed residents and their representative at risk of not being informed and having input in their care plan. Findings include: The facility's Care Plan - Baseline Plan of Care policy, revised 12/22/23, documented the Baseline Care Plan was to be developed within 48 hours of admission. The person providing the written summary of the baseline care plan should have obtained a signature from the resident or representative to verify that the summary was provided and make a copy of the summary for the medical records. If the summary was provided verbally by telephone, the nurse would indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident representative. The following resident records did not include documentation their baseline care plan was provided and discussed with the resident and/or their representative: a. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure and hypertension. A MDS assessment, dated 2/15/24, documented Resident #13 was cognitively intact. Resident #13's record did not include documentation a baseline care plan was provided and discussed with her or her representative. b. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and Type 2 diabetes. A MDS assessment, dated 3/22/24, documented Resident #14 was cognitively intact. Resident #14's record did not include documentation a baseline care plan was provided and discussed with him or his representative. c. Resident #22 was admitted to the facility on [DATE], with multiple diagnosis including cervical vertebra (spinal) fracture and respiratory failure. A MDS assessment, dated 3/14/24, documented Resident #22 was cognitively intact. Resident #22's record did not include documentation a baseline care plan was provided and discussed with him or his representative. d. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnosis including sepsis (a life-threatening complication of an infection) and respiratory failure. A MDS assessment, dated 3/26/24, documented Resident #27 was cognitively intact. Resident #27's record did not include documentation a baseline care plan was provided and discussed with her or her representative. e. Resident #141 was admitted to the facility on [DATE], with multiple diagnosis including acute respiratory failure and urinary tract infection. Resident #141's record did not include documentation a baseline care plan was provided and discussed with him or his representative. On 4/16/24 at 4:31 PM, the SSD stated there was no documentation residents' baseline care plans were reviewed or signed by residents or their representative. On 4/16/24 at 4:50 PM, the CRN stated there was no documentation baseline care plans were reviewed or signed by residents or their representative.

Based on record review and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 1 of 6 residents (Resident #15) whose care plans were reviewed. This created the potential for harm if cares/or services were not provided appropriately due to inaccurate information in the care plans. Findings include: The facility's Care Plan Revisions Upon Status Change, revised 12/22/23, documented comprehensive care plans should be reviewed, and revised as necessary when a resident experiences a status change. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including bladder cancer and muscle weakness. A physician's order, dated 2/15/24, directed staff to irrigate Resident #15's neobladder (new bladder made from a piece of a person's own small intestine that is formed into a pouch and positioned inside the body in the same position as the original urinary bladder) two times a day with 500 - 1,000 cc of saline. The order documented to push 2-3 syringes full, then remove, and repeat. Resident #15's care plan did not include documention his neobladder was to be rrigated two times a day. On 4/17/24 at 3:46 PM, the Clinical Resource Nurse reviewed Resident #15's care plan and stated irrigation of his neobladder was not in the care plan. The Clinical Resource Nurse stated residents' care plans should be updated as needed and quarterly.

Based on observation, staff and resident interviews, review of Incident and Accident reports, and resident record review, it was determined the facility failed to ensure professional standards were followed for 2 of 8 residents (#1 and #2) who were reviewed for standards of practice. Resident #1 was harmed when diagnostic and medical treatment was delayed for 4 days after she experienced a fall resulting in a left ankle fracture. Resident #2 had the potential for harm when the facility failed to follow physician orders [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE], for multiple [DIAGNOSES REDACTED]. A 5-day MDS assessment, dated 4/24/19, documented Resident #1 was cognitively intact and required the assistance of one staff with bed mobility and transfers. Resident #1's admission physician's orders [REDACTED]. An Incident and Accident report, dated 1/30/19 at 7:00 AM, documented Resident #1 had a fall while ambulating herself to the bathroom and received a skin tear to her left elbow and landed on her right knee. The report documented Resident #1 had a possible twist and the body diagram circled to the right lower extremity. The report documented Resident #1 stated she may have twisted her ankle. LPN #1 documented Resident #1 was able to move her ankle without pain, range of motion was within normal limits, and she had no bruising or swelling at the time of the incident. The report did not specify which ankle Resident #1 stated she twisted and what ankle was assessed by LPN #1. A Physician Annual Examination, dated 1/30/19, documented Resident #1 was transferred to the facility for rehabilitation care. The examination documented she had a left sprained ankle with swelling and bruising related to a fall that morning. The nurse's progress note, dated 1/30/19 at 6:49 PM, documented Resident #1 did not have skin changes or notable changes in functional ability. There was no documentation Resident #1 had a fall on 1/30/19 at 7:00 AM. A nurse's progress note, dated 1/31/19 at 1:59 PM, documented Resident #1 left ankle was swollen and bruised from a fall. A physical therapy note, dated 1/31/19 at 3:05 PM, documented Resident #1 had pain to her left ankle and it was swollen. Resident #1's Narcotic Record for [MEDICATION NAME] 10-325 mg from 1/29/19 to 2/3/19 documented she received one tablet four times a day for severe pain. Resident #1's record did not include documentation of where her pain was located. There were no nurse's progress notes documented on 2/1/19 regarding Resident #1's left ankle injury. A nurse's progress note, dated 2/2/19 at 1:10 AM, documented Resident #1 had no skin changes and was working with therapy to improve functional abilities. The documentation did not include her pain level or a description of Resident #1's left ankle. A physician's orders [REDACTED]. A nurse's progress note, dated 2/3/19 at 10:54 AM, documented Resident #1 had no new skin issues and no changes in functional ability. The documentation did not include pain level or a description of Resident #1's left ankle. A nurse's progress note, dated 2/3/19 at 8:58 PM, documented Resident #1's left ankle bruise was getting larger and extended up to her knee and her leg was very swollen. There was no documentation the physician was notified of the change of Resident #1's left leg. A nurse's progress note, dated 2/4/19 at 9:47 AM, documented Resident #1's, left leg is very swollen this morning, which has increased throughout the night. The note documented Resident #1's family member took her to the ER (emergency room ) to get an x-ray and to rule out blood clots to her left lower leg. Discharge instructions from the hospital, dated 2/4/19, documented Resident #1 was diagnosed with [REDACTED]. The special instructions documented Resident #1 was to remain non-weight bearing on her left ankle and to follow up with an Orthorpedic surgeon. A nurse's progress note, dated 2/4/19 at 8:54 PM, documented Resident #1 was non-weight bearing to her left lower extremity. There was no documentation if Resident #1 was wearing a brace and a description of her left lower extremity. A nurse's progress note, dated 2/6/19 at 10:06 PM, documented Resident #1 saw the orthopedic surgeon and was scheduled for surgery to her left ankle on 2/12/19. A nurse's progress note, dated 2/12/19 at 9:36 AM, documented Resident #1 left the facility for same day surgery to her left ankle. A nurse's progress note, dated 2/12/19 at 8:46 PM, documented Resident #1 returned from the hospital after surgery to repair her left ankle fracture. The note documented she had physician orders [REDACTED]. Resident #1 had an incision to her left ankle and was to wear a boot for stability. The (MONTH) 2019 TAR, dated 2/12/19 to 2/14/19, documented licensed staff were to elevate Resident #1's affected extremity above her heart for 48-72 hours, apply ice to the wound for 48-72 hours, and to notify the physician for signs and symptoms of severe pain, fever, swelling, impaired circulation, increased numbness, or tingling. The (MONTH) 2019 TAR did not include documentation licensed staff monitored the incision to her left ankle every shift and monitored the boot placement. The TAR did not direct staff on how often Resident #1 was to wear the boot. On 4/22/19 at 1:15 PM, Resident #1 stated she had a fall 2 days after she was admitted to the facility on [DATE]. Resident #1 stated she had surgery to repair her broken left ankle on 2/12/19. Resident #1 was observed with a scar approximately an inch long on her inner left ankle. Resident #1 stated she wore a walking boot with velcro straps when she was up and working with therapy staff. Resident #1 stated she had physician orders [REDACTED]. On 4/24/19 at 1:15 PM, Resident #1 stated she fell on [DATE] and received a skin tear to her left elbow and twisted her left ankle. Resident #1 stated at the time of the fall, her left ankle did not hurt and she was able to participate with therapy that day. Resident #1 stated by the end of the afternoon, she stated her left ankle was swollen, achy, and bruised. Resident #1 stated around 5:30 PM on 1/30/19, she noticed her left ankle was swollen and it was purple and blue in color from her mid foot up to her shin on the front and inner side of her left leg. Resident #1 stated it looked terrible and she was having pain. Resident #1 stated she had to request ice and the nurses would not even look at her ankle. She stated the nurses kept telling her, it was just a sprain and it was normal to have bruising and swelling. She stated she continued to work with therapy and ambulate with them. Resident #1 stated it was painful, but she was able to tolerate the pain with pain medication and she stated she had [MEDICAL CONDITION] in both of her legs, so she did not really feel that much anyway. Resident #1 stated the bruising and swelling kept getting worse day after day, and on 2/4/19, she and her son had to insist on going to the ER for x-rays. She was diagnosed with [REDACTED]. Resident #1 stated her son drove her to the ER in his private car. On 4/24/19 at 2:30 PM, the DNS reviewed the nurse's progress notes and stated the nurses did not document thorough assessments of Resident #1's left ankle and they should have ordered x-rays the day of the incident when her leg became swollen and bruised. Resident #1 was harmed when she experienced a left ankle fracture on 1/30/19 and the facility did not initiate medical interventions and treatment until 2/4/19, 4 days later, to determine the cause of the swelling, bruising, and pain to her left ankle. 2. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#2 was to receive [MEDICATION NAME] 20 mg one tablet a day for GERD. A physician's orders [REDACTED]. This order was added to the Medication Administration Record [REDACTED]. Resident #2's MARs documented he received [MEDICATION NAME] 20 mg once daily and the 40 mg twice daily for a total of 60 mg in the morning and 40 mg in the evening from 12/7/18 to 3/2/19. On 4/24/19 at 4:00 PM, the DNS stated the facility should have discontinued the [MEDICATION NAME] 20 mg daily medication for Resident #2 when the order was increased to 40 mg twice a day. The DNS stated Resident #2 received duplicate doses of the [MEDICATION NAME] and the physician should have been notified to clarify the dose for the [MEDICATION NAME].

Based on staff interview, policy review, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 5 residents (#3 and #4) reviewed for pressure ulcers. Resident #3 was harmed when he developed a suspected deep tissue injury that worsened to a Stage 3 pressure ulcer to his right heel. Resident #4 was harmed when he developed a suspected deep tissue injury that worsened to a Stage 3 pressure ulcer to his left heel. Findings include: The facility's Prevention of Pressure Ulcers policy, dated (MONTH) 2005, documented, The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in conditions are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. The policy documented interventions and preventive measures for residents with impaired mobility. One preventative measure was, When in bed, every attempt should be made to float heels (elevate heels off the bed to prevent pressure on them) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. The National Pressure Ulcer Advisory Panel website (www.npuap.org), accessed on 4/29/19, stated a pressure injury is damage to an area of skin and underlying soft tissue, usually located over a bony prominence, and may be associated with a medical or other device. The pressure injury can appear as intact skin or an open ulcer. A pressure injury results from severe and/or prolonged pressure or pressure with shearing. The website documented the following: * A Stage 2 pressure injury is partial-thickness loss of skin with exposed dermis (thick layer of living tissue below the top of the skin that contains blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal), slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or devitalized tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. * A Stage 3 pressure injury is a full-thickness skin loss, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. * An unstageable pressure ulcer is an full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. The Lippincott Manual of Nursing Practice, tenth edition, stated measures to prevent pressure ulcer development included repositioning every two hours, using special devices to cushion the specific area, and use an alternating pressure mattress or air fluidized bed for patients who are at high risk. 1. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The admission skin assessment, dated 1/7/19, documented Resident #3 had a wound to his left knee and had multiple scabs on his entire body due to him picking at his skin. Resident #3's skin/integumentary care plan, dated 1/7/19, included interventions for staff to encourage him to his float heels, provide him assistance with mobility/turning and repositioning during cares, provide a standard facility mattress, and if the resident refused skin related treatment, report the refusal to the charge nurse. The care plan did not include when or how often to float Resident #3's heels with pillows while in bed. The care plan did not include the use of a pressure reduction mattress. A Wound Care Clinic Progress Note, dated 1/11/19, documented Resident #3 was receiving wound care treatment for [REDACTED].#3 had a wound to his right heel. A Weekly Pressure Ulcer Skin Assessment, dated 1/16/19 at 12:47 PM, documented Resident #3 had an in-house acquired blister to his right heel that was first observed on 1/16/19. The blister was documented as a suspected deep tissue injury with measurements of 7.5 cm x 5.2 cm x 0 cm to his right heel. The physician was notified and the facility received treatment orders for the licensed staff to apply skin prep (a liquid that when applied to the skin forms a protective film or barrier) to the blister, apply a heel foam dressing, and to secure the dressing with [MEDICATION NAME] (gauze) wrap. Resident #3's skin integrity care plan, revised on 1/16/19, documented he needed a pressure relieving/reducing mattress, pillows, and sheepskin padding to protect his skin while in bed. Resident #3's physician's orders [REDACTED]. Resident #3's (MONTH) 2019 TAR documented wound care to his right heel blood blister every other day and that an air mattress was initiated 1/17/19. Resident #3's admission MDS assessment, dated 1/21/19, documented he was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. The MDS documented Resident #3 was at risk for pressure ulcers, but did not have pressure ulcers at the time of the assessment. The assessment did not include documentation of the pressure wound on his right heel identified on 1/16/19. A Wound Care Clinic Progress Note, dated 1/18/19, documented Resident #3 had a wound to his right calcaneus (heel bone) and to change the dressing every other day. The progress note did not include a description of the right heel wound or type of dressing to use. A Weekly Pressure Ulcer Skin Assessment, dated 1/22/19 at 3:54 PM, documented Resident #3 had a pressure ulcer to his right heel. The right heel pressure ulcer measured 7.5 cm x 5.2 cm. The assessment documented the wound's progress was unchanged and to continue with the treatment to the right heel with skin prep, apply a heel foam dressing, and secure the dressing with a [MEDICATION NAME] wrap. A Weekly Pressure Ulcer Skin Assessment, dated 1/29/19 at 5:04 PM, documented Resident #3's right heel pressure ulcer was improved with the measurements of 7.5 cm x 5.2 cm. The assessment documented Resident #3's wound was an in-house acquired pressure ulcer identified on 1/16/19. Resident #3's 30 day MDS assessment, dated 2/4/19, documented he was at risk for pressure ulcers and he developed one unstageable pressure ulcer with suspected deep tissue injury. As previously noted, the National Pressure Ulcer Advisory Panel website documents when slough or eschar are removed from an unstageable pressure injury, a Stage 3 or Stage 4 pressure injury will be revealed. A Weekly Pressure Ulcer Skin Assessment, dated 2/5/19 at 8:20 PM, documented Resident #3's right heel pressure ulcer, with measurements of 7.5 x 5.3 x 0.5 cm, had deteriorated. The ulcer had a depth of 0.5 cm, which it previously did not. There was no documentation the physician was notified of the deterioration of the right heel pressure ulcer. A Weekly Pressure Ulcer Skin Assessment, dated 2/19/19 at 8:56 PM, documented Resident #3's right heel pressure ulcer had scant amount of serous drainage (thin, watery, clear fluid). The wound measured 7.5 cm x 5.3 cm x 1.4 cm and granulation tissue was present. As previously noted, the National Pressure Ulcer Advisory Panel website documents granulation tissue is not present on a Stage 2 pressure ulcer, however, may be present on a Stage 3 pressure ulcer. Physician orders, dated 2/26/19, documented Resident #3 was to wear a heel suspension boot to his right foot while in bed. A Weekly Pressure Ulcer Skin Assessment, dated 3/19/19 at 9:17 PM, documented Resident #3's right heel pressure ulcer had a small amount of serous drainage. The wound had beefy red granulation tissue and measured 7.3 cm x 5.0 cm x 1.3 cm. Resident #3's record did not include documentation the facility floated his heels from 1/7/19 to 1/16/19. On 4/24/19 at 3:30 PM, the DNS stated Resident #3's record did not include documentation the facility staff float his heels while he was in bed from 1/7/19 to 1/16/19, to prevent the development of the pressure ulcer to his right heel. 2. Resident #4 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #4's MDS assessments, dated 12/13/18, 12/20/18, 12/27/18, 1/3/19 and 1/31/19, documented he did not have unhealed pressure ulcers. The MDS completed on 2/15/19 documented he had one Stage 3 pressure ulcer. Resident #4's skin integrity care plan, dated 12/6/18, documented to have staff encourage him to float his heels. A weekly skin assessment, dated 12/11/18, documented Resident #4 had a left heel blister. A physician's orders [REDACTED]. Resident #4 was referred to a wound care clinic on 1/2/19. Resident #4's record did not include documentation the facility floated his heels from 12/6/18 to 12/11/18. On 4/23/19 at 3:15 PM, the DNS stated the facility had identified concerns with skin assessments and preventative measures for pressure ulcers. The DNS stated the facility should have prevented Resident #4's pressure ulcer to his left heel by floating his heels with pillows when he was in bed.

Based on record review and resident, family and staff interview, it was determined the facility failed to implement interventions to prevent falls. This was true for 2 of 9 sampled residents (#s 3 & 4). Resident #4 was harmed when she fell twice after being given a medication for sleep, and needed staples for a laceration to the back of her head. The resident suffered additional harm when identified fall interventions were not implemented, the resident fell again, and sustained a laceration to her knee which required emergency treatment. The potential for harm was created when Resident #3 fell as a result of not having her call light within reach. Findings included: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment, dated 9/25/14, documented the resident had fallen in the past 30 days, had muscle weakness, an unsteady gait, used a walker and required others to propel her when in a wheelchair. The Fall Risk Assessments, dated 9/25, 10/2, 10/8, and 10/11 documented the resident was not considered at high risk for potential falls. A Fall Risk Care Plan, initiated on 9/25/14, documented interventions to observe gait for unsteadiness, report observed medication side effects to MD, call light within reach, assist with transfers, provide necessary assistance with transfer, keep area free of clutter, encourage participation to extent able, and needed two person extensive assistance for transfers. The resident's Admission MDS, dated [DATE], documented the resident was cognitively intact with a BIMS score of 15. The resident had impairment on one side when assessed for functional limitation in range of motion, and needed extensive assistance of 1 person for bed mobility, transfer, walk in room, and toilet use. The MDS noted that "never or 1 day" during the look-back period the resident had difficulty with sleep. A Physician's Telephone order, dated 10/9/14, documented an order for [REDACTED]. The October 2014 Medication Record documented the resident received Ambien nightly 10/9/14 through 10/25/14, and was discontinued on 10/27/14. A care plan for the problem, "resident is attempting to self transfer," dated 10/9/14, and marked x 2 weeks, documented interventions to include education concerning call light and using request assistance. A line was drawn diagonally through the care plan and marked resolved. No documentation was found as to why the care plan was in effect for only two weeks, why it had been resolved, the date it was resolved, or initials of who discontinued the care plan. Patient Fall Scene Investigation & Incident Reports (FSI), dated 10/11/14 and 10/25/14, documented the following: a) An FSI, dated 10/11/14 at 1:00 AM, documented an unwitnessed fall on 10/11/14 at 12:00 AM (midnight). The FSI documented staff responded to a loud noise and found the resident lying on the floor with a laceration to her head, which was bleeding. She was transported to a local hospital where the laceration to her scalp was sutured with 8 staples and she returned to the facility. The FSI documented the resident got up to change her TV, but did not use her call light, which was within reach. The New Interventions section documented, "Education w/patient on importance of getting help when trying to get up." The Root Cause section documented, "Patient attempted to self transfer." The initial interventions to prevent future falls documented, "Education with patient on importance of asking for help." A Physician's Telephone Order, dated 10/11/14, documented a bed alarm was added for safety. A care plan for the problem, "resident is attempting to self transfer," dated 10/11/14, marked x 2 weeks, documented interventions to orient/educate the resident concerning call light use, encourage to use call light, request staff assistance, and bed alarm to alert for staff assistance. A Fall Risk Assessment, dated 10/11/14, documented the resident was not considered at high risk for potential falls. b) An FSI, dated on 10/26/14 at 1:00 AM, documented an unwitnessed fall on 10/25/14 at 11:35 PM. The FSI documented the resident was found on the floor of her bathroom in a sitting position with a large open wound to her right knee which was bleeding. The resident was transported to a local hospital. The New Interventions section documented, "None at this time. (Name of resident) expressed concerns re: functions of call light - she was educ. (ated) re: call light above door of her room and how to tell if it's on by looking at wall (light) in her room. She did demonstrate appropriate use of call light." The Root Cause section documented, "Pt. attempted to self ambulate to the restroom and did not use her call light which was on her bed. Pt. was under the influence of Ambien and may not have been fully awake." The initial interventions to prevent future falls documented, "(Name of resident) shown how to determine if call light is on. Order for Ambien discontinue obtained from physician." A Nursing Note, dated 10/25/14 at 11:35 PM, documented, "Pt (Patient) found on floor sitting against wall in her bathroom. Staff reacted within seconds to a crash heard down 100 Hall. Pt was severely lacerated (10 cm x 10 cm) on right knee. EMS was activated by 2340 (11:40 PM). Pt transported to (a local hospital) @ (at) 2405 (12:05 AM) by ambulance." A local hospital ER (emergency room ) report, dated 10/26/14 at 12:24 AM, documented the resident had a right anterior knee skin tear with exposed subcutaneous tissue. The report documented the resident had a "full thickness skin tear...flap too far retracted to allow suturing...X-rays negative...will hold Coumadin x 2 days and recheck Monday." The report documented dressing to the right knee and the resident returned to the facility. The FSI further documented the resident received Ambien at 9:00 PM and was observed sleeping at 10:30 PM. The root cause documented the resident was under the influence of Ambien and may not have been fully awake. The interventions added to prevent falls were to educate the resident on how to determine when the call light was on and to discontinue the order for Ambien. The DON documented on the FSI, the resident stated, "I got up and went into the bathroom...walker tipped on me." The DON documented the resident was able to use her call light appropriately and was encouraged to seek staff assistance with transfer. A care plan for the 10/25/14 fall, documented interventions to observe the resident for three days for signs and symptoms of complaint of injury, notify physician with any concerns, nurse to re-educate resident and answer questions regarding how to tell if call light is on. A care plan, dated 10/27/14, for not utilizing the call light for toileting assistance and transfers, self transferring, and Ambien use, documented interventions to discontinue the Ambien in favor of Melatonin, educate resident in call light use, encourage to utilize (call) light and staff assistance for transfers and ambulation, and to monitor the resident for one week for effectiveness of discontinued Ambien related to confusion at night. On 1/13/15 at 4:15 PM, one of the the resident's family stated, "things were bad at first...things are better now, they check on her more." On 1/14/15 at 11:20 AM, the surveyor interviewed Resident #4 regarding the 10/11 and 10/25 falls. She stated the falls could have been due to a combination of medications and she did not use her call light. The resident stated, "For a while there, I was taking sleep medication and I didn't know about it." On 1/16/15 at 10:45 AM, the DON was interviewed regarding the 10/11 and 10/25 falls. She stated a bed alarm was added 10/11, after the first fall. The surveyor asked the DON if the bed alarm was working when the resident fell on ,[DATE], since a NN documented staff had responded to "a crash." She stated she would check into it. The DON stated, after the second fall on 10/25, the LN on duty thought the Ambien could have caused the fall. The LN documented this as being the root cause on the FSI, and Ambien was discontinued on the 10/27. The DON explained the resident was re-educated in call light use and encouraged to utilize the call light for staff assistance with transfers or ambulation. On 1/16/15 at 12:50 PM, the DON provided a copy of the TAR for the month of November 2014 which documented bed alarm checks. When asked if the bed alarm was on and working for the 10/25/14 fall, the DON responded, "I can't answer that." The facility failed to provide an increase in supervision to keep the resident from falling after a sleep medication was added to the resident's medication regimen. Resident #4 was harmed when she fell and required 8 staples to a laceration to her head. The facility was unable to determine why the bed alarm did not alert staff the resident had gotten out of bed. 2. Resident #3 was admitted to the facility on [DATE] with acute myocardial infarction (heart attack), [DIAGNOSES REDACTED] (abnormal brain function) and a urinary tract infection. A 12/25/14 Incident/Accident Report (I/A) documented the resident was "found on floor next to bed. PT (patient/resident) says trying to get up..." The area to document injuries was blank. The Root Cause section of the IA documented the resident needed to get up and the call light was "clipped to wall outlet." Interventions identified to prevent future falls documented the call light needed to be within reach. On 1/15/15 at 4:50 PM the DON stated, "It is expected the call light is within reach at all times." The Administrator was present and stated the facility had provided staff training, after the incident, to ensure residents' call lights were always within reach.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure a resident who had [MEDICAL CONDITION] and Diabetes Mellitus wore heel protectors while in her wheel chair and recliner to prevent pressure sore development and to evaluate and modify improperly fitting diabetic shoes. This was true for 1 of 9, (#2) sampled residents. This deficient practice caused harm when Resident #2 developed a pressure sore to her right heel on 8/29/13 and another pressure sore on her left heel on 9/6/13. Findings include: Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's most recent Quarterly MDS, dated [DATE], coded the following: - BIMS of, "15" or cognitively intact. - Extensive assistance of 1 person for bed mobility, transfers, dressing, and toilet use. - Limited assistance of 1 person for personal hygiene and bathing. - Functional limitation in range of motion to upper/lower extremity, "No impairment." - Is the resident at risk for developing pressure ulcers, "Yes." - Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher, "No." - Skin and Ulcer treatment, "pressure reducing device for bed." Resident #2's Pressure Ulcer CAA (Care Area Assessment) dated 4/4/13, documented the following, "...Resident has decreased mobility and comorbidity that increase risk for skin issues. Resident has pressure relieving mattress to bed. Licensed nurse to do weekly skin assessment. Will continue the plan of care." NOTE: Chapter 4 of the RAI Manual, CAA Process and Care Planning, page 4-2 documented, When implemented properly, the CAA process should help staff: - "Develop, to the extent possible, interventions to help improve, stabilize, or prevent decline in physical, functional, and psychosocial well-being, in the context of the resident's condition, choices, and preferences for interventions." Resident #2's "Skin Plan of Care," dated 8/26/12, identified the following problem, "admitted with soft heels...." Resident #2's "Skin Plan of Care," dated 8/26/12 and reviewed on 10/21/12, 1/8/13, 4/3/13, 7/1/13 identified the the following problem area, "Potential for further development of unavoidable skin integrity related to decreased mobility and [DIAGNOSES REDACTED]. The interventions were dated 11/14/12, and documented the following: - Heel protectors as ordered; - Air mattress overlay on Standard Facility Mattress with a hand written DC'd (discontinued) date of 8/14/13; - Gel Mattress (hand written), dated 8/14/13; - Licensed nurse to do weekly skin assessment; and - Encourage her (the resident) to change position often. Resident #2's October 2013 physician's orders [REDACTED]. - "Skin checks (head to toe) every week (monday eve(ning). - Heel protectors on while in bed or wheel chair." - On 10/21/13 at 3:15 p.m., Resident #2 was observed sitting outside on the patio, in her wheel chair with her diabetic shoes on. - On 10/21/13 at 4:15 p.m., Resident #2 was observed sitting her recliner, in her room, with her diabetic shoes on. - On 10/22/13 at 8:15 a.m., and 5:30 p.m. Resident #2 was observed in the dining room, in her wheel chair, with her diabetic shoes on.- On 10/22/13 at 1:45 p.m., Resident #2 was observed sitting her recliner, in her room, with her diabetic shoes on. NOTE: The resident did not have heel protectors on as care planned, but was observed wearing shoes. Resident #2's Nurse Treatment Notes documented the following: - 8/12/13 - "No new skin issues noted trace amount BLLE (bilateral lower extremity [MEDICAL CONDITION])." - 8/19/13 - "No new skin issues noted 1+ [MEDICAL CONDITION] BLLE..." - 8/26/13 - "No new skin issues..." - 8/29/13 - "Res(ident) c/o (complains of right) heel pain on assessment 1cm x 0.5 cm x ukn(own) area to heel. N.O. (new order) obtained skin prep area BID (twice daily) float heels (with) heel protectors while in bed measure weekly and resolve when appropriate." A facility Incident Report, dated 8/29/13 at 11:00 a.m., documented the following: - "Res(ident) was (in the) bathe (sic) today cna alerted LN that pt (patient) had a dark area to (right) lateral heel." - Assessment by the licensed staff, "1cm x 0.5cm x unk(nown) perimeter clean/clear intact, (zero) abrasive noted to shoe... pt (patient) does state 'tenderness' to area." - Current interventions in place, "Skin prep area BID (twice daily) float heels while in bed." - Immediate interventions implemented, "Skin prep area, physician notified order received for eval(uation) (at) wound clinic for vascular changes appt. (appointment) (with podiatrist)." A hand written Short Term Care Plan, dated 8/29/13, documented the following: - Assessment and Identification of problem, "1 cm x 0.5 cm x unk(nown) perimeter to (right) lateral heel." - Interventions, "1. Treat per facility skin treatment protocol. 2. Pt (patient) will be evaluated for vascular changes at wound clinic. 3. Keep MD informed as appropriate." Resident #2's Nurse Treatment Notes documented the following: - 9/2/13 - "...Skin intact over bony prominences... (Zero) other skin issues at this time." - 9/5/13 - "(Zero) change in (right) lateral foot ulcer. Area is dry intact. perimeter of wound is intact." - 9/6/13 - "New issue, (left) lateral heel area 1.5cm x 1.5cm circle skin still intact. Skin prep applied, heel boots, heels floated." A second facility Incident Report, dated 9/6/13 at 2125 (9:25 p.m.), documented the following: - Assessment by licensed staff, "While applying skin prep to (right) lateral heel diabetic ulcer pt (patient) informed me that she believed she had one on her (left) heel. Diabetic ulcer noted same location on (left) heel as on (right) heel 1.5 cm x 1.5cm w(idth)." - Current interventions in place, "Heel boots applied and heels floated while in bed." - Immediate interventions implemented, "Skin prep applied and heel boots on heels floated. Pt (patient) has appointment for evaluation of lower extremity vascular changes. Pt (patient) has order for diabetic shoes." A hand written Short Term Care Plan, dated 9/6/13, documented the following: - Assessment and Identification of problem, "1.5cm x 1.5cm wound to left heel." - Interventions, "1. Treat per facility skin treatment protocol. 2. Pt (patient) will be evaluated for vascular changes at wound clinic. 3. Keep MD informed as appropriate. 4. Order for diabetic shoes." Resident #2's Nurse Treatment Notes documented the following: - 9/7/13 - "Dry (dressing) gently removed from (right) lateral heel ulcer, leaving an area 0.5 x 0.5 x 0. Area protected with [MEDICATION NAME] with center cut out followed with Allevyn. Pt encouraged to off load heel while in chair." - 9/10/13 - "(Right) heel is healing well (without) complications, perimeter of wound is sloughing/intact. (Left) heel is macerated, indented (with) protected [MEDICATION NAME]. Area left OTA (Open To Air) and will follow (treatment) as (right) heel will cont(inue) (treatment with) floating heels and use of heel protectors." - 9/10/13 - " Pt does have a gel mattress. Diabetic shoes are pending arrival." - 9/17/13 - "PT (Patient) cont(inues) to go to WCC (wound clinic) for diabetic foot. Bilateral feet healing well getting smaller in size." - 9/21/13 - "...(Right and Left) lateral ulcers healing well. Cont(inues) to use heel protectors while in recliner/ bed. Uses blue slippers and areas decreasing in size." - 9/29/13 - "Pt (patient) rec(eived) diabetic shoes on 9/23/13 wears them daily (without) discomfort. On 9/26 pt (patient) DC'd (discontinued) from WCC (wound clinic) state, 'pt (patient) is healed.' Will cont(inue) to monitor [MEDICATION NAME] tx (treatment) to prevent further complications. Will continue floating heals while in bed. Heel protectors while in recliner." NOTE: The facility failed to monitor and evaluate the effectiveness of the initial preventative interventions and to modify those interventions as necessary to prevent the development of a second pressure ulcer. A hand written time-line and measurements, provided by the facility was received by the Bureau of Facility Standards, on 10/27/13. It documented the following: - 8/28 (Right) lateral heel 1cm x 0.5cm x unk(nown), treatment skin prep BID (twice daily) float heels. - 9/5 (Right) lateral heel 1cm x 0.5 cm x unk, treatment heel protectors. - 9/6 (Left) lateral heel 1.5cm x 1.5cm x unk, (treatment) same as right heel. - 9/10 (Left) lateral heel 2 cm x 1.7cm x unk. - 9/14 (Right) lateral heel 0.6cm x 0.5cm x (less than or equal to) 0.1cm. - 9/21 (Right) lateral heel 0.3cm x 0.5cm x (less than or equal to) 0.1cm. - 9/14 (Left) lateral heel 2cm x 1.7cm x unk. - 9/21 (Left) lateral heel 1.5cm x 1.3cm x unk. - 9/26 Wound Clinic visit, "(patient) is healed." QM (Quality Measures) will cont(inue) [MEDICATION NAME] (treatment) to prevent further complications - 9/27 Treatment (changed) to [MEDICATION NAME] border per WCC. - 9/29 (Right) lateral heel 0.6cm x 0.3cm x (less than or equal to) 0.1cm, - 9/29 (Left) lateral heel 1.5cm x 1.3cm x unk. - 10/7 Resolved heel ulcers. NOTE: The above hand written time-line and measurements were not found in Resident #2's record during the survey process. Resident #2's, "Charge Nurse Notes" documented the following: - 8/29/13 - "Follow up on report of 1cm x 0.5cm x unk(nown) perimeter wound to Right lateral heel. Patient states, 'It started hurting a few days ago.' (Resident's name) states that she does wear her shoes daily upon getting up in the morning. Shoes inspected and noted that fabric around back of heel, (but not in area of reported site) is starting to wrinkle down. Order received from (Physician's name) to obtain appointment at wound clinic for evaluation of vascular changes. Appt. will also be made for podiatrist to seek order for shoes." - 9/7/13 - "F/U (follow up) on report of 1.5cm x 1.5cm wound to left heel. Pt (patient) states, 'I think I hurt my foot when I put it down.'" Resident #2's, "Nurses Notes" documented the following: - 9/6/13 - "...While applying skin prep to (Right) lateral heel. Resident informed me she thinks she has one on her (Left) heel. Noticed diabetic ulcer (Left) lateral heel 1.5cm x 1.5cm, MD notified. Skin prep applied, heel boots applied, heels floated, will cont(inue) to observe." - 9/7/13 - "Bilat(eral) heels evaluated." - 9/9/13 - "...(dressing) intact to (left) heel. Will assess on 9/10 a.m." - 9/10/13 - "Pt (right) [MEDICAL CONDITION] is getting smaller in size and is stable. (Left) heel is macerated. Area (treatment) will be (changed) to skin prep (bid) OTA (open to air). Float heels/heel protectors while in bed/recliner. Pt is to receive diabetic shoes...(Left) heel has (zero) signs odor/infection/drainage. Res to float heels while up in recliner." - 9/11/13 - "Were (wear) blue slippers while up. Pt heels floated while up in chair." - 9/21/13 - "...Bilat(eral) heels cont. to heal (without) complications. Ulcers getting smaller in size. Cont. to float heels (with) heel protectors while in bed/recliner. Use blue slippers daily." NOTE: None of the above listed interventions were on the resident's permanent "Skin Plan of Care," nor were the interventions listed on the Treatment Record. The only intervention listed on the Treatment Record (TAR) for July, August, and September 2013 was, "Heel protectors on while in bed or in wheel chair." This intervention was identified on the TAR as information only. The boxes for the nurses' initials were blank and it could not be determined whether or not the heel protectors were being used. Resident #2's, "Doctor's Progress Notes" documented the following: - 9/5/13 - "(Right) lateral foot (ulcer) 2cm x 2cm area with hyperpigmentation..." - 9/9/13 - The resident was seen by the Podiatrist and he documented the following, "...She does have cracks/wounds on heels (bilateral)... Continue keeping the wounds clean, apply antibiotic ointment and bandages until healed... Keep heel protectors on feet as much as possible and avoid pressure on her heels." - 9/23/13 - "Diabetic shoes dispensed. They fit well. Break them in slowly, watch for sings (signs) of rubbing or irritation." - 9/24/13 - "[MEDICAL CONDITION] -causing foot ulcer which with treatment are getting better so no intervention for vessels yet." - 10/17/13 - "(Bilateral) heel ulcers appear to be healing well; but will cont. to closely monitor as plan will be to re-eval vasculature via angiogram (and) potential angioplasty if heel sores are not healing well." Wound care and hyperbaric medicine clinic notes documented the following: - 9/12/13 - "...Attention was then directed to the heel wound, the right heel wound reveals a very small eschar over the lateral aspect of the heel. This wound is completely healed, does not require any specific treatment today. There is an intact lesion along the lateral posterior left heel. There is no open wound noted, then no specific wound care was provided today with the exception of silver foam and cover." - 9/19/13 - "...Bilateral heels: patient had some blisters that were noted at her previous appointment..." NOTE: The only documentation of eschar on the resident's right heel was on 9/12/13, when the resident was seen by the wound care clinic. A letter from the resident's attending physician was provided to the Bureau of Facility Standards, on 10/27/13 documented the following: - 10/26/13 - "In my understanding she (Resident #2) was found to have two mirror image superficial skin openings on each lateral heal, but about 8 days apart. I believe these were probably from abrasions by her shoes that were tighter than usual due to more [MEDICAL CONDITION]." The physician reviewed the clinical visit note from the WCC on 9/12/13 and wrote,"The report says both right and left heal wounds were healed over and only needed protection. Obviously these wounds were very superficial that they could heal so quickly, despite very poor circulation. I believe her weight and [MEDICAL CONDITION] fluctuates so much because she cannot tolerate [MEDICAL TREATMENT] taking off as much fluid as would be best. (Resident's name) does not ambulate more than a couple of steps, so the shoes she wore were only meant for standing and transfers. More [MEDICAL CONDITION] of her feet contributed to the new problem with her heels, I believe. Both lateral heel wounds were healed, according to (wound clinic physician's name) at the wound clinic, by 9/12/13, the very next visit. For both to heal that quickly the wounds must have both been superficial." On 10/22/13 at 1:45 p.m. the following was observed by the DNS, charge nurse, and surveyor: - Bilateral heels were pink, soft (as described by LN #1), and had superficial skin slough. - Yellow, dry, closed, scabbed areas present to the lateral aspect of bilateral heels, - Right Great Toe, tip of the toe, hyperpigmentation, hard, and calloused, - On the top of each foot, in the same place, was a blanchable red area where the tongue of the resident's shoe had been. The DNS stated to the charge nurse, the resident's shoes needed to be looked at because it looked liked the resident's shoes were "too tight or not fitting right." - On 10/24/13 at 10:45 a.m. the DNS and MDS nurse were interviewed related to facility's failure to review and revise the "Skin Plan of Care" after identification of the right heel pressure ulcer to prevent the left heel pressure ulcer from developing. The DNS and MDS nurse said daily skin checks were completed on the Right heel. The surveyor asked the DNS how the facility determined the effectiveness of the above intervention and how was the Plan the Care reviewed and revised to discontinue ineffective interventions and implement new interventions. The DNS and MDS nurse said the facility implemented the same interventions for the left heel pressure ulcer identified on 8/29/13 and the right heel pressure ulcer identified on 9/6/13. Resident #2 was harmed when: - The facility failed to ensure a resident who had [MEDICAL CONDITION] and Diabetes Mellitus wore heel protectors while in her wheel chair and recliner to prevent pressure sore development. - The facility failed to evaluate and modify improperly fitting shoes, that contributed to the development of the pressure sores when she had increased [MEDICAL CONDITION] in her feet. - The facility failed to have consistent documentation of the size, shape, location, and appearance of the areas on the bilateral heels. - The facility failed to review and revise the resident's Plan of Care after the first pressure sore was identified. On 10/24/13 at 2:00 p.m. the Administrator and DNS were notified. Additional information was submitted to the Bureau of Facility Standards on 10/27/13 via fax. However, the information did not alter the findings.

Based on observation, staff interview, record review and review of facility incident reports it was determined the facility did not provide adequate supervision for 1 of 6 sampled residents (#9) reviewed for falls. The resident was known to be high risk for falls and fell while toileting at the facility. The resident was harmed when she fractured her hip and subsequently had surgery to repair the fracture. Findings include: Resident #9 was originally admitted to the facility on [DATE] for rehabilitation after a left hip fracture which occurred at the assisted living she resided in. The resident was discharged back to the assisted living on 11/18/11 and fell again fracturing her pelvis and was readmitted to the facility on [DATE]. The resident fell during toileting in the facility and fractured her right hip which required surgery and another hospital stay. She was readmitted to the facility for rehabilitation on 3/15/12. The resident's other [DIAGNOSES REDACTED]. The admission MDS assessment, dated 12/26/11, documented: *BIMs score of 10 for cognition (moderately impaired category). Indicators for ability in long or short term memory were not documented. *Total dependence for bed mobility with two staff support. *Total dependence for transfer with two staff support. *Total dependence for toilet use with two staff support. *Had a fall history, had fallen in last 2-6 months and had a fracture. The admission (initial) care plan was not dated. A problem was identified on 12/20/11, "At risk for injury r/t (related to) unfamiliar environment." Approaches included: *Orient the resident to environment. *Ensure belongings are within reach. *Instruct resident to request assistance whenever needed. *Report observed meds. (medication) side effect to MD (Medical Doctor). NOTE: Interventions did not include how many staff should be used with transfers or indicate that staff should stay with the resident when toileting. The care plan that resulted after the admission MDS assessment was not dated. Potential for falls/injury related to history of falls was carried over from the October 2011 admission. A hand written date of 12/26/11 was documented next to previously identified problem. Interventions were: *Keep call light in reach. *Assist with cares and transfers as needed. *Keep usually used items in same location. *If fall/injury occur notify MD and treat as ordered. On 1/21/12 a new problem identified, "Pt (Patient) trying to self transfer." New interventions included: *Tabs and bed alarm placed to alert staff of patient needs r/t hx (history) of falls and pt self-transferring. Hx dementia. The "Patient Incident Report" (facility incident report), dated 3/11/12, documented the following: "Door to room and bathroom were closed. I saw wheelchair by foot of pt bed. I opened pts (bathroom) door to find her laying on floor. I called for the nurse and took pts vidals (sic)." The License Staff assessment portion documented: "Pt leaning on door frame. Upon visual assessment R LE (right lower extremity) shorter & and unnatural position. Pain (with) touch or movement. Small red area on back of head. Pt alert & crying, able to make herself understood. Unable to move pt to assess further." The staff caring for the resident documented the following statement: "Place pt on toilet 20 minutes prior to finding pt on the ground. Pt was given the call light." The summary/results of the investigation were: "Pt had been taken to the bathroom & put on the toilet. CNA had given the pt the call light & instructed her to call when she was done. (Name) heard pt banging on the walls. Pt found sitting on floor (with) back & head against door jam. It appeared as though the pt had stood up, grabbed the side rails & tried to take a step & lost her footing & fell backwards. There was BM in the toliet (sic) (not) flushed yet. Pt. has a history self trans(fers) 1/21/11." NOTE: The fall was not witnessed and the sequence of events may not have happened as staff determined they appeared to have happened. The nurse progress notes for 3/11/12 documented, "Pt. admitted to hospital for R hip (fracture)." There was no assessment documented or description of the accident. The incident report above was not part of the resident's record. Please refer to F514 for further findings related to documentation related to clinical records. The resident had one additional incident report related to a fall which occurred on 5/19/12 at 3:30 pm. The witness documented, "Aid (sic) found pt. on the floor leaning against her chair." The License Staff assessment portion documented: "Full set vitals- WNL (within normal limits). Pt's ROM (range of motion) WNL and no pain (with) exception of left leg. Pt stated some discomfort (with) L(eft) leg. No apparent injury- pt had cont(inuous) assessment." It was documented the call light was in reach of the resident. Summary: "Pt appeared to have slipped out of her recliner, possibly wanting to go the restroom r/t incontinence of urine." This report had an additional "Fall Scene Investigation Report" attached. This report indicated the resident had slipped out of her recliner, the fall was unwitnessed, was last toileted at 2:00 pm, and was confused which was the resident's usual mental status. The resident was confused and grabbed cord to remote and pushed remote buttons. (NOTE: The documentation stated the remote would be kept out of reach of the resident. It was not identified as to what type of remote the resident used, i.e., television or chair movement control.) Under the section for current interventions in use, there was no documentation that a tab alarm was on the resident or sounded when she fell . There were no nurse progress notes documented the day of the fall. One nurse progress note, dated 5/20/12, documented, "Pt sleepy and rests a lot today; not necessarily diff(erent) than other days. Pt denies any discomfort from sliding off chair early eve(ning) 5/19/12. No concerns." The current plan of care for March 2012 documented an identified problem dated 3/29/12. "Potential for falls/injury related to history of falls. Dx. dementia." The goal was for the resident not to have any avoidable falls or injury. Interventions included: *Keep call light in reach. *Assist with cares and transfers as needed. *Keep usually used items in same location. *If fall/injury occur notify MD and treat as ordered. Hand written entries followed: "Bed & tabs alarm as ordered." This was not dated. "5/19/12 Move recliner remote out of reach." (Added after the fall). NOTE: No extra supervision was indicated on the care plan. There was no indication that the resident should not be left in the bathroom unattended related to the prior fall which caused a fracture to her right hip. The problem related to toileting and incontinence (page 9) documented the following intervention: "Assist with toileting as needed." NOTE: The MDS quarterly assessment, dated 6/13/12, documented the resident still required extensive assistance for toileting. The resident was observed on 7/25/12 at 12:05 pm, being assisted with the use of her wheel chair to leave her room and go to the dining room for lunch. She remained in the wheel chair for the meal and did not transfer. The resident had been noted to be confused when another resident tried to talk with her during meals. She usually just smiled and did not consistently answer questions appropriately. The current quarterly MDS assessment, dated 6/13/12, documented the resident's cognition with a BIMs score of 3. This indicated severe cognitive impairment. The resident required extensive assistance by one staff for most ADL care including toileting. The DON stated on 7/26/12 at approximately 2:20 pm, that the day the resident fell they had directed on the care tracker (electronic computer tracking device used by CNAs) not to leave the resident on the toilet alone. The DON stated the CNA assigned to take care of Resident #9 only worked occasionally and probably did not know the resident should not be left alone. A letter dated 7/24/12 and written by the resident's physician was provided by the DON and Administrator. The letter indicated the resident had poor judgement, and poor long and short term memory. The physician documented staff had tried to provide dignity for the resident while using the bathroom for defecation. The facility failed to supervise the resident who had a known history of falls placing her at high risk. The facility did not increase supervision for the resident. Expectations for the resident to use her call light when she had memory problems and was confused were unrealistic. The resident was left alone on the toilet for 20 minutes, without staff intervention, until she was heard banging on walls for help. The facility determined the fall in May 2012 could have been related to a need for toileting. However, changing the frequency of toileting for the resident was not indicated on the care plan. The concern for the resident's dignity/privacy for using the toilet while commendable was not practical. The attention to the resident's privacy/dignity could be accomplished by having staff stay close to the door and occasionally asking her if she was ready for assistance. This could provide more observation for keeping her safe.

Based on observation, resident and staff interview, and record review it was determined the facility failed to prevent avoidable pressure ulcers from developing after residents were admitted to the facility. Additionally, documentation was incorrect and confusing, which may have contributed to the failure to prevent and heal pressure ulcers. This was true for 3 of 10 sampled residents (#s 5, 7 and 9), and resulted in harm for Resident #5, who developed 3 Stage II pressure ulcers at the facility. Resident #7 developed a Stage II pressure ulcer on the inner buttocks crease/coccyx area. Resident #9 developed a Stage II pressure ulcer on the heel, and complained of severe pain related to the pressure ulcer. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 7/8/12 Admission MDS assessment coded: * Cognitively intact * Required extensive assistance by 2 or more staff for bed mobility, transfers, dressing, toileting, and hygiene * Decreased range of motion in one lower extremity * At risk to develop pressure ulcers, but none present * Occupational and Physical therapies provided 6 days since admission The resident's Admission Plan of Care and June (sic) 2012 Plan of Care documented the following problems and interventions: * 7/2/12 - "Skin at risk... 1. Protective/preventive skin care. 2. Provide necessary assistance with mobility/turning and repositioning. 3. Pressure relieving appliances: bed. 4. Meds and treatment as ordered. 5. If resident is noncompliant with pressure reducing devices, report immediately to the nurse. 6. Report to the nurse any skin anomalies found while providing routine cares such as dressing, showers, incontinent care, etc." * 7/10/12 - "Preventative care for feet. Heel protectors." * 7/17/12 - "Nutrition: (Resident) has need of therapeutic diet... at risk for (weight) fluctuation (due to) rehabilitation activities... may lose (weight due to) post hospitalization ... Offer (resident) med pass supplement (three times daily)." * 7/17/12 - "Potential for impaired skin integrity related to decreased mobility secondary to left hip hemiarthroplasty... 1. Assist with turning and positioning as needed. 2. Pressure relieving mattress. 3. Treatments as ordered. 4. Medications as ordered. 5. Preventative skin care. 6. Notify (physician) if skin issues occur and treat as ordered." * 7/17/12 - "Potential for abnormal bruising/bleeding related to anticoagulation therapy... 1. Medication and treatments as ordered. 2. Observe for abnormal bleeding/bruising." NOTE: The care plans did not document that the resident developed multiple Stage II pressure ulcers at the facility, what treatments were in place for the pressure ulcers, or increased interventions to prevent the development of additional pressure ulcers. The resident's 7/18/12 Care Plan Conference Summary did not document any discussion of skin care or pressure ulcer prevention, although the medical record documented "abrasions" on the resident's bilateral "insteps" on 7/12/12 and left posterior calf on 7/21/12. The resident's 7/2/12 Nurse's Treatment Notes (initial skin assessment) documented: "(Resident is) alert and oriented, (resident) does not have much mobility to lower extremities, (resident) has thick black toenails and warts on both feet. (No) [MEDICAL CONDITION], (resident) has fatty tumor on right upper thigh. He states it has been there a long time. (Resident's) skin is intact. (Resident) has surgical incision on his (left) hip, (staples) intact, no (signs or symptoms) of infection." Physician's Telephone Orders documented: * 7/4/12 at 4:05 PM- "TED hose." NOTE: DoctorQA.com documents, "TED brand is the most popular (brand of) anti-embolism stockings... prescribed to non-ambulatory patients, or those... who are recovering from a surgical procedure. They are designed to reduce the risk of blood clots in bed-ridden patients," and "Compression... stockings are made of a material that has a very high elasticity. Because of this, they often feel tight when a patient first wears them, which is completely normal. Compression socks and compression stockings encourage upward flow so that blood is more likely to move toward the heart rather than collect in the legs and feet." (http://www.doctorqa.com/vein/procedures/compression-socks) * 7/10/12 at Midnight - (Resident) to have an Allevyn on the instep of both feet for prevention of sores and breakdown from TED hose. Change once a week. Monitor daily." * 7/12/12 at 2:00 PM - "Float heels or heel protectors while in bed to prevent breakdown... Non-adherent (dressing with) [MEDICATION NAME] to left posterior calf, (change every) 3 days (and as needed)." Weekly Skin Assessment Sheets documented the resident as "low risk" for the development of pressure ulcers on the following dates (a score of 21 or greater indicated low risk, 17-20 indicated moderate risk, and less than 17 indicated high risk): * 7/2/12 - 30 * 7/4/12 - 30 * 7/11/12 - 25 * 7/18/12 - 25 NOTE: The resident was actually at high risk based on the admission [DIAGNOSES REDACTED]. The resident's Ulcer Skin Condition Record first documented a left heel Stage II pressure ulcer on 7/21/12. Non-Pressure Skin Conditions Records documented: * 7/10/12 - "Prevention bruises (sic) both (right and left) foot insteps, irregular shape, (too numerous to count)." NOTE: The "abrasions" on the resident's bilateral anterior ankles were documented as present on his insteps, and there was no documentation present in the chart that the wounds had opened or were Stage II pressure ulcers caused by TED hose (see below). * 7/12/12 - Left Posterior Calf abrasion, 3 cm x 2 cm. The resident's Treatment Record documented, "Float heels or heel protectors while in bed to prevent breakdown" was done each shift from 7/12/12-7/24/12. Nurse's Notes documented: * 7/10/12 day shift - "(Resident) to have an Allevyn on both instep (sic) of each foot to relieve friction and provide protection from TED hose." * 7/11/12 at 9:30 PM - "Rested at long intervals." * 7/20/12 (time not documented) - "Stage II ulcer on his (left) heel measuring 3 cm (centimeters) x 3 cm round, with a 2 cm x 2 cm blister in the center. Treatment in place. Please see TAR (treatment administration record)." * 7/21/12 at 5:00 AM - (Resident) has a Stage II ulcer on his (left) heel, measuring 3 cm x 3 cm (with) 2 cm x 2 cm blister in the middle, edges are red, but intact, a treatment sheet has been put in place, please see TAR." * 7/22/12 at 12:45 PM - "We are trying to keep him up in his (wheelchair) today because when lying down he kicks his heel protectors off and we are trying to keep his left heel from breaking down." NOTE: The resident's left heel was documented to have a Stage II pressure ulcer 2 days prior to this entry. * 7/22/12 evening shift - "(Resident) has been encouraged to sit up in wheelchair to keep the pressure off of his heel, (resident) has been told to use heel protectors several times. I have walked into room and he is not using heel protectors." A 7/23/12 Nutritional Progress Note documented, "(Resident) has wound on (left) heel... Plan to recommend (vitamin) C and zinc supplements to aide in wound healing." The resident was observed to be asleep in bed, positioned on his back with no heel protectors in use, on 7/23/12 at 5:04 PM and 7/24/12 at 7:30 AM. On 7/25/12 the DON was interviewed about Resident #5's wounds. At 9:30 AM she stated, "We knew about his potential (to develop pressure ulcers) so we did (implement) heel protectors. At 9:40 AM she stated, "We don't have a diagram for wounds." At 10:30 AM she stated that the resident's calf abrasion was, "from his TED hose." NOTE: The Nurse's Treatment Notes and Non-Pressure Skin Conditions Record forms both included a body diagram to document wound locations, but the facility did not use them. On 7/25/12 at 4:15 PM, the DON and Surveyor observed Resident #5's feet and ankles. Upon entry to the room, the resident was not wearing heel protection boots, and had Allevyn bandages covering both anterior ankles. The bandages were removed, and the following wounds were observed: * Right anterior ankle - 3 open areas covering an area of approximately 2 inches long x 0.5 inches tall x 0.25 inches deep, in a clearly defined line of demarcation, in the area the ankle bends between the foot and leg. * Left anterior ankle - 2 open areas covering an area of approximately 2 inches long x 0.5 inches tall x 0.25 inches deep, in a clearly defined line of demarcation, in the area the ankle bends between the foot and leg. * Left heel - an open, opaque area where a blister had been, approximately 1 inch in diameter; a larger area of redness, approximately 2 inches in diameter, surrounded the open area. * Right heel - a darkened area approximately 1.5 inches in diameter NOTE: The resident was wearing gray non-slip socks which were ankle length. On each ankle, the elastic band of the sock aligned with and covered the open areas beneath the bandages. The bilateral anterior ankle wounds were located in the area where TED hose frequently bunch up when worn. The DON stated that the anterior ankle wounds "must be the instep (areas) that are charted." She called LPN #1 to the room and asked, "Is this what you mean by instep?" LPN #1 replied, "yes." The DON stated, "This is not an instep." LPN #1 stated, "I just went off the treatment sheet and initialed the documentation. I never gave it a second thought." The DON then stated, "The TED hose were discontinued because they caused (the resident) a lot of grief." The DON was asked when the TED hose were discontinued and she stated, "I don't know, the orders change all the time." The DON then placed the heel protection boots on the resident. LPN #1 stated, "(The resident) doesn't move when he's in bed." On 7/26/12 at 9:00 AM, the DON and Surveyor observed the resident's left posterior calf. There was a healing, abraded area approximately 1 inch in diameter, with intact skin. On 7/26/12 at 9:10 AM, the DON and Administrator were informed of the findings. They provided a letter from the resident's Nurse Practitioner, which documented: "Patient is a high risk for potential skin breakdown regardless of skin management preventative efforts (due to history) of diabetes, smoking (history) of 2.5 packs of cigarette (sic) a day, sedentary lifestyle... Since admission, skin preventative management was instigated, i.e. patient was on pressure relieving mattress with load bearing cell to redistribute pressure, and heels floated. His [DIAGNOSES REDACTED]. According to my assessment Patient only has one (1) stage II pressure ulcer to his left heel and not 3. The other 2 superficial wounds on the anterior ankles are classified as Non-pressure wounds probably obtained by friction by his socks or TED hose and underlying Peripheral Vascular Insufficiency. For the first 2 weeks during rehabilitation stay, Patient made little progress; he was fearful of his pain and unmotivated and he prefer (sic) to stay in bed despite staff's effort to get him mobile... Due to complex co-morbidities and medical condition as stated above, and despite of (sic) preeminent effort for preventative skin management Patient remains to be (sic) at unavoidable risk to develop further skin breakdown." NOTE: The medical record did not document a [DIAGNOSES REDACTED]. The facility was aware of the risks for pressure ulcer development but failed to implement, monitor, and revise interventions to prevent their development and the resident ultimately developed 3 Stage II pressure ulcers. Resident #5 was admitted to the facility at high risk for pressure ulcers and was known to spend long periods of time in bed with his ankles bent and heels pushing down into the air mattress. Heel protection boots were not implemented until 7/12/12, 2 days after the resident developed Stage II pressure ulcers on his bilateral anterior ankles. The resident then developed a third Stage II pressure ulcer on his left heel; the facility stated that the resident removed the heel protection boots, but did not document consideration of the reasons why or implement additional interventions to prevent pressure ulcers or address the resident's refusal to wear the boots. 2. Resident #9 was readmitted to the facility on [DATE] after fracturing her pelvis during a fall at her assisted living. The resident fell during toileting at the facility and fractured her right hip which required surgery and another hospital stay. She was readmitted to the facility for rehabilitation on 3/15/12. The resident's other [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 12/26/11, documented the following: *BIMs score of 10 for cognition (moderately impaired category). Indicators for ability in long or short term memory were not documented. *Total dependence for bed mobility with two staff support. *Total dependence for transfer with two staff support. * At risk for pressure sores but no pressure sores or history of healed pressure sores. When the resident returned from the hospital, her admission MDS assessment, dated 3/15/12, documented: *BIMs score of 5 for cognition (severely impaired category). *Required extensive assistance for most ADLs. *At risk for pressure sores but no pressure sores or history of healed pressure sores. The admission care plan (initial) dated 3/15/12 documented an identified problem for skin at risk. Interventions included: *Protective/preventative skin care *Provide necessary assistance with mobility/turning and repositioning. (NOTE: This did not provide direction as to how often the resident should be repositioned). *Pressure relieving appliances: Bed (NOTE: Did not indicate what type). *Medications and treatments as ordered *If resident is noncompliant with pressure reducing devices, report immediately to the nurse. (NOTE: No pressure reducing devices for wheel chair were documented as in use). *Report to the nurse any skin anomalies found while providing routine cares such as dressing, showers, incontinent care, etc. (NOTE: No routine skin checks, such as one time weekly, indicated). The current plan of care indicated for March 2012, except page 6, which indicated April 2012. Page 6 had the problem identified for, "Potential for unavoidable impaired skin integrity related to decreased mobility admitted with S/P (status/post) [MEDICAL CONDITION], left posterior distal thigh lipoma." Interventions included: *Preventative skin care. *Assist with turning and positioning as needed. *Treatments as ordered. *Licensed nurse to do weekly skin assessment. *Pressure relieving mattress to bed. (NOTE: Did not indicate what kind of pressure relieving mattress or date it was placed on bed). *Notify MD and treat as ordered. (NOTE: There was no direction to use heel protectors or float heels. However, the treatment record for July 2012 indicated heel protectors daily). On 7/25/12 at 9:30 am the DON was asked to provide documentation of skin condition related to pressure sores for Resident #9. A facility "Non-Pressure Skin Conditions Record" form documented the resident was found with a "Receding blister" to the left heel on 4/9/12. The size of the wound was documented as "(Length) 5 cm x (Width) 5 cm x (Depth) unknown." The form had boxes for daily monitoring of progress of the wound, dressing change, tunneling/undermining, pain and signs and symptoms of infection. The form did not have documentation for odor, color, exudate or how the area around the wound looked. Daily documentation was indicated on the form up to 4/30/12. The "order/intervention" indicated, "Apply [MEDICATION NAME] on wound area with Allevyn once weekly and prn (as needed) Monitor for intactness daily Resolve when appropriate." This order was also on the form the facility used to document physician orders [REDACTED]. Other than a nurse progress note, dated 5/10/12, that indicated the resident had heel protectors on in bed, there was no documentation in nurse notes related to the pressure ulcer. The Physician Orders" recapitulation for the month of July 2012 documented heel protectors were ordered on [DATE]. A treatment sheet for the month of May 2012 was provided. The form required measurements for length and "s/sx (signs/symptoms)." At least 20 days did not have measurements documented. The form indicated the pressure sore resolved on 5/29/12 (almost 2 months after it was acquired). A facility form "Nurse Treatment Notes" dated 5/1/12 documented the following: "Patient complaining of severe pain r/t (left) heel blister. On assment (sic) nurse found bandage had coiled up and taken top layer of skin off blister. Bandage and Ted hose removed- bandage changed and replaced with Allevyn dressing. Patient reporting relief after bandage change. Heel protectors placed." On 7/23/12 at 4:38 pm, a surveyor observed Resident #9's skin condition. The resident had heel boots on and Ted hose on. The resident's right heel was clear and the left heel had a triangular shaped (3/4" x 3/4") red area. It was dry and intact. The resident had intact skin to the hips and buttocks. An old scar was observed on the left buttock close to the coccyx and was oval in size and about 1/4 inch across. The facility failed to implement prevention measures for the resident's heels until the day a Stage II pressure sore was found. There were no prior care plans to indicate the facility had been floating the resident's heels. Other pressure relieving devices for the resident's wheel chair and bed were not documented. Documentation did not include complete descriptions of the pressure ulcer. The care plan was changed in April 2012 when the resident developed a pressure sore to her heel. The problem documented the resident had potential for "unavoidable" impaired skin integrity. However, the facility failed to determine the pressure sore to the resident's heel was unavoidable, and in fact, healed the pressure sore. 3. Resident #7 was admitted to the facility for rehabilitation on 7/7/12 after surgery on her left hip. Other [DIAGNOSES REDACTED]. The resident's initial MDS assessment, dated 7/13/12, documented: *Extensive assistance of two required for bed mobility and transfers. *No pressure sores documented. The first page of nursing notes was used to document physician order [REDACTED]. The page was a pink color in comparison to white forms for nurse notes documentation. An entry on 7/20/12 documented, "Skin (check) completed - found St(age) II pressure ulcer R(ight) inner fold of buttox/coccyx (sic). Zinc (with) Allevyn (3 times a day, 1 time a week change and prn, 1 time a week measurement)." There was no corresponding documentation in nurse progress notes related to the pressure sore. The facility care plan was not dated. The care plan was a combination of the admission care plan and the current care plan. The current care plan did not address skin issues but the initial care plan identified, "Skin at risk." The interventions included: *Protective/preventative skin care *Provide necessary assistance with mobility/turning and repositioning (NOTE: Frequency not documented). *Pressure relieving appliances: Bed (NOTE: Type of pressure relief not indicated) *Medications and treatments as ordered *If resident is noncompliant with pressure reducing devices, report immediately to the nurse. (NOTE: No pressure reducing devices for wheel chair were documented as in use). *Report to the nurse any skin anomalies found while providing routine cares such as dressing, showers, incontinent care, etc. (NOTE: No routine skin checks, such as one time weekly, indicated). The resident's "Ulcer Skin Condition Report" for July 2012 documented a pressure sore to the right (R) inner fold/coccyx. Measurements were documented as (length 1.6 x width 1.4 x depth 0.1). The documentation was not designated as centimeters but this was the likely conclusion. Interventions included, "Apply zinc, apply allevyn, check intactness TID (3 x a day), change weekly and (as needed) measure 1 x week." A "Nurses Treatment Notes" form was documented by IDT (interdisciplinary team) on 7/23/12. Documentation indicated the resident had developed a pressure sore on 7/20/12 and the measurements as above were included and designated as centimeters. Documentation indicated the resident had been using a "comfort cushion" in her wheel chair that had been replaced with a Roho cushion. Also, "Will apply a air mattress to her bed also (sic)." The note also indicated the resident was very sedentary and in her w/c (wheel chair) most of the time except when working with therapy. The resident's meal intake was poor and a supplement was started on 7/18/12. A surveyor observed the pressure sore area on 7/23/12 at 4:30 pm. The resident was noted to have approximately a 1 to 1.5 inch circular dark area with approximately a 1/4 x 1/3 inch pink area inside. The area was open but almost healed and was bandaged. The facility did not prevent a facility acquired pressure sore for Resident #7. Devices to relieve pressure were not implemented until after the pressure sore was discovered on 7/20/12. Care plans were not revised to show the new pressure relieving devices.